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Gender Affirming Surgeries and Complications

While some trans and non-binary people transition their gender socially without changing their bodies, or with only hormone therapy, many choose to have surgery to help align their body with their sense of identity, and to decrease dysphoria. Some of these procedures are small, and fall into the category of minor plastic surgery, while others are more comparable to major invasive surgeries. It is important to remember that there is no one way to be trans or non-binary, and different patients will have had some, all, or none of these procedures. In addition, there is no fixed order in which these procedures must be done, and indeed, many trans people choose never to have some of these procedures. What is important to understand is that there is no such thing as a “complete” transgender person, and your patients’ identity is not necessarily tied to their current bodies or genitals, or their plans to change them.

Feminizing Procedures

“Bottom surgery”
Some trans women experience dysphoria surrounding their genitalia and wish to have their penis removed. This is usually done with several procedures including a penectomy, orchiectomy, vaginoplasty, clitoroplasty, and vulvoplasty; typically collectively referred to as “bottom surgery.” The basic technique for this involves inversion of the penile skin, placement of a pedicled colosigmoid transplant, and free skin grafts to make up a neovagina. The neovaginal vault is created between the rectum and the urethra, using the penile skin to line the vagina. Labia are created using scrotal skin, the testes are removed, and a clitoris is created from a portion of the glans. Often, prior to the procedure, trans women undergo electrolysis of the penile and scrotal skin to create hair-free tissue.11 Post operatively, gauze packing or stents are placed inside of the newly created vaginal vault to create a negative space. After the packing is removed 5-7 days later, the patient is usually instructed on the use of vaginal dilators to increase diameter of the neovagina post operatively. 

Complications of this procedure include typical surgical complications, such as bleeding or infection, as well as complete or partial necrosis of the vagina, clitoris, or labia if the blood supply is interrupted. This anatomy is also susceptible to bladder or bowel fistulas into the vagina, urethral stenosis, as well as a lifetime increased risk of UTI, as the urethra is now considerably shorter similar to cisgendered women.

Breast Augmentation
Many trans women develop breast tissue if they are taking estrogen and testosterone blockers, and many are satisfied with the appearance of their chest after 12-18 months.11 However, some women also choose to get breast implants as well to increase their breast size. This carries the risks of any other breast augmentation surgery, such as infection, bleeding, or rupture. In addition, trans women that have had breast implants are less likely to be able to breastfeed, should they desire to do so.

Facial Feminization
Many trans women undergo some type of plastic surgery to create a more feminine facial appearance. This can include alterations to the jaw, chin, cheeks, forehead, nose, and eyelids, as well as hair implants or adjusting the hairline.11 For some, these procedures decrease dysphoria and allow trans women to be safely present in settings where their trans status might otherwise put them in harm’s way.11

Tracheal Shave
Some trans women have this procedure done to decrease the size of the thyroid cartilage or “adams apple.” A small incision is made under the chin to reduce scarring, and the cartilage is reduced and resized.11

Silicone Free Injection
Many surgical procedures for trans people are very expensive, and many people in the trans community have limited access to insurance or health care. In contrast, silicone free injections are up to 90% cheaper than traditional surgery, so they are an appealing option for face, hip, and chest contouring for many people.11 However, this is not an FDA approved use of silicone, and it carries a high risk of complications. In addition, many people that get free injections do so from non-physician providers, including on the black market, where the silicone may be injected in extremely high doses or contaminated with other substances.11 These  injections can cause infection, necrosis, migration of silicone, allergic reaction, silicone pulmonary embolism, and other organ damage.11 These complications can evolve over time, or happen immediately after injection.

Masculinizing Procedures

“Mansculpture”
Some trans men feel a sense of dysphoria about their hips, thighs, stomach, or other areas and wish to get liposuction to create a more masculine body contour. Complications are similar to any other liposuction treatment, and include bruising, pain, bleeding, and infection.

Hysterectomy
Many trans men opt to get a hysterectomy, typically with a bilateral salpingo-oophorectomy. In previous decades, this was often a criteria for starting on hormones, as there was some thought that testosterone might increase cancer risk, although this is not supported by current data. Today, some trans men still opt to have the surgery because of a continued sense of caution over possibly increased cancer risk, or dysphoria over having a uterus. Other trans men may wish to keep their uterus and preserve the option of getting pregnant.

Phalloplasty
This refers to the creation of a penis with a free flap or pedicle flap of skin from the arm or thigh, which is then rolled into a tube structure and grafted onto the inguinal area. Typically, the clitoris forms the base of this structure in order to retain erotic sensation.11 A urethral extension is made from a cheek or vaginal mucosa donor site, and often an erectile implant is placed within the phallus. Complications of this include urinary tract stenosis, loss of erotic sensation, necrosis or infection of the phallus, and wound breakdown, which often occurs at the perineal-scrotal junction. There is also a concern for rectal injury.

Scrotoplasty
Here a scrotum is typically created with skin flaps from the labia majora and testicular implants are placed inside. Often small expanders will be placed within the tissue and gradually filled with increasing amounts of saline in order to encourage new skin growth prior to the surgery and permanent implants being placed.11

Metoidioplasty
This procedure allows for the growth of the clitoris, which occurs with long term testosterone injection, to create a small 1-3 inch phallus. After sufficient growth, the clitorus/phallus is freed from ligamentous attachments to the labia and body, with some labial skin further attached to increase girth.11 Often the urethra is lengthened at this time as well to allow for urination through the phallus. This is called a “urethral hookup” and typically uses skin from either the mouth or labia majora.11 Some trans men choose to get a vaginectomy or scrotoplasty with this procedure, but it is not required.11 However, penetration, pap smears, and vaginal exams may be impossible afterwards due to the decreased size of the vaginal opening, if it remains.11

Mastectomy
This is the most common procedure for transmasculine people. It differs from other types of mastectomy in that there is more male chest contouring, and most procedures allow for nipple retention. There are several methods of “top surgery”, depending on the size of the breasts, skin elasticity, and other factors. The most common is “double incision,” where an incision is made above the nipple line, fatty tissue and gland is removed, and then the nipple is replaced above the incision.11 For smaller breasts, there is also the option of “periareolar” incision, where an incision is made around the areola, and fat and gland are extracted from there, after which the nipple is reattached.11 Both of these procedures typically require drain placement, often in the axilla. Complications are similar to other types of mastectomy, such as wound infection, drain blockage, or dehiscence. Some trans men and non-binary people with very little breast tissue may opt for liposuction alone, although they should be warned that if they become pregnant this may make their breast tissue more prominent.11