Trans Men - Surgery & Followup Care

BREAST / CHEST "TOP" SURGERY

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Mastectomy:

Surgical Technique2

Double Incision Top Surgery

• Best for large-chested patients

• Incisions around lower border of pectoralis muscle & around nipple

Keyhole Top Surgery "Limited Incision"

• Best for small-chested patients (no larger than "A" cup)

• Does not reposition nipple/areola, incision around nipple

Perioperative Care

• 1 week: sleep on back

• 3-4 weeks: elastic compression wrap, once daily removal for showering

Outcomes: Study with 88 transmen

• 83%of those who responded were "very satisfied"

• 100% would recommend this procedure to other transgender individuals4

GENITAL "BOTTOM" SURGERY

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REMOVAL OF FEMALE ORGANS

Hysterectomy & Oopherectomy

• Counseling and perioperative planning same as for cisgender women3

• Technique may affect future genital reconstruction outcome7

Vaginectomy

• Not performed on patients with a uterus

• Preservation of the vagina until the time of genital reconstruction may be beneficial

• Sometimes performed in conjunction with scrotoplasty7

• Lower complication rates when performed at same time as phalloplasty and urethral lengthening compared with vaginal preservation9

• Risks include blood loss, bladder damage, and damage to the rectum

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MALE GENITAL RECONSTRUCTION

Metoidioplasty3,10

Phallus average length 1-3 inches, girth close to thumb size3,10

Procedure

• Release of clitoral attachments, elongation to form the glans, and lengthening of native urethra with vaginal and labial flap

Pros

• Typically a single, simpler procedure than phalloplasty, 3-4 hours long

• No grafting required, uses local tissue and less invasive than phalloplasty

• Phallus sensate and capable of erection, standing urination possible

• Urethral construction optional

Cons

• Penetrative intercourse not guaranteed

• Phallus not large enough for penile implants

Phalloplasty

Phallus typically 5-6 inches19

Pros3,10

• Phallus long enough for penile implants for penetrative intercourse

• May elect to avoid urethroplasty if standing urination not a goal

• May elect to avoid vaginectomy

• Phallus long enough for penile implants

• Vaginectomy or vaginal closure, urethroplasty, scrotoplasty, and testicular prosthesis placement

Cons3,10

• Complex and multi-part surgery

• More complications compared to metoidioplasty

• Requires tissue grafts from remote sites

Types of Phalloplasty7,10,14,16

Radial Forearm Free Flap (RFFF)

• Penis is created with a 3 cm strip of skin from forearm that is rolled into a tube

• Forearm then covered with a skin graft

• Dimension of 15 by 17 cm for adequate size for tube-in-tube construction15

Musculocutaneous Latissimus Dorsi (MLD)

• Con: subsequent urethroplasty necessary to lengthen urethra17

Anterior Lateral Thigh (ALT)

• Common alternative to RFFF

• Pros: avoids the forearm scar or if forearm size is too small

• Con: Higher rate of urethral complications versus RFFF18

Outcomes: Metoidioplasty v. RFFF Phalloplasty

Satisfaction with Aesthetic Outcome11

• Metoidioplasty 87%

• Phalloplasty 70%

Erogenous Sensation11

• Metoidioplasty 100%

• Phalloplasty 69%

Successful Penetrative ntercourse11

• Metoidioplasty 51%

• Phalloplasty 43%

Phallus length

• Metoidioplasty: average length 1 - 3 inch phallus and girth close to thumb size3,10

• Phalloplasty: typically 5-6 inches19

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OTHER GENITAL RECONSTRUCTION SURGERIES

Urethroplasty

Penile Urethroplasty

• Creates urinary tract within neophallus20

Perineal Urethroplasty

Urethra is lengthened for standing micturition9

Glansplasty

• Creation of glans shape22

Scrotoplasty

• Labia majora is used to create scrotum15

Clitoroplasty3

Buried Clitoris:

• Typically set under the base of the neophallus

Unburied:

• Preservation of he skin on the glans clitoris

Prostheses: Testicular & Penile

Separate surgery from the phalloplasty and scrotoplasty

Malleable prostheses:

• Rigid rods placed within the neophallus

Inflatable prostheses:

• Fluid pump device in scrotum transfers fluid to hollow cylinder within neophallus

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References

1. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. 7th version. World Professional Association for Transgender Health; 2012. https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care_V7%20Full%20Book_English.pdf

2. Crane Center for Transgender Surgery. “FTM Top Surgery.” Crane Center for Transgender Surgery, Crane Center for Transgender Surgery, https://cranects.com/ftm-top-surgery

3. Ferrando, C, Zhao, LC, Nikolavsky, D. Transgender surgery: Female to male. In:UpToDate, Elmore, J (Ed), UpToDate, Waltham, MA.

4. Frederick MJ, Berhanu AE, Bartlett R. Chest surgery in female to male transgender individuals. Ann Plast Surg. 2017;78(3):249-253. doi: 10.1097/SAP.0000000000000882 [doi].

