Gender Affirmation - 2 - 815961108 PDF

33734
Gender
Medical& Surgical Perspectives
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Gender
Edited by
Christopher J. Salgado, MD
Professor of Surgery and Section Chief,
Division of Plastic Surgery, University of Miami/Jackson Memorial Hospital;
Medical Director of Gender and Sexual Health Programs, Miami, Florida
Stan J. Monstrey, MD, PhD

Professor and Chair,
Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium
Miroslav L. Djordjevic, MD, PhD

Professor of Urology and Surgery, Department of Surgery,
University of Belgrade School of Medicine, Belgrade, Serbia
Assistant Editor
Harvey W. Chim, MD
Assistant Professor, Division of Plastic Surgery,
University of Miami Miller School of Medicine,
Miami, Florida
With Illustrations by Renée Cannon, MA
iii
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CRC Press
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K24940_C000_FM_r5_cl.indd 4 8/26/2016 3:48:02 PM

This book is dedicated to my mother, Margarita M. Salgado, who passed away recently.
She taught me to accept everyone for who they are, to never judge, and to simply love
thy neighbor. This early teaching enabled me to try to understand and to embrace all
individuals, particularly those who are not in the mainstream and have faced external
diffi lties with their identity and gender expression. I have come to love and admire these
individuals, and this has allowed me to care for them with compassion. The transgender
patient has become my focus and has brought me the most gratifying experiences
surgically, emotionally, and personally.
Remembering my mother’s teachings will further motivate me to advance our current

techniques in gender surgery and modify them based on evaluated outcome studies.
If we closely scrutinize our results and adjust our techniques, each patient’s transition
will enhance our care of the next patient.
I will continue to find strength in the care of this very special group of strong, determined
individuals. These patients inspire us every day by their bravery and belief in themselves,
even in the face of adversity.
C.J.S.
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EXECUTIVE EDITOR Sue Hodgson
SENIOR PROJECT EDITING MANAGER Carolyn Reich
SENIOR DEVELOPMENTAL EDITOR Megan Fennell
EDITORIAL ASSISTANT Ellen Wynne
GRAPHICS MANAGER Brett Stone
DIRECTOR OF ILLUSTRATION AND DESIGN Brenda Bunch
SENIOR MANAGING EDITOR Suzanne Wakefiel
PROJECT MANAGER Idelle Winer
PRODUCTIONISTS Debra Clark, Chris Lane
PROOFREADER Linda Maulin
INDEXER Nancy Newman
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Contributors
Clara Alvarez-Villalba, MD Melany Castillo, MD

Assistant Professor of Psychiatry, Department of Division of Endocrinology, Diabetes and Metabolism,
Psychiatry and Behavioral Sciences, University of University of Miami Miller School of Medicine, Miami,
Miami Hospital Miller School of Medicine, Miami, Florida
Florida
Harvey W. Chim, MD
Marta Bizic, MD Assistant Professor, Division of Plastic Surgery,
Department of Urology, University Children’s Hospital, University of Miami Miller School of Medicine, Miami,
University of Belgrade School of Medicine, Belgrade, Florida
Serbia
Britt Colebunders, MD
Walter O. Bockting, PhD Resident in Plastic Surgery, Department of Plastic
Professor of Medical Psychology (in Psychiatry and Surgery, Ghent University Hospital, Ghent, Belgium
Nursing), Division of Gender, Sexuality, and Health;
Research Scientist, New York State Psychiatric Institute Curtis Crane, MD
and the Columbia University Department of Psychiatry Department of Plastic Surgery and Reconstructive
and the Columbia University School of Nursing, New Urology, Stanford Adjunct Clinical Faculty, San
York, New York Francisco, California
Mark-Bram Bouman, MD, FESSM Salvatore D’Arpa, MD, PhD

Department of Plastic, Reconstructive and Hand Adjunct Kliniekhoof, Department of Plastic and
Surgery; Centre of Expertise on Gender Dysphoria, Reconstructive Surgery, Ghent University Hospital,
Vrije University Medical Center, Amsterdam, The Ghent, Belgium
Netherlands
Miroslav L. Djordjevic, MD, PhD
Marci L. Bowers, MD Professor of Urology and Surgery, Department of
Plastic Surgeon, Private Practice, Trinidad, Colorado Surgery, University of Belgrade School of Medicine,
Belgrade, Serbia
Marlon E. Buncamper, MD
Plastic Surgeon, Department of Plastic, Reconstructive Christopher Estes, MD
and Hand Surgery, Vrije Universiteit, Amsterdam, The University of Miami School of Medicine, Transgender
Netherlands Center, Obstetrics and Gynecology, Miami, Florida
Luis Capitán, MD, PhD Lydia A. Fein, MD, MPH

Oral and Maxillofacial Surgeon, Specialist in Facial Resident, Department of Obstetrics and Gynecology,
Feminization Surgery, FACIALTEAM Surgical University of Miami/Jackson Memorial Hospital,
Group, Department of Surgery, Marbella High Care Miami, Florida
International Hospital, Marbella, Malága, Spain
vii
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Contributors
Renee Gasgarth, MD Daniel Simon, DDS

Chief Resident, Department of Plastic Surgery, Oral and Maxillofacial Surgeon, Specialist in Facial
University of Miami/Jackson Memorial Hospital, Feminization Surgery, FACIALTEAM Surgical
Miami, Florida Group, Department of Surgery, Marbella High Care
International Hospital, Marbella, Malága, Spain
Piet Hoebeke, MD, PhD
Professor of Paediatric Urology, Department of Varsha R. Sinha, MD
Urology, Ghent University Hospital, Ghent, Belgium Resident, Department of Urology, University of Miami/
Jackson Memorial Hospital, Miami, Florida
Michelle Horne, AICI, CIP
Image Consultant, Putting It Together Image Vishal K. Sinha, BS
Consulting, Carleton Place, Ontario, Canada Medical Student, University of Miami Miller School of
Medicine, Miami, Florida
Natalie R. Joumblat, BS
Research Associate, Department of Plastic Surgery, Norman P. Spack, MD
University of Miami Miller School of Medicine, Miami, Associate Physician in Medicine Emeritus, Department
Florida of Medicine, Boston Children’s Hospital, Boston,
Massachusetts
Sinisa Kojic, MD, PhD
Surgeon, Department of Plastic, Reconstructive Klara Sputova, MD
and Aesthetic Surgery, St. Medica General Hospital, University of Miami Miller School of Medicine, Miami,
Belgrade, Serbia Florida
Jamie P. Levine, MD Dusan Stanojevic, MD

Associate Professor of Plastic Surgery, Hansjör Wyss Medical Faculty, University of Belgrade, Belgrade,
Department of Plastic Surgery, NYU Langone Medical Serbia
Center, New York, New York
Borko Stojanovic, MD
Nicolaas Lumen, MD, PhD, FEBU Department of Urology, University Children’s Hospital,
Professor and Head of Clinic, Department of Urology, University of Belgrade School of Medicine, Belgrade,
Ghent University Hospital, Ghent, Belgium Serbia
Wilhelmus J.H.J. Meijerink, PhD, MD Amir Adam Tarsha, MD

Colorectal Surgeon, Department of Surgery, Vrije Resident, Department of Psychiatry and Behavioral
University, Amsterdam, The Netherlands Sciences, Northwestern University, Chicago, Illinois
Stan J. Monstrey, MD, PhD James P. Th mas, MD

Professor and Chair, Department of Plastic Surgery, Private Practice, VoiceDoctor, Portland, Oregon
Ghent University Hospital, Ghent, Belgium
Wouter B. van der Sluis, MD
Christopher J. Salgado, MD Research Fellow, Department of Plastic, Reconstructive
Professor of Surgery and Section Chief, Division of and Hand Surgery, Vrije University, Amsterdam, The
Plastic Surgery, University of Miami/Jackson Memorial Netherlands
Hospital; Medical Director of Gender and Sexual
Health Programs, Miami, Florida Marilyn K. Volker, EdD
Adjunct Faculty, University of Miami, St. Thomas
Daniel E. Shumer, MD, MPH University, Florida International University, Barry
Assistant Professor, Department of Pediatrics and University, Miami; Private Practice, Sexologist/Gender
Communicable Diseases, University of Michigan, Ann Specialist, Miami, Florida
Arbor, Michigan
viii
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Contributors
Roy E. Weiss, MD, PhD, FACP, FACE, FAAP Lee C. Zhao, MD

Kathleen and Stanley Glaser Distinguished Chair and Assistant Professor, Department of Urology, New York
Professor, Department of Medicine, University of University School of Medicine, New York, New York
Miami Miller School of Medicine, Miami, Florida
Yasmina Zoghbi, BS
Yuka Yamaguchi, MD Medical Student, DeWitt Daughtry Family Department
Department of Pediatrics, University of California of Surgery, Division of Plastic, Aesthetic and
San Diego School of Medicine, La Jolla, California Reconstructive Surgery, University of Miami Miller
School of Medicine, Miami, Florida
ix
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K24940_C000_FM_r5_cl.indd 10 8/26/2016 3:48:03 PM
Preface
As surgeons who have long cared for transgender patients, we were inspired to write Gender
Affirmation: Medical & Surgical Perspectives as we watched the rapid evolution of transgen-
der medicine and surgery occurring around us. We began working in this fi ld long before
transgender celebrities graced the headlines of every media outlet and before the use of
public restrooms sparked contentious political debate. This new wave of public attention,
along with increasingly accessible health care, has inspired an ever-growing number of prac-
titioners to care for transgender individuals. What was once a niche specialty with a small
number of physicians has now sparked the interest of the international medical community.
Since the fi st gender-affirming procedures were performed in the early twentieth century,
the fi ld of transgender surgery has been advanced by the ingenuity, curiosity, and audac-
ity of individual surgeons. The complex operations have been passed from one generation
of surgeons to the next largely by apprenticeship, because formalized academic training
in the fi ld, by which medical specialties are traditionally taught, has not existed. Only in
recent years, with the formation of the World Professional Association of Transgender
Health and a few established academic surgical centers accepting trainees, has there been
a unifying organizational body and an opportunity for formalized training. The physicians
who have pioneered cross-sex hormone and puberty-blocking therapies as well as mental
health providers have faced similar challenges within their fi lds.
Given the history of transgender medicine, we are elated to bear witness to this new genera-
tion of physicians and to be a part of the professional transformation that has taken hold of
our growing specialty. We are proud to be among the veterans, but also recognize that with
this distinction comes responsibility. Our transgender patients are among our most cher-
ished, and we have witnessed their painstaking journeys and fi mly believe that they are
deserving of the highest level of care. We believe that during a time of such rapid growth,
we must remain committed to preserving the integrity of the field and the standards of care
to which we abide. Therefore we came together, along with international leaders in trans-
gender medicine and surgery, to produce this book to provide the medical community with
an unparalleled reference for transgender medical and surgical care.
Th s book begins with an Introduction that establishes the context for the issues that face
our patients and the processes that are undertaken to assist them in making a successful
transition. The book is organized to focus on the intricacies of surgical and medical inter-
ventions to help individuals transition to their true gender.
The importance of establishing feminine facial harmony for transgender women cannot be
underestimated, and the surgical aspects of these varied interventions are well illustrated
and detailed. Although hormonal and nonsurgical but therapeutic influences on voice of-
ten facilitate transition from male to female and female to male, surgical interventions are
also addressed to expand options in this aspect of transgender care.
xi
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Preface
Chest conversion, an intervention requiring support by the patient’s mental health thera-
pist, is for some patients their fi st surgical procedure. Conversion from a male-to-female
and female-to-male chest is beautifully detailed and illustrated. The safe incorporation of
a hysterectomy and oophorectomy is also addressed. Gender affirmation bottom surgery,
or genital sexual reassignment, is one of the most challenging procedures in all of surgery
because of its complex anatomy, the risk of injury to bowel and bladder, the necessity for
sensorineural, urinary, and sexual function, and the goal of obtaining aesthetic optimi-
zation. Conversion from male-to-female and female-to-male procedures are elucidated,
presenting all forms of reconstructive options and the preferred techniques based on geo-
graphic regions of the world. Implant placement in transgender males who have undergone
gender affirmation surgery remains a particular challenge. Operative techniques for achiev-
ing successful, safe outcomes are detailed by the most experienced surgeons in the world.
Despite our best efforts, extremely complex operations may occasionally lead to complex
postoperative complications. A candid approach to the diagnosis and management of un-
toward events following GAS procedures is detailed and illustrated, as well as the very im-
portant aspects of sexual therapy following these innovative and technologically advanced
procedures.
The psychological impact of the initial stages of an individual’s transition is addressed in a

chapter on mental health assessment and the management of gender dysphoria according
to the clinical guidelines of the WPATH. Hormonal therapy beginning in the prepubes-
cent or adult stage is addressed, adhering to Endocrine Society standards, and therapeutic
regimens are provided. An invaluable facet of assisting individuals in their transition is
addressed in a chapter on gender expression, emphasizing the value of image consultants
in coaching transgender person on speech, manner of dress, hairstyle, posture, walk, and
body language to assist individuals to present themselves as their true gender.
Th s reference offers readers the essential information on care for those in male-to-female
and female-to-male transition. In addition, an e-book is provided for easy, portable access,
with video clips that demonstrate state-of-the-art techniques for gender affirmation surgery.
We are honored to be a part of the advancement of transgender medicine and are inspired
by the exceptional patients who invite us to be a part of their transitions. With this publi-
cation, our goal is to both educate and to provide new insight into this incredible fi ld. As
transgender health care moves toward a new horizon of an ever-growing number of pro-
viders, greater access to care, and formalized training, we are confide t that Gender Affir-
mation: Medical & Surgical Perspectives will be an important guide for all those committed
to the highest level of care for transgender individuals.
Christopher J. Salgado
Stan J. Monstrey
Miroslav L. Djordjevic
xii
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Contents
Introduction 1
Christopher J. Salgado, Lydia A. Fein
1 Facial Feminization Surgery: A Global Approach 3

Luis Capitán, Daniel Simon
2 Speech Modifi ation 31

James P. Thoma
3 Top Surgery 51
Britt Colebunders, Salvatore D’Arpa, Stan J. Monstrey
4 ombined Hysterectomy, Oophorectomy, and Chest Reconstruction

C
in Female-to-Male Transgender Patients 67
Christopher J. Salgado, Renee Gasgarth, Lydia A. Fein, Christopher Estes
5 Male-to-Female Gender Affirmation Skin-Flap Vaginoplasty 83

Miroslav L. Djordjevic, Dusan Stanojevic, Marta Bizic
6 ale-to-Female Gender Affirmation Colon Vaginoplasty: Total

M
Laparoscopic Sigmoid Vaginoplasty 95
Mark-Bram Bouman, Wouter B. van der Sluis, Marlon E. Buncamper,
Wilhelmus J.H.J. Meijerink
7 Female-to-Male Gender Affirmation Metoidioplasty 109

Marci L. Bowers, Borko Stojanovic, Marta Bizic
8 emale-to-Male Gender Affirmation Phalloplasty: Radial

F
Forearm Free Flap 119
Christopher J. Salgado, Harvey W. Chim, Varsha R. Sinha, Piet Hoebeke, Stan J. Monstrey
9 Anterolateral Thi h Flap Phalloplasty 135

Stan J. Monstrey, Salvatore D’Arpa, Britt Colebunders, Nicolaas Lumen, Piet Hoebeke
Expert Commentary 151

Curtis Crane, Klara Sputova
xiii
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Contents
10 Female-to-Male Gender Affirmation Phalloplasty: Latissimus

Dorsi Flap 155
Miroslav L. Djordjevic, Sinisa Kojic, Borko Stojanovic
11 Testicular and Erectile Implants in Transmen After Phalloplasty 171

Piet Hoebeke, Nicolaas Lumen
12 Management of Unfavorable Urologic Sequelae After Phalloplasty

in Transgender Patients 177
Yuka Yamaguchi, Jamie P. Levine, Lee C. Zhao
13 Unfavorable Results and Complications in Phalloplasty Surgery 189

Salvatore D’Arpa, Nicolaas Lumen, Piet Hoebeke, Christopher J. Salgado, Vishal K. Sinha,
Natalie R. Joumblat, Stan J. Monstrey
14 Medical Treatment of Adolescent Transgender Patients 209

Daniel E. Shumer, Norman P. Spack
15 Adult Hormone Therapy in Transgender Patients 223

Melany Castillo, Roy E. Weiss
16 Mental Health Care for Transgender and Gender Nonconforming

Children, Adolescents, and Adults 243
Walter O. Bockting, Amir Adam Tarsha, Yasmina Zoghbi, Clara Alvarez-Villalba
17 Sexual Health After Surgery for Transgender Individuals 259

Marilyn K. Volker, Lydia A. Fein
18 Gender Expression and Image 273

Michelle Horne, Lydia A. Fein
Credits 285
Index 287
xiv
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Video Contents
1-1 Facial Feminization Surgery: Forehead Reconstruction

