As part of gender transitioning, some trans people will choose to have surgery. It is not a requirement for social transition; however, in some jurisdictions, it is a requirement for legal transition. Apart from legal requirements, surgery may be performed for gender affirmation, to allow desired sexual interactions, to allow standing urination, and/or to reduce stigma when being given personal care in an aged-care setting.

There are a limited number of surgeons in Australia who perform gender-affirming surgery, especially masculinising and feminising genitoplasty. Trans people may choose to travel overseas for their surgery. At the present time, most of the surgery in Australia is performed in the private sector. Surgical teams are often multi-disciplinary and may involve plastic surgeons, urologists, colorectal surgeons and gynaecologists. It is important that the whole healthcare team is well-versed in transgender care to avoid misgendering patients and the resultant distress.

For simplicity, in this article I have used the terms trans men and trans women, however, I acknowledge that some people will identify as gender diverse or non-binary. I have also used the terms neovagina and neophallus, as this is intended for a surgical audience, when I am aware that many trans people will use the terms vagina and penis for the same structures.

The World Professional Association for Transgender Health (WPATH) Standards of Care document sets out pre-operative requirements for gender-affirming surgery. This includes appropriate psychiatric or physiological assessment prior to surgery. These guidelines have been written to support and protect both doctors and patients. It would be usual practice in Australia to ensure the conditions described in this document are met prior to any gender-affirming surgical procedure.

It is important to acknowledge that discussion around fertility preservation must take place in pre-operative counselling. Fertility preservation techniques such as gamete freezing are well established.

Bottom surgery

Bottom surgery refers to internal and external reproductive organs and genitals. The internal reproductive organ surgery required by some trans men is well within the remit of a general gynaecologist and fairly self-explanatory. It includes hysterectomy with or without salpingoopherectomy. These procedures may be performed for gender-affirming reasons or for any of the typical gynaecological indications. The usual routes of surgery are all possible, however, vaginal surgery is less common given this population may opt not to carry children, or to have elective caesarean births and, thus, vaginal hysterectomy may not be possible. An abdominal hysterectomy through a small Pfannenstiel incision may be preferred by some trans men to avoid the vaginal component of surgery altogether. Laparoscopic hysterectomy is often the preferred technique, however, gynaecologists must be aware that placement of vaginal instruments may be difficult due to testosterone use and subsequent atrophy. Careful assessment and discussion pre-operatively is important. Often, trans men will benefit from the addition of topical vaginal oestrogen for six to eight weeks pre-operatively. Vaginectomy may be performed as an independent procedure, however, it is usually done at the same time as masculinising genitoplasty, as some of the redundant tissue may be used for urethral lengthening.

There are two main options for masculinising genitoplasty; metoidioplasty and phalloplasty. Metoidioplasty is a simple one-stage procedure with a lower complication risk, although urinary fistulas may occur. It involves releasing the chordee (suspensory ligaments of the clitoris) and advancing the urethra to the tip of the phallus. Metoidioplasty gives more masculine-appearing genitals and the ability to stand to urinate. It is often done in combination with vaginectomy, but does not require it, so the vagina may remain patent. Phalloplasty is a much more complex multi-stage procedure and requires multiple surgeons from different disciplines, generally, plastics, urology and sometimes gynaecology. Post-phalloplasty, a trans man will have a more typically sized phallus, with the ability to sexually penetrate their partner/s and stand to urinate. The aim is for a neophallus that is sensate, achieves erection (often through an implanted erection device) and has good cosmetic appearance. Phalloplasty is performed via generation of a flap from either the abdomen, latimus dorsi, anterior lateral thigh or, the commonly preferred technique, radial forearm. Complications are common and generally involve the urethral component or the donor site. Urethral complications can be difficult to treat and include fistulae, stricture and stone formation.

Trans women may elect to have vaginoplasty, labioplasty or a simple orchidectomy, which was, and is, performed for trans women to adhere to transphobic and archaic legal requirements in some jurisdictions, requiring sterilising surgery in order to legally transition. Alternatively, some trans women find anti-androgen medication problematic and will elect for an orchidectomy to remove the need for anti-androgens.

Labioplasty alone is often requested by trans women who do not desire a vagina for penetration, but would like a more feminine external genital appearance. Often, these women are older and planning a transition to supported living and have concerns about how they may be perceived when receiving personal care. Labioplasty generally produces very convincing external female genitalia with a vaginal dimple. The clitoris is often fashioned from the glans penis and clitoral sensitivity and orgasm are possible post-labioplasty.

