Skip to main content

Advertisement

SpringerLink
Log in

Gender Affirmation Surgery for the Transmasculine Patient

  • Care for the Transgender Patients (C Ferrando, Section Editor)
  • Published:
Current Obstetrics and Gynecology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The aim of this review is to introduce and describe many of the surgical procedures, physical elements, and associated complications that can be performed and encountered for transmasculine patients pursuing gender affirmation.

Recent Findings

Increased exposure and understanding of the variations, elements, differences, and complications that exist within gender affirmation surgery (GAS) can lead to improved care for transmasculine patients.

Summary

Gender affirmation care represents a burgeoning field within healthcare across the globe. As increasing numbers of patients demonstrate interest and pursuit in surgical transition, more providers will find themselves tasked with providing postoperative and general health care to this growing population. Gender affirmation surgery for transmasculine patients encompasses a tremendous breadth of procedures as well as outcomes in the pursuit to resolve gender dysphoria. While each procedure can be intricate in its details, a strong foundation in the overarching surgical offerings, elements, outcomes, and associated complications can lead to improved patient outcomes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

US:

United States

GAS:

Gender affirmation surgery

WPATH:

World Professional Association for Transgender Health

HRT:

Hormone replacement therapy

TWT:

Tube within a tube

ALT:

Anterolateral thigh flap

MLD:

Musculocutaneous latissimus dorsi flap

RFFF:

Radial forearm free flap

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Lambrou NH, Cochran KM, Everhart S, et al. Learning from Transmasculine Experiences with Health Care: Tangible Inlets for Reducing Health Disparities Through Patient-Provider Relationships. Transgend Health. 2020;5(1):18–32. Published 2020 Mar 16. https://doi.org/10.1089/trgh.2019.0054

  2. Hanna B, Desai R, Parekh T, Guirguis E, Kumar G, Sachdeva R. Psychiatric disorders in the U.S. transgender population. Ann Epidemiol. 2019;39:1–7.e1. https://doi.org/10.1016/j.annepidem.2019.09.009. Epub 2019 Oct 4. PMID: 31679894.

  3. Klein DA, Paradise SL, Goodwin ET. Caring for Transgender and Gender-Diverse Persons: What Clinicians Should Know. Am Fam Physician. 2018;98(11):645–53 (PMID: 30485050).

    PubMed  Google Scholar 

  4. McFarland W, Wilson E, Fisher RH. How Many Transgender Men Are There in San Francisco? J Urban Health. 2018;95(1):129–33. https://doi.org/10.1007/s11524-017-0150-5.PMID:28462471;PMCID:PMC5862690.

    Article  PubMed  Google Scholar 

  5. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality 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, 2011). 2016.

  6. Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC 2nd, Haider AH, Lau BD. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg. 2018;153(7):609–16. https://doi.org/10.1001/jamasurg.2017.6231.PMID:29490365;PMCID:PMC5875299.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Nolan IT, Daar DA, Poudrier G, Motosko CC, Cook TE, Hazen A. Barriers to bottom surgery for transgender men. Plastic Reconstruct Surg. 2020;145(3):667e-669e. https://doi.org/10.1097/PRS.0000000000006601

  8. Schechter LS, Safa B. Introduction to Phalloplasty. Clin Plastic Surg. 45(3):387–89. https://doi.org/10.1016/j.cps.2018.03.014

  9. Morrison SD, Chen ML, Crane CN. An overview of female-to-male gender-confirming surgery. Nat Rev Urol. 2017;14(8):486–500. https://doi.org/10.1038/nrurol.2017.64 (Epub 2017 May 16 PMID: 28508877).

    Article  PubMed  Google Scholar 

  10. • Hadj-Moussa M, Agarwal S, Ohl DA, Kuzon WM Jr. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev. 2019;7(1):141–55. https://doi.org/10.1016/j.sxmr.2018.06.004 (Epub 2018 Aug 16 PMID: 30122339). This publication provides an extensive and detail-oriented outline overviewing a large breadth of genital as well as nongenital transmasculine surgical transition.

    Article  PubMed  Google Scholar 

  11. Schechter LS, Safa B. Introduction to Phalloplasty. Clin Plastic Surg. 2018;45(3):387–9. https://doi.org/10.1016/j.cps.2018.03.014

  12. Müller-Richter UDA, Driemel O, Mörtl M, Schwarz S, Zorger N, Wagener H, Roldán JC. The value of Allen’s test in harvesting a radial forearm flap: correlation of ex-vivo angiography and histopathological findings. Int J Oral Maxillofac Surg. 2008;37(7):672–4. https://doi.org/10.1016/j.ijom.2008.01.012

    Article  PubMed  Google Scholar 

  13. • Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: techniques and outcomes. Transl Androl Urol. 2019;8(3):248–53. https://doi.org/10.21037/tau.2019.06.12. PMID:31380231;PMCID:PMC6626308. This publication provides an extensive overview and surgical experience with metoidioplasty as an alternative to phalloplasty.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Morrison SD, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK. Phalloplasty. Plast Reconstr Surg. 2016;138(3):594–615. https://doi.org/10.1097/PRS.0000000000002518.