1-2 Burring of the Lateral Brow

1-3 Facial Feminization Surgery: Hairline Lowering Surgery

1-4 Facial Feminization Surgery: Adam’s Apple Reduction

2-1 Feminization Laryngoplasty

James P. Thomas
5-1 Male-to-Female Penile Skin Inversion

6-1 Colon Vaginoplasty Result

8-1 Insertion of Foley Catheter in the Bladder

8-2 Transgender Male Urinating in Standing Position

xv
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K24940_C000_FM_r5_cl.indd 16 8/26/2016 3:48:03 PM
Gender
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K24940_C000_FM_r5_cl.indd 18 8/26/2016 3:48:03 PM
Introduction
Christopher J. Salgado, Lydia A. Fein
The rapidly evolving field of transgender health and the need for well-educated provi -
ers caring for transgender and gender nonconforming persons provided the impetus for
this book. Gender Affirmation: Medical & Surgical Perspectives arrives at a time when
transgender persons have been thrust into the spotlight of media, politics, and culture,
which has sparked an international human rights debate. As transgender actors, athletes,
and activists are celebrated in popular culture, the acceptance and inclusion of trans-
men and transwomen within society continues to grow. In the health sector, transgender
individuals have also experienced great victories, with the widespread expansion of in-
surance coverage for transgender health care, including gender affirmation surger , and
the surge of providers who seek to include transgender persons among their patients.
Despite these successes, we must not forget the continued challenges faced by trans-
gender persons, as evidenced by the recent hate crime targeting the LGBT community
in Orlando, Florida, and the discriminatory North Carolina “bathroom law” that has
initiated an abhorrent precedent with reverberations around the country. Over the past
year, an increase in violence against transgender persons has plagued the United States,
including a record number of murders. In addition to these societal threats perpetuated
by misinformation and unfounded hate, many of these individuals also face socioeco-
nomic and personal challenges that lead to high rates of psychiatric comorbidities such
as depression. Among transgender individuals, suicide attempts occur at a rate forty
times higher than in the general population. It is therefore incumbent on health care pro-
viders to ensure the highest quality of care for transgender patients. As an ever-growing
number of health care providers incorporate transgender care into their practices, it is
imperative that we ensure appropriate training as well as high-quality evidence-based
tools to guide their management. It is our goal with the publication of this book to con-
tribute to this fund of knowledge.
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INTRODUCTION

This book delivers robust content from internationally recognized innovators and ex-
perts in the fi ld of transgender medicine and surgery. The text provides detailed in-
formation about all stages of an individual’s transition, including discussions of initial
lifestyle modifications mental health assessment, and management of gender dyspho-
ria in accordance with the clinical guidelines of the World Professional Association of
Transgender Health (WPATH). Hormonal therapy, both in the prepubescent and adult
stages, is addressed, with management and guidelines that adhere to Endocrine Society
standards. In addition, comprehensive, cutting-edge techniques and illustrations of all
surgical procedures associated with gender transition are detailed.
Gender transition is a uniquely individualized and multifaceted process, one that can
be lifelong and arduous, but also one that has been shown to help to alleviate the sig-
nificant distress often experienced by transgender persons and improve their qualit
of life. The challenges of the transition process ultimately lead to infinite rewards for
transmen and transwomen, but the complexity of each stage requires providers who
are skilled in their disciplines and can offer the best care to transgender individuals.We
strongly believe that every transgender person who is transitioning deserves a team of
well-trained, committed, and compassionate providers. This book provides a roadmap
for dedicated health care professionals to support the profound journey embarked on
by these transgender individuals.
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CHAPTER
1
Facial Feminization Surgery:
A Global Approach
Key Points
❖❖ Facial feminization surgery is primarily based ❖❖ Forehead reconstruction, which has a signifi-
on structural bone modification and the conse- cant impact on facial gender identification, is
quent readaptation of the overlying soft tissues one of the key procedures in facial feminization Fa
to the modified bone structure. surgery.
❖❖ Through bone sculpture, the volume or shape ❖❖ A preliminary and meticulous evaluation and
of the craniofacial skeleton can be modified by diagnosis of a patient are essential to adapt the
means of osteotomies, burring, or a combina- surgical options to her individual needs rather
tion of both. Bone sculpture is the keystone of than taking a standardized approach.
facial feminization surgery. ❖❖ The goal of facial feminization surgery is to
❖❖ When facial feminization surgery is performed obtain natural results with the use of hidden
to adjust the facial features that influence the approaches, protocolized surgical techniques,
visual identification of a person’s gender, it can and standardized postoperative management.
also be called facial gender affirmation surgery.
K24940_Book.indb 3 8/22/2016 7:15:04 AM

CHAPTER 1
Facial Feminization Surgery: A Global Approach
The best way to begin this chapter on facial feminization surgery (FFS) is to pose the fol-
lowing question: Is the face important when it comes to recognizing a person’s gender?
Indeed, modifying facial gender in the transition protocol is undoubtedly as important as
hormone therapy and genital reconstruction. Feminizing what are visually identifi d as
masculine facial traits raises the self-esteem and confide ce of patients, leading to greater
acceptance in their personal and family circles, better adaptation in the workplace, and a
dramatic decline in social rejection, which unfortunately a large number of transgender
patients continue to experience to this day.1,2
What Is Facial Feminization Surgery?

From a technical point of view, FFS can be defi ed as the set of surgical procedures asso-
ciated with different surgical specialties (oral and maxillofacial surgery, craniofacial sur-
gery, and plastic and reconstructive surgery) designed to soften and modify facial features
perceived as masculine, exaggerated, or nonharmonic and therefore decisive in the visual
identifi ation of facial gender.3
These features are defi ed by different craniofacial skeletal structures. In general, the three
basic pillars of craniofacial gender are the frontonasal-orbital complex, the nose, and the
jaw and chin complex. However, other structural elements, including the cheeks or the
trachea, are also important when addressing a patient’s feminization needs and will be dis-
cussed in this chapter.
FFS is not cosmetic surgery and should not be mistaken as such. However, it does overlap
to some degree, and that can cause a great deal of confusion for patients. Facial feminiza-
tion is based on bone surgery and the readjustment of the overlying soft issues over the
modifi d bone structure. In some patients, especially older ones, the soft tissue may be too
slack to readapt fully to changes in the jaw and chin area. In these patients surgical adjust-
ment (lifting) of the soft issues may be required. Th s kind of adjustment should not be
undertaken at the same time as jaw and chin surgery but should be done several months
later, when the swelling from the jaw and chin surgery has subsided.
The purpose of FFS is to treat gender dysphoria, helping the patient feel more comfortable
in her own body, but also helping her to be perceived by others as the woman she is.
Facial gender modifi ation surgery that is accurate, predictable, and established by protocol
must begin with an exhaustive functional, anatomic, aesthetic, and surgical understanding
of the craniofacial skeleton.
Primary Aspects: Gender of the Craniofacial

Skeleton
The effect of testosterone and its derivatives, particularly during puberty, conditions the
appearance of facial features related to gender identity,4 which can be divided into primary
and secondary aspects. Primary aspects—those features determined by the development of
the craniofacial skeleton—differentiate the masculine and feminine craniofacial structure
in signifi ant ways.5 Generally speaking, the male facial skeleton has greater bone volume
and some well-defi ed features that distinguish it from its female counterpart. These dif-
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CHAPTER 1
Nose area Lower jaw body Temporal ridges Frontal bossing and supraorbital rims
Lower jaw angles Chin Cheeks Frontal region
Fig. 1-1 Male skull in three positions, color coded to designate the different areas responsible for facial gender iden-
tification.
ferentiating features appear in the frontonasal-orbital complex, nose, malar region, jaw and
chin complex, dentition, and thyroid cartilage (Fig. 1-1).
Frontonasal-Orbital Complex
The frontonasal-orbital complex is quite possibly the greatest determinant of facial gen-
der.3,6-9 Th s region encompasses the forehead, supraorbital ridge, eye sockets, frontal boss-
ing, frontomalar region, temporal ridges, and frontonasal transition. It determines the posi-
tion of the eyebrows and the positioning of the periorbital soft tissues, such as the eyelids.
Typically, all of these areas are more pronounced and have greater bone volume in the male
skeleton than in the female skeleton.
Nose
From the perspective of gender difference, the male nose is generally larger than the female
nose because of the increased volume of bone and cartilage. These differences are most vis-
ible at the nasal dorsum and tip of the nose.
Malar Region
The cheek area (zygomaticomalar region of the facial skeleton) usually has some structural
differences that must be defi ed, because it can readily lead to confusion with regard to fa-
cial feminization. As a general rule, malar bone volume is greater in men, which can result
in well-defi ed cheeks. However, prominent, round cheeks in the middle third of the face
are compatible with femininity because woman have a greater concentration of fat in this
area (that is, the greater volume is not from the bone but from the soft issues). Th s has
specific implications when it comes to deciding the best treatment for this region.
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CHAPTER 1
Jaw and Chin Complex

Along with the frontonasal-orbital region and the nose, the complex formed by the jaw and
chin constitutes the third pillar of craniofacial gender features.
The male jaw has a series of characteristics that can influence the perception of facial gender.
To better understand the jaw, we need to consider it divided into the mandibular angle area
and the mandibular body. The mandibular angle area is usually squarer, with well-defi ed
corners. The mandibular body typically has greater bone volume, which produces a wider
lower facial third in men than in women. It also gives the male jaw its greater vertical height,
an important factor when planning mandibular reshaping techniques in FFS.
The chin tends to be squarer in men, with more pronounced and defi ed transitions be-
tween the chin and mandibular body, with greater bone volume and a more signifi ant
vertical dimension. Gender does not necessarily determine the position of the chin; for
instance, retropositioned or overprojected chins can be found in both men and women.
However, a well-defi ed and projected chin may improve the overall aesthetics of the jaw-
chin region.
Dentition
Despite the differences in male and female dentition, which are primarily associated with
the format and size of the teeth, at this time this is not a standard line of treatment in FFS.
Although some teams have worked with teeth to increase the perception of femininity, few
protocols have been established in this area.
Thyroid Cartilage (Adam’s Apple)

On its own, this feature is one of the most prominent hallmarks of male gender and a true
source of stigma for a large number of transgender women.
The tracheal structure, which plays a key role in such basic life processes as breathing and
phonation, has a greater volume and is greater in diameter and longer in men. The tracheal
structure itself should never be approached with the idea of feminizing it, because this
poses the unacceptable and unnecessary risk of damaging the vocal cords or even caus-
ing respiratory problems. Only the most prominent part of the thyroid cartilage should be
modifi d. Th s allows a signifi ant reduction in the Adam’s apple without compromising
structural integrity.
The development of the structures previously described under hormonal influence is not
reversible, and thus these features, which determine a signifi ant part of an individual’s fa-
cial gender, can only be approached and modifi d with surgery. The surgeon must always
respect the intrinsic architecture and anatomy of the craniofacial skeleton (Fig. 1-2).
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CHAPTER 1
Fig. 1-2 Three-dimensional CT scan study comparing female (left) and male (right) skulls.
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CHAPTER 1
Secondary Aspects
In addition to structural facial features, a series of secondary traits are equally important in
the identifi ation of facial gender. These include, most notably, the hair and hairline shape,
facial hair, skin texture, and the distribution and volume of facial fat.
The male hair may be conditioned by androgenic alopecia (loss of hair from hormonal influ-
ence) and have an M-shaped primary hairline, with recessions at the temples.10 The hairline
of women usually has a rounded shape; their hair is not normally affected by alopecia, and
proportionally the hairline implantation is higher in the center than in men.11,12 Almost all
men have facial hair, which to a large extent conditions their skin type and quality, making
it thicker and rougher. For many patients, facial hair is an important determining factor in
their transition process.
The distribution and volume of facial fat are equally influenced by hormones. Women have
a greater volume of facial fat, with the distribution more concentrated in the middle third
of the face (cheek area).13
Because all of these features can be heavily determined by hormones, they generally re-
spond well to hormone therapy.14 Conceptually, secondary features play an important role
in determining facial gender, and therefore it is preferable to treat them before beginning
structural FFS (Fig. 1-3).
Fig. 1-3 Patient before and 1 year after hormone treatment; note the change in secondary aspects
(hair, facial hair, skin texture, and facial fat) before any type of surgical procedure was performed.
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CHAPTER 1
Evaluation and Diagnosis

One of the most important preliminary steps in FFS is a meticulous evaluation and diag-
nosis of the patient. Each patient has a unique facial structure, with specific eatures re-
sponsible for the male identifi ation of the face, so it is important to adapt surgical options
to a patient’s individual needs rather than taking a standardized approach. Th s diagnosis
includes an accurate clinical evaluation, imaging tests, an evaluation of patient requests,
and adjusting expectations. In addition, it is extremely important that photographs be taken
systematically throughout the entire feminization process.
Clinical Evaluation
Clinical evaluation consists of recognizing the features that contribute to male facial iden-
tifi ation in a particular patient and identifying which of these features can be realistically
and predictably modifi d with surgery. In this process, a distinction must be made between
secondary aspects, which can be corrected with nonsurgical treatment, and the primary
aspects that are conditioned by the individual’s craniofacial structure. Th s is why it is pref-
erable for the patient to begin her hormonal transition early enough (at least 1 year before
surgery), so that the secondary aspects do not obscure the diagnosis. The surgeon’s experi-
ence is essential when deciding the procedures that can most effectively contribute to the
feminization of the face and therefore achieve a satisfactory result.
The features that must be analyzed to obtain a thorough evaluation are listed here. The pro-
cess is more easily understood when we differentiate four key areas:
1. Upper third: Hairline and frontonasal-orbital complex
2. Middle third: Nose, cheeks, and upper lip
3. Lower third: Jaw and chin
4. Neck: Thyroid cartilage (Adam’s apple)
Each of these features must be evaluated not only on an individual basis but also in the
context of the proportionality and symmetry of the face as a whole. Later in this chapter
we analyze the details related to the evaluation of some specific features.
Imaging Tests
Imaging tests are an essential part of a correct diagnosis and proper surgical planning. To-
day the combination of CT and three-dimensional reconstruction makes it possible to ob-
tain detailed anatomic information. Th s is essential to detect the facial features that can be
modifi d; these tests can provide the patient with precise information and assist in surgical
planning. Moreover, comparing these preoperative images with postoperative CT results
is extremely useful in assessing and explaining the changes made to the bone structure.
In some patients we recommend the use of stereolithographic three-dimensional models

to improve preoperative planning. In this respect the standardized incorporation of three-
dimensional printing is an important advance in diagnosis.
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CHAPTER 1
Evaluating Requests and Adjusting Expectations

It is critical to listen to and understand the patient’s own ideas about her face. She will often
provide valid ideas about the features that from her perspective determine the recognition
of her facial gender. However, patients often have ideas about the possible results of their
feminization surgery that are far from reality. The surgeon must explain that the surgery will
modify certain features; at no time will surgery modify the core identity of the patient’s face
or change it completely, because this is counter to the principle of naturalness, which is a
basic tenet of facial gender modifi ation surgery. If these factors are correctly addressed by
the FFS specialist through suffici t consultation methods, the facial feminization treatment
has the potential to emerge as a crucial step in the complex process of transition (Fig. 1-4).
1. Patient ideas about her needs
2. Clinical evaluation:
Masculine facial features identification
Hairline
Upper third Forehead

Cheeks
Nose
Middle third Upper lip
Lower jaw
Lower third Chin
Neck Adam's apple
3. Complementary evaluation:
Three-dimensional CT scan, stereolithography,
three-dimensional models, virtual FFS
4. Adjustment patient expectations
5. Definition of ideal treatment plan
Fig. 1-4 Evaluation and diagnosis protocol.
10
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CHAPTER 1
Collecting Photographs
The entire process of a patient’s facial gender modifi ation must be recorded in photographs,
following a clear protocol. These should include clinical photographs, both preoperative
and postoperative (7 days, 6 months, and 1 year after surgery), as well as intraoperative
photographs of the procedures performed (Fig. 1-5).
Th s complete photographic record gives an objective view of the changes obtained with
FFS at different stages of the patient’s postoperative evolution.
Fig. 1-5 Representative preoperative and intraoperative photographs taken before and during the FFS procedure.
Continued
11
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CHAPTER 1
Fig. 1-5, cont’d Postoperative results in the same patient after FFS procedure.
Virtual Facial Feminization Surgery

Virtual facial feminization surgery (VFFS) is a powerful tool that makes it possible to pre-
dict the potential results of an FFS procedure with a high degree of realism (Fig. 1-6). It
helps the patient to understand the effect of the proposed procedures on her facial gender;
it also helps to adjust her expectations. For the surgeon, this tool is particularly useful when
evaluating and diagnosing each case. The predicted results are always midterm or long-term
depictions after the postoperative recovery phase has ended. Patients must be made aware
of this fact when presented with their virtual result.
VFFS must be done by experts in facial gender who can realistically predict the expected
facial changes after the bone structure has been modifi d. However, as with all simulations,
there is some margin of variability with respect to the results obtained with FFS.
12
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CHAPTER 1
Fig. 1-6 VFFS imaging. (Courtesy of Alexandra Hamer.)
Facial Feminization Procedures

Surgeons must be able to clearly describe the main procedures that make up FFS, including
a technical description and clarifi ation of some important concepts that might otherwise
lead to confusion. Any patient undergoing FFS must have clear, detailed information about
the techniques, how they are carried out, the associated postoperative experience, and all
of the potential risks and complications. All of this information must be contained in spe-
cific informed consent forms for each of the procedures, which the patient must sign after
13
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CHAPTER 1
reading and understanding the information well in advance of the operation and after any
resulting questions have been answered.
Once again, the face is divided into thirds, and the most important procedures for each
third are discussed.
The Upper Third: Forehead and Hairline

