Feminizing surgery

Overview

Feminizing surgery, also called gender-affirming surgery, involves procedures that help better align the body with a person's gender identity. Research has found that gender-affirming surgery can have a positive impact on well-being and sexual function.

Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations.

Your healthcare team can talk with you about your options and help you weigh the risks and benefits.

Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. This is called gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

• Removal of the testicles alone. This is called orchiectomy.
• Vaginoplasty. This is a procedure that may include:
  • Removal of the penis, called penectomy.
  • Removal of the testicles.
  • Creation of a vagina, called vaginoplasty.
  • Creation of a clitoris, called clitoroplasty.
  • Creation of labia, called labioplasty.
• Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
• Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
• Body-contouring. These procedures may include:
  • Tummy tuck, called abdominoplasty.
  • Buttock lift, called gluteal augmentation.
  • Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
• Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
• Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
• Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
• Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis. It involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Risks

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and a reaction to anesthetic. Depending on the procedures, other health concerns that might happen due to feminizing surgery include:

• Delayed wound healing.
• Fluid buildup beneath the skin, called seroma.
• Bruising, also called hematoma.
• Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness.
• Damaged or dead body tissue — a condition known as tissue necrosis — such as in the surgically created vagina or labia.
• A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism.
• Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina.
• Urinary problems, such as incontinence.
• Pelvic floor problems.
• Permanent scarring.
• Loss of sexual pleasure or function.
• Worsening of a behavioral health problem.

Fertility

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk with your healthcare professional before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your healthcare team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take. Before surgery, you also may need to stop using nicotine, including vaping, smoking and chewing tobacco.

Consent

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

• Risks and benefits.
• Cost.
• Alternatives to surgery, if applicable.
• Expectations and goals.
• Potential complications.
• Impact on sexual function and fertility.

Evaluation for surgery

Before surgery, a healthcare professional evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a health professional with expertise in transgender medicine. The evaluation might include:

• A review of your personal and family medical history.
• A physical exam.
• Lab tests.
• A review of any hormone therapy you've had.
• A review of your vaccinations.
• Screening tests for some conditions and diseases.
• Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, and HIV or other sexually transmitted infections.
• Discussion about birth control, fertility and sexual function.

You also may have a behavioral health evaluation by a healthcare professional with expertise in transgender health. That evaluation might assess:

• Gender dysphoria.
• Mental health concerns.
• Sexual health concerns.
• The impact of gender dysphoria at work, at school, at home and in social settings.
• Substance use or use of hormone therapy or supplements not recommended by a health professional.
• Support from family, friends and caregivers.
• Your goals and expectations of treatment.
• Care planning and follow-up after surgery.

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking with others who have had feminizing surgery. If you don't know someone, ask your healthcare professional about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery

Facial feminization surgery may involve a range of procedures to change facial features, including:

• Moving the hairline to create a smaller forehead.
• Enlarging the lips and cheekbones with implants.
• Reshaping the jaw and chin.
• Undergoing skin-tightening surgery after bone reduction.

These surgeries are typically done on an outpatient basis, so you don't have to stay in a hospital overnight. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, a surgery may be needed first to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a healthcare professional are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

Orchiectomy

Orchiectomy is a surgery to remove the testicles. Because testicles make sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

This type of surgery typically does not require a hospital stay. A local anesthetic may be used, so only the testicular area is numbed. Or the surgery may be done using general anesthesia. This means you are in a sleep-like state during the procedure.

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other genital surgery.

Vaginoplasty

Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. Labiaplasty is sometimes done without creation of a vaginal canal. This is called zero-depth vaginoplasty.

To surgically create a clitoris, a surgeon uses the tip of the penis and the nerves that supply it. This procedure is called a clitoroplasty. In some people, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. During vaginoplasty, the testicles are removed if that hasn't been done before.

Most surgeons require laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That process can take several months.

After vaginoplasty, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your healthcare professional gives you instructions about when you may begin sexual activity with your new vagina.

After surgery, you're given a set of vaginal dilators of increasing sizes. You insert the dilators in your vagina to maintain, lengthen and stretch it. Follow your healthcare professional's directions on how often to use the dilators. To keep the vagina open, dilation needs to continue long term.

Because the prostate gland isn't removed during surgery, you need to follow age-appropriate recommendations for prostate cancer screening. Following surgery, it is possible to develop urinary symptoms from enlargement of the prostate.

Results

Gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your healthcare professional's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk with members of your healthcare team about what to expect after surgery and the ongoing care you may need.