masculinization surgeriesAchieving gender congruence is the objective of trans men who undergo masculinizing surgeries. Seen to alleviate distress in those who experience feelings of misalignment between their assigned sex and the gender by which they identify, masculinizing surgeries work to reduce or eliminate feminine features and create or enhance more masculine features.

Profound consideration is required before beginning with any gender affirming surgery. Sadly, while insurance coverage is increasing for gender affirming surgeries, those without coverage must give plenty of consideration to affordability. It is for this reason, many trans men and women seek alternatives abroad; these options are often less expensive and have the same or better results due to the volume of such surgeries some surgeons perform

Also important to consider are the risks associated with each surgery. As each surgery includes its own risks, it’s important that any person contemplating surgery liaise with medical professionals to fully assess the risks posed by each surgery. While untreated distress is harmful, inherent surgery risks should be weighed against the benefit of proceeding.

While a patient must make informed decisions regarding surgeries, the surgeon and related medical teams might have suitability requirements too. In British Columbia, for example, provincially insured surgeries require completion of a Surgical Readiness Assessment.

These Surgical Readiness Assessments are conducted by a qualified assessor or assessors (depending on the surgery under consideration). It is meant to ensure the patient is emotionally and mentally equip to manage surgery including the execution of an aftercare plan. Also considered is past health history, the post-surgery support network, the patient’s understanding of the procedure, the implications of potential risks and the overall healing time.

Some medical professionals may also require an individual to have lived the gender role that aligns with their preferred gender identity; in some cases, that hormone therapy is well underway at this point.

While provincial or state standards of care may exist, some physicians elect to adhere to the Standards of Care provided by the World Professional Association for Transgender Health.  WPATH brings together diverse professionals to develop standards of health care, backed by science and expert consensus which is specific to the health of the transgender community. Both the guidelines provided by WPATH or other forms of surgical readiness are intended to ‘maximize health, psychological well-being, and self-fulfillment.’

The information included below is based on a compilation of information provided by various online sources. Please remember that none of the information below should be considered medical advice or guidance of any kind; it is intended as informative only.

Surgeries for Trans Men

While all the surgeries to follow may be undergone by a single patient, some patients undergo, one, some, or none of the surgeries listed below. The surgeries are categorized into transmasculine top surgery, transmasculine bottom surgery and facial masculinization surgeries.

Transmasculine Top Surgery

Generally, transmasculine top surgeries include removing the breast tissue, creating a flatter more masculine chest. The size of one’s breasts, including the skin’s elasticity, will determine the method by which the breast tissue is removed. Where some surgeon-based decisions on breast size, one physician uses the inframammary angle to make surgical decisions. Those patients with high inframammary angles require the least invasive techniques while those with small angles require the most invasive surgeries.

Below are three common surgeries to remove breast tissue; each one is specific to the existing breast size and elasticity of the skin.

Keyhole

The keyhole procedure is often used for those with smaller breasts (A cup) and high skin elasticity. A small incision is made beneath the areola where liposuction then works to remove breast tissue. The incision is then closed with the nipple and areola unmoved. Keyhole procedures are advantageous in that nerve sensation is generally maintained. Surgery usually includes anesthesia and takes roughly one and a half to three hours.

Peri-areolar / Concentric Circle

The peri-areolar or concentric circle procedure is good for patients with B to C cup breast size and healthy skin elasticity.  The procedure involves two circular incisions, the first maps the perimeter of the areola, with the second one, which is circular in nature, a few centimeters from the first incision. The result is a ring of breast tissue which is then removed. Breast tissue beneath the incision is removed by scalpel and or liposuction. Occasionally, the nipple requires resizing. Finally, the breast is reconnected using a drawstring technique. Like the keyhole technique, nerve sensation is well maintained as the nipple stalk remains untouched.

The peri-areolar technique is usually conducted under general anesthesia and takes between three and five hours.

Double Incision / Bilateral Mastectomy

The double incision / bilateral mastectomy is the most invasive top surgery. It is best suited for those with larger breasts (C, D and larger cup sizes) and those with lower than average skin elasticity. The procedure begins with a large horizontal incision running beneath the nipple.  Next, the skin is pulled back, where breast tissue is removed with a scalpel and liposuction.  Excess skin is removed during this procedure too. Sadly, this procedure often requires that the nipple is removed and subsequently grafted, where nipple sensation is then often lost.

In rare cases, free nipple grafts fail, leaving a patient with no nipple. While tattooing is a viable option, tattoos lack the dimension of an actual nipple. 3D nipple tattooing is now available. This procedure helps mimic the appearance and dimension of an authentic nipple. It is conducted under general anesthetic and typically takes between 3-4 hours.

Transmasculine Bottom Surgery

Transmasculine bottom surgeries work to remove existing female anatomy including the uterus, fallopian tubes, ovaries, cervix and vagina and then working to create male anatomy. Some patients may choose to have every surgery listed below, while others might opt for only one or a select few.

Hysterectomy with Bilateral Salpingo_Oophorectomy

A hysterectomy with bilateral salpingo-oophorectomy includes the removal of the uterus, fallopian tubes and ovaries. Three to five small incisions are made on the lower abdomen. The abdomen is then inflated with gas to create space for a surgeon to have easier access. A telescope is inserted through the incisions allowing a surgeon to see. A tool is also inserted through various incisions where the uterus, fallopian tubes, ovaries, and cervix are detached and removed through the vagina. Finally, the vagina is closed (colpectomy) with dissolving sutures and the gas released from the abdomen.