Forehead Reconstruction
Video Forehead reconstruction is one of the basic procedures in facial feminization. It completely
1-1
modifies the frontonasal-orbital region and softens and feminizes the patient’s expression.
The surgical objective is to reposition and remodel the forehead complex. Th s is best
achieved by combining bone sculpture and frontonasal-orbital reconstruction, including
osteotomy and repositioning of the anterior wall of the frontal sinus.3 The sequence in Fig.
1-7 and Video 1-1 provides a step-by-step description of the reconstruction technique pro-
posed by our team.
A B C
D E F
Fig. 1-7 Step-by-step sequence of the forehead reconstruction technique in FFS. The example shows a modified coronal
approach. Forehead reconstruction technique sequence. A, Patient’s profile before surgery. B, Modified coronal approach,
with elimination of the scalp strip. C, Coronal flap, preserving the frontal branch of the facial nerve. D, Pericranial flap until
the frontonasal-orbital ridge and both frontomalar apophyses are reached. E, Skull profile; note the protrusion of the frontal
bossing. F, Osteotomy of the anterior wall of the frontal sinus with a saw.
14
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CHAPTER 1
G H I
J K L
Fig. 1-7, cont'd G, Access to the frontal sinus. The anterior wall is preserved in saline solution during skull recontouring.
H, Sculpture of the entire frontonasal-orbital complex, with special attention to the frontonasal transition. I, Elimination of
bony interferences of the anterior wall of the frontal sinus. J, Stable fixation of the anterior wall of the frontal sinus with os-
teosynthesis. K, Meticulous closure of the pericranial flap and placement of resorbable anchors (Endotine forehead fixation
device, Coapt Systems, Palo Alto, CA) to achieve the correct repositioning of the eyebrows over the new bone structure.
L, Patient’s profile after surgery.
With this procedure, it is possible to soften all of the anatomic areas in the forehead region
(frontal bossing, supraorbital rims, frontomalar buttresses, and temporal ridges), improve
the frontonasal transition, refi e the orbital opening, and maintain the anatomic integrity
of the entire region. For these reasons, we recommend using this technique, even with pa-
tients with sinus agenesis (patients lacking a frontal sinus).15 Although other authors6,7,9,16 Video
defend different techniques (for example, isolated burring and the use of filling materials), 1-2
in our experience, the proposed reconstruction technique offers satisfactory and safe re-
sults, regardless of the anatomy of the frontal region (Fig. 1-8).
15
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CHAPTER 1
Fig. 1-8 Preoperative, postoperative, and intraoperative photographs of forehead reconstruction. Note the fixation
mechanism used (osteosynthesis with a titanium microscrew). The procedures performed included forehead recon-
struction, rhinoplasty, and Adam’s apple reduction.
Finally, it is important to discuss the best access (approach route) to reach the frontal bone
region—the hairline approach or a modified coronal approach. In our opinion, this access
should be based on the characteristics of the patient’s hairline and its implantation (the dis-
tance from the nasal root to the beginning of the hairline). We will describe both techniques.
Hairline Treatment
The hairline is a basic part of facial gender identifi ation and therefore must be approached
optimally to obtain satisfactory and natural results in the upper third of the face. At this
16
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CHAPTER 1
A B
Fig. 1-9 Comparison of the two types of hairline implantation. A, Candidate for surgical hairline low-
ering; note the round hairline pattern and its high implantation (excessive forehead height) in the pre-
operative photograph. B, Candidate for a forehead reconstruction with immediate hair transplantation.
Note the M-shaped hairline pattern and suitable forehead height (nasal root–hairline distance) in the
preoperative photograph.
time, two alternatives exist for hairline treatment: hairline-lowering surgery and redefini g
the hairline with hair transplantation.
Hairline-Lowering Surgery Lowering of the hairline is recommended only for patients

with a round hairline pattern (without any or with only mild recession at the temples) and
a signifi ant and disproportional higher implantation of the hairline toward the center.17
For those transwomen with hairline implantation within feminine parameters and with
temple recession, this technique is not recommended, because it does not improve or cor-
rect the recessions. Th s means that surgical lowering of the hairline is not the treatment
of choice for most transpatients. In our experience a hairline approach is only suitable for
1 of every 20 patients (Fig. 1-9).
The hairline-lowering surgical technique consists of removing a maximum 2 cm strip of

skin and locating the incision area (future scar) some 2 mm inside the hair, following the
implantation line. Hairline advancement is achieved by placing a resorbable fix tion device
(Endotine forehead fix tion device 3.0), which not only expedites the advancement but Video
also eliminates the tension between the edges of the wound, which helps to produce a bet- 1-3
ter scar. The lateral extension of the incision is hidden in the hair, because advancing this
side region is not the goal of the surgery. Video 1-3 contains a presentation of the surgical
technique to advance the hairline.
With patients for whom this procedure is recommended and who require forehead recon-
struction, this is the approach route used (Fig. 1-10).
17
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CHAPTER 1
Fig. 1-10 Preoperative and postoperative photographs of the same patient as in Fig. 1-9, A, with fore-
head reconstruction and surgical hairline lowering. Note that the incision design respects the natural
hair implantation line.
Redefin tion of the Hairline With Hair Transplantation Redefi ing the hairline by
transplanting hair is recommended for patients with an M-shaped hairline (common in
transwomen),18 with sufficient hair density and without active androgenic alopecia (typically
alopecia stabilizes with hormone treatment, although each case must be evaluated on an
individual basis). The main area of focus for hair transplantation is the recessed corners of
the hairline; however, the central section of the hairline can also be addressed if hair density
here is an issue, or if a small advancement (up to 1 cm) of the hairline is desired. Depend-
ing on how the hair follicles are obtained, two different techniques can be used: follicular
unit strip (FUS) or follicular unit extraction (FUE).19 In the FUS technique the follicles are
obtained from a strip of scalp removed in a small surgical procedure, whereas in the FUE
18
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CHAPTER 1
technique, the follicles are obtained one by one without any need for an associated surgical
process. Th s latter technique usually requires more experience given its technical complex-
ity and generally takes longer.
The new hairline is designed to look natural, with special attention to parameters such as
density and unevenness (no hairline is completely straight).
If the patient is a candidate for hairline modifi ation through hair transplantation and is
also a candidate for forehead reconstruction, our team has developed an immediate hair
transplant (IHT) technique. Th s consists of taking advantage of the strip of scalp obtained
in the modified coronal approach,3 which we have used to access the frontal region. This
allows us to harvest the hair follicles on this strip in the same way that they are obtained
with the conventional FUS transplant technique previously described. After the forehead
reconstruction is done, a new hairline is designed, and the hair follicles obtained are grafted
in place (there is an average of 2000 follicular units per strip, meaning some 3900 hairs). To
reduce the risks associated with prolonged general anesthesia, the patient is awakened and
kept under light sedation for the duration of the IHT procedure. Thanks to this technique,
the entire upper third can be treated as part of the same surgical process, which is highly
advantageous for many patients. Androgenic alopecia must be completely stabilized before
this technique can be used. In patients in whom there has been notable hair loss from the
area where the strip of scalp would normally be obtained, we can simply position the coro-
nal incision further back—even in the occipital region if necessary (Fig. 1-11).
Fig. 1-11 Obtaining follicular units from the strip taken during a modified coronal approach and surgical im-
plantation of the individual units.
19
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CHAPTER 1
Fig. 1-12 Six-month postoperative results are seen for this patient, the same transwoman as in
Fig. 1-9, B, who underwent forehead reconstruction and hairline redefinition with an IHT procedure
to eliminate temple recessions. A lip lift was also performed.
The surgeon must stress to candidate patients that this technique is an excellent opportunity
to take advantage of the large number of hair follicles in the strip of scalp obtained during
a modifi d coronal approach. The number of follicles that can be obtained from the strip
is limited, so if the result of the IHT does not fully meet the objective of closing the temple
recession (Fig. 1-12) or if more density of hair is required, a second standard hair transplant
procedure (FUS or FUE) can be performed some months later.
The Middle Third: Cheeks, Nose, and Upper Lip

The Cheeks
Although various cheek augmentation alternatives exist,20 we propose two options based
on our experience.
Fixed Porous Polyethylene Implants Porous, rigid polyethylene implants are fi ed to the
bone with osteosynthesis (positioning screws) to ensure stability.21 When necessary, they
can be customized to the patient’s specific needs. The porous structure of these prosthetics
allows bone tissue to grow into it.22 They must be placed through an intraoral approach.
The results are quite stable over time. If the volume of the implant is not carefully consid-
ered, the results may appear artific al.
Fat Transfer An autologous fat graft s obtained, usually from the abdominal region or
the thighs. The fat is deposited in the supraperiosteal zone, avoiding excessively superfi-
cial areas.23 Quite natural satisfactory results can be obtained, but this technique requires
extensive experience on the part of the specialist to obtain and manipulate the graft nd
20
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CHAPTER 1
meticulously place it in the key areas. Much of the fat may be reabsorbed, so the technique
typically requires multiple sessions to build permanent volume.24
The Nose
Many patients believe that refini g the nose can make a signifi ant improvement in their
appearance. Indeed, a rhinoplasty can have an overall complementary effect, making the
face more delicate. Standard rhinoplasty techniques can be used to make the nose smaller
and give it a more feminine and harmonious contour in proportion with the rest of the
face and forehead.25
The fi al result depends to some degree on the patient’s skin type. If the skin is thin, reduc-
tion of the underlying structures may be visible from the outside, but if the skin is thick, as
is common in men, the underlying changes may be less apparent.
Nose surgery statistically is one of the procedures with the greatest rates of complications in
the midterm to long term (asymmetry, deviation, and tip collapse).26,27 Th s mainly occurs
when the surgeon only addresses the aesthetic problems of the nose and does not consider
the nose’s inner structure and support. In these patients the immediate results are satisfac-
tory, but over time problems tend to develop.
Our technique is always based on both structure and aesthetics. The main areas of collapse
(tip and dorsum) are normally reinforced with cartilage grafts, hich avoids undesirable
postoperative changes in the midterm and long term.28
The Upper Lip

Generally speaking, the distance between the upper lip and nose is longer in men than in
women. Th s can result in less exposure of the upper teeth in men when the mouth is open
and at rest, and this effect is intensifi d with aging. To reduce the vertical dimension, a lip
lift echnique is used. Our lip lift rocedure is a modifi ation of the bullhorn technique29;
fi st, the key points are established, and straight incisions are then made to connect them. A
strip of skin and subcutaneous tissue are removed without violating the orbicularis muscle,
and the wound is closed in two layers (Fig. 1-13).
Fig. 1-13 Lip lift design and postoperative result.
21
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CHAPTER 1
The Lower Third: Lower Jaw and Chin

The procedures used on the jaw and chin are fundamental to achieving adequate feminiza-
tion of the lower third of the face. The possible goals of this treatment include modifying
the width and height of the jaw, softening the jawline (including the transition between the
jaw and chin), and modifying the size, shape, and position of the chin (Fig. 1-14).
The choice of treatment must be based on image diagnosis and the clinical evaluation of
the patient. In this context, a strong jawline or one with pronounced angles is not neces-
sarily synonymous with masculinity, because these features fit some female facial profiles
quite well; thus there is a need for an individualized evaluation that meets the particular
patient’s needs. Likewise, feminization techniques for the jaw and chin do not affect or
modify the patient’s bite.
Fig. 1-14 Patient shown before and after jaw and chin feminization. Forehead reconstruction, rhino-
plasty, lower jaw and chin recontouring, and Adam’s apple reduction were performed.
22
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CHAPTER 1
Access to the jaw and chin should always be through intraoral approaches to prevent vis-
ible external scars. With the jaw, two small incisions are made at the base of the vestibule
parallel to the end molars. To access the chin, an incision is made in the lip area (far from
the teeth and dental gums), which provides an excellent view and access to the area to be
treated and a scar that is imperceptible after the scarring period. It is frequently necessary
to treat the jaw and chin as a whole. In this case we recommend connecting the described
incisions through a subperiosteal tunnel, which creates an excellent working area, avoids
an overly large incision (mandibular degloving), and helps to protect the mental nerves by
not exposing them. Th s produces a better postoperative result with regard to scarring and
functional recovery (Figs. 1-15 and 1-16).
A B
Fig. 1-15 Triple approach to treat the jaw and chin simultaneously. A, Intraoperative photograph
showing jaw and chin exposition without degloving. Note the mucosal bridges protecting the mental
nerves (marked in black). B, Anatomic cadaver dissection. Note the excessive nerve exposure when a
degloving technique is used in comparison with the proposed combined approach.
Fig. 1-16 The triple approach, showing the mental nerves and their intramandibular trajectory (in the
lateral view), and lines of basal osteotomies for lower jaw and chin recontouring.
23
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CHAPTER 1
Surgical techniques are based in bone sculpture—namely, burring, standard osteotomies

(bone cutting), osteotomies with piezosurgery (Piezosurgery ultrasonic cutting system),
and endoscopic control. Field magnifi ation with surgical loupes is recommended when
working on the jaw and chin.
The use of high-speed burrs reduces the bone volume in the mandibular body, mandibular
angle, and chin. A very high degree of control is required with this technique to prevent
damage to the surrounding structures (mental nerves, muscles, or vessels) or excessive
weakening of the jawbone cortex.
A standard osteotomy is primarily recommended for the chin. Th s involves making cuts
in the bone with a reciprocating saw, which makes it possible to move the bone segments
and to modify the chin position (for example, to advance it).
Osteotomy with piezosurgery is the technique of choice for basal mandibular and chin
bone resectioning and for redesigning mandibular angles. With piezoelectric bone surgery,
it is possible to make very precise cuts into the mineralized tissue (bone) without affect-
ing other structures, thus avoiding any type of damage to the mucosa, muscle, nerves, or
blood vessels30 (Fig. 1-17).
Fig. 1-17 Intraoperative photographs showing different alternatives during chin feminization. Note
the possible changes in height, width, and shape by using a combination of burring and osteotomy
with piezosurgery.
24
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CHAPTER 1
Endoscopic control is highly useful when checking mandibular osteotomies, particularly

in the distal part of the angle, a region that is difficult to access and can present great tech-
nical complexity (Fig. 1-18).
Some time is required, possibly up to 12 months, for the soft tissues to readjust to the new
jaw and chin structure, volume, and position. Generally speaking, for patients with prior
soft issue drooping or signifi ant laxity afterward, we recommend surgical readjustment
with a lifting procedure in a second surgical session to correct the laxity and make the bony
work clear (Figs. 1-19 and 1-20).
Fig. 1-18 Endoscopically assisted lower jaw and chin recontouring with field magnification with 2.5×
surgical loupes.
25
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CHAPTER 1
Fig. 1-19 This 64-year-old patient underwent structural FFS surgery, including extensive lower jaw
and chin recontouring. Note the increase in previous soft tissue excess on the lower third (arrows). This
patient is a candidate for a soft tissue readaptation surgery in a second stage. Forehead reconstruction,
lower jaw and chin recontouring, and Adam’s apple reduction were performed.
26
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CHAPTER 1
Fig. 1-20 This patient is seen before and after FFS. Procedures done in the first surgical phase were
forehead reconstruction with an IHT, a lip lift, lower jaw and chin recontouring, and Adam’s apple re-
duction. Six months later, a second surgical phase was performed for soft tissue readaptation, including
a facelift and neck lift and lower and upper blepharoplasty.
27
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CHAPTER 1
A B
C D
Fig. 1-21 A and C, Before Adam’s apple reduction. B, Tracheal structure and high-positioned incision
distant from the working area. D, After Adam’s apple reduction.
The Neck: Thyroid Cartilage (Adam’s Apple)

As previously noted, this is an important feature for identifying gender and a cause of dis-
may for many transwomen. To approach the Adam’s apple, we recommend making an inci-
Video sion distant from the cartilage itself, preferably in the region of the cervicomental fold. Th s
1-4 prevents visible scarring and adhesions between the thyroid cartilage and upper layers. The
incision must not exceed 2 cm. The surgeon must avoid excessively small access points that
negatively affect the cartilage reduction procedure. Applying the characteristics of the car-
tilage (hardness and position), the reduction can be performed by burring or using a scal-
pel. When the recontouring is done by burring, the use of diamond burs is recommended,
because they are very effective for sculpting the cartilage and not very aggressive with the
adjacent soft tissue. Exact anatomic knowledge of the treated region is important to avoid
sculpting in the area near the vocal cord attachments and thus affecting their function. The
approach can be closed in one layer (intradermal suture), which has a positive effect on
scarring and the postoperative aesthetic result (Fig. 1-21 and Video 1-4).
28
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CHAPTER 1
Postoperative Management in Facial

Feminization Surgery
One of the most important factors in FFS involves the appropriate postoperative manage-
ment of the patient, both immediately after the operation and in the midterm to long term.
Proper recovery has a strong influence on whether the patient quickly returns to her usual
routine. The immediate postoperative period is the most intensely influential period, both
physically and emotionally. It requires a strict protocol to ensure that the patient receives
constant care and is made to feel that she is receiving the close support of the profession-
als involved in her treatment. Although the situation may vary according to the patient,
the face usually experiences signifi ant inflammation after surgical manipulation, which
is most obvious in the eyelid, nose, jaw, and chin areas. The immediate application of hi-
lotherapy (Hilotherm Clinic device, Hilotherm GmbH, Ludwigsburg, Germany), which is
a controlled cooling therapy that does not impede lymphatic drainage, can help to resolve
edema quickly and produces a subjective feeling of well-being in the patient.31 Additionally,
the early (2 to 5 days after surgery) application of manual lymphatic drainage by special-
ists considerably decreases any edema and speeds the recovery and adjustment of the soft
tissues.32 Finally, we recommend the use of compression therapy for 2 to 3 weeks after jaw
and chin recontouring surgery to assist in tissue repositioning.
Between 6 and 10 days after surgery, when acute inflammation and other symptoms are un-
der control, the patient enters a 2- to 3-week period of progressive recovery, during which
time we recommend that the patient take it as easy as possible and avoid overexertion. Af-
ter this period, the patient can return to her usual routine. Moderate physical exercise can
begin 3 to 6 months after surgery. Finally, the patient should know that defin tive and stable
results may not appear until up to 1 year after the intervention. The patient must have easy
access to the specialists involved in her case at all times; she must keep them up-to-date
about her evolution and aware of any complications that need resolution.
We fully believe in applying a multidisciplinary approach to FFS, and we encourage other

