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An overview of female-to-male gender-confirming surgery

Key Points

  • Gender-confirming surgery is becoming a more frequently encountered procedure for urologists, plastic surgeons, and gynaecologists

  • Female-to-male gender-confirming surgery consists of facial masculinization, chest masculinization, body contouring, and genital surgery

  • Metoidioplasty (hypertrophy with systemic hormones and mobilization of the clitoris with urethroplasty) can produce a sensate microphallus

  • Phalloplasty can produce an aesthetic and sensate phallus with ability to micturate in a standing position and engage in penetrative sexual intercourse if proper nerve coaptation and prosthetic insertion are performed

  • Urethral complications following genital surgery in transmen are generally higher than 30% and include urethral fistulas and strictures; revisional urethroplasty can address most urethral complications following genital surgery

  • Advances in basic sciences, transgender-specific prostheses, and patient-reported outcomes will continue to offer options for improvements in gender-confirming surgery

Abstract

Gender dysphoria is estimated to occur in approximately 25 million people worldwide, and can have severe psychosocial sequelae. Medical and surgical gender transition can substantially improve quality-of-life outcomes for individuals with gender dysphoria. Individuals seeking to undergo female-to-male (FtM) transition have various surgical options available for gender confirmation, including facial and chest masculinization, body contouring, and genital surgery. The World Professional Association for Transgender Health guidelines should be met before the patient undergoes surgery, to ensure that gender-confirming surgery is appropriate and indicated. Chest masculinization and metoidioplasty or phalloplasty are the most common procedures pursued, and both generally result in high levels of patient satisfaction. Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients.

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Figure 1: Skeletal and soft-tissue differences between male and female faces.
Figure 2: Outcomes of metoidioplasty.
Figure 3: Outcomes of anterolateral thigh (ALT) phalloplasty.
Figure 4: Outcomes of radial forearm free flap (RFFF) phalloplasty.
Figure 5: Design of mushroom flap for glansplasty.
Figure 6: Prosthetic options and outcomes.
Figure 7: Scrotoplasty outcomes.

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Contributions

S.D.M., C.N.C and M.C. researched data for article, made substantial contributions to discussions of content, and reviewed and edited the manuscript before submission. S.D.M. and M.C. wrote the article.

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Correspondence to Curtis N. Crane.

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PowerPoint slides

Glossary

Gender dysphoria

Inherent discordance of a patient's gender expression and their anatomy leading to distress

Nipple-areolar complex

Tissue forming the nipple and surrounding areola on the breast or chest

Allen's test

A physical examination test to determine the patency of the palmar or plantar arches as a correlate for the dominant inflow vessel to the hand or foot. Most commonly it is used in the hand where the radial and ulnar arteries are both occluded with pressure from the examiners hand and each is released sequentially while maintaining the pressure on the other artery. The perfusion of the hand is monitored to ensure both vessels can perfuse the hand.

Cismale

A person born as a male and whose gender identity is male.

Johanson procedure

Urological procedure for urethral strictures, in which the ventral aspect of the phallus is opened through the urethra. The urethra is secured to the skin and urine is diverted. A second stage completed months later is used to repair the urethra with grafted tissue over a catheter.

Chimeric flaps

Flaps containing multiple tissue types (skin, bone, mucosa.) based on a single angiosome used for complex reconstruction.

V–Y advancement

Local flap used for advancing tissue generally to cover a wound, but can be used in other procedures. An incision shaped like a V is made through the subcutaneous tissue, advanced into its new position relying on subcutaneous perfusion, and closed in a Y pattern.

Heineke–Mekulicz principle

Closure of a urethral stricture with a longitudinal incision followed by a transverse closure.

Transman

A person born with female sexual organs, but whose gender identity is male

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Morrison, S., Chen, M. & Crane, C. An overview of female-to-male gender-confirming surgery. Nat Rev Urol 14, 486–500 (2017). https://doi.org/10.1038/nrurol.2017.64

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