Clitoral Release

Trans men on masculinizing hormone therapy tend to see an enlargement of the clitoris; however, the growth is limited to only a few centimeters. A clitorial release includes cutting the ligaments surrounding the clitoris; this releases it from the pubis (or pubic bone), creating more length and a phallus (or penis) in doing so. As the urethra is untouched during this procedure, the length of the urethra remains in tack. Patients risk developing hypersensitivity or limited sensitivity. On its own, this procedure leaves the resulting penis too small for penetrative sex.

Metoidioplasty

Metoidioplasty also inherently includes a clitoral release as described above; it also involves the extension of the urethra to the tip of the phallus. Skin may be removed from the labia minora and grafted around the phallus to add bulk.

Phalloplasty

Phalloplasty creates a penis, scrotum and testes. Phalloplasty includes a number of sub procedures, occurring in various stages. In other words, phalloplasty would not be completed in one surgery. The sub-procedure includes:

  • Creation of a Penis:
    • A graft is acquired through removal of skin, nerves, veins and arteries from a forearm or thigh. The graft site requires prior permanent removal of hair which can take as long as nine to eighteen months
    • A portion of the graft is used to extend the urethra
    • The remaining portion of the graft is wrapped around the urethra to create a penis and glans.
  • Urethroplasty essentially works to lengthen the urethra; which is typically completed so urinating is possible while standing. An elongated urethra might be created using tissue from skin, vagina, or oral mucosa.
  • Vaginectomy includes destruction of the vagina mucosa and closure of the vaginal walls. The vaginal mucosa is destroyed through employment of a cautery tip, and the walls are subsequently sutured together.
  • Glansplasty is the procedure necessary to create the tip or head of the penis. Numerous procedures exist; one includes creating a circumferential incision and subsequent skin flap which is raised, folded back on itself and reattached thereby creating a ridge.
  • Scrotoplasty includes the creation of a scrotum and insertion of testicular implants. A small incision is made above the pubic bone and in the lower part of the labia majora. By turning up the flap and stitching the lower ends, a pouch (or scrotum) is formed. The testicular implants (if desired) are inserted into the pouch later.
  • Erectile Device is meant to replace the spongy tissue that normally fills with blood resulting in an erection. Erectile devices are available in a variety of diameters and lengths. There are numerous types of penile implants; these include, non-inflatable penis implants, 2-piece inflatable penile implants, and 3-piece inflatable implants.

Facial Masculinization Surgeries

Masculine facial features are often more chiseled, having more pronounced angles than softer, rounded features typical in females) when compared to female facial features. Features like a square jaw and longer chin are common to males. Male chins are often flat, where female chins are soft and round. While hormone therapy will enhance masculine features, similar to the growth of facial hair, there are certain features that can only be corrected with surgery. Like the upper and lower surgeries described above, individuals might choose one, some, all or none of the facial surgeries to follow.

Forehead Lengthening / Augmentation

The typical male forehead is generally longer than those of females. Lengthening the forehead is accomplished in two ways. The first involves increasing the distance between the eyebrows and hairline by shifting the hairline back. Augmentation, on the other hand, is achieved by molding the forehead with a prosthetic material and inserting it through an incision made at the hairline.

Cheek Augmentation

Through an incision inside the cheek, implants are inserted to create a more masculine shape.

Rhinoplasty

Rhinoplasty is reshaping of the nose. Acting as the focal point of the face, contouring and reshaping the nose can instantly transform one’s appearance. Potential modifications include better projection, better side profile, balanced nostrils, reduction of a bulbous tip, and the removal of any bumps.

Chin Recontouring (Genioplasty)

Recontouring often includes the insertion of a chin implant in addition to liposuction. Where some surgeons use an implant to create a more defined chin, others re-shape the existing bone to create a similar effect.

Jaw Augmentation & Contouring

Jaw contouring works to enlarge the margins of the jaw, making it more prominent and well defined. While existing bone might be re-shape, masculinizing the jaw might include insertion of a jaw implant. Jaw and chin augmentation are frequently completed together.

Thyroid Cartilage Enhancement

Enhancement of the thyroid cartilage includes creation of an Adam’s Apple. A small incision is made in the throat beneath the chin, where an implant is inserted. The throat muscles are then closed over the implant.

Facial Hair Transplant

Hair transplant is common to enhance the eyebrows, moustache, sideburns, and beard too. While hormone therapy will enhance hair growth and the thickness of hair, facial hair transplant will produce more dense hair. The follicular unit extraction method includes removal of healthy follicles from a donor site, usually the back of the head, which are then transplanted to the desired facial area.

Otoplasty

Frequently called ‘pinning’ of the ears, otoplasty works to decrease the projection of the ears through removal of cartilage. While both females and males might have projected ears, ear pinning helps to masculinize the head.

Liposuction

Females tend to store fat in their hips, thighs and buttocks, where males hold fat in their abdomen. Additionally, females store more fat when compared to males. While hormone therapy in conjunction with a healthy diet and exercise can help contour the body, stubborn fat is challenging to eliminate. As many individuals seeking masculinization idolize a v-shaped torso, some turn to liposuction to further enhance a masculine physique.

Final Notes

Surgery could be considered medically necessary for some individuals as it could eliminate or reduce the distress associated with gender dysphoria. Risks though, must be examined and considered prior to proceeding with surgery. Speaking with medical professionals, therapists and those who’ve undergone surgical procedures will be helpful in making informed choices, in addition to choosing the surgeries necessary to achieve one’s desired look.

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