specialists in the fi ld to share and publish their experiences. It is time to establish FFS as
a recognized and solid discipline in the clinical and scientific fi lds, and this goal will only
be achieved when the body of knowledge and the ethical responsibilities of surgical teams
working within FFS are shared.
Acknowledgments
We thank all those who helped this exciting project see the light of day: to Drs. Bailón, Bellinga, Herrera,
Kaye, Tenorio, and Tobal for urging us to improve our work day after day; the hair transplant team for
helping us to develop a pioneering surgical technique; and our anesthesia unit for making us feel secure.
We thank our staff: Mili, Lilia, Ana, Fernanda, Tamara, Laura H., Laura G., Antonio, Grassyt, and Eva
for being the driving force behind our project; Jenny Bowman for making a dream come true; Alexandra
Hamer for being a constant source of inspiration; Pamela for her incredible professionalism; Jorge
Laguna for helping us to grow; Marcos Nascimento for giving shape to our ideas; Curra for always be-
ing on the other side; and Dr. Luis Fermín Capitán for his active participation in the preparation of this
chapter. We also thank our families for their constant love and patience, in particular Ino, Camila, Javier,
Carolina, Lara, Felipe, and Martina. Finally, we thank our dear patients for letting us participate in their
journey; without you none of this would be a reality.
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CHAPTER 1
References
1. Davey A, Bouman WP, Arcelus J, et al. Social 17. Kabaker SS, Champagne JP. Hairline lowering.
support and psychological well-being in gen- Facial Plast Surg Clin North Am 21:479, 2013.
der dysphoria: a comparison of patients with 18. Jung JH, Rah DK, Yun IS. Classifi ation of
matched controls. J Sex Med 11:2976, 2014. the female hairline and refi ed hairline cor-
2. Walch SE, Ngamake ST, Francisco J, et al. The rection techniques for Asian women. Derma-
attitudes toward transgendered individuals tol Surg 37:495, 2011.
scale: psychometric properties. Arch Sex Be- 19. Gupta AK, Lyons DC, Daigle D. Progression
hav 41:1283, 2012. of surgical hair restoration techniques. J Cu-
3. Capitán L, Simon D, Kaye K, et al. Facial tan Med Surg 19:17, 2015.
feminization surgery: the forehead. Surgical 20. Binder WJ, Azizzadeh B. Malar and submalar
techniques and analysis of results. Plast Re- augmentation. Facial Plast Surg Clin North
constr Surg 134:609, 2014. Am 16:11,2008.
4. Marečková K, Weinbrand Z, Chakravarty 21. Matros E, Momoh A, Yaremchuk MJ. The ag-
MM, et al. Testosterone-mediated sex differ- ing midfacial skeleton: implications for reju-
ences in the face shape during adolescence: venation and reconstruction using implants.
subjective impressions and objective features. Facial Plast Surg 25:252, 2009.
Horm Behav 60:681, 2011. 22. Yaremchuk MJ. Facial skeletal reconstruction
5. Iscan MY, Steyn M, eds. Sex. In The Human using porous polyethylene implants. Plast
Skeleton in Forensic Medicine, ed 3. Spring- Reconstr Surg 111:1 818, 2003.
fi ld, IL: Charles C Thomas, 2013. 23. Marten TJ, Elyassnia D. Fat grafting in facial
6. Hoenig JF. Frontal bone remodeling for gen- rejuvenation. Clin Plast Surg 42:219, 2015.
der reassignment of the male forehead: a 24. Clauser LC, Consorti G, Elia G, et al. Th ee-
gender-reassignment surgery. Aesthetic Plast dimensional volumetric restoration by struc-
Surg 35:1043, 2011. tural fat grafting. Craniomaxillofac Trauma
7. Spiegel JH. Facial determinants of female Reconstr 7:63, 2014.
gender and feminizing forehead cranioplasty. 25. Rohrich RJ, Adams WP, Ahmad J, et al, eds.
Laryngoscope 121:250, 2011. Dallas Rhinoplasty: Nasal Surgery by the
8. Becking AG, Tuinzing DB, Hage JJ, et al. Masters, ed 3. London: CRC Press, 2014.
Transgender feminization of the facial skel- 26. Beck DO, Kenkel JM. Evidence-based
eton. Clin Plast Surg 34:557, 2007. medicine: rhinoplasty. Plast Reconstr Surg
9. Ousterhout DK. Feminization of the fore- 134:1356, 2014.
head: contour changing to improve female 27. Surowitz JB, Most SP. Complications of rhi-
aesthetics. Plast Reconstr Surg 79:701, 1987. noplasty. Facial Plast Surg Clin North Am
10. Norwood OT. Male pattern baldness: classifi a- 21:639, 2013.
tion and incidence. South Med J 68:1359, 1975. 28. Rohrich RJ, Hoxworth RE, Kurkjian TJ. The
11. Nusbaum BP, Fuentefria S. Naturally occur- role of the columellar strut in rhinoplasty:
ring female hairline patterns. Dermatol Surg indications and rationale. Plast Reconstr Surg
35:907, 2009. 129:118e, 2012.
12. Hamer A. Hairline height. Available at http:// 29. Moragas JS, Vercruysse HJ, Mommaerts MY.
www.virtualffs.co.uk. “Non-filling” procedures for lip augmenta-
13. Wan D, Amirlak B, Rohrich R, et al. The tion: a systematic review of contemporary
clinical importance of the fat compartments techniques and their outcomes. J Craniomax-
in midfacial aging. Plast Reconstr Surg Glob illofac Surg 42:943, 2014.
Open 1:e92, 2013. 30. Pavlikova G, Foltan R, Horka M, et al. Piezo-
14. Hembree WC, Cohen-Kettenis P, Delemarre- surgery in oral and maxillofacial surgery. Int
van de Waal HA, et al; Endocrine Society. J Oral Maxillofac Surg 40:451, 2011.
Endocrine treatment of transsexual persons: 31. Rana M, Gellrich NC, Joos U, et al. 3D evalu-
an Endocrine Society clinical practice guide- ation of postoperative swelling using two
line. J Clin Endocrinol Metab 94:3132, 2009. different cooling methods following orthog-
15. Capitán L, Simon D, Kaye K, et al. Reply: Fa- nathic surgery: a randomised observer blind
cial feminization surgery: the forehead. Sur- prospective pilot study. Int J Oral Maxillofac
gical techniques and analysis of results. Plast Surg 40:690, 2011.
Reconstr Surg 136:561e, 2015. 32. Leduc A, Leduc O, eds. Drenaje Linfático.
16. Ousterhout DK, Zlotolow IM. Aesthetic im- Teoría y Práctica. Issy-les-Moulineaux,
provement of the forehead utilizing methyl- France: Elsevier Masson, 2012.
30 methacrylate onlay implants. Aesthetic Plast
Surg 14:281, 1990.
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CHAPTER
2
Speech Modification
James P. Thomas
Key Points
❖❖ Surgery for male-to-female gender voice ❖❖ Current methods include cricothyroid approxi-
change is indicated by a patient’s dissatisfac- mation, laser vocal cord thinning, anterior vo-
tion with his or her perceived gender. Typically cal cord webbing, anterior partial laryngectomy,
this decision is based on sound alone, with thyrohyoid elevation, or some combination of
male dominant characteristics. these.
❖❖ Modification of voice pitch and resonance is ❖❖ Surgery is the only way to correct the complica-
possible in some individuals through practice or tion of vocal cord detachment after thyroid car-
voice therapy. tilage reduction, a frequent surgery during gen-
❖❖ Multiple surgical approaches are available, but der affirmation.
there is no single, clear, correct method.
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Voice is a very important part of our identity, sometimes representing the entire portion of
our identity, such as when we are speaking on the phone. Voice is also a significant aspect of
our gender identity, because within seconds, most of us make a decision about the gender
of the person speaking. Individuals wishing to alter the gender identity of their voice may
benefit from surgical alteration of their sound-producing mechanism.
Indications and Contraindications to Surgery

Indications
❖❖ Individuals who cannot alter their voice through therapy or practice who want to be
perceived as female by sound alone, such as during a telephone conversation
❖❖ Individuals who can voluntarily alter their voice to sound female but wish to remove
even the potential for inadvertently sounding male if they let their guard down
❖❖ Individuals who can voluntarily alter their voice to sound female but wish to no longer
think about sounding female before initiating each phonation and are willing to accept
the risks of surgery
❖❖ Individuals whose speaking pitch and vocal range have dropped from the complica-
tion of vocal cord detachment after tracheal shave (thyroid cartilage reduction)
Contraindications
❖❖ Individuals who cannot tolerate the chance that surgery will not accomplish a pitch
and/or resonance change; all surgeries have the risk of incomplete alteration of the
voice from male to female, and most surgery has some risk of no change in the gender
quality of the voice
❖❖ Individuals who cannot tolerate a loss of maximal volume are not surgical candidates
Patient Evaluation
Surgeons should take a history from patients that elicits the reason they wish to change
their voice. Many individuals have the primary complaint that they identify with the fe-
male gender and are living as females, but when they speak, their voice betrays them. Th s
may range from (1) never passing as a female once they speak to (2) passing as a female in
person but not on the phone to (3) passing as a female all the time, but fatigue or discom-
fort sets in after prolonged speaking in a feminine voice. There is also relatively more nu-
anced reasoning, such as a desire to feel female without the need to think about sounding
female; that is, naturally sounding female. Some individuals express the desire to sound
more gender neutral. Another indication is an individual who sounded female until the
thyroid cartilage reduction procedure.
A voice recording should be made of the following vocal capabilities:

❖❖ Comfortable speaking pitch reading a standard passage of several sentences
❖❖ Lowest pitch that can be produced, including a glide downward
❖❖ Highest pitch that can be produced, including a glide upward
❖❖ Loud phonation, a robust yell; vegetative sounds, cough, and a throat clearing
❖❖ Soft singing of several words at high and low pitches, such as “Happy Birthday to You”
Th s degree of vocal assessment will adequately document the voice both in pitch range and
quality before and after surgical intervention. The surgeon can use this type of evaluation
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to learn what is working well and what is not. It also provides legal documentation that
is more believable than a written assessment. Vocal assessment may also provide valuable
feedback to patients, who hear their voice internally in a manner that is signifi antly dif-
ferent from the way others hear it. Often enough, individuals express that they sound the
same after voice surgery; however, before and after recordings can provide feedback about
the degree of change and improve a patient’s confide ce in the new voice.
Recording an endoscopic examination (with audio) provides vital information to the sur-
geon about the effects of surgical intervention and augments legal documentation. An
endoscopic recording of the pharynx at low and high pitches documents a portion of vo-
cal resonance variation. An endoscopic recording of the vocal cords should include quiet
respiration, sniffing for maximal abduction, and phonation. A stroboscopic examination,
including phonation at a comfortable speaking pitch and then at a high and low pitch,
completes the examination.
Preoperative Planning and Preparation

Informed written consent for the procedure and the precise procedure depend on the voice
modifi ation planned.
Surgical Techniques
Six current techniques are currently used alone or in some combination: cricothyroid ap-
proximation (CTA), laser vocal cord reduction, vocal cord webbing, anterior commissure
advancement, anterior partial laryngectomy, and thyrohyoid elevation. Surgeon preference
seems to currently drive the choice of procedure, but each has some pros and cons. In ad-
dition, some combination of procedures occasionally provides an optimal voice.
Cricothyroid Approximation
CTA,1-8 which is one of the simplest and most commonly performed pitch surgeries, mimics
the normal action of the cricothyroid muscle to lengthen the vocal cord. 9 The vocal qual-
ity produced by this increase in tension (by lengthening) of the vocal cord is called falsetto.
By bringing the thyroid cartilage and cricoid cartilage into approximation in the anterior
midline, CTA surgery effectively sutures the cricothyroid muscle into a permanent position
of contraction, although the degree is variable.
Some of the positive attributes of CTA surgery include:

❖❖ The surgery is relatively easy to perform, because the anatomy is located very close
beneath the skin.
❖❖ Surgeons inexperienced with the procedure can perform the technical aspect of the
surgery relatively well.
❖❖ There is minimal discomfort with the procedure, and it may be performed with the
patient under local anesthesia.
❖❖ The patient may speak during the procedure, and for some, “CTA surgery is typi-
cally performed with intentional hyperelevation of pitch in anticipation of gradual
relaxation of the induced vocal fold tension over time.”10
❖❖ Because this procedure is relatively easy to perform and safe from intraoperative
surgical complications and can be performed in a relatively short time, surgical
costs are low.
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In a personal review of CTA surgery, presented at the Biennial Meeting of the Harry Ben-
jamin International Gender Dysphoria Association on September 12, 2003, in Ghent, Bel-
gium, for male-to-female transgender patients wishing to speak comfortably at a higher
pitch in day-to-day conversation, 23 patients had an elevation in the comfortable speaking
pitch by 7 semitones. Th s ranged from a lowering of the speaking pitch by 2 semitones in
one patient to an elevation in pitch by 18 semitones in another patient. The range was wide
and seemingly unpredictable. To most patients’ relief, individuals also lost an average of
9 semitones from the bottom of their speaking range, providing a speaking pitch not at risk
of a sudden drop to a deep bass pitch.
However, signifi ant issues were noted with the CTA procedure. Some patients experienced
an initial elevation in pitch that faded back to a baseline pitch over a few months; ultimately
they had no permanent change in their voice. Th s occurred in about one third of patients,
although the vocal cords remained visibly stretched on endoscopy. Neumann and Welzel7
also noted that about one third of patients had a neutral pitch, and about one third failed
to gain in pitch. During attempted surgical revisions, in which various sutures and suture
placement techniques were used, no cricothyroid suture failure was noted. The cricothy-
roid space remained ablated despite inadequate pitch elevation, typically with the cricoid
and thyroid cartilage fused in the anterior midline. Although various suturing techniques
are used, it is uncommon to have sutures pulled out. Internally, during quiet respiration,
the vocal process and membranous vocal cord margins are often in alignment, a position
typically only seen when the cricothyroid muscle is contracted. Patients appear to lose pitch
elevation by losing internal vocal cord tension.
Another problematic issue with patients undergoing CTA surgery is that many patients
with successful pitch elevation may speak with an unnatural, hyperelevated pitch, ranging
from an extreme falsetto to a mild falsetto quality to the voice. Patients may describe this
as a “gay male” sound.
My experience with revision surgery is that the cricoid and thyroid cartilages frequently
fuse in the anterior midline. However, even when separated, patients do not typically regain
control over their falsetto range. It is theorized that the cricothyroid joints ankylose after a
sufficient period of immobilization and may subsequently become fixed, perhaps subluxed,
such that an individual may almost completely lose the ability to change pitch and volume
at all, leaving the individual with a monotonal voice.
Despite a successful change in comfortable speaking pitch, after CTA a patient forfeits the
use of her cricothyroid muscles. Tensioning the thyroarytenoid muscle must now produce
all pitch changes.
Laser Vocal Cord Reduction

There are various types of lasers and various modalities for using lasers on the vocal cords.
One type of laser treatment, laser-assisted voice adjustment, attempts to increase vocal pitch
through a thinning and tightening of the vocal cords. Increases in fundamental frequency
with this technique tend not to be as large as with other surgical methods.11One advantage
is that no external incision is required. Laser-assisted voice adjustment may be used after
CTA for enhancement of pitch if needed.
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The potassium titanyl phosphate (KTP) laser may be used to create a surface burn on the
superior surface of both vocal cords, which will lead to tightening of the vibratory margin
and an increase in pitch. Th s procedure is easy to perform in the office ith the use of a
topical anesthetic on the vocal cord. One half to one and one half semitones seems to be
about the limit of pitch change with this surface-tightening technique.
In the operating room, the CO2 laser may be used to incise the superior surface of the vo-
cal cord adjacent to or within the ventricle. The thyroarytenoid muscle can be removed
through the incision; however, a patient can expect a prolonged period of aphonia if bi-
lateral surgery is performed (1 to 3 months), presumably from edema and stiffness despite
avoiding the vocal cord margins.
Th s laser has been useful in raising pitch and pulling vocal cord margins to a straight posi-
tion after other types of surgery, such as webbing or feminization laryngoplasty, improving
volume, clarity, and pitch.12
Vocal Cord Webbing

Vocal cord webbing,11,13-15 which has recently gained in popularity, is an attempt to shorten
the effective vibratory length of the vocal cords. This procedure is performed with mi-
crolaryngoscopy with the patient under general anesthesia. There is no external incision.
Surgeons have removed mucosa from the anterior vocal cords, and some surgeons also re-
move some muscle. The raw edges of the anterior vocal cords are sutured together.15 Sutur-
ing within the laryngoscope is a technical challenge for some, and an experienced surgeon
should be sought.
Anterior Commissure Advancement

Tucker16 described anterior commissure advancement, and Somyos Kunachak (personal
communication, 2015) more recently performed a modifi ation of this procedure. A skin
incision is placed over the thyroid cartilage. The thyroid cartilage is incised vertically, leav-
ing the anterior commissure attached. After pulling this forward, sutures may be placed
through the remaining thyroid cartilage and vocal cords, securing the advancement. The
advanced strut may then be removed.
Anterior Partial Laryngectomy

Kunachak et al17 proposed an open laryngoplasty to alter pitch. Th s procedure reduced the
size of the larynx to a more female size in its cross-sectional dimension and shortened the
length of the vibratory vocal fold. Video
2-1
Thyrohyoid Elevation
Transgender patients particularly adept at creating a female voice quality are able to main-
tain muscle tension with two pharyngeal parameters: elevation of the larynx and narrow-
ing of the pharynx. Based on these, I have begun to suspend the larynx higher in the neck
(thyrohyoid elevation component), shortening the chamber. Th s modifi ation still requires
the patient to address the diameter of the chamber with muscle contraction.
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Surgical Procedures
Cricothyroid Approximation
Anesthesia
A local anesthetic, with or without sedation, is used.
Markings
The incision is placed within or parallel to a skin crease, preferably within 1 cm of the cri-
cothyroid space.
Patient Positioning
The patient is placed in the supine position, and the head may be extended with a shoulder
roll if needed to allow adequate room to work over the cricothyroid space.
Technique
The surgeon makes a horizontal incision, dissects through the adipose tissue, and raises
the superior and inferior flaps, visualizing the strap muscles. The strap muscles are divided
in midline. The larynx is exposed from the midthyroid cartilage superiorly to the inferior
border of the cricoid cartilage. The perichondrium is incised along the inferior border of
the thyroid cartilage and elevated from the thyroid cartilage for 3 to 5 mm along the inner
lamina. A 1 mm hole is drilled in each side of the thyroid lamina, angling inferiorly.
The cricoid cartilage perichondrium is incised along the superior border, and a tunnel is
created beneath the cricoid cartilage. A permanent suture, such as 0-Ethibond, is passed
around the cricoid cartilage from below. The suture may grasp a small amount of the crico-
thyroid tissue and is passed from the posterior aspect of the thyroid cartilage out the drilled
hole. A second suture is passed in a similar fashion through the second hole. The sutures
are drawn tight (while the surgeon may listen to the change in voice) and tied.
Neck incisions may be closed with a 4-0 Monocryl suture, placing a single inverted suture
to draw the strap muscles back to midline. Inverted sutures are placed in the deep subcu-
taneous layer that aligns with the platysma. A single running subcuticular suture closes the
epithelium in a cosmetic fashion, from lateral to the incision and ultimately exits through
the skin on the opposite side. Cyanoacrylate glue is used on the skin.
Ancillary Procedures
No ancillary procedures are performed.
Postoperative Care
The patient may speak. No voice rest is required. The incision may be wet after 24 hours.
Laser Vocal Cord Reduction: Tightening

