Gender dysphoria describes an internal conflict caused by a discrepancy between a person’s gender identity and his or her gender assigned at birth.1 Although not all transgender and gender-nonconforming individuals experience gender dysphoria, those who do may transition to their identified gender through a variety of medical and surgical approaches. Recent years have seen significant advances in the care of transgender individuals, with the formation of numerous multidisciplinary centers for integrated care in the United States and around the world. These integrated centers provide thorough trans-competent care encompassing social, psychological, medical, and surgical approaches to alleviate gender dysphoria.2
The estimated prevalence of gender dysphoria varies but may represent up to 1.3 percent of the world’s population.3–5 Recent improvements in insurance coverage for this cohort were gained by means of a 2014 U.S. Department of Health and Human Services determination that its 1981 Medicare exclusion of transgender surgical treatments contradicted current standards of care.6 Individual states followed with additional bans on transgender exclusions, thereby halting a policy of categorical denial of coverage by third-party payers. The resulting broadened coverage made previously cost-prohibitive operations newly accessible, generating increased patient demand for gender-affirming care, thus exposing the inadequately mismatched supply of qualified surgical practitioners.
With increased demand for health professionals, the World Professional Association for Transgender Health has developed guidelines to establish standards of care for transgender and gender-nonconforming individuals. These guidelines include criteria for medical, endocrine, and psychological care, and for various gender-affirming surgical procedures, with an overarching goal of establishing harmony between their body and self-identity. Furthermore, the World Professional Association for Transgender Health has initiated a global education initiative, developing expert practitioners globally to better care for transgender and gender-nonconforming individuals, with an emphasis on multidisciplinary collaboration among primary care providers, endocrinologists, psychiatrists/psychologists, social workers, and surgeons of various specialties. In this masculinization-focused CME article, we review the key terminology and current standards of care, and provide an overview of masculinizing gender-affirming surgical procedures.
The mental health professional is critical in the evaluation and treatment of individuals with gender dysphoria. Gender-affirmation surgery may be warranted if associated mental health issues are absent or well-controlled and both the health provider and patient agree that surgery would help alleviate gender dysphoria. The World Professional Association for Transgender Health Standards of Care guidelines recommend formal referral letters from mental health professionals before surgical treatment—one letter for chest surgery, and two for genital surgery. However, referral letters are not required for facial surgery.7
Hormone therapy can have a profound effect on secondary sexual characteristics. Typically, a minimum of 1 year of hormone treatment is recommended before genital surgery, but it is not mandatory for masculinizing chest surgery.7,8
Hormone Therapy for Trans Men
Testosterone is most commonly administered using intramuscular or transdermal formulations and induces dramatic increases in facial and body hair, muscle mass, male pattern baldness, clitoral enlargement, and deepening of the voice.9 Potential adverse effects of testosterone treatment include polycythemia vera, an abnormal lipid profile, and osteoporosis. Therefore, before initiating testosterone therapy, a baseline hematocrit and lipid profile should be obtained in addition to a baseline bone mineral density if the patient is at significant risk for osteoporosis.10,11
Although gender is not a binary phenomenon, gender-affirming procedures are typically classified as either feminizing (trans feminine) or masculinizing (trans masculine) (Table 1). This CME article focuses on masculinizing procedures.
Gender-affirming surgical techniques for patients on the transmasculine spectrum include chest reconstruction, hysterectomy, salpingo-oophorectomy, metoidioplasty, and phalloplasty.
Because of the masculinizing effects of testosterone (e.g., facial hair, male-pattern hairline, hair loss), facial masculinization procedures are seldom performed. For this reason, facial masculinization surgery techniques for transgender patients were not established until years after the development of facial feminization techniques. These operations were once performed only on cis-gender men who wanted more masculine features. In 2015, however, Deschamps-Braly, et al. performed the first masculinization procedure on a trans male. His research group published their report on this new masculinization surgery in 2017.12 In their study in Plastic and Reconstructive Surgery, they also described a new technique for thyroid masculinization using autologous rib cartilage.
Chest-Wall Contouring Surgery
Also known as “top surgery,” contouring of the chest in trans men involves constructing an aesthetically pleasing male chest by means of removal of parenchymal and fatty tissue, size reduction, relocation of the nipple-areola complex, and skin excision if indicated.13 Monstrey et al. have provided an algorithm useful for approaching chest reconstruction in the context of several preoperative parameters, including breast volume, degree of excess skin, nipple-areola complex size and position, and skin elasticity.14 Their review of five different techniques provides an excellent framework for individual patient evaluation.
