This article is a good summary of surgeries used in medical transition. It is not a study or review of studies, but it is written by two experienced surgeons from the United Kingdom. They provide some numbers related to complications and some valuable information on specific techniques.
It is important to remember that this is not a scientific study or survey; it is a report by surgeons based on their experience. The results in other clinics may be different. If you are seeking surgery, ask your doctor about their work.
The authors’ discussion of sexual pleasure and orgasm is very limited. They do not discuss patient satisfaction. They do not look at the mental health effects of surgery, either, just the physical outcomes.
As always, there are many areas where we do not yet have any studies and we don’t know the answer. We could use more studies and articles about the various techniques, their outcomes, and their complications. Any evaluation of these techniques should include patient satisfaction and sexual function.
So what are the physical outcomes and complications of various surgeries that the authors discuss?
SURGERIES FOR TRANS WOMEN
Some Complications and Risks, Vaginoplasty
Death from pulmonary embolism – 1 in 1000 among recent patients at their clinic.
Pulmonary embolism (blood clot that travels to the lungs) – 2 in 1000 among recent patients at their clinic. The length of the surgery makes blood clots a problem; this clinic works to reduce them.
“MtF surgery can be complicated by all the normal nonspecific complications of major surgery. For instance, venous thromboembolic disease is a particular problem, partly owing to the nature of the operation (pelvic surgery), the prolonged duration of the operation (5 h in some units) and the practice, which is still common, of keeping patients on bed rest for several days after the operation. In our unit, the operative time is reliably in the region of 120–150 min and patients are mobilized immediately after surgery to reduce the risk of thromboembolism. Combined with routine use of low-molecularweight heparins and compression stockings, we have seen only two pulmonary emboli in the last 1,000 MtF surgical procedures (one of which was fatal).”
Clinically significant bleeding – At least 10%. Most of the bleeding is from the “corpus spongiosum surrounding the urethra.”
“Specific to the operation itself, the most common complication of MtF surgery is bleeding. In units with large numbers, labial hematomas are seldom seen, but do occasionally occur. Most may be managed conservatively, but they do result in an increased incidence of wound dehiscence [opening up along the incision], as observed in our institution. The principle source of postoperative hemorrhage is from the corpus spongiosum surrounding the urethra. Even with meticulous suturing, some 10% of patients will experience clinically significant bleeds. This bleeding may be reduced by leaving the postoperative pressure dressing in place for longer, but that in turn can inhibit patient mobilization and may result in increased risk of thromboembolism.”
Fistula (hole) between the rectum and vagina – 6 in 800 at their clinic in 2008 – the numbers are unknown in general and possibly “seriously under-reported.” The cause is unknown.
Fistuals frequently require further surgery and sometimes lead to the removal of the neovagina.
“When a fistula occurs, a defunctioning colostomy is usually needed. About 50% of fistulas will then close spontaneously, but in the remainder further surgery is needed. In difficult cases, removal of the neovagina may be required.”
Narrowing of the urethra – 3-4% minimum rate. This problem causes “dribbling incontinence.” The narrowing develops a few months after the operation and requires surgery. The surgery is usually effective – “although a few do go on to long-term intermittent catheterization.”
Loss of vaginal depth and width – The authors give no numbers, but believe that these complications are under-reported. The loss of depth could be due to loss of skin; in this case a new vaginoplasty is required using using tissue from the bowel. Loss of depth and width could also be caused by not following a proper dilation routine.
“Again, these complications are probably markedly under-reported, as some patients are effectively celibate or do not need much vaginal depth and width for their chosen sexual activities.”
Growth of hair in the vagina – This is caused by not removing hair either before surgery or perioperatively. There is no cure; if your surgeon is using skin from the scrotum, be sure to have the hair removed.
“Once hair growth is seen in the vault of the neovagina, little can be done to prevent its continued growth, and a number of patients will have to return at intervals for removal of hairballs.”