Anesthesia
A topical anesthetic is used; 4% lidocaine is sprayed in both nostrils, along with a decon-
gestant such as oxymetazaline. A mixture of 4% lidocaine and phenylephrine, along with
stevia and peppermint for palatability, is used. Then 4% lidocaine (up to 4 ml) is gradually
dripped onto the phonating vocal cords, creating a laryngeal gargle. The effects of the topi-
cal anesthetic last 15 minutes or more.
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Markings
There are no markings.
Patient Positioning
The patient is seated. Frequently a sniffing position everts the larynx for better exposure.
Technique
A KTP laser may be used to create a burn on the superior surface of the vocal cords, which
results in a contracture and tightening of the vocal cord margins.
A KTP laser fiber of 400 to 600 nm is passed through the working channel of the endo-
scope. The endoscope is passed through the larger nostril. It is more challenging to make
the bend in the nasopharynx with the 600 nm fiber. Typical settings are 30 W, with a pulse
width of 40 ms and a repeat of 2 pulses per second.
By positioning the fiber close to the mucosa, a burn may be created along the superior sur-
face of the vocal cord, working from just lateral to the vibratory margin into the laryngeal
ventricle. The surgeon is careful to avoid a burn on the vibratory margin of the membra-
nous vocal cord. The posterior limit is the vocal process, and the anterior limit is the ante-
rior commissure. As the mucosa is cauterized, it turns white and may even be vaporized,
leaving muscle exposed.
Occasionally the false vocal cord is so large that it is difficult to reach the superior surface
with the laser. Instead of applying the energy during respiration, the patient may phonate
softly, bringing the vocal cords into adduction, for periods of 10 to 15 seconds. It is easier
to determine the vibratory edge during phonation, and high pitch phonation will expose
more of the surface than low pitch.
A similar degree of burn is applied to the contralateral vocal cord. Because of the lateral
position of the laser fiber within the endoscope, the surgeon’s view may be obscured while
trying to reach the superior surface, and the endoscope may need to be withdrawn, in-
verted, and reinserted.
A 10 Fr suction catheter may be placed through the smaller nostril and attached to a smoke
evacuator suction. The patient and staff members wear eye protection.
Postoperative Care
Although patients may speak after the procedure, their voice will deepen as swelling sets in.
When monitoring patients after surgery, those who talk tend to induce more bruising on the
vocal cords. Consequently, it is recommended that patients have 1 week of voice rest. The
voice gradually becomes smoother, and the pitch rises over about 6 weeks in most patients.
Laser Vocal Cord Reduction: Mass Reduction

Anesthesia
General anesthesia with a 6-0 laser-safe endotracheal tube is used.
Markings
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Patient Positioning
The patient is in the supine position. The patient’s head may be elevated into a sniffing po-
sition for improved exposure of the laryngeal introitus.
Technique
A programmable CO2 laser (DEKA, Florence, Italy) may be used to incise the superior
vocal cord's mucosa and debulk some of the thyroarytenoid muscle. Typical settings of
10 W and a 0.8 mm depth may be used. A line length of 40% (about 4 mm) is also used.
Each laser device may have different settings. The goal is to use the cutting aspect of the
laser while minimizing collateral thermal damage.
An incision is made in the superior surface of the vocal cord along the central 80% of the
length of the membranous vocal cord. The incision is centered at approximately the edge
of the laryngeal ventricle. The incision is spread open, and the thyroarytenoid muscle is
gradually removed.
I often err on the side of removing too little muscle and on the side of doing the least ther-
mal damage to the remaining muscle.
The incision, if narrow, may be left o close by secondary intention, or alternatively, 8-0
Vicryl suture may be used to close the incision with a single stitch to expedite healing.
Postoperative Care
Although the patient may be allowed to speak after the procedure, she quite possibly will
become aphonic, because there can be signifi ant intracord edema. The more muscle re-
moved, the longer the period in which the vocal cord margins will not vibrate. However,
as long as there is no thermal damage to the vibratory margin, the voice will return when
the margins become flex ble again.
Vocal Cord Webbing

Anesthesia
General anesthesia with a 6-0 laser-safe endotracheal tube is used.
Markings
Patient Positioning
The patient is in the supine position. The patient’s head may be elevated into a sniffing po-
sition for improved exposure of the laryngeal introitus. The patient and staff ear protec-
tive eyewear.
Technique
A programmable CO2 laser (DEKA) with settings of 5 W and a 0.45 mm depth is used, and
the line length is set to 40% (about 4 mm). Each laser device has different settings, and the
goal is to use the cutting aspect of the laser while minimizing collateral thermal damage.
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The mucosa is incised on the left ocal cord along the superior surface, just lateral to the
vibratory margin, from the anterior commissure to the 50% point of the membranous vo-
cal cord. The mucosa is removed along the medial margin into the subglottic region, and
a similar amount of mucosa is removed from the contralateral vocal cord. If the muscle
protrudes medially from the incised edge, it may be removed with the laser.
A 6-0 nylon suture is placed, starting at the midportion of the incision and passing into
the right vocal cord’s superior cut edge of mucosa through the thyroarytenoid muscle from
the superior surface to the inferior surface and out through the inferior cut edge of mu-
cosa. The suture enters the left ocal cord through the incised mucosa’s inferior margin,
through the thyroarytenoid muscle from inferior to superior and exits through the supe-
rior cut edge of mucosa. At a slightly different position, the suture is passed through both
vocal cords again. Th s figu e-of-eight suture is pulled tight, bringing the raw edges of the
muscle into apposition.
A second suture is placed in the midmembranous vocal cord at the posterior extent of the
incision. Th s will create the new anterior commissure.
Postoperative Care
Patients should rest their voice for 2 weeks after surgery.
Anterior Commissure Advancement

Anesthesia
General anesthesia, or possibly local anesthesia, is used.
Markings
The markings are horizontal in or parallel to a skin crease overlying the thyroid cartilage.
Patient Positioning
The patient is in the supine position.
Technique
The anterior thyroid cartilage is exposed, and a vertical incision is placed about 2 mm on
either side of midline. The central cartilage strip is pulled forward while the two thyroid
alae are collapsed together beneath the advanced portion. Permanent sutures such as 4-0
nylon are passed through the cut anterior edge of the thyroid ala on each side, and the cut
edges are drawn together with soft tissue compressed between them. After two or three are
placed, the advanced piece of central cartilage may be removed.
Postoperative Care
Voice rest may not be necessary.
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Anterior Partial Laryngectomy

Anesthesia
General anesthesia is used.
Markings
The markings are horizontal in or parallel to a skin crease overlying the thyroid cartilage,
approximately 5 cm long. The surgeon may be able to work through an incision as high as
the hyoid bone, although the higher the incision placement in the neck, the wider the inci-
sion required, because the inferior skin edge needs to be pulled down to expose the inferior
border of the thyroid cartilage.
Antibiotics
Clindamycin and cefotaxime are administered at the time of surgery. The patient receives
7 days of postoperative oral therapy with either cefuroxime or levofl xacin.
Steroids
The patient receives 10 mg of intravenous dexamethasone at the beginning of surgery. Oral
prednisone or methylprednisolone is given postoperatively in selected cases if signifi ant
swelling develops 1 to 3 days later.
Patient Positioning
The patient is in the supine position, with the neck extended.
Technique
Superior and inferior flaps are elevated beneath the platysma layer. Strap muscles are sepa-
rated in the midline, exposing the anatomy from the hyoid bone to the upper cricothyroid
membrane (Fig. 2-1, A through D).
If a thyrohyoid elevation is included, the upper 10 mm of the thyroid cartilage alae are re-
moved with a knife or saw (Fig. 2-1, E and F). The surgeon must avoid going too far poste-
riorly, because this seems to cause edema and ecchymosis of the arytenoids.
The thyroid cartilage is divided vertically with an oscillating saw about 4 to 7 mm on either
side of midline; the saw kerf removes about 1 additional mm of cartilage (Fig. 2-1, G and H).
The goal is to narrow the internal aperture of the laryngeal glottis by collapsing the thyroid
alae medially. A prior CTA may preclude this removal.
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A B
C D
E F
G H
Fig. 2-1 Anesthetist’s view of the surgical site. A, Horizontal incision placed in or parallel to a skin
crease. B, Dissection to the layer beneath the platysma. C, Self-retaining retraction for exposure. D, The
entire thyroid cartilage is separated in the midline from the superior notch to the cricothyroid space,
and the superior thyroid alae are removed. E, Marking with electrocautery of the superior alar bulge.
F, Cut edge of the cartilage after removal of the central thyroid cartilage. G, Vertical cuts 4 to 7 mm on
either side of midline. H, Elevating strut away from the internal thyroid perichondrium and soft tissue.
Continued
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I J
Fig. 2-1, cont'd If thyroid cartilage cuts are placed perpendicular to the thyroid cartilage surface
rather than parallel to the sagittal plane, only the inner table will approximate. The inner thyroid lamina
will often not approximate, because contours and a postoperative air leak are likely. I, Anterior vocal
ligaments are visible through the perichondrium as two dense white patches. J, The larynx is entered
just superior to the anterior commissure.
Cuts are nearly parallel to the midsagittal plane. Beveling the cuts slightly allows complete,
airtight closure of the new anterior larynx in midline. A cut at a 90-degree angle to the sur-
face of the cartilage allows only the inner thyroid lamina to approximate. The inner lamina
is more contoured than the outer lamina, with an internal bulge inferior to the vocal cords.
If tight closure is precluded because of an inappropriate saw angle or any variation of thick-
ness in the cartilage, the margin may be adjusted with a cutting burr.
The central strip of anterior thyroid cartilage is elevated away from the inner soft issue
and removed with electrocautery (Fig. 2-1, I and J). Removal of the vertical anterior thyroid
cartilage segment will both narrow the internal laryngeal aperture and remove the Adam’s
apple contour (more completely than a “thyroid cartilage reduction”). The airway is not
typically entered, although if it is, penetration usually occurs in the thinnest area, which is
just superior to the anterior commissure.
The thyroid alae may be retracted laterally for a better view of the internal glottis. The an-
terior ligaments of the vocal cord are identifi d, and the airway is entered just superior to
the anterior commissure.
The false vocal cords are split, and the anterior 5 mm of each false vocal cord, probably in-
cluding the saccule, are removed, thus reducing the diameter of the supraglottis after sur-
gery (Fig. 2-1, K and L). During surgery, this also provides an improved view of the true
vocal cords and more space to manipulate needles within the larynx.
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K L
M N
Fig. 2-1, cont'd K, The anterior right false cord excised with right-angle scissors. L, The anterior com-
missure on stretch to identify true vocal cord length. M, A temporary marking suture is placed through
the membranous vocal cord at about the 50% location. N, The anterior 40% of the true vocal cord, vocal
ligament, and thyroarytenoid muscle are excised with right-angle scissors.
The anterior glottic ligament should be pulled to assess how much of the anterior vocal
cords must be removed to collapse the thyroid alae back into midline while maintaining ten-
sion on the vocal cords (Fig. 2-1, M). With half of a double-ended CV-5 polytetrafluroeth-
ylene (Gore-Tex) suture, the surgeon marks the membranous vocal cords at the 50% point
between the anterior commissure and the vocal process. Because the vocal ligament can be
difficult to identify after anterior cord removal, this suture helps to maintain not only a sym-
metrical length to the neovocal cords but also to the vibratory margin’s vertical symmetry.
Typically, the anterior 40% of each membranous vocal cord and thyroarytenoid muscle
anterior to the marking suture is removed (Fig. 2-1, N). By keeping the inferior extent of
the excision superior to the lower boundary of the thyroid cartilage, the length of the in-
cision inferior to the vocal cord is minimized. If the subglottic incision continues beyond
the inferior edge of the thyroid cartilage into the cricothyroid membrane, it will be more
difficult to obtain an airtight closure.
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P Q
Fig. 2-1, cont'd O, A Gore-Tex suture is passed into the left thyroarytenoid muscle, through the vocal
ligament, and catches about 2 mm of mucosa; it then passes into the right vocal cord mucosa, passing
through the vocal ligament, and exits the thyroarytenoid muscle. P, The same suture is passed in re-
verse 1 to 2 mm inferiorly; ultimately both free ends leave the left thyroarytenoid muscle. Q, The mark-
ing suture is removed and passed in opposition to the above suture; both ends extend out of the right
thyroarytenoid muscle.
The vocal cords are stretched as the thyroid lamina are brought back together to verify they
are not too long to be placed under tension when secured against the inner thyroid lamina.
If they will not be under adequate tension, more vocal cord can be removed.
With CV-5–expanded Gore-Tex, a horizontal mattress suture is placed (Fig. 2-1, O). The
needle enters the medial portion of the left hyroarytenoid muscle, passes through the vo-
cal ligament (which feels slightly dense), and includes about 1 mm of medial margin vocal
cord epithelium exiting at the upper vibratory lip of the membranous vocal cord. The su-
ture is then passed into the opposite cord (Fig. 2-1, P) at a corresponding location, begin-
ning with the vocal cord epithelium and passing out through the central portion of the cut
thyroarytenoid muscle. Both ends of this fi st suture exit the left hyroarytenoid muscle.
The surgeon removes the Gore-Tex marking suture, reusing it, passing it in opposition, and
using a similar path beginning with the right thyroarytenoid muscle (Fig. 2-1, Q). At the
conclusion, both ends of one suture exit the left ocal cord, and both ends of the second su-
ture exit the right vocal cord. Pulling on these brings the new anterior commissure together.
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R S
Fig. 2-1, cont'd R, With both Gore-Tex sutures not yet tied, the thyroid alae may collapse back to-
gether. When both sutures are tensioned, the anterior commissure should not extend between the cut
margins of the thyroid cartilage. S, Four 0-Ethibond sutures are passed through drilled holes in the hy-
oid bone and the upper thyroid cartilage, two on each side.
When the thyroid alae are brought back together (Fig. 2-1, R), the glide of the Gore-Tex
suture allows it to slide between the cartilage halves.
For the thyrohyoid elevation portion, the muscles are elevated from the anterior inferior
margin of the central hyoid bone with electrocautery. Strap muscles are divided at their in-
sertion along the inferior edge of the hyoid bone for 15 mm on either side of midline. Two
holes are placed along each superior border of each thyroid ala where the upper wings were
removed. The softer the cartilage, the further from the upper cut edge of thyroid cartilage
the holes are placed to avoid tearing when tightening.
Four holes are drilled into the hyoid bone, two on either side of midline. These are angled
slightly inferiorly to allow passage of the large needle.
Two 1 mm holes are drilled in the new anterior edge of each thyroid cartilage. One is in-
ferior at the level of the subglottis, and one is superior at the level of the false vocal cords.
Each hole is angled toward midline internally.
Four large braided, nonabsorbable sutures are individually passed through each hole in the
superior edge of the thyroid cartilage and then through a corresponding hole in the hyoid
bone (Fig. 2-1, S). Sutures are not secured until the end of the procedure.
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U V
Fig. 2-1, cont'd T, The 4-0 nylon or Monocryl sutures are passed. The upper suture enters a 1 mm
hole in the left thyroid cartilage, passes through the cut edge of each false vocal cord, and back out the
right thyroid cartilage. An identical suture passes into a hole in the lower left thyroid cartilage, passing
through the cut mucosal edges in the subglottis, and then out the right thyroid cartilage. All sutures re-
main untied at this point. U, The upper and lower thyroid cartilage sutures are tied; the thyroid cartilage
is closed tightly in the anterior midline. A titanium plate is curved to match the thyroid cartilage. V, The
4 mm self-tapping screws are placed into some or all of the holes, leaving one end of each Gore-Tex su-
ture above the plate and one below the plate.
A 4-0 monofilament suture is placed through the upper holes in the superior thyroid car-
tilage (Fig. 2-1, T) and internally, including the cut edges of the false vocal cords, with the
intent of pulling them against the inner thyroid lamina during closure. This needle remains
attached temporarily.
A 4-0 absorbable suture is passed through the inferior holes and includes the cut edge of
the subglottic mucosa, again with the intent that the mucosa will reattach to the inner thy-
roid perichondrium and that there will be an airtight seal in the immediate postoperative
period. The needle also remains attached temporarily.
The edges of the thyroid cartilage are brought together, and monofilament sutures are tied
(Fig. 2-1, U). Using the residual upper suture, the tissue at the base of the epiglottis is pulled
tight against the upper border of the thyroid cartilage. The residual inferior suture is used
to pull the soft tissue of the cricothyroid membrane against the inferior border.
A four-hole, dog bone–shaped plate is bent to the shape of the newly angled anterior thyroid
cartilage. It is placed preferably at the same level as the original attachment of the anterior
commissure; 4 mm, self-tapping screws are placed bilaterally (Fig. 2-1, V). The Gore-Tex
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W X
Y Z
Fig. 2-1, cont'd W, Pulling the Gore-Tex sutures re-creates the anterior commissure and snugs the an-
terior vocal cords against the inner thyroid perichondrium. The sutures are then tied over the plate. The
0 Ethibond sutures pull the larynx superiorly in the neck. X, After clipping all the excess suture material,
the wound is ready for irrigation. Y, The 4-0 Monocryl sutures close the strap muscles in the midline and
the subcutaneous layer. Z, The 4-0 running subcuticular suture reapproximates the skin edges.
sutures are pulled between the coapted edges of the thyroid cartilage, tightened, and tied
around the plate to maintain the new anterior commissure against the inner thyroid peri-
chondrium.
The 0 Ethibond sutures are tightened and tied, pulling the larynx superiorly in the neck
(Fig. 2-1, W and X). Typically the thyroid cartilage does not quite reach the hyoid bone.
The wound is irrigated with saline solution containing bacitracin. The strap muscles are
reapproximated and can be slightly plicated, pulled superiorly, and reattached to the hyoid
bone under some tension. Subcutaneous tissues are closed with 4-0 absorbable sutures.
Cyanoacrylate glue seals the incision (Fig. 2-1, Y and Z).
Postoperative Care
Surgery is performed on an outpatient basis.
Flexible laryngoscopy is performed every day for 3 days to check for subcutaneous emphy-
sema, supraglottic edema, or erythema.
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Two weeks of complete voice rest are suggested. Pain is typically fairly minimal (although it
varies by individual). A narcotic is prescribed for pain control and cough suppression. The
patient cannot lift anything heavier than 10 pounds for 1 month. Other forms of straining,
such as the Valsalva maneuver, are strongly discouraged.
No elective endotracheal intubations can be done for 3 months. If intubated after that time
for general anesthesia, the patient should request that a No. 6 endotracheal tube be used.
Thyrohyoid Elevation
Anesthesia
A local anesthetic is used.
Markings
The markings are made horizontal in or parallel to a skin crease near the hyoid bone.
Patient Positioning
The patient is in the supine position.
Technique
Although generally included with the anterior partial laryngectomy approach, this eleva-
tion can be performed alone. The hyoid bone is exposed, and the muscles are elevated
from the anterior and inferior margins of the central hyoid bone with electrocautery. Strap
muscles are divided at their insertion along the inferior edge of the hyoid bone for 15 mm
on either side of midline. The upper 10 mm of the thyroid cartilage alae are removed with
a knife or saw.
Two 1 mm holes are placed along the superior border of each thyroid ala where the upper
wings were removed. The softer the cartilage, the further from the upper cut edge of thy-
roid cartilage these holes are placed to avoid tearing later when tightening. Four holes are
drilled in the central hyoid bone.
A 0-Ethibond suture is passed through a thyroid cartilage hole and a corresponding hyoid
bone hole. After all four sutures have been placed, the larynx is drawn superiorly and the
sutures are tied. The incision is closed in layers.
Postoperative Care
The skin suture may be removed 1 week later.
Discussion
After exposure to testosterone, typically during puberty, the thyroid cartilage enlarges, both
increasing the internal luminal size of the larynx and altering the neck profile by visible
protrusion of the Adam’s apple. The vocal cords elongate and thicken, lowering the com-
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fortable speaking pitch and lowest vocal pitch. A reduction of the upper vocal range or at
least a change in the quality of the upper vocal range is usually present, because thicker vo-
cal cords must be stretched tighter to produce the same pitch as thinner vocal cords. The
relaxed laryngeal position drops lower in the neck, increasing the internal length of the
pharyngeal chamber; a longer chamber selectively amplifies the lower notes.
In individuals identifying as the female gender (whether genetically male, intersex, or