It should be noted that although there is some resemblance to techniques involved in gynecomastia treatment, several significant differences exist. Trans men will typically have greater volume, skin excess, and ptosis compared to a patient with gynecomastia. The distribution of breast tissue is more likely to extend to the tail of Spence. Furthermore, “breast binding,” in which patients regularly wrap their chest to reduce the visibility of underlying volume, often leads to increased skin elasticity. It is therefore more likely that patients will require reduction of the skin envelope by direct excision, necessitating planning for placement of final scars in accordance with the underlying pectoralis major contour and other aesthetic concerns.15,16
Chest surgery in trans men also differs from mastectomy for cancer prophylaxis or treatment. Specifically, relatively thick adipocutaneous flaps aid to mitigate contour deformities and necessitate a dissection plane different from oncologic mastectomy. Notably, breast cancer after bilateral modified subcutaneous mastectomy in trans men has been reported, likely associated with this deliberate incomplete excision of parenchymal tissue.17 Although it is generally accepted that parenchymal removal with top surgery offers some element of risk reduction, mammography may not be technically feasible postoperatively. Accordingly, trans men should be counseled to continue with appropriate breast cancer screening that accounts for their personal and familial risk factors. Below is a review of the five techniques described by Monstrey et al., with some modifications based on the authors’ experience.
- The infra-areolar approach applies to patients with small breasts and acceptable skin elasticity and whose skin is expected to contract postoperatively, and uses a semicircular infra-areolar incision similar to that described by Webster in 1946 for gynecomastia (Fig. 1).18 It is critical that tissue be preserved just deep to the nipple-areola complex to avoid depression and nipple-areola deformation. Given the difficulty accessing peripheral parenchymal tissue through a small incision, adjunct suction lipectomy is useful. No skin is excised, and despite postoperative compression, there is the potential for residual skin excess and wrinkling, which is quite dissatisfying to patients, making patient selection the key element to this approach.
- For patients with large nipples requiring reduction, the aforementioned technique can be modified to a transareolar approach, similar to what was reported by Pitanguy in 1966.19 Nipple projection is reduced by direct excision, along with direct parenchymal resection and/or suction lipectomy. No skin is excised.
- Patients with excess skin and/or a large nipple-areola complex are candidates for a circumareolar incision for areolar and surrounding skin reduction, followed by parenchymal reduction through an inferior full-thickness access incision (Fig. 2). This resembles the description by Davidson for gynecomastia, and circumareolar mastopexy in which a small amount of skin and/or areola is excised, and a Benelli-type suture may be used.20 As reported by Monstrey et al., this is applied to a relatively small breast that is not expected to retract postoperatively because of poor skin elasticity. With an eccentric circumareolar pattern, the nipple-areola complex can be repositioned by several centimeters, but not sufficiently to address severe ptosis.
- If significant dog-ears are anticipated with a circumareolar approach, this modification adds two triangular skin excisions on either side (Fig. 3). The final location of the scars centrally on the chest and thus away from the pectoralis major border may not be acceptable to patients.
- Patients with C-cup or larger breasts, or with significant ptosis, are candidates for the “double-incision” technique. This involves a long inferior/midpole skin crescent excision oriented to yield a scar essentially emulating the natural contour of the pectorals major muscle (Fig. 4). Although the double-incision approach yields the most visible scarring, it provides maximum control over skin envelope and nipple-areola positioning. The ability to camouflage the long inferior scar along the pectoralis major border is critical to patients’ acceptance of this technique (Fig. 5).
The nipple-areola complex is typically harvested as a full-thickness graft, reduced and shaped to a more masculine appearance, and inset over deepithelialized lateral skin at the fourth or fifth intercostal space. Monstrey et al. describe placing the horizontal incision 1 to 2 cm above the inframammary fold, and then moving superolaterally just below the pectoralis major border. The native inframammary fold attachments are typically effaced with this approach.14,15,17
In a minority of patients, a small central parenchymal pedicle can be preserved for the nipple-areola complex in lieu of a graft, with a goal of reducing the risk of graft loss and potentially preserving sensation. However, this carries a risk of excess fullness and volume, resulting in persistent dysphoria.
In patients with significant lateral chest and subaxillary fullness, suction lipectomy followed by compression is appropriate. For more severe cases, and if there is significant skin excess, the lateral portion of the horizontal scar can be extended to include a lentiform or similar subaxillary pattern. Although this may relocate the lateral scar away from the pectorals major border, this adjunct resection is useful for addressing tissue that is otherwise unsatisfactory for patients because of a relatively greater projection after resection of more anterior tissue. In the higher body mass index patient, the high rate of revision for the subaxillary area may best be addressed by setting patient expectations with an anticipated two-stage approach, consisting of a double-incision technique followed by a planned revision including lateral reduction.
