Transitioning, either emotionally, physically and/or socially has been proven effective in reducing the negative symptoms of gender dysphoria. Transitioning might include social changes including the use of new pronouns in addition to dressing in clothes aligning with one’s gender identity. Where social transitioning is an effective strategy for some, others turn to physical changes which might include hormone therapy and/or surgery. While hormone therapy  is helpful in making needed physical changes, there are certain physical traits that can’t be changed without surgery.

Surgeries for Trans Women

Many of the procedures listed below are costly. As gender affirming surgeries are proven to aid the symptoms of gender dysphoria, more and more health insurers are providing coverage for such surgeries. Before deciding to proceed with surgery, it is beneficial to investigate costs in addition to any potential medical insurance coverage.

Some trans women consider surgeries in countries abroad when insurance coverage is lacking, or when the overall procedure cost is too high. This is because many surgeries are less expensive abroad with no loss in the quality of surgery and final results.

Most surgeries will have the following expected costs:

  • Consultation fees
  • A surgeon’s fee
  • The hospital or surgery centre fee
  • The cost of anesthetic
  • Prescribed medications
  • Medical tests

Feminization Surgeries

Male bodied individuals who are correcting their gender incongruity undergo procedures which reduce masculine features and enhance those which are female. And, it should be noted that while trans women are commonly referenced, some individuals undergo procedures to become more neutral in their gender. Individuals who undergo surgery for a neutral state are referenced as MTN (male to neutrosis) or FTN (female to neutrosis). As such, additional surgeries (not covered here) may be performed to create a neutral appearance rather one that skews either toward a more masculine and feminine look.

Transfeminine Top Surgery

While hormone therapy causes breast growth, the results are not always what the trans woman desires. As such, many consider breast augmentation surgery. Breast augmentation is meant to enlarge the breasts and to refine their shape.

Prior to getting the augmentation, patients need to determine cup size, which, in terms of implants, is referred to by volume. Implant (often saline or gel) volume is usually done in cubic centimeters or cc’s. Common ranges include 120cc to 850cc. Surgeons, through consultation, work with patients to determine the appropriate volume for the desired look.

Next, the type of solution contained in the implant is also an important consideration. Saline, essentially salt water, offers patients the potential for a smaller incision line and a lower cost. Silicone implants, consist of a gel-like substance, are perhaps more popular, they offer a natural appearance, but are generally more expensive than saline.

Patients must also consider implant shape; the most common being round and teardrop, but each person has their own preferences. While teardrop implants offer a more natural look and is thought to be great for those with limited breast tissue, rotation of the implant is a small potential risk. Round implants are thought to be most popular perhaps because the risk of rotation is less when compared with a tear drop implant.

Finally, depending on the choice of implant, the existing tissue, and other factors, the incision location (or pattern) is chosen. Incisions can be made along the areola, below the chest muscle or through the armpit.

There are, of course, inherent risks with all surgeries. Risks specifically related to augmentation include: loss of nipple sensation, implant leak, capsular contracture, anaplastic large cell lymphoma and risks from anesthesia.

Transfeminine Bottom Surgery

Transfeminine bottom surgeries rework the existing male genitalia into female genitalia. The most common bottom surgery includes both an orchiectomy and penile inversion vaginoplasty. While some individuals only opt to have an orchiectomy, others have both procedures. An orchiectomy, includes the removal of the testicles, where penile inversion vaginoplasty reworks the remaining male genitalia into female anatomy including a vagina, clitoris, and labia majora.

Orchiectomy

The removal of the testes, or orchiectomy, is a relatively simple procedure that allows many patients to be released home the day of surgery. Healing varies, but often happens in a matter of days or one week.

The procedure includes an incision made in the middle of the scrotum, the removal of the testes, and closing of the incision with sutures which is then covered with surgical dressing.

Vaginoplasty

PlasticSurgery.org shares a brief and simple overview of penile inversion vaginoplasty.

The procedure begins with the skin from the penis shaft being removed from the penile tissue beneath. The removed penile skin will subsequently be used to create the vagina. Next, a small portion of the penile tissue (which is dense with blood vessels and nerves) is removed and preserved as it will serve to create the clitoris. Any penile tissue not used is removed entirely.

The new vagina is made using the skin of the penis. It is in a newly created space between the rectum and bladder. A device is inserted to maintain the opening and create the shape. Next, the preserved penile tissue with blood vessels and nerves is used to create the clitoris. The urethra is also set in place, with the lips of the vagina (or labia majora) being created from scrotal skin (also known as labiaplasty).

The risks of transfeminine bottom surgery are significant. Some risks include infection, poor healing of incisions, hematoma (pooling of blood in an area which it doesn’t belong), nerve injury, stenosis (narrowing) of the vagina, inadequate depth of the vagina, damage to the urinary tract, painful intercourse and risks common to anesthesia.