female), speech therapy or self-practice may result in learning to produce a desirable
speaking vocal pitch and resonance, masking these changes induced by testosterone.
These techniques use active muscle contraction of intrinsic laryngeal, pharyngeal, and
cervical muscles and require ongoing effort. Some individuals are successful in devel-
oping a habitual contraction to the point of requiring a conscious effort to lower their
larynx into a typical genetic anatomic position and speak with their “male voice.” Many
individuals, however, develop ongoing fatigue from these attempts at maintaining female
pitch and resonance through tonic muscle contraction. Some individuals are unable to
accomplish this task. Even when successful, some individuals remain fearful of letting
their guard down for even a moment in a sensitive situation in which a masculine voice
would be inappropriate.
Ideally after gender transition, comfortable speech would occur at a feminine pitch and
with a feminine quality without the need to think about contracting several muscles before
every phonation. Thus individuals acquire either a female voice as second nature, or they
consider surgical modifi ation of their phonatory tract.
A fundamental frequency of speech is one distinctive parameter in determining a male

versus a female voice.1,2 A number of pitch-altering surgeries, discussed in these articles,
have been pursued to address this voice-gender mismatch.
Although the proposed fundamental frequency (Fo) range for adult females is 145 to
275 Hz (D3-C#4) and for adult males is 80 to 165 Hz (D#2-E3),12 this leaves an area of
overlap from 145 to 165 Hz (D3-E3), in which fundamental frequency alone may be insuf-
ficie t to determine the sex of a patient. Th s is important because transgender patients
with Fo as high as 181 Hz have been perceived as male. “It appears that it is the interaction
between Fo, Fo range, intonation and resonance that ultimately determines the percep-
tion of the speaker as female.”18 Addressing these components as complements to each
other is a more desirable approach to voice modifi ation compared with fundamental
pitch change alone.
Resonant frequency also affects gender perception of voice. Th s is especially true in the
gray area, in which normal male and female speaking pitches overlap.19 Resonant frequency
is inversely related to the length of the resonant tube, the pharynx.17 Speech therapy tech-
niques have been used to modify the mouth opening and tongue placement.18 Thomas
and Macmillan20 noted that when comparing transexuals’ male versus female voice, the
resonance patterns change. They hypothesized that this was accomplished by practiced
manipulation of oropharyngeal shape and the elevation of the larynx.2,20 Elevation of the
larynx enables higher resonant frequency of the pharynx, because the length of the reso-
nant tube is decreased.21
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References
1. Brown M, Perry A, Cheesman AD, et al. Salsomaggiore, Italy: Union European Pho-
Pitch changes in male-to-female transsexu- niatricians, Oct 1990.
als: has phonosurgery a role to play? Int J 12. Koçak I, Akpınar ME, Cakır ZA, et al. Laser
Lang Comm Dis 35:129, 2000. reduction glottoplasty for managing andro-
2. Wagner I, Fugain C, Monneron-Girard L, et phonia after failed cricothyroid approxima-
al. Pitch-raising surgery in fourteen male-to- tion surgery. J Voice 24:758, 2010.
female transsexuals. Laryngoscope 113:1157, 13. Donald PJ. Voice change surgery in the trans-
2003. sexual. Head Neck Surg 4:433, 1982.
3. Isshiki N, Morita H, Okamura H, et al. Thy- 14. Gross M. Pitch-raising surgery in male-to-
roplasty as a new phonosurgical technique. female transsexuals. J Voice 13:246, 1999.
Acta Otolaryngol 78:451, 1974. 15. Remacle M, Matar N, Morsomme D, et al.
4. Isshiki N, Taira T, Tanabe M. Surgical altera- Glottoplasty for male-to-female transsexual-
tion of the vocal pitch. J Otolaryngol 12:335, ism: voice results. J Voice 25:120, 2011.
1983. 16. Tucker HM. Anterior commissure laryngo-
5. Isshiki N. Mechanical and dynamic aspects plasty for adjustment of vocal fold tension.
of voice production as related to voice ther- Ann Otol Rhinol Laryngol 94(6 Pt 1):547,
apy and phonosurgery. J Voice 12:125, 1998. 1985.
6. Matai V, Cheesman AD, Clarke PM. Crico- 17. Kunachak S, Prakunhungsit S, Sujjalak K.
thyroid approximation and thyroid chondro- Thyroid cartilage and vocal fold reduction: a
plasty: a patient survey. Otolaryngol Head new phonosurgical method for male-to-
Neck Surg 128:841, 2003. female transsexuals. Ann Otol Rhinol
7. Neumann K, Welzel C. The importance of Laryngol 109:1082, 2000.
the voice in male-to-female transsexualism. 18. Mastronikolis NS, Remacle M, Biagini M, et
J Voice 18:153, 2004. al. Wendler glottoplasty: an effective pitch
8. Yang CY, Palmer AD, Murray KD, et al. Cri- raising surgery in male-to-female transsexu-
cothyroid approximation to elevate vocal als. J Voice 27:516, 2013.
pitch in male-to-female transsexuals: results 19. Wendler J. Pitch raising by shortening of the
of surgery. Ann Otol Rhinol Laryngol 111:477, glottis. In Abstracts of Thi d International
2002. Symposium on Phonosurgery. Kyoto, Japan:
9. Hong KH, Ye M, Kim YM, et al. Functional International Association of Phonosurgeons,
differences between the two bellies of the June 26-28, 1994.
cricothyroid muscle. Otolaryngol Head Neck 20. Thomas JP, Macmillan C. Feminization la-
Surg 118:714, 1998. ryngoplasty: assessment of surgical pitch ele-
10. Orloff LA, Mann AP, Damrose JF, et al. vation. Eur Arch Otorhinolaryngol 270:2695,
Laser-assisted voice adjustment (LAVA) in 2013.
transsexuals. Laryngoscope 116:655, 2006. 21. Carew L, Dacakis G, Oates J. The effective-
11. Wendler J. Vocal pitch elevation after tran- ness of oral resonance therapy on the percep-
sexualism male to female. In Proceedings tion of femininity of voice in male-to-female
of the Union European Phoniatricians. transsexuals. J Voice 21:591, 2007.
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CHAPTER
3
Top Surgery
Britt Colebunders,
Salvatore D’Arpa, Stan J. Monstrey
Key Points
❖❖ Top surgery is one of the most commonly per- ❖❖ Breast volume, as well as skin quality, is a
formed gender reassignment surgeries. key factor that should determine the appropri-
❖❖ For most transwomen, breast augmentation ate subcutaneous mastectomy technique in
greatly increases subjective feelings of transmen.
femininity. ❖❖ The Ghent algorithm helps us to choose from
❖❖ Despite some sexual differences in chest wall five techniques, resulting in an aesthetically
and mammary anatomy, the implantation of pleasing male chest.
a breast prosthesis is not essentially different
from breast augmentation in a female patient.
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Indications and Contraindications

Top surgery is one of the most commonly performed gender reassignment surgeries. Male-
to-female top surgery consists of breast augmentation with implants and/or autologous
tissue. Female-to-male top surgery includes mastectomy and creation of a male chest. The
Standards of Care (SOC) of the World Professional Association of Transgender Health
(WPATH) offers flex ble guidelines for the treatment of people experiencing gender dys-
phoria and puts forth the following criteria for top surgery1:
❖❖ A persistent, well-documented gender dysphoria
❖❖ The capacity to make a fully informed decision and to give consent for treatment
❖❖ Age of majority in a given country
❖❖ If a prospective candidate for top surgery has a signifi ant medical or mental health
concern, it must be well controlled.
Although not an explicit criterion, it is recommended that transwomen undergo feminizing

hormone therapy (minimum 12 months) before breast augmentation surgery. The purpose
is to maximize breast growth to obtain better surgical (aesthetic) results.
Top surgery can greatly facilitate patients’ experience of living in a gender role that is con-
gruent with their gender identity. Th s experience is required for 12 months before bottom
surgery (vaginoplasty or metoidioplasty/phalloplasty). However, for some transgender in-
dividuals, top surgery may be the only surgical step that is undertaken during transition.
Breast Augmentation in Transwomen

For most transwomen, breast augmentation (or breast “reconstruction”) greatly increases
subjective feelings of femininity. Mammaplasty provides a more feminine profile, facilitat-
ing adjustment to the gender identity and increasing factors involved in passability (Fig.
3-1). In a prospective, noncomparative, cohort study, it was shown that the gains in breast
satisfaction, psychosocial well-being, and sexual well-being after transwomen underwent
breast augmentation were statistically signifi ant and clinically meaningful to the patient
shortly after surgery, as well as in the long term.2
A B
Fig. 3-1 Breast augmentation. A, Preoperative. B, Postoperative.
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There are few changes that occur, even after years of estrogen therapy, which create a femi-
nine appearance in the biologic male body. Hormonal therapy has no effect on voice, hand,
feet, or shoulder dimensions. Although some breast formation occurs, for many, it is insuf-
ficie t. Unfortunately, no studies have closely looked at the minimum period of hormone
therapy that must be completed before breast surgery may be performed. However, most
surgeons recommend a 12-month period of feminizing hormone therapy before breast aug-
mentation surgery to maximize breast growth and obtain better surgical (aesthetic) results.
Mammogenesis in transwomen receiving estrogens follows a pattern similar to female pu-

bertal mammogenesis as described by Marshall and Tanner.3 As breast development, it is
not exclusively dose responsive—67% to 75% of the transwomen require an augmentation
mammaplasty, because hormonal treatment only results in a softly pointed breast as seen
in young girls or the small conical form found in young adolescents (Tanner stage 2 or 3).4
Surgical Techniques
Breast Implant
Because breast prostheses are implanted in transsexuals with “young adolescent” breast de-
velopment, the patient should be informed that the complex feminine form and age-related
changes to the breast cannot be imitated by using symmetrical hemispheric implants. There-
fore the results of an augmentation mammaplasty in a transwomen with minimal hormone-
induced mammogenesis may be poor.4 Other anatomic differences, which should be taken
into consideration in transwomen, are the wider male chest, a stronger pectoral fascia, a
more developed pectoralis muscle, and the smaller dimensions of the nipple and areola.
Usually a larger-volume breast implant is chosen by transwomen than that chosen for breast
augmentation by a female patient, but even with a larger implant, it is often impossible to
avoid abnormally wide cleavage between the breasts. The nipple and areola should always
overlie the implant centrally, and a very medial position of these implants could result in a
divergent nipple position with an unacceptable breast appearance.5
Despite some sexual differences in the chest wall and mammary anatomy, the implantation
of breast implants is not essentially different from breast augmentation in a female patient,
except that larger prostheses are usually used. The same choices apply regarding the type
of implant, position of the pocket, and surgical approach. Patient and surgeon can choose
between a silicone gel–filled implant and a saline-filled implant. In most patients, a textured
implant is chosen to reduce the potential for capsular contracture. When a more cohesive
gel-filled implant is chosen, it can be an anatomic implant, resulting in additional filling of
prominence in the lower part of the breast.
The incision can be either axillary, inframammary, or even periareolar, although the latter
is less popular in transwomen because of the smaller size of the areola. If an inframam-
mary incision is used, it should be positioned lower than the preoperative inframammary
fold, because the distance between the inferior areolar margin and inframammary fold will
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expand after augmentation mammaplasty, probably resulting from the recruitment of the
inframammary or even abdominal skin.4
The pocket for the implant can be created behind the glandular tissue or pectoralis muscle.
Some authors recommend implanting the prosthesis in a subglandular position. 4 This is
especially indicated in patients who have more subcutaneous and glandular tissue to start
with (Tanner stage 4 or 5). The surgical procedure is easier to perform and less painful.
Many surgeons, however, prefer to put the implant in a retropectoral position. In this case
the lower portion (as well as part of the medial origin) of the pectoralis muscle should be
detached from the thoracic cage.6 In the retropectoral position, the prosthesis is covered
with more soft tissue (important in thin patients), and a lower risk of capsular contraction
has also been reported.
In most institutions breast augmentation is often performed during the same surgical pro-
cedure as genital surgery. In this case the operation starts with breast augmentation, which
is the most sterile part of the intervention. However, both procedures can even be carried
out simultaneously if two surgical teams are available. For various reasons, some patients
may prefer to have the augmentation mammaplasty performed as a preceding procedure
(eventually combined with castration to allow offi al gender change) or as a subsequent
surgical intervention.
Fat Grafting
Fat grafting or lipofilling is a technique in which fat is harvested by liposuction of the ab-
domen or thighs. Subsequently, the fat is centrifuged to separate the oil, fluid, and blood
supernatants.7 As a result, a concentrated, “purifi d” fat sample is obtained, which can be
injected into the subcutaneous plane (Fig. 3-2). In transwomen who already have some
breast volume from hormone treatment, fat grafting can be a good option to provide a
moderate augmentation of the breast, thereby avoiding the need for an implant. However,
Fig. 3-2 Fat grafting can be used to provide a moderate augmentation (here only at the left side).
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patients should be informed that a variable percentage of the injected fat is resorbed, and
that a second or even a third procedure may be necessary to achieve suffici t volume.
We have also used fat grafting as an adjunct to breast augmentation with implants. Fat is
injected into the subcutaneous plane to make the implant less visible and palpable and to
narrow the wide cleavage between the breasts.
Autologous Flap Surgery

Breast reconstruction with autologous free flaps or pedicled flaps in transwomen has not
yet been described. However, in an era in which screening for a genetic predisposition of
breast cancer is more commonly performed, this procedure may become important in the
future. A bilateral prophylactic mastectomy and consecutive primary reconstruction with
either autologous tissue (for example, a deep inferior epigastric perforator flap) or a breast
implant should be offered to patients with a genetic predisposition for breast cancer.8
Complications
Kanhai et al4 reported the main (but rarely occurring) complications after breast augmen-
tation: hematoma, synmastia, capsular contracture, a decreased sensation in the nipple
and/or part of the breast, leakage of the prostheses (more obvious in saline-filled pros-
theses than in cohesive silicone gel–filled prostheses), and malposition of the prostheses.
Although it is very rare in these patients, mastopexy can be the treatment of choice to cor-
rect substantial mammary ptosis, but usually an augmentation is suffici t to fill out the
(slightly) ptotic breasts.
Galactorrhea is another rare condition that can occur preoperatively or postoperatively.

It requires an extensive hormonal evaluation, with particular attention to the pituitary
gland. Except for hormonal causes, excessive prolactin secretion causing galactorrhea
may also result from a peripheral stimulus, such as breast manipulation or intercostal
nerve stimulation. Galactorrhea in the latter case is associated with chest incisions or
inflammation of the chest wall and thus may also be caused by mammary implants. In
many patients, however, no cause for the galactorrhea can be found, and the condition
remains idiopathic.
Postoperative follow-up is mandatory in all patients undergoing breast augmentation.