Vaginoplasty involves the creation of a neovagina and female-appearing external genitalia, including a sensate clitoris, and removal of the testes. Neovaginal creation is commonly performed via penile or scrotal tissue inversion and, alternatively, may be done using a section of sigmoid colon or by bringing down peritoneal lining to the introitus. The inversion technique is the most common and generally has a low complication rate, the most common being granulation tissue formation and stenosi, either at the introitus or higher up the neovagina. Rectovaginal fistulae are also possible.

Hair growth within in the neovagina may be an issue and it is preferable for trans women to have permanent hair removal pre-operatively if hair-bearing skin is to be used. Dilation is required post-operatively and trans women who wish to have a patent vagina must continue with either regular dilation or penetrative sexual activity. Douching is required to remove skin cell debris. Some trans women find they benefit from the addition of probiotics, topical oestrogen and/or acidifying gels or pessaries to reduce troublesome discharge.

Neovaginas formed from colon are more prone to complications, which can include: prolapse; introital stenosis; adhesion formation or other complications from the abdominal component of the surgery; mucositis; discharge and/or odour; and the possibility of carcinoma. Using peritoneal lining is less common, with the main concern being total vaginal length, which seems to be less with this technique.

More and more young trans people are using puberty blockers to avoid a natal puberty and the resultant distress. However, an unintended result of this is that less genital tissue will be available for future procedures. This is likely to lead to development of new techniques, including the possibility of using a combination of the genital inversion technique, with the addition of peritoneal lining, to increase total vaginal length. Overall, vaginoplasty is a well-tolerated procedure with a fairly low complication rate and postoperative sexual function satisfaction scores comparable to cis females.

Top surgery (chest or breast)

Chest reduction surgery (mastectomy) is a common procedure for trans men. The recovery can be painful, however, the cosmesis is generally very good. Surgical management of nipples can be via grafting, 3D tattoos or reconstruction. Larger nipples tend not to graft as successfully, as there is a greater tissue bulk and some areola can be lost, leading to a less visually pleasing nipple-to-areola ratio. In this situation, 3D tattoos or nipple reconstruction may lead to better cosmesis.
Some trans women will be dissatisfied with their spontaneous breast development and will seek augmentation surgery. This is similar in principle to cis female breast augmentation, however, there are a few issues the plastic or cosmetic surgeon will need to take into account. In trans women, the sternum and inter-nipple distances tend to be wider and the breasts located lower on the chest. It is best to time the surgery for after the plateau in breast growth. Postoperative physiotherapy should be considered to optimise recovery.

Other surgery (face and voice)

For some time now, facial feminising and masculinising surgery has been used by cis people who are dissatisfied with their facial features. Recently, more trans people have been accessing this surgery. Masculinising surgery aims to increase the squaring of the jaw and prominence of the forehead and eyebrow ridge. It is done with a combination of non-surgical and surgical fillers. Surgically, silicone and bone matrix fillers tend to be used. Facial feminising surgery aims for the opposite effect. Nose and lip enhancement may also be performed. A large number of these procedures now use non-surgical cosmetic techniques. Surgery involving bone, such as reduction in frontal bossing, can be quite invasive and have a significant recovery time. However, procedures such as lip-fillers can be done in a lunch break!

Most voice interventions for trans people occur via hormonal therapy (testosterone) and/or voice training by a speech therapist. Some trans women will have voice feminisation surgery, the aim being to increase pitch and, over time, reduce breathiness. This surgery requires significant pre- and postoperative speech therapy and a prolonged period of voice rest, so it is only appropriate for people who are motivated and able to adhere to the prehabilitation and rehabilitation. Trans women may choose this surgery because of inadequate results from voice training, the significant cognitive load that conscious control of voice takes, to reduce voice strain and daily maintenance, and to avoid being ‘betrayed’ by a male voice, typically when startled or making non-verbal vocalisations such as laughing or coughing. There are a number of open and endoscopic techniques for this surgery and it is performed by an ear, nose and throat (ENT) surgeon in conjunction with a speech therapist for prehabilitation and rehabilitation. Tracheal appearance can be altered by tracheal shave for Adam’s apple reduction or tracheal augmentation with rib cartilage transplant.

Conclusion

There are many available options for gender-affirming surgery. Appropriate pre-operative preparation, including a discussion about realistic expectations and risk of complications, will allow transgender individuals to make informed decisions and maximise positive long-term outcomes.

Further reading

1. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender and gender-nonconforming people, version 7. International Journal of Transgenderism 2012; 13(4):165-232.
2. Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nature Reviews Urology 2011;8274-282.
3. Mcneill, E. The Journal of Laryngology & Otology 2006;120:521-523.
4. Cornelise VJ, Jones RA, Fairley CK, Grover SR. The medical care of the neovagina of transgender women: a review. Sexual Health 2017;14(5):442-450.