Overall complicate rate – Under 25%. It is not clear exactly what complications they are including in this number.
The authors don’t give numbers on orgasms or sexual satisfaction. In their experience, the vast majority of innervated neoclitorides have sensations.
Some surgeons create additional erogenous sensation by putting the part of the glans penis left after making the clitoris between the urethra and neoclitoris.
Past techniques led to problems with urethtral fistualas and leaking pee, but the techniques have changed.
“The rate of urinary leakage from urethral fistulas was substantial with this technique and it has now been largely superseded by techniques in which the neurovascular bundle to the glans, which lies between Buck’s fascia and the corpora cavernosa, is preserved. This technique has been widely described and seems to provide good rates of sensitivity and sexual satisfaction.”
Creating labia minora is challenging. The best technique to use will depend on how much skin is left from the penis; this may vary depending on the individual and the surgery. There aren’t any guidelines on how to do this.
“Overall, a balance needs to be achieved between construction of a satisfactory neovagina, and a good, realistic, cosmetic external appearance. To date, no guidelines exist that give an indication of when and how penile or scrotal skin should be used for clitoral hood or labia minora reconstruction, or the ideal penile skin length, depth of the vagina or tissue that should be used. The choice of technique for labioplasty is, therefore, largely that of the individual surgeon.”
The authors describe one technique which has a low rate of immediate complications like bleeding, but can lead to peeing upwards or narrowing of the urethra. In addition, this technique leaves in place some erectile tissue that swells during sexual arousal.
The authors prefer a different technique which creates a satisfactory direction of pee and which they believe looks better cosmetically. However it has a raised risk of bleeding.
Specifically, with the first technique they “divide the urethra in the proximal bulb and suture the urothelium direct to the skin (bringing the urethra through the anterior skin flap)” and with the second they “spatulate the urethra, and excise some or all of the corpus spongiosum posterior to the urethral meatus.”
Other Surgeries for Trans Women
The authors briefly mention breast augmentation, vocal cord and throat surgery, and facial feminization surgery.
Breast augmentation in trans women is similar to breast augmentation in cis women, but will be affected by the shape and size of the starting breast tissue and muscles.
Speech therapy is required after vocal cord surgery.
“In facial feminization, good results are achieved by shaving of the frontal bossae, the brow ridges, the mandible angles and the chin, accompanied sometimes by rhinoplasty.”
SURGERIES FOR TRANS MEN
Some Complications and Risks, Metoidioplasty
One of the advantages of a metoidioplasty is that there are few complications and recovery time is “quick.”
“The complication rate is relatively low (overall complication rate <20%)—especially when compared with more elaborate microsurgical techniques, in which complications are reported in 40% of patients.”
The disadvantages of this type of surgery are that it produces a short phallus that may not be capable of sexual penetration. Not everyone can pee standing up.
On the other hand, sexual sensations are well preserved which is a pretty important factor. The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.
“…micturition in a standing position is somewhat, but not always, achievable. Despite the small size, some patients report satisfactory intercourse with female partners, and sensation is usually well preserved. Nevertheless, this approach is not well suited to individuals in whom clitoral hypertrophy is less marked, and the small size of the resultant phallus is unsatisfactory for most patients, not least because it is inadequate to show in clothing and for satisfactory sexual penetration.”
Are they trying to cause dysphoria here? I don’t think there are any numbers on what percentages of trans men prefer which form of surgery.
Some Complications and Risks, Phalloplasty
Overall complication rate – Over 40%. it is not clear exactly what complications they are including.
Microsurgical flap failure – Less than 2%.
Fistulas involving the neourethra – 25-30% in most series.
“Most fistulas will eventually close after a period of catheterization, but many require revision surgery.”
Urethral stricture formation (narrowing of the tube that carries pee out of the body) – 18%.
Postmicturition dribble (dribbling after peeing) – In one study, 79% of patients reported this problem.