Gooren et al9 performed a cohort study documenting the occurrence of breast cancer
in 2307 transgender individuals with an exposure to cross-sex hormones between 5 and
30 years and reported 10 cases of breast cancer in transwomen. All patients received oral
estrogens for prolonged periods to maintain secondary female characteristics. Th ee of
these 10 cases were not estrogen-dependent breast carcinomas. Their study suggested that
cross-sex hormone administration does not increase the risk of breast cancer development
in transwomen. Breast carcinoma incidences were comparable with male breast cancers and
thus lower than in the female population. However, the historic use of cross-sex hormones
may have been too short for malignancies to develop. Therefore good screening and follow-
up are imperative. Moreover, because breast examinations are also very well accepted by
transwomen, transgender patients should be encouraged to participate in relevant cancer
screening protocols, which for breast cancer screening is the same as for cisgender women.10
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Routine preoperative investigation of family history is imperative. Screening for genetic pre-
disposition (for example, BRCA mutations) should be considered in patients with multiple
breast and/or ovarian cancers within their family (often diagnosed at an early age)—two
or more primary breast and/or ovarian cancers in a single family member and/or cases of
male breast cancer within their family.
Subcutaneous Mastectomy in Transmen

Because hormonal treatment has little influence on breast size, the fi st (and arguably most
important) surgery performed in transmen is the creation of a male chest by means of sub-
cutaneous mastectomy (SCM). Th s procedure allows the patient to live more easily in the
male role and thereby facilitates the experience of living in a gender role that is congruent
with their gender identity, which is a prerequisite for external genital surgery. A large body
of literature on the optimal technique for performing SCM exists, but the majority focuses
on women with breast disease or men with gynecomastia. There is a paucity of information
regarding removal of the breasts in transmen.
Obviously, the male and female chests are anatomically different.11,12 The female chest has
excess skin, excess glandular tissue, and a surrounding surplus of subcutaneous fat. Regard-
ing the inferior confi ement of the breast, in the female, the inframammary fold is well de-
fi ed. In the average male, the chest does not show an inframammary fold, and the inferior
margin of the pectoralis muscle (often somewhat squared by rudimentary breast tissue and
nipple) represents the dim inferior margin of the chest. The importance of obliterating the
inframammary fold while contouring the male chest has been stressed by several authors.11
From a purely anatomic viewpoint, SCM in transmen is virtually identical to that of the
mastectomy for breast disease or prophylaxis. However, the goals for transmen differ, be-
cause they include aesthetic contouring of the chest wall by removal of breast tissue and
excess skin, reduction and proper positioning of the nipple and areola, obliteration of the
inframammary fold, and minimization of chest wall scars—in short, the creation of an aes-
thetically pleasing male chest.12 Many of the techniques for the treatment of gynecomastia
have been used or modifi d in SCM for transmen, and the methods and indications for
each have been discussed in the literature.12-14 The reports describe liposuction, semicircu-
lar circumareolar techniques, concentric circular techniques, transareolar incisional tech-
niques, and more radical procedures, such as breast amputation with a free nipple graft 15-19
Poor aesthetic outcomes include contour abnormalities (breast, inframammary fold, and
nipple), issues related to the nipple-areola complex (NAC) (size, placement, and viability),
skin redundancy, and poor scarring.11 Secondary corrections are occasionally necessary.
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Fig. 3-3 A, The use of breast binding to camouflage a feminine-looking chest. B, Breast binding can
result in a ptotic breast with poor skin elasticity.
Indeed, performing SCM in transmen is more difficult than correction of gynecomastia in

males, because in most cases transmen will usually have more breast volume and a greater
degree of skin excess and ptosis. According to Hage and Bloem,12 skin excess and not breast
volume is the factor that should determine the appropriate SCM technique. Based on more
than 400 SCMs we have performed for transmen over the past 15 years, we agree that skin
quality—specifi ally, skin “elasticity”—is also a key factor. It can make the difference be-
tween a good aesthetic outcome and a poor one, especially with a less experienced surgeon.
In this patient population, poor skin quality can be exacerbated when the patient has en-
gaged in years of “breast binding” (Fig. 3-3).
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SMALL MEDIUM LARGE VERY LARGE

A cup, grade 1 ptosis B cup, grades 1 or 2 ptosis C cup, grade 2 ptosis Grades 2 or 3 ptosis
Poor
ELASTICITY
ELASTICITY Moderate
Moderate to poor
Good
ELASTICITY
Moderate to poor
Good
Will
YES patient accept YES
Nipple reduction
required? free nipple
graft?
NO NO
Semicircular Transareolar Concentric circular Extended concentric Free nipple graft
Fig. 3-4 Algorithm for choosing the appropriate SCM technique.
Surgical Techniques
Preoperative parameters to be evaluated include breast volume, the degree of excess skin,
NAC size and position, and skin elasticity. If a patient is a smoker, the surgeon should dis-
cuss the effects of smoking on skin quality, wound healing, and vascularity and encour-
age the patient to stop smoking. Hormonal therapy is stopped 2 to 3 weeks before surgery.
Because of the multitude of techniques, the difficulty with SCM lies less in the procedure
itself (although it is wrongly considered an “easy” procedure) and more in the choice of
technique. Therefore we have developed an algorithm, which helps us to choose from five
techniques, resulting in an aesthetically pleasing male chest20 (Fig. 3-4).
Regardless of the technique, it is extremely important to preserve all subcutaneous fat when
dissecting the glandular tissue from the flaps. Th s ensures thick flaps that produce a pleas-
ing contour and do not subsequently become tethered to the chest wall. For the same rea-
son, we preserve the pectoralis fascia. We do not perform liposuction at the anterior aspect
of the breast. However, judicious use of liposuction can occasionally be indicated laterally
or to obtain complete symmetry at the end of the procedure. The inframammary fold is al-
ways released and is an especially important maneuver for patients with large breasts. Th s
is done by extending the inferior flap onto the abdomen, and where a tight band exists, in-
cising it with multiple transverse cuts. Postoperatively a circumferential elastic bandage is
placed around the chest wall and maintained day and night for 4 to 6 weeks.
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B C
Fig. 3-5 Semicircular technique. A, Incisions and scars. B, Preoperative view. C, Postoperative result.
Semicircular Technique
The semicircular technique (Fig. 3-5) is essentially the same procedure as that described by
Webster19 in 1946 for the correction of gynecomastia. It is useful for individuals with smaller
breasts. The resulting scar will be confined to the lower half of the periphery of the areola
(infraareolar). A sufficient amount of glandular tissue should be left in situ beneath the NAC
to avoid a depression. The advantage of this technique is the small and well-concealed scar,
which is confined to the NAC. The major drawback is the small window through which
to work, making excision of breast tissue and hemostasis more challenging. The surgeon
must avoid overzealous traction on the skin edges with the retractors, which could result
in wound dehiscence or marginal skin necrosis.
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B C
Fig. 3-6 Transareolar technique. A, Incisions and scars. B, Preoperative view. C, Postoperative result.
Transareolar Technique
In patients with smaller breasts with large, prominent nipples, the transareolar technique
(Fig. 3-6) is used. This is similar to the procedure described by Pitanguy18 in 1966. It allows
a subtotal resection of the nipple and usually incorporates the upper aspect, which tends
to ameliorate the downward effect of gravity. The resulting scar traverses the areola hori-
zontally and passes around the upper aspect of the nipple. The additional advantage of this
technique is that it allows an immediate nipple reduction. The disadvantage is the same as
with the semicircular technique—it is more difficult to excise breast tissue and achieve he-
mostasis. In addition, the transareolar scar is usually somewhat more apparent.
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B C
Fig. 3-7 Concentric circular technique. A, Incisions and scars. B, Preoperative view. C, Postoperative result.
Concentric Circular Technique

The concentric circular technique was described by Davidson15 in 1979 (Fig. 3-7). It is used
for breasts with a medium-sized skin envelope (B cup) or smaller breasts with poor skin
elasticity. The resulting scar will be confi ed to the circumference of the areola. The concen-
tric incision can be drawn as a circle or ellipse, enabling deepithelialization of a calculated
amount of skin in the vertical or horizontal direction.12 Access is gained through an inci-
sion in the inferior aspect of the outer circle. Glandular tissue is carefully dissected off the
overlying NAC, leaving it widely based on a dermal pedicle. In this case it is unnecessary
to leave excess glandular tissue beneath the NAC, because the folded deepithelialized der-
mis surrounding the areola provides suffici t NAC projection and prevents nipple–chest
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wall tethering. A permanent purse-string suture is placed and set to the desired areolar di-
ameter (usually 25 mm). The advantage of this technique is that it allows reduction and/or
repositioning of the areola where required and removal of excess skin. It also affords good
exposure for glandular excision and hemostasis. However, it requires experience to deter-
mine the amount of skin to be deepithelialized. Widening of the scar can be seen postop-
eratively, sometimes necessitating an aesthetic scar correction.
Extended Concentric Circular Technique

The extended concentric circular technique is similar to the concentric circular technique
but includes one or two additional triangular excisions of skin and subcutaneous tissue,
which may be inferior and lateral or medial and lateral (Fig. 3-8). Access for excision of
the glandular tissue is provided through these additional skin excisions. Th s technique is
useful to correct skin excess and wrinkling produced by large differences between the in-
B C
Fig. 3-8 Extended concentric circular technique. A, Incisions and scars. B, Preoperative view. C, Post-
operative result.
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ner and outer circles. On the few occasions in which a single vertical triangular excision
inferior to the NAC was used, the results were suboptimal. Subsequently, this technique
was abandoned. Here too a permanent purse-string suture is placed and set to the desired
areolar diameter. The resulting scars will be around the areola, with horizontal extensions
onto the breast skin, depending on the degree of excess skin. The advantages of this tech-
nique are the wide exposure for glandular excision and hemostasis, NAC reduction and
repositioning and tailoring of excess skin resulted in fewer wrinkles around the areola. The
major drawbacks are that the residual scarring is no longer confined to the NAC, and ex-
perience is required in planning the amount of tissue to be excised and/or deepithelialized.
Free Nipple Graft Technique

The free nipple graft technique has been proposed by several authors for patients with large
and ptotic breasts13,14,21,22 (Fig. 3-9). It consists of harvesting the NAC as a full-thickness skin
B C
Fig. 3-9 Free nipple graft technique. A, Incisions and scars. B, Preoperative view. C, Postoperative result.
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graft, amputating the breast, and grafting the NAC onto its new location on the chest wall.
Our preference is to place the incision horizontally 1 to 2 cm above the inframammary fold
and then move upward laterally below the lateral border of the pectoralis major muscle.
The incisions should not cross the midline. After breast amputation, the superior flap is
pulled downward to eliminate skin redundancy. At this stage, judicious defatting or lipo-
suction may be performed laterally and medially to avoid a dog-ear formation and ensure
symmetrical contouring. Again, the surgeon should leave the fat on the undersurface of
the skin flaps. After closure, the NAC is grafted onto the desired position on the chest wall.
Regarding the ideal placement of the NAC, we feel that the use of absolute measurements
can be misleading. We agree with the recommendations of many authors, who position the
NAC according to the patient’s own anatomic landmarks.23,24 Atiyeh et al25 state that the po-
sition of the nipple can be deducted from the distance between the umbilicus and anterior
axillary fold apex and the umbilicus to suprasternal notch. The internipple distance and
position of the horizontal nipple plane relative to the suprasternal notch can be calculated
from these measurements (umbilicus and anterior axillary fold apex and umbilicus to su-
prasternal notch).25 In our series, the nipples were placed along the existing vertical nipple
line, and the height was adjusted to approximately 2 to 3 cm above the lower border of the
pectoralis major. In a typical patient, this will correspond to the fourth or fi h intercostal
space. However, clinical judgment is most important, and we always sit the patient up in-
traoperatively to check fi al nipple position.
The diameter of the NAC is 20 to 25 mm and is cut while the area is stretched circumfer-
entially. The resulting scars will include a line on the inferior aspect of the new male breast,
in addition to one around the areola. The advantages of the free nipple graft technique are
excellent exposure and more rapid resection of tissue, as well as nipple reduction, areola
resizing, and repositioning. The disadvantages are the long residual scars, NAC pigmentary
and sensory changes, and the possibility of incomplete graft take.
Complications
The overall postoperative complication rate was 10% in our series and similar to that in
most other series described in the literature. A hematoma was the most frequent compli-
cation. As one may expect, the frequency of hematoma decreases as one moves from the
periareolar technique to the extended concentric and free nipple graft technique, in which
wider access is provided. Some of the other complications were associated with hematoma,
including (partial) nipple necrosis and abscess formation. Drains and compression ban-
dages did not necessarily prevent the occurrence of this troublesome complication. Th s
underscores the importance of achieving good hemostasis intraoperatively. Smaller hema-
tomas and seromas can be evacuated through puncture. However, in about half of the cases,
surgical evacuation was required.
A signifi ant complication includes simple skin slough of the NAC, which can be left o
heal by conservative means. The exceptional cases of partial or total nipple necrosis may
require a secondary nipple reconstruction.
Despite a rather low complication rate, about one third of patients required an additional
procedure to improve the aesthetic results. The likelihood of an additional aesthetic cor-
rection should be discussed with the patient in advance.24
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Some surgeons prefer to perform a planned two-stage procedure.11In the fi st stage, the skin
initially is left versized to enable it to shrink fully without stretching the scars and areola.
Th s may somewhat reduce the length of the ultimate scar (depending on the elasticity of the
skin). The second procedure removes the excess skin still present after a period of shrinking.
Recommendations
For a breast with a small envelope and good skin elasticity, a semicircular technique is suit-
able. The same breast with an oversized nipple is well suited to a transareolar technique.
The same breast with moderate-to-poor elasticity or a breast with a larger envelope (B cup,
grade 1 or 2 ptosis) will require a concentric circular technique. A moderate-sized breast
(B and C cups, grade 1 or 2 ptosis) with poor skin elasticity will require an extended con-
centric circular technique. Finally, a large-volume breast (C cup or larger) with substantial
skin excess and little or no skin elasticity will likely require a breast amputation with free
nipple grafting. The algorithm demonstrates that moving from left to right in the algorithm,
the techniques require progressively longer incisions with an inherent increase in residual
scarring. When skin elasticity is suboptimal, and all other factors are equal, it is much better
to move one step to the right in the algorithm than to risk a poor aesthetic outcome with
wrinkled or uneven skin. Inevitably, this involves more incisions and longer scars.
Th s approach appears to be in stark contrast to the “short scar” concepts that are so popu-
lar in breast reduction and mastopexy. However, in our experience with this patient group,
increasing scar length is far preferable to puckering, wrinkling, tethering, and excess skin
on a masculine-appearing chest. Of course, good skin elasticity leads to fewer incisions,
less scarring, and possibly less cutaneous wrinkling. However, when choosing between a
scar or contour, we have noticed that most of our patients prefer a better contour than a
shorter scar; for this reason, we have performed many more SCMs with the free nipple
graft technique in recent years.
In 2014 a retrospective study was performed at the Sahlgrenska University Hospital com-
paring our algorithm with a two-step concentric circular approach.26 Th study showed
that the number of complications (for example, hematoma, nipple necrosis, seroma, wound
dehiscence, and infection) and the total number of surgeries performed to satisfy patients
were lower after using Monstrey’s algorithm.26
Transmen are rightfully becoming better informed and more demanding. Indeed, good
results, although sometimes difficult to accomplish and possibly requiring an additional
correction, are crucial to improve the patient’s body image.
Finally, there have been reports of breast cancer after bilateral SCM in this population.27-29
Preservation of the NAC after SCM leaves behind insensate ductal tissue at risk for malig-
nant transformation. Residual breast tissue persists even after the most radical prophylactic
mastectomy, and a regular SCM never removes all glandular tissue. Although the precise
causative role of androgens in breast cancer origin is unclear, the association between high
androgen levels and breast cancer risk is well documented. Apparently, high-circulating
androgens in postmenopausal women may increase estrogens by peripheral aromatiza-
tion of dehydroepiandrostenedione to estradiol and estrone in breast and adipose tissue.
Th s prolonged and unopposed estrogenic stimulation could increase the development of
breast cancer. In addition, a family history of breast cancer may play a role in this scenario.
Therefore lifelong follow-up of these patients is required.
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References
1. Coleman E, Bockting W, Botzer M, et al. 15. Davidson BA. Concentric circle operation for
Standards of Care for the Health of Transsex- massive gynecomastia to excise the redun-
ual, Transgender, and Gender-Nonconform- dant skin. Plast Reconstr Surg 63:350, 1979.
ing People, version 7. Int J Transgenderism 16. Dolsky RL. Gynecomastia. Treatment by
13:165, 2011. liposuction subcutaneous mastectomy. Der-
2. Weigert R, Frison E, Sessiecq Q, et al. Patient matol Clin 8:469, 1990.
satisfaction with breasts and psychosocial, 17. Letterman G, Schurter M. The surgical cor-
sexual, and physical well-being after breast rection of gynecomastia. Am Surg 35:322,
augmentation in male-to-female transsexu- 1969.
als. Plast Reconstr Surg 132:1421, 2013. 18. Pitanguy I. Transareolar incision for gyneco-
3. Marshall WA, Tanner JM. Variations in pat- mastia. Plast Reconstr Surg 38:414, 1966.
tern of pubertal changes in girls. Arch Dis 19. Webster JP. Mastectomy for gynecomastia
Child 44:291, 1969. through a semicircular intra-areolar incision.
4. Kanhai RC, Hage JJ, Karim RB, et al. Excep- Ann Surg 124:557, 1946.
tional presenting conditions and outcome 20. Monstrey S, Selvaggi G, Ceulemans P, et al.
of augmentation mammaplasty in male-to- Chest-wall contouring surgery in female-
female transsexuals. Ann Plast Surg 43:476, to-male transsexuals: a new algorithm. Plast
1999. Reconstr Surg 121:849, 2008.
5. Laub DR, Fisk N. A rehabilitation program 21. Kluzak R. Sex conversion operation in female
for gender dysphoria syndrome by surgical transsexualism. Acta Chir Plast 10:188, 1968.
sex change. Plast Reconstr Surg 53:388, 1974. 22. Wray RC Jr, Hoopes JE, Davis GM. Correc-
6. Monstrey S, Hoebeke P, Dhont M, et al. tion of extreme gynaecomastia. Br J Plast
Surgical therapy in transsexual patients: a Surg 27:39, 1974.
multidisciplinary approach. Acta Chir Belg 23. Beckenstein MS, Windle BH, Stroup RT Jr.
101:200, 2001. Anatomical parameters for nipple position
7. Strong AL, Cederna PS, Rubin JP, et al. The and areolar diameter in males. Ann Plast
current state of fat grafting: a review of har- Surg 36:33, 1996.
vesting, processing, and injection techniques. 24. Beer GM, Budi S, Seifert B, et al. Config
Plast Reconstr Surg 136:897, 2015. ration and localization of the nipple-
8. Colebunders B, T’Sjoen G, Weyers S, et al. areola complex in men. Plast Reconstr
Hormonal and surgical treatment in trans- Surg 108:1947; discussion 1953, 2001.
women with BRCA1 mutations: a controver- 25. Atiyeh BS, Dibo SA, El Chafic AH. Vertical
sial topic. J Sex Med 11:2496, 2014. and horizontal coordinates of the nipple-
9. Gooren LJ, van Trotsenburg MA, Giltay EJ, et areola complex position in males. Ann Plast
al. Breast cancer development in transsexual Surg 63:499, 2009.
subjects receiving cross-sex hormone treat- 26. Bjerrome Ahlin H, Kölby L, Elander A, et al.
ment. J Sex Med 10:3129, 2013. Improved results after implementation of the
10. Weyers S, Villeirs G, Vanherreweghe E, et Ghent algorithm for subcutaneous mastec-
al. Mammography and breast sonography tomy in female-to-male transsexuals. J Plast
in transsexual women. Eur J Radiol 74:508, Surg Hand Surg 48:362, 2014.
2010. 27. Burcombe RJ, Makris A, Pittam M, et al.
11. Hage JJ, van Kesteren PJ. Chest-wall con- Breast cancer after bilateral subcutaneous
touring in female-to-male transsexuals: basic mastectomy in a female-to-male trans-
considerations and review of the literature. sexual. Breast 12:290, 2003.
Plast Reconstr Surg 96:386, 1995. 28. Symmers WS. Carcinoma of breast in trans-
12. Hage JJ, Bloem JJ. Chest wall contouring for sexual individuals after surgical and hormonal
female-to-male transsexuals: Amsterdam ex- interference with the primary and secondary
perience. Ann Plast Surg 34:59, 1995. sex characteristics. Br Med J 2:83, 1968.
13. Eicher W. [Transsexualism] Dtsch Kranken- 29. Secreto G, Toniolo P, Berrino F, et al. In-
pfle ez 45:183, 1992. creased androgenic activity and breast cancer
14. Lindsay WR. Creation of a male chest in fe- risk in premenopausal women. Cancer Res
male transsexuals. Ann Plast Surg 3:39, 1979. 44(12 Pt 1):5902, 1984.
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CHAPTER
4
Combined Hysterectomy, Oophorectomy,
and Chest Reconstruction in
Female-to-Male Transgender Patients
Christopher J. Salgado, Renee Gasgarth,