Vaginoplasty Post Surgery

As anyone can imagine, surgery involving the genitalia is significant. As such, recovery from vagioplasty is much more involved than that of an orchiectomy. The post-opt requirements are crucial to healthy healing. Some of the recommended post-opt requirements are listed below:

A urinary catheter is in place for roughly five days following surgery. The catheter opens the urethra which may be closed from swelling. After approximately five days, some individuals still can’t urinate in which case a second catheter would be inserted

A prosthesis will be inserted into the vagina to keep the vaginal canal open, and to keep the skin grafts in place

Douching, using water or another solution, is often necessary to flush out vaginal discharge

Vaginal dilators are necessary to maintain the width and depth of the new vagina; post-surgery dilation is necessary several times per day, gradually decreasing to once per week

Sitz baths, intended to keep the surgical site clean, are necessary for two months following surgery

Maxi pads are worn for at least one month post-opt to manage bleeding and discharge

Swelling, numbness, bruising, and itchiness are all expected following surgery. Also common is the sensation of small electric shocks as the nerve endings begin to heal and reconnect. Antibiotics and painkillers are often prescribed to ward off infection and manage pain.

Risks

The following are some of the many significant risks associated with vaginoplasty:

Blood pooling (hematoma)

Numbness (loss of sensation)

Scarring

Changes of sensation in the skin of the legs with the most severe (but rare) cases causing immobility in the legs

Urological Fistulas – meaning urine flows somewhere other than the urethra. Fistulas are corrected with further surgery.

Narrowing of the urethra making urination difficult

As vaginoplasty is a highly involved surgery, a surgeon often considers only suitable candidates.  Criteria for determining a candidate might include:

The age of consent

A person who’s been living as their desired sex

A person having persistent gender dysphoria

A person under the care of a mental health professional who is willing and able to provide a letter of surgery recommendation

The decision to proceed with vaginoplasty is highly individualized. It is best to liaise with mental and medical health practitioners to help make informed choices. It is crucial to carefully weigh the potential changes against the very plausible risks.

Facial Feminization Surgery

Facial feminization surgery (or FFS) works to reduce or eliminate masculine features, enhancing or creating feminine features instead. FFS includes both bone and soft tissue procedures. As many procedures are possible, consultation with a surgeon will help determine the procedures necessary for one’s desired appearance. And, in the case where multiple procedures are performed, some people choose to merge them into one surgery appointment.

Other Feminization Procedures

 

Bichat Fat Pad Resection

As the fat located beneath the cheekbones diminishes with age, adding fat through a small internal incision helps to ‘refine the face and to provide a more feminine appearance’. For those looking for a more permanent enhancement, cheekbone implants, like Medpor, can be inserted.

Brow Bone Reduction or Frontal Bossing Plasty

The forehead of males and females are distinct from one another. Males have ridges near their eyebrows (above the eyes), and a notable flat spot between their eyebrows known as front bossing. Males, when considering their profile, have a forehead that slants, where a female forehead is more vertical in nature. Brow bone reduction works by shaving the bone of the forehead, removing the ridges, and recontouring the bone. In many cases, the forehead is reshaped with shaving and filling; the best result us achieved by the removal of the frontal sinus bone, remodeling it, and setting it back in place. Brow bone reduction is frequently combined with the lowering of the hairline.

Hairline Lowering

As females have a lower hairline than males, hairline lowering does as the name implies; the procedure works to lower the hairline. In doing so, the forehead also becomes less dominant in its’ appearance. Using an incision along the hairline, the ‘hair bearing’ scalp is moved forward.  Some hair follicles may be transplanted too, to aid in feminizing the hairline.

Tracheal Shave / Chondrolaryngoplasty

Taking only 30 to 45 min, a tracheal shave essentially reduces the size of the Adam’s Apple. As the Adam’s Apple is distinctly masculine, some individuals prefer to shrink its appearance.

Mandibular Angle Resection

Also known as chin reduction or augmentation. Female chins tend to be soft and small when compared with male jaws which are vertically longer, wider, and more chiseled in appearance. Lessening the squareness of the male jaw is achieved through bone shaving done through a small incision through the mouth. Because jaw muscles further contribute to the shape of the jaw, Botox, which relaxes the muscles, can also be used to reduce squareness.

Blepharoplasty

Blepharoplasty is surgery for the eyelids. While no large differences are seen between men and women, blepharoplasty is meant to rejuvenate tired looking eyes.

Lip Augmentation

As female lips are generally fuller when compared to men, lip augmentation includes plumping the lips using fillers like Juvederm or Restylane.

Nose Reshaping & Rhinoplasty

Feminizing the nose might include changing the angle of the nose, removing the dorsal bump (where applicable), and changing the overall shape. As female noses tend to point slightly upwards when compared to men whose nose point forward or down.  Additionally, male noses tend to be bulkier with wider nostrils.

Final Notes

Deciding to undergo any form of surgery should only be done with plenty of thought and extensive consultation with mental and medical health professionals. Having a sense of insurance coverage might further provide clarity on potential surgeries as cost is a crucial factor for most. The surgeries and risks listed above are likely not exhaustive but are meant to provide an overview of the available MTF gender affirming surgeries.

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