    Article  CAS  PubMed  Google Scholar 

  15. Stojanovic B, Bizic M, Bencic M, et al. One-Stage Gender Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med. 2017;14:741–6.

    Article  Google Scholar 

  16. Perovic SV, Djordjevic ML. Metoidioplasty: a variant of phalloplasty in female transsexuals. BJU Int. 2003;92(9):981–5. https://doi.org/10.1111/j.1464-410x.2003.04524.x.

    Article  CAS  PubMed  Google Scholar 

  17. Stojanovic B, Djordjevic ML. Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenders. Clin Anat. 2015;28(3):368–75. https://doi.org/10.1002/ca.22525 (Epub 2015 Mar 4 PMID: 25740576).

    Article  PubMed  Google Scholar 

  18. Miller TJ, Safa B, Watt AJ, Chen ML, Lin WC. An abnormal clinical Allen’s Test is not a contraindication for free radial forearm flap. Clin Case Rep. 2020;8(11):2191–4. https://doi.org/10.1002/ccr3.3093.PMID:33235756;PMCID:PMC7669401.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Djordjevic ML, Bizic MR. Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery. J Sex Med. 2013;10(5):1431–8. https://doi.org/10.1111/jsm.12108 (Epub 2013 Feb 27 PMID: 23444841).

    Article  PubMed  Google Scholar 

  20. Djordjevic ML, Bizic M, Stanojevic D, et al. Urethral Lengthening in metoidioplasty (female-to-male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap. Urology. 2009;74(2):349–53. https://doi.org/10.1016/j.urology.2009.02.036 (Epub 2009 Jun 7 PMID: 19501885).

    Article  CAS  PubMed  Google Scholar 

  21. Djordjevic ML. Novel surgical techniques in female to male gender confirming surgery. Transl Androl Urol. 2018;7(4):628–38. https://doi.org/10.21037/tau.2018.03.17.PMID:30211052;PMCID:PMC6127556.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Ercolano A. FAQ: Phalloplasty: The Johns Hopkins Center for Transgender Health. FAQ: Phalloplasty | The Johns Hopkins. 2021. https://www.hopkinsmedicine.org/center-transgender-health/services-appointments/faq/phalloplasty.

  23. Hadj-Moussa M, Agarwal S, Ohl DA, Kuzon WM Jr. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev. 2019;7(1):141–55. https://doi.org/10.1016/j.sxmr.2018.06.004 (Epub 2018 Aug 16 PMID: 30122339).

    Article  PubMed  Google Scholar 

  24. • Heston AL, Esmonde NO, Dugi DD 3rd, Berli JU. Phalloplasty: techniques and outcomes. Transl Androl Urol. 2019;8(3):254–65. https://doi.org/10.21037/tau.2019.05.05. This publication describes essential decision points that must be considered when performing phalloplasty and in addition, provides an extensive discussion regarding the common complications encountered.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Kang A, Aizen JM, Cohen AJ, et al. Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male. Transl Androl Urol. 2019;8(3):273–82. https://doi.org/10.21037/tau.2019.06.02.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, De Cuypere G, Monstrey S. Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty. Plastic Reconstruct Surg. 2009;123(6):1710–8. https://doi.org/10.1097/PRS.0b013e3181a659fe.

  27. Lucas JW, Lester KM, Chen A, et al. Scrotal reconstruction and testicular prosthetics. Transl Androl Urol. 2017;6(4):710–21. https://doi.org/10.21037/tau.2017.07.06

  28. Cohen O, Stranix JT, Zhao L, Levine J, Bluebond-Langner R. Use of a Split Pedicled Gracilis Muscle Flap in Robotically Assisted Vaginectomy and Urethral Lengthening for Phalloplasty: A Novel Technique for Female-to-Male Genital Reconstruction. Plast Reconstr Surg. 2020;145(6):1512–5. https://doi.org/10.1097/PRS.0000000000006838 (PMID: 32195856).

    Article  CAS  PubMed  Google Scholar 

  29. Monstrey SJ, Ceulemans P, Hoebeke P. Sex Reassignment Surgery in the Female-to-Male Transsexual. Semin Plast Surg. 2011;25(3):229–44. https://doi.org/10.1055/s-0031-1281493.PMID:22851915;PMCID:PMC3312187.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P, Van Landuyt K, Blondeel P, Hamdi M, Roche N, Weyers S, De Cuypere G. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124(2):510–8. https://doi.org/10.1097/PRS.0b013e3181aeeb06 (PMID: 19644267).

    Article  CAS  PubMed  Google Scholar 

  31. McRoberts JW, Sadove RC. Penile reconstruction with a free sensate osteocutaneous fibula flap in the surgical management of the intersex patient. Adv Exp Med Biol. 2002;511:283–7; discussion 287–8. https://doi.org/10.1007/978-1-4615-0621-8_18. PMID: 12575769.

  32. Preto M, Blecher G, Timpano M, et al. The Frontier of Penile Implants in Phalloplasty: Is the ZSI 475 FTM what we have been waiting for? Int J Impot Res. 2021;33:779–83. https://doi.org/10.1038/s41443-020-00396-2.