Masculinizing Genital Surgery: Metoidioplasty
Genital surgery for transgender men and transmasculine spectrum patients requires individualization. Surgery may range from metoidioplasty to phalloplasty.
Metoidioplasty refers to lengthening of the hormonally hypertrophied clitoris, usually performed in a single procedure, and can be performed in conjunction with vaginectomy (removal of the vaginal canal), scrotoplasty (creation of a scrotum from labia skin), and urethral lengthening (creation of a neourethra from skin or mucosal tissue through the phallus to achieve the ability to urinate while standing). Hysterectomy may also be completed at the same time and is necessary if vaginectomy is elected.
Urethral lengthening (creation of the pars fixa), if desired, is accomplished by means of tubularization of hairless skin from the labia minora with or without mucosal tissue, such as an anterior vaginal flap. This lengthened urethra can be advanced to the transposed clitoris (in a metoidioplasty) or anastomosed to the urethra created within the phalloplasty (pars pendulans).
Masculinizing Genital Surgery: Phalloplasty
Phalloplasty broadly involves the creation of a neophallus using a flap from a donor site and optional placement of an erectile device. Surgery can be performed in a single-stage fashion,21 or can be staged in two to three operations, spaced several months apart. The length of hospitalization for these stages can range from 1 day to 1 week or more. Like metoidioplasty, phalloplasty can include vaginectomy, scrotoplasty (Figs. 6 and 7), and urethral lengthening (Figs. 8 and 9). Typically, a team of plastic, gynecologic, and/or urologic surgeons will perform these procedures.
Radial Forearm Phalloplasty
The radial forearm flap is the most commonly used flap for phalloplasty. Advantages include a reliable and predictable blood supply, supple tissue allowing consistent formation of a double tube, adequate innervation density, and the ability to form an aesthetic phallus in one stage (including glansplasty). The main disadvantage is the conspicuous donor site and possible need for hand therapy to regain preoperative range of motion and strength.
The surgical technique is demonstrated in Videos 1 through 6. (See Video, Supplemental Digital Content 1, which displays radial forearm phalloplasty flap markings and key design elements, http://links.lww.com/PRS/D382. See Video, Supplemental Digital Content 2, which displays radial forearm phalloplasty flap double-tube formation and glansplasty, http://links.lww.com/PRS/D383. See Video, Supplemental Digital Content 3, which displays radial forearm phalloplasty neurotization by means of lateral antebrachial cutaneous nerve coaptation to the clitoral nerve and ilioinguinal nerve, http://links.lww.com/PRS/D384. See Video, Supplemental Digital Content 4, which displays preservation of sensory nerves during radial forearm phalloplasty flap harvest, http://links.lww.com/PRS/D385. See Video, Supplemental Digital Content 5, which displays radial forearm phalloplasty flap end-to-side arterial anastomosis to the superficial femoral artery, http://links.lww.com/PRS/D386. See Video, Supplemental Digital Content 6, which displays radial forearm phalloplasty venous anastomoses to the saphenous vein and a tributary, http://links.lww.com/PRS/D387. These videos can be found in the “Related Videos” section of the full-text article at PRSJournal.com or at the links given above.)
A tube-within-a-tube design is used with the urethral segment placed either eccentrically22 (Fig. 10 and Video, Supplemental Digital Content 1, http://links.lww.com/PRS/D382) or centrally (Fig. 11).23 Once the neophallus is harvested (Fig. 12), it is shaped before division of the pedicle (Fig. 13 and Video, Supplemental Digital Content 2, http://links.lww.com/PRS/D383). The lateral antebrachial cutaneous nerve is typically used for innervation when the urethra is designed eccentrically (Figs. 14 and 15 and Video, Supplemental Digital Content 3, http://links.lww.com/PRS/D384); the medial antebrachial cutaneous nerve can be used in addition to the lateral antebrachial cutaneous nerve for flaps with a centrally placed urethra. Recipient nerves can include the clitoral nerve (Fig. 16), ilioinguinal nerve, or a combination (Fig. 17 and Video, Supplemental Digital Content 4, http://links.lww.com/PRS/D385). Recipient vessels typically include either the femoral/saphenous system or the deep inferior epigastric vessels (Videos, Supplemental Digital Content 4 and 5, http://links.lww.com/PRS/D385 and http://links.lww.com/PRS/D386, respectively). The neophallus is inset in the midline, and a urinary catheter is placed in the neourethra as a stent for 1 to 2 weeks (Figs. 18 and 19).
