Genital realignment surgery (female-to-male)
Genital realignment surgery (also known as sex reassignment surgery) from anatomical female to male, involves removal of the breast tissue, reproductive organs, and reshaping the genitals into a form with the appearance of the male genitalia.
Many trans men, considering the surgical options, do not opt for complete genital reassignment surgery. Many do undergo so called "top surgery" (the sculpting of a male contoured chest) and hysterectomy (the removal of internal female sex organs) along with hormone treatment using testosterone. With current procedures, trans men are not implanted with testies from either a donor, or lab cultured organs. This means that they are unable to father children, and that they will need to remain on hormone therapy after their surgery to maintain normal hormonal levels.
Most trans men require bilateral mastectomy in a process known as "top surgery", the removal of most of the lipid tissues of the breast, and shaping of a male contoured chest.
Trans men with moderate to large breasts usually require a formal bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoralis muscle, but allows for easier resizing of the nipple and placement in a typically male position.
By some doctors, the surgery is done in two steps, first the contents of the breast are removed through either a cut inside the areola or around it, and then let the skin retract for about a year, where in a second surgery the excess skin is removed. This technique results in far less scarring, and the nipple-areola needs not to be removed and grafted. Completely removing and grafting often results in a loss of sensation of that area that may take months to over a year to return, or may never return at all; and in rare cases in the complete loss of this tissue. In these rare cases, a nipple can be reconstructed as it is for surgical candidates whose nipples are removed as part of treatment for breast cancer.
For trans men with smaller breasts, a peri-areolar or "keyhole" procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional mastectomy, but the nipples may be larger and may not be in a perfectly male orientation on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a peri-areolar mastectomy, and less time is required for sensation to return.
Genital reconstructive procedures use either the clitoris, which is enlarged by androgenic hormones (metoidioplasty), or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (phalloplasty). The latter usually include multiple procedures, more expense and with a less satisfactory outcome, in terms of replicating nature.
In either case, the urethra can be rerouted through the phallus to allow urination through the reconstructed penis. The labia majora (see vulva) are united to form a scrotum, where prosthetic testicles can be inserted.
Hysterectomy and bilateral salpingo-oophorectomy
Hysterectomy is the removal of the uterus. Bilateral Salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in cisgendered women is sometimes referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs.
Some trans men desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.
For many trans men however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer  . (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men compared to the general female population. The risk will probably never be known since the overall population of transgender men is very small; even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.
Decreasing cancer risk is however, particularly important as trans men often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, trans men should see a gynecologist for a check-up at least every three years. This is particularly the case for trans men who:
- retain their vagina (whether before or after further genital reconstruction,)
- have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
- have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
One important consideration is that any trans man who develops vaginal bleeding after successfully ceasing menses on testosterone, MUST be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a cisgendered woman and may herald the development of a gynecologic cancer.
Post op care
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After surgery, depending on the stage of completion and the type of surgery, aftercare is needed as to reduce the chance of complications.
In metoidioplasty, the recovery time is shorter due to less possibility of complications from urethral extension, or blood flow.
In phalloplasty, the neopenis is required to be parallel to the abdomen during initial recovery so reduce tension that may cause lack of blood flow. If the urethra is extended, a foley catheter will be placed in to allow the mucosa to heal without urine affecting the process. There is still the risk of a urinary tract infection.
In December 2009, researchers at the National Institute for Medical Research discovered a way to convert the biological function of ovarian tissue into the same as testicular tissue. By artificially deleting the FOXL2 gene, the SRY target gene Sox9 caused tissue level conversion and subsequent raise in serum testosterone levels to that of a normal XY adult male. In the future, this could be an alternative to oophorectomy and possibly serve to eliminate the need for artificially produced testosterone for HRT.
The demonstration here that upon loss of Foxl2 mature granulosa/theca cells undergo transdifferentiation into Sertoli/Leydig-like cells with high levels of testosterone production is one of the few documented examples of in vivo lineage reprogramming in an adult organism (Zhou and Melton, 2008).
- Somatic Sex Reprogramming of Adult Ovaries to Testes by FOXL2 Ablation by N. Henriette Uhlenhaut, Susanne Jakob, Katrin Anlag, Tobias Eisenberger, Ryohei Sekido, Jana Kress, Anna-Corina Treier, Claudia Klugmann, Christian Klasen, Nadine I. Holter, Dieter Riethmacher, Günther Schütz, Austin J. Cooney, Robin Lovell-Badge and Mathias Treier (Cell, Volume 139 Issue 6, 11 December 2009)
- Total sex-reassignment surgery in female-to-male transsexuals: a one-stage technique by C. Trombetta, G. Liguori, M. Pascone, S. Bucci, S. Guaschino†, G. Papa and E. Belgrano (BJU International, Volume 90 Issue 7, Oct 2002)
- Two-stage versus one-stage sex reassignment surgery in female-to-male transsexual individuals by S. Weyers, G. Selvaggi, S. Monstrey, M. Dhont, R. Van den Broecke, P. De Sutter, G. De Cuypere, G. T‘ Sjoen and P. Hoebeke (Gynecological Surgery, Volume 3 Number 3, September 2006)
- Factors Which Influence Individual's Decisions When Considering Female-To-Male Genital Reconstructive Surgery by Katherine Rachlin from the International Journal of Transgenderism. This article also discusses some general issues of GRT for trans men.
- Surgeons who perform top surgery
- Dr. Paul Costas of Concord, Massachusetts
- Dr. Peter Raphael of Plano, Texas
- Dr. Gary P. Lawton of San Antonio, Texas
- Dr. Douglas L. Gervais of Minneapolis, Minnesota
- Dr. Michael Bermant of Chester, Virgina
- Dr.Michael L.Brownstein of San Francisco, California
- Dr. David L. Buchanan of Santa Barbara, California
- Dr. Charles E. Garramone of Plantation, Florida
- Dr. Daniel A. Medalie of Cleveland, Ohio (top and bottom)
- Dr. Camron Bowman of Vancouver, British Columbia, Canada
- Dr. Hugh A. McLean of Mississauga, Ontario, Canada
- SurgiCare in Birmingham, UK
- Harley Medical Group
- Nuffield Hospital Leicester (Surgeons need a referral from your doctor)
- Surgeons who perform bottom surgery
- Dr Kate O'Hanlan of Portola Valley, California (hysterectomy only)
- Dr Linda Mihalov of Seattle, Washington (hysterectomy only)
- Dr. Sherman Leis of Bala Cynwyd, Pennsylvania
- Dr. Christine McGinn of New Hope, Pennsylvania
- Dr. Marci L. Bowers of Trinidad, Colorado
- Dr. Suman K. Das of Flowood, Mississppi
- Dr. Gary Alter of Beverly Hills, California
- Dr. Toby R. Meltzer of Paradise Valley, Arizona
- Dr. Harold Reed of Bay Harbor Islands, Florida
- Dr Pierre Brassard of Montreal, QC, Canada
- Mr David J Ralph of London, UK
- Dr. Jürgen Schaff of München, Germany
- Dr. Michael Sohn of Frankfurt, Germany
- Dr. Daverio und Dr. Krueger of Berlin, Germany - Written in German
- Miroslav Djordjevic of Belgrade, Serbia
- Dr. Sava Perovic of Belgrade, Serbia
- Dr. Stan Monstrey of Gent, Belgium
- Dr. Takamatsu Ako of Saitama, Japan
- Associate Professor Peter Haertsch of Concord, NSW, Australia
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