    Article  PubMed Central  Google Scholar 

  33. Kim SK, Lee KC, Kwon YS, et al. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plastic Reconstruct Aesthetic Surg. 2008;62(3):309–17. https://doi.org/10.1016/j.bjps.2007.11.011

  34. Byun J, Cho B, Baik B. Results of One-Stage Penile Reconstruction Using an Innervated Radial Osteocutaneous Flap. J Reconstruct Microsurg. 1994;10(05):321–31. https://doi.org/10.1055/s-2007-1006601

  35. Santanelli F, Paolini G. Glans, Urethra, and Corporeal Body Reconstruction by Free Osteocutaneous Forearm Flap Transfer. Ann Plast Surg. 2003;50(5):545. https://doi.org/10.1097/01.sap.0000038149.

    Article  PubMed  Google Scholar 

  36. D’Arpa S, Claes K, De Wolf E, et al. Abstract: Comparison of Radial Forearm Flap and Antero-Lateral Thigh Flap Phalloplasty: Analysis of 413 Cases. Plast Reconstr Surg Glob Open. 2018;6(9 Suppl):71–71. Published 2018 Sep 26. https://doi.org/10.1097/01.GOX.0000546913.10198.b3

  37. 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):206–14. https://doi.org/10.1016/j.juro.2017.07.084 (Epub 2017 Jul 29 PMID: 28765066).

    Article  PubMed  Google Scholar 

  38. Orandi A. Phalloplasty and saphenous vein urethroplasty. Invest Urol. 1965;3(2):111–6 (PMID: 5318062).

    CAS  PubMed  Google Scholar 

  39. Byne W, Bradley SJ, Coleman E, et al. American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759–96. https://doi.org/10.1007/s10508-012-9975-x. PMID: 22736225.

  40. Gillies H. Congenital absence of the penis. Br J Plast Surg. 1948;1(1):8–28. https://doi.org/10.1016/s0007-1226(48)80006-8 (PMID: 18874748).

    Article  CAS  PubMed  Google Scholar 

  41. Alanis SZ. An innovation in total penis reconstruction. PlastReconstr Surg. 1969;43:418–22.

    Article  CAS  Google Scholar 

  42. Fleming JP. Reconstruction of the penis. J Urol. 1970;104:213–8.

    Article  CAS  Google Scholar 

  43. Mueller A, Gooren L. Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Eur JEndocrinol. 2008;159:197–202.

    Article  CAS  Google Scholar 

  44. Burivong W, Leelasithorn V, Varavithya V. Common lower urinary tract fistulas: A review of clinical presentations, causes and radiographic imaging. Int J Case Rep Images. 2011;2(1):1–7.

    Article  Google Scholar 

  45. Kovar A, Choi S, Iorio ML. Donor Site Morbidity in Phalloplasty Reconstructions: Outcomes of the Radial Forearm Free Flap. Plast Reconstr Surg Glob Open. 2019;7(9):e2442. Published 2019 Sep 23. https://doi.org/10.1097/GOX.0000000000002442

  46. Lumen N, Monstrey S, Goessaert AS, Oosterlinck W, Hoebeke P. Urethroplasty for strictures after phallic reconstruction: a single-institution experience. Eur Urol. 2011;60(1):150–8. https://doi.org/10.1016/j.eururo.2010.11.015 (Epub 2010 Nov 21 PMID: 21145648).

    Article  PubMed  Google Scholar 

  47. Santucci RA. Urethral Complications After Transgender Phalloplasty: Strategies to Treat Them and Minimize Their Occurrence. Clin Anat. 2018;31(2):187–90. https://doi.org/10.1002/ca.23021 (Epub 2018 Jan 22 PMID: 29178533).

    Article  PubMed  Google Scholar 

  48. Chen ML, Safa B. Single-Stage Phalloplasty. Urol Clin North Am. 2019;46(4):567–80. https://doi.org/10.1016/j.ucl.2019.07.010 (PMID: 31582030).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Urology Institute, University Hospitals - Cleveland Medical Center, Cleveland, OH, USA

    Michael Callegari, Gaetan Pettigrew & Shubham Gupta

  2. Case Western Reserve University College of Medicine, Cleveland, OH, USA

    John MacLean

  3. Department of Urology, New York University Langone Health, New York, NY, USA

    Kirtishri Mishra

  4. Division of Plastic and Reconstructive Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA

    Joseph S. Khouri

Authors
  1. Michael Callegari
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gaetan Pettigrew
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John MacLean
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kirtishri Mishra
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joseph S. Khouri
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Shubham Gupta
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael Callegari.

Ethics declarations

Conflict of Interest

The authors have no relevant financial or non-financial interests to disclose. The authors have no competing interests to declare that are relevant to the content of this article. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript. The authors have no financial or proprietary interests in any material discussed in this article.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Care for the Transgender Patients

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Callegari, M., Pettigrew, G., MacLean, J. et al. Gender Affirmation Surgery for the Transmasculine Patient. Curr Obstet Gynecol Rep 11, 66–74 (2022). https://doi.org/10.1007/s13669-022-00330-x

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13669-022-00330-x

Keywords

Search

Navigation