The donor site is skin grafted using a sheet graft and, if desired, may be concealed by a tattoo once the graft has fully matured (Figs. 20 and 21). A suprapubic catheter is placed for urinary diversion and is typically removed after a voiding trial 4 to 6 weeks postoperatively.
Anterolateral Thigh Phalloplasty
The anterolateral thigh phalloplasty may be used in patients whose thigh tissues are amenable to formation of a single or a double tube (Fig. 22). However, the typical bulk of the thigh skin and subcutaneous fat precludes the formation of a double tube. Aggressive immediate defatting of the flap should not be performed in sensate flaps, as the lateral femoral cutaneous nerve lies on the deep aspect before arborizing and innervating the overlying skin. Patients who do not desire urethral lengthening may choose to undergo a single-tube anterolateral thigh flap phalloplasty. The glansplasty is typically delayed when performing an anterolateral thigh flap phalloplasty (Figs. 23 and 24). Because the blood supply is based on one or more perforators, incising the dermis distally may jeopardize the vascularity of the phallus tip at the same stage as flap harvest.
Other phalloplasty flaps have been described, including pedicled flaps such as abdominal tube or groin flaps, free flaps such as the latissimus dorsi myocutaneous flap,24 free fibula osteocutaneous flap, or a combination of free flaps and pedicled flaps.
Complications of Phalloplasty
As phalloplasty encompasses a series of complex operations, it is generally associated with higher complication rates than other gender-affirming procedures. These complications include flap loss (partial or complete), urinary fistulas and/or strictures, inadequate nerve regeneration, delayed wound-healing, donor-site issues, hematomas, seromas, poor aesthetic outcomes, rectal or urethral injury, and implant-related complications, to name a few. The importance of proper counseling and informed consent therefore cannot be overstressed.
Free flap survival rates have increased to 98 percent in many large series, whereas pedicled flaps rarely show total flap loss. Nevertheless, flap survival is of paramount importance, as even partial loss can lead to exposure of implant, urethral fistulae, infection, and thrombosis of the pedicle, leading to total flap loss. The radial forearm has the highest reported rates of survival among the most commonly performed free flaps.24,25 Total and partial flap failure rates are more commonly seen in osteocutaneous free flaps compared with other flaps.26–30
Urinary fistulas and strictures can occur at any point along the lengthened urethra. Suprapubic abdominal flaps have a high fistula rate of 55 percent.31 Radial forearm free flap phalloplasty has reported fistula rates ranging from 22 to 68 percent.26,32 Fistulas appear to be more common with more proximal urethral anastomoses.32 Reduced fistula rates have been reported when local flaps are used for urethroplasty in addition to the radial forearm free flap.33
Phalloplasty with a suprapubic abdominal flap has the highest urethral stricture rate of 64 percent.31 Radial forearm free flap stricture rates vary from 17 to 31 percent.32,34 Similar to the urethral fistula rates, the urethral stricture rates are much lower in cases of radial forearm free flap urethroplasty only, or extended pedicled groin flap phalloplasty (2.56 percent29 and 4.15 percent,30 respectively). Stricture locations include the meatus, phallic urethra, urethral anastomosis (most common), fixed urethra, or multiple sites.
Rigidity in the neophallus can be achieved by using external devices or by insertion of either autologous tissue, or semirigid or inflatable prostheses. Autologous tissues include rib and cartilage grafts, but are complicated by resorption, fracture, extrusion, and a permanently rigid or semirigid state. Implantable prostheses are also associated with high extrusion and infection rates. Up to 30 percent of implants have implant-related complications, mostly in the form of infection or device failure, leading to high implant removal rates.27,34
Recent and ongoing advances in psychological, medical, and surgical treatments have led to improved access to care for transgender and gender-nonconforming patients. Gender-affirming surgery presents one facet of a multidisciplinary approach to help such patients receive much-needed care. The surgical plan must be tailored to the individual patient, because not all patients desire or require all procedures. Ultimately, providing quality care to transgender and gender-nonconforming patients requires collaboration between the surgeon, medical provider, and mental health professional in the framework provided by the World Professional Association for Transgender Health guidelines.
All patients have provided written consent for use of their images.
The authors recognize the contributions of Rudolf Buntic, M.D. (The Buncke Clinic), for providing them with his original work in the form of illustrations to enhance this CME article.
1. Brown G. A review of clinical approaches to gender dysphoria. J Clin Psychiatry 1990;51:57–64.
2. Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: A review. JAMA Surg. 2017;152:394–400.
3. Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry 2015;30:807–815.
4. Conron KJ, Scott G, Stowell GS, Landers SJ. Transgender health in Massachusetts: Results from a household probability sample of adults. Am J Public Health 2012;102:118–122.
5. Winter S, Diamond M, Green J, et al. Transgender people: Health at the margins of society. Lancet 2016;388:390–400.
6. Green J. Transsexual surgery may be covered by Medicare. LGBT Health 2014;1:256–258.
7. Coleman E, Bockting W, Botzer M, et al.; World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. Int J Transgenderism 2012;13:165–232.
8. Monstrey S, De Cuypere P, Ettner R. Ettner SR, Monstrey S, Eyler AE. Surgery: General principles. In: Principles of Transgender Medicine and Surgery. 2007:New York: Haworth Press; 89–104.
9. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al.; Endocrine Society. Endocrine treatment of transsexual persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94:3132–3154.
10. Unger CA. Hormone therapy for transgender patients. Transl Androl Urol. 2016;5:877–884.
11. den Heijer M, Bakker A, Gooren L. Long term hormonal treatment for transgender people. BMJ 2017;359:j5027.
12. Deschamps-Braly JC, Sacher CL, Fick J, Ousterhout DK. First female-to-male facial confirmation surgery with description of a new procedure for masculinization of the thyroid cartilage (Adam’s apple). Plast Reconstr Surg. 2017;139:883e–887e.
13. Lindsay WR. Creation of a male chest in female transsexuals. Ann Plast Surg. 1979;3:39–46.
14. Monstrey S, Selvaggi G, Ceulemans P, et al. Chest-wall contouring surgery in female-to-male transsexuals: A new algorithm. Plast Reconstr Surg. 2008;121:849–859.
15. Hage JJ, van Kesteren PJ. Chest-wall contouring in female-to-male transsexuals: Basic considerations and review of the literature. Plast Reconstr Surg. 1995;96:386–391.
16. Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25:229–244.
17. Burcombe RJ, Makris A, Pittam M, Finer N. Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. Breast 2003;12:290–293.
18. Webster JP. Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg. 1946;124:557–575.
19. Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr Surg. 1966;38:414–419.
20. Davidson BA. Concentric circle operation for massive gynecomastia to excise the redundant skin. Plast Reconstr Surg. 1979;63:350–354.
21. Monstrey S, Hoebeke P, Selvaggi G, et al. Penile reconstruction: Is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124:510–518.
22. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74:251–258.
23. Gottlieb LJ, Levine LA. A new design for the radial forearm free-flap phallic construction. Plast Reconstr Surg. 1993;92:276–283; discussion 284.
24. Perovic SV, Djinovic R, Bumbasirevic M, Djordjevic M, Vukovic P. Total phalloplasty using a musculocutaneous latissimus dorsi flap. BJU Int. 2007;100:899–905; discussion 905.
25. Doornaert M, Hoebeke P, Ceulemans P, T’Sjoen G, Heylens G, Monstrey S. Penile reconstruction with the radial forearm flap: An update. Handchir Mikrochir Plast Chir. 2011;43:208–214.
26. Leriche A, Timsit MO, Morel-Journel N, Bouillot A, Dembele D, Ruffion A. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int. 2008;101:1297–1300.
27. Fang RH, Lin JT, Ma S. Phalloplasty for female transsexuals with sensate free forearm flap. Microsurgery 1994;15:349–352.
28. Papadopulos NA, Schaff J, Biemer E. The use of free prelaminated and sensate osteofasciocutaneous fibular flap in phalloplasty. Injury 2008;39(Suppl 3):S62–S67.
29. Dabernig J, Shelley OP, Cuccia G, Schaff J. Urethral reconstruction using the radial forearm free flap: Experience in oncologic cases and gender reassignment. Eur Urol. 2007;52:547–553.
30. Perović S. Phalloplasty in children and adolescents using the extended pedicle island groin flap. J Urol. 1995;154:848–853.
31. Bettocchi C, Ralph DJ, Pryor JP. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 2005;95:120–124.
32. Rashid M, Sarwar SU. Avulsion injuries of the male external genitalia: Classification and reconstruction with the customised radial forearm free flap. Br J Plast Surg. 2005;58:585–592.
33. Kim SK, Moon JB, Heo J, Kwon YS, Lee KC. A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. Ann Plast Surg. 2010;64:759–764.
34. Garaffa G, Raheem AA, Christopher NA, Ralph DJ. Total phallic reconstruction after penile amputation for carcinoma. BJU Int. 2009;104:852–856.