5. Kaariainen M, Salonen K, Helminen M, Karhunen-Enckell U. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg. 2017;106(1):74-79. doi: 10.1177/1457496916645964 [doi].

6. Cregten-Escobar P, Bouman MB, Buncamper ME, Mullender MG. Subcutaneous mastectomy in female-to-male transsexuals: A retrospective cohort-analysis of 202 patients. J Sex Med. 2012;9(12):3148-3153. doi: 10.1111/j.1743-6109.2012.02939.x [doi].

7. Gorton R, Women L, Buth J. Medical therapy and health maintenance for transgender men: A guide for health care providers; 2005. https://www.researchgate.net/publication/239573753_Medical_Therapy_and_Health_Maintenance_for_Transgender_Men_A_Guide_For_Health_Care_Providers

8. ACOG committee opinion no. 444: Choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114(5):1156-1158. doi: 10.1097/AOG.0b013e3181c33c72 [doi].

9. Hage JJ, De Graaf FH. Addressing the ideal requirements by free flap phalloplasty: Some reflections on refinements of technique. Microsurgery. 1993;14(9):592-598. doi: 10.1002/micr.1920140910 [doi].

10. Crane, C. “Phalloplasty and metoidioplasty - overview and postoperative considerations.” Phalloplasty and metoidioplasty - overview and postoperative considerations | Transgender Care, University of California, San Francisco, 17 June 2016, https://transcare.ucsf.edu/guidelines/phalloplasty

11. Frey JD, Poudrier G, Chiodo MV, Hazen A. A systematic review of metoidioplasty and radial forearm flap phalloplasty in female-to-male transgender genital reconstruction: Is the "ideal" neophallus an achievable goal? Plast Reconstr Surg Glob Open. 2016;4(12):e1131. doi: 10.1097/GOX.0000000000001131[doi].

12. Cohanzad S. Extensive metoidioplasty as a technique capable of creating a compatible analogue to a natural penis in female transsexuals. Aesthetic Plast Surg. 2016;40(1):130-138. doi: 10.1007/s00266-015-0607-4 [doi].

13. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The surgical techniques and outcomes of secondary phalloplasty after metoidioplasty in transgender men: An international, multi-center case series. J Sex Med. 2019;16(11):1849-1859. doi: S1743-6095(19)31358-X [pii].

14. Crane Center for Transgender Surgery. “Phalloplasty.” Crane Center for Transgender Surgery, Crane Center for Transgender Surgery, https://cranects.com/ftm-phalloplasty/

15. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: Is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124(2):510-518. doi: 10.1097/PRS.0b013e3181aeeb06 [doi].

16. Kim SK, Lee KC, Kwon YS, Cha BH. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62(3):309-317. doi: 10.1016/j.bjps.2007.11.011 [doi].

17. Djordjevic ML, Bencic M, Kojovic V, et al. Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery. World J Urol. 2019;37(4):631-637. doi: 10.1007/s00345-019-02641-w [doi].

18. Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery. J Urol. 2018;199(1):206-214. doi: S0022-5347(17)77248-5 [pii].

19. Ercolano, Alexa. “FAQ: Phalloplasty: The Johns Hopkins Center for Transgender Health.” FAQ: Phalloplasty | The Johns Hopkins Center for Transgender Health, 17 Sept. 2019, www.hopkinsmedicine.org/center-transgender-health/services-appointments/faq/phalloplasty

20. Al-Ali M, Al-Hajaj R. Johanson's staged urethroplasty revisited in the salvage treatment of 68 complex urethral stricture patients: Presentation of total urethroplasty. Eur Urol. 2001;39(3):268-271. doi: 52451 [pii].

21. Monstrey SJ, Ceulemans P,Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25(3):229-244. doi: 10.1055/s-0031-1281493 [doi].

22. Sommeling CE, De Wolf EJ, Salim A, et al. A new technique for coronaplasty in penile reconstruction. J Sex Med. 2018;15(6):920-923. doi: S1743-6095(18)30078-X [pii].

23. Carson CC,3rd, Mulcahy JJ, Harsch MR. Long-term infection outcomes after original antibiotic impregnated inflatable penile prosthesis implants: Up to 7.7 years of followup. J Urol. 2011;185(2):614-618. doi: 10.1016/j.juro.2010.09.094 [doi]. Accessed February 1, 2020.

24. Neuville P, Morel-Journel N, Maucourt-Boulch D, Ruffion A, Paparel P, Terrier JE. Surgical outcomes of erectile implants after phalloplasty: Retrospective analysis of 95 procedures. J Sex Med. 2016;13(11):1758-1764. doi: S1743-6095(16)30422-2 [pii].

25. Hoebeke PB, Decaestecker K, Beysens M, Opdenakker Y, Lumen N, Monstrey SM. Erectile implants in female-to-male transsexuals: Our experience in 129 patients. Eur Urol. 2010;57(2):334-340. doi: 10.1016/j.eururo.2009.03.013 [doi]