Erectile function – Most phalloplasty techniques require the insertion of an inflatable prosthesis to become erect for sexual activity. “…the failure rate for penile prostheses is considerable, usually owing to infection of the device…”
We don’t know much about this yet. “Long-term results on the use of these erectile implants in FtM transsexuals is still lacking.”
There are some techniques that do not require a prosthesis, but they may have other issues.
“When a latissimus dorsi myocutaneous free flap is used, sexual intercourse is possible by contraction of the muscle, which stiffens, but shortens, the penis without requiring a prosthesis. Flaps harvested with bone (for example, fibula or osteocutaneous radial forearm flap) do not need stiffeners, but this flap type results in a permanent erection.”
Sexual sensation – For free-flap phalloplasties, “Sexual sensation with retention of ability to orgasm is usually preserved.” The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.
Different techniques – There are a few different techniques for phalloplasty, but we don’t have any studies comparing them to see which ones are best.
“To date, the gender team at Ghent University Hospital, Belgium, has published the largest series on phalloplasty (with radial forearm flap technique). The investigators demonstrated that the radial forearm flap is a reliable technique, although evidence that other techniques are similarly reliable, or even better than the radial forearm flap, is lacking.”
An earlier review found few studies of mastectomies specifically for trans men. However, as the authors note here, it is important to have a surgeon experienced in mastectomies for trans men. The surgery is not the same as it is for women.
The authors give no numbers on complications but note that people often need minor revisions for cosmetic reasons.
The authors provide a few notes on techniques:
“The exact technique will depend on the volume of breast tissue, and the skin excess and elasticity. In small breasts, a satisfactory result may be achieved by subcutaneous mastectomy via a circumareolar incision, but in most patients more extensive surgery, with additional noticeable scars, is required. For very ptotic breasts, a breast amputation with free nipple– areola complex graft is indicated. Finally, the nipple itself and the diameter of the areola are often reduced. When done properly, the results may be very satisfactory, but poor technique can lead to unacceptable cosmetic results. Minor revisions to ameliorate the final cosmetic outcome are often required.”
Other Surgeries for Trans Men
For scrotal reconstruction, “As long as this advancement of the neoscrotum to the natural position in front of the legs is carried out, very satisfactory results can be obtained with no major complications.”
The authors say patients should get their uteruses and ovaries removed. They don’t provide any additional information on the procedures.
“Patients will also require hysterectomy and ovariectomy, because of the potential risk of endometrial carcinoma with protracted testosterone use, and are usually accomplished laparoscopically at the time of one of the stages of subsequent phalloplasty. The short blind-ended vagina can be left in place or removed.”
We could use more studies and articles on all of the above surgeries.
“Gender reassignment surgery—in which elective surgery is performed to alter an individual’s body to resemble the other sex and in doing so adapt the body to the patient’s perception and lifestyle—is one of the most challenging surgical disciplines.
In MtF surgery, the technique is largely standardized, but refinements are needed to satisfy specific patient requests, such as vaginal depth and ‘perfect’ cosmetic outcome.
In FtM surgery, the variety of techniques available demonstrates that the ideal technique has not yet been identified and, depending on a patient’s request, a different surgical approach should be used. Furthermore, very few centers have the experience of, and subsequently can offer, different techniques for FtM gender reassignment. Moreover, complications are frequent and limitations to the ideal reconstruction are present with every technique used.
The complex psychological background of the patients and their expectations further challenge gender reassignment surgeons. The cooperation of the gender team in making a diagnosis, selecting appropriate patients for surgery, and deciding timing and type of surgical procedures to be performed, is crucial in reducing patients’ regrets or minor dissatisfactions (at both physical and psychosocial functioning levels) as a result of possible complications or for not having achieved the result expected.”
Gender reassignment surgery: an overview by Selvaggi G, Bellringer J. in Nat Rev Urol. 2011 May;8(5):274-8.