Lydia A. Fein, Christopher Estes
Key Points
❖❖ For female-to-male (FTM) patients who desire ❖❖ Laparoscopic technique is recommended for
the removal of breasts and female reproductive the hysterectomy and oophorectomy in trans-
organs for the cessation of endogenous pro- gender male patients.
duction of feminizing gonadal hormones, an ex- ❖❖ Five techniques for aesthetically pleasing sub-
cellent option is a combined chest reconstruc- cutaneous mastectomy have been described. a
tion and total laparoscopic hysterectomy (TLH) The appropriate technique should be selected
with bilateral salpingo-oophorectomy (BSO). based on breast size and the degree of ptosis.
❖❖ Combined TLH/BSO and chest reconstruction ❖❖ Combined TLH/BSO has been shown to be
is safe and efficacious and reduces the total successful in gender dysphoric adolescents
number of trips to the operating room that a and should be considered a viable option in
transgender patient must undergo to alleviate this age group if these surgeries are indicated
his gender dysphoria. to help the patient to achieve his gender ex-
pression goals.
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Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming

People (SOC) published by the World Professional Association for Transgender Health
(WPATH) are the professional guidelines that establish recommendations for performing
gender affirmation surgery (GAS) on transgender patients.1 The SOC are specific in cer-
tain guidelines, such as recommending that all patients undergo at least 1 year of hormone
therapy before gonadectomy to introduce a period of reversible changes in appearance
before the patient undergoes irreversible surgery. However, they are notably more vague
in others, because WPATH acknowledges that therapeutic and surgical goals are unique
to each patient. Box 4-1 lists the WPATH SOC for breast/chest surgery and hysterectomy/
oophorectomy.1
Notably, the SOC do not specify the order in which transition surgeries should occur.
The number and order can vary, depending on the patient’s unique needs and how he or
she chooses to coordinate a treatment plan with the surgical teams. Breast/chest surgery
can be performed independently, which may be ideal for a person wishing to keep his or
her reproductive organs intact. However, many patients choose to undergo gonadectomy
and genital reconstructive surgery, in addition to breast/chest surgery. Specifi ally, for the
Box 4-1 World Professional Association for Transgender

Health Criteria for Breast/Chest Surgery and Hysterectomy/
Oophorectomy in the Female-to-Male Patient
Breast/Chest Surgery*
1. One referral from a mental health professional with experience in the care of transgender
patients
2. Persistent, well-documented gender dysphoria for at least 1 year
3. Capacity to make a fully informed decision and to consent for treatment
4. Age of majority in a given country (if younger, follow the SOC for children and
adolescents)
5. If significant medical or mental health concerns are present, they must be reasonably
well controlled
Hysterectomy/Oophorectomy
1. Two referrals from mental health professionals with experience in the care of
transgender patients
2. Persistent, well-documented gender dysphoria for at least 2 years
3. Capacity to make a fully informed decision and to give consent for treatment
4. Age of majority in a given country (if younger, follow the SOC for children and
adolescents)
5. If significant medical or mental health concerns are present, they must be well controlled
6. Twelve continuous months of hormone therapy as appropriate to the patient’s gender
goals (unless hormones are not clinically indicated for the individual)
*Hormone therapy is not a prerequisite.
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female-to-male (FTM) patient desiring chest reconstruction, gonadectomy, and subsequent

GAS, it is often benefic al to combine chest reconstruction with a total laparoscopic hyster-
ectomy and bilateral salpingo-oophorectomy (TLH/BSO) into one procedure.
Performing these surgeries together—the former by plastic surgeons and the latter by gy-
necologists—can be accomplished safely and effici tly with few or no complications and
can confer great benefit to the patient.2,3 The combined procedure can result in fewer total
trips to the operating room, less time away from work, reduced hospital costs, and the psy-
chological benefits of removing multiple components of the anatomy that potentiate gender
dysphoria. Although the timing of surgery should always be tailored to the individual needs
of the patient, combining these surgeries can be presented as a safe option to FTM patients.
Another area in which the SOC are nonspecific is in the treatment of adolescents. Although
they recommend that irreversible surgery should be withheld until the age of consent, they
acknowledge that this decision should ultimately be left o the patient, his or her parents,
and the physicians. Therefore, under the appropriate circumstances, irreversible surgery
may be performed on adolescents. Existing literature supports the assertion that GAS in a
carefully selected adolescent population is benefic al for alleviating gender dysphoria and
contributing to a successful gender transition.4,5

Transgender patients with well-documented diagnoses of gender dysphoria who desire
irreversible GAS procedures are candidates for combined chest reconstruction and TLH/
BSO. The indication for surgery is generally made fi st by a psychiatrist or psychotherapist,
who provides the patient with a referral letter containing the diagnosis of gender dysphoria.
Patients should meet all the criteria outlined by the WPATH SOC to be considered candi-
dates for surgery. Exposure to long-term testosterone therapy may also present additional
indications for hysterectomy. Long-term testosterone therapy may confer increased risk of
malignancy of the upper female genital tract, although the data are somewhat limited and
confli ting.6,7 In addition, some evidence suggests that testosterone exposure increases the
risk of abnormal uterine bleeding in certain individuals, which can also be an indication
for hysterectomy.8,9
There are no absolute contraindications to combined chest reconstruction and TLH/BSO.

However, careful counseling regarding options for fertility preservation must be performed
by a professional (either personally or by referral) who is well versed in the available op-
tions before proceeding with surgery. The patient should be made aware of the option to
preserve the uterus and use assisted reproductive technologies to become pregnant. The
patient may also elect to undergo oocyte harvesting and cryopreservation before TLH/
BSO. The preserved oocyte can then be used for in vitro fertilization and implanted in the
uterus of a female partner or surrogate. The patient must be made aware of the fact that he
will need to discontinue testosterone therapy during preparation and performance of these
procedures. If he elects to attempt to carry a pregnancy, testosterone must also be discon-
tinued for the entire gestation. Finally, cost considerations must be discussed. The expenses
associated with assisted reproductive technology are generally not covered by insurers and
can carry a substantial cost.
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Patient Evaluation
Both the plastic surgeon and gynecologist who will perform the combined procedures
should evaluate the patient before surgery. Respective evaluations can take place separately
and can proceed in the standard fashion for presurgical physical examination for mastec-
tomy and TLH/BSO by each physician.
Presurgical evaluation for hysterectomy/oophorectomy should also include a discussion

of the patient’s future plans for genital reassignment surgery (GRS) and the desire for vagi-
nectomy, which may be performed at the time of hysterectomy or GRS. If the patient de-
sires vaginectomy at the time of hysterectomy and the surgeon is comfortable performing
this procedure, it may be incorporated into the surgical plans. If the patient desires GRS,
the patient can opt to undergo vaginectomy during either surgery. However, vaginectomy
at the time of GRS may be preferred, because vaginal mucosa is often used for urethral
lengthening during neophallus creation.
Preoperative Management
It is well known that certain factors affect wound healing and cosmetic outcomes. Surgical
candidates who smoke and/or are overweight should be counseled to refrain from smok-
ing and to achieve a healthy BMI before surgery.10,11 Conditions such as diabetes that affect
wound healing should also be appropriately controlled before surgery.12
In the perioperative period, the patient’s hormone therapy is frequently discontinued, often
at least 2 weeks before surgery. Supraphysiologic testosterone levels can lead to elevated se-
rum estrogen levels, which potentially increase the risk for thromboembolic events.13 How-
ever, the incidence of thromboembolic events in transgender individuals is low.14 Therefore
the decision to withhold hormone therapy before surgery is individualized based on the
presentation of the patient and should be a decision involving a discussion among the surgi-
cal team, endocrinologist, and patient. Perioperative thromboembolic prophylaxis by medi-
cal treatment, such as heparin or enoxaparin, and mechanical means, such as compression
stockings, sequential compression devices, and early ambulation, should also be considered.
Performing two surgeries simultaneously in the same operative setting also raises concern
about the increased risk of infection. Administration of antibiotic prophylaxis with cover-
age of both gram-negative and gram-positive organisms and anaerobes is advised. The two
surgeries do not need to be performed in any particular sequence. Both TLH/BSO pre-
ceding chest reconstruction and the reverse order result in similarly successful outcomes. 3
Surgical Technique: Total Laparoscopic

Hysterectomy and Bilateral Salpingo-oophorectomy
A total hysterectomy involves the complete removal of the uterus and cervix, and in trans-
gender patients, it is generally performed in combination with a salpingo-oophorectomy,
which is the removal of the ovaries and fallopian tubes. For patients who do not have an-
other contraindication for laparoscopy, TLH is recommended. It is aesthetically pleasing
because it avoids creating a lower abdominal scar and produces the best results with the
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Fig. 4-1 TLH port site placement for an approach that uses a periumbilical port and three additional
trochars. The patient underwent concomitant panniculectomy.
fewest complications.15,16 In addition, it can potentially decrease postoperative pain and can
preserve structures that are generally necessary for subsequent phalloplasty, such as the
inferior epigastric vessels and rectus muscles.17 Vaginal hysterectomy, although minimally
invasive, can be a challenge in transgender men, because they are frequently nulliparous
and may have signifi ant atrophy of the vaginal canal resulting from a combination of the
effects of testosterone and not having receptive vaginal intercourse.18 In some patients vagi-
nal hysterectomy may be appropriate. However, because the laparoscopic technique is more
commonly performed in transgender patients, it will be described here.
The procedure starts by placing the patient under general endotracheal anesthesia followed
by positioning him in dorsal lithotomy. After skin and vaginal disinfection, the bladder is
drained by Foley catheterization. A uterine manipulator is inserted vaginally with a cup
around the cervix. It can be secured to the cervix by a single suture through the ring and
secured with a hemostat. Accessing the abdomen and establishing pneumoperitoneum
can be accomplished by the surgeon’s preferred technique (open, direct entry, or Veress
needle), taking into consideration any patient factors that could affect its safety. Pneumo-
peritoneum with intraabdominal pressure at 12 to 15 mm Hg is recommended to maintain
adequate visualization of the pelvic organs without having an adverse impact on the need
for positive-pressure ventilation. In some techniques for TLH/BSO a periumbilical port
and three trocars are used (Fig. 4-1). In another technique, two incisions are placed lateral
to the epigastric vessels for the 5 mm trocars. In either situation, the sites can be adjusted
according to uterine size and the presence of other pathology.3,17,19
Abdominal and/or adnexal adhesions should be removed first if they are present. The
round ligaments and infundibulopelvic ligaments are coagulated and cut, and the broad
ligaments are opened to identify the ureters and then cut to the lateral edges of the uterus.
The uterine arteries are then skeletonized. The surgeon should mobilize the inferior leaf of
the peritoneum caudally and laterally to move the ureters well away from the area where
the uterine arteries will be divided. After this, the vesicouterine peritoneum overlying the
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cervix is dissected and mobilized inferiorly. The cup that is placed around the cervix in the
vagina can be pressed cephalad to aid this dissection and prevent injury to the bladder and
ureters during dissection. The surgeon should carefully mobilize the bladder inferiorly only
to the extent necessary to eventually amputate the cervix and uterus from the vagina. Dis-
secting too far inferiorly will increase the risk of bleeding and injury to the ureters. After
adequate mobilization of the bladder is achieved, the uterine vessels can be coagulated and
cut at the level where the incision will be made in the vaginal cuff. Afterward, the uterus
and cervix must be separated from the vaginal apex by pushing cephalad with the uterine
manipulator and using the cup as a backboard. Monopolar or harmonic energy devices can
be used to amputate the specimen. The uterus can be pulled through the vagina if it fits,
and it can remain there to maintain pneumoperitoneum during suturing. Alternatively, it
can be fully removed, and a glove with two 4 × 4 sponges can be used in its place. If the
uterus is too large to fit through the vagina, which is unlikely in an FTM patient, it can be
morcellated transvaginally. The vaginal cuff an be closed with absorbable sutures in an
interrupted fashion. The surgeon should include the vaginal mucosa and pubocervical and
rectovaginal fascia. The uterosacral ligaments may be included in the closure of the apices.
Finally, all instruments and ports are removed and the sites are closed.
Surgical Technique: Chest Reconstruction

Chest reconstruction surgery is regarded as a safe and benefic al option for the FTM patient
to convey a more masculine appearance.20,21 In addition, quality of life has been found to be
higher in individuals who have undergone chest reconstruction.21,22 Subcutaneous mastec-
tomy (SCM) is the technique best suited for FTM transgender patients, because it produces
the aesthetic appearance of a male chest by removing breast tissue and excess skin, reducing
and repositioning the nipple and areola, and obliterating the inframammary fold, the goal
of which is to minimize chest scars. Liposuction alone cannot address the excess skin or
allow complete redraping of the inframammary fold or repositioning of the nipple-areola
complex (NAC). Although many techniques for subcutaneous mastectomy have been de-
scribed, the choice should ultimately be based on the surgeon’s experience. However, the
amount of skin excess rather than breast volume is the main determinant of technique. Skin
elasticity is also an important factor and can be problematic for the transgender population,
which often engages in “breast binding.”20,23-25
Monstrey et al26 described an algorithm of five different techniques to perform an aestheti-

cally satisfactory SCM (Fig. 4-2). Preoperative parameters to be evaluated include breast
volume, the degree of excess skin, NAC size and position, and skin elasticity. Regardless of
the technique, subcutaneous fat should be preserved when dissecting the glandular tissues
from the flaps to ensure thick flaps that produce a pleasing contour. The skin flaps should
not be as thin as those used in oncologic mastectomies, and the surgeon must be aware of
the central aspect of the flap to avoid “hollowing out.” Liposuction can be used as an ad-
junctive procedure to aid in contouring the lateral chest wall or to improve symmetry at
the end of the procedure. The semicircular technique involves the smallest incision, usually
along the inferior aspect of the areola. It is most useful for the treatment of individuals with
smaller breasts and elastic skin. Th s technique is familiar to many surgeons, because it is
frequently advocated in the excisional treatment of gynecomastia.27 A suffici t amount of
glandular tissue should be left in s tu beneath the NAC to avoid a depression. The advantage
of this technique is the well-hidden scar. However, this incision provides the least visual-
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SMALL MEDIUM LARGE VERY LARGE

A cup, grade 1 ptosis B cup, grades 1 or 2 ptosis C cup, grade 2 ptosis Grades 2 or 3 ptosis
Poor
ELASTICITY
ELASTICITY Moderate
Moderate to poor
Good
ELASTICITY
Moderate to poor
Good
Will
YES patient accept YES
Nipple reduction
required? free nipple
graft?
NO NO
Semicircular Transareolar Concentric circular Extended concentric Free nipple graft
Fig. 4-2 This algorithm provides five different techniques for performing an aesthetically satisfactory subcutaneous
mastectomy.
Fig. 4-3 A patient after chest reconstruction

by the transareolar approach.
ization of the underlying tissue and creates a technical challenge. Furthermore, it does not
allow resection of excess skin or alterations in the NAC location or size.
A transareolar technique was also originally described in the gynecomastia literature.

It allows improved visualization through a larger incision and subtotal resection of the
NAC. The scar is still well camouflaged, but again, this incision does not allow resection
of excess skin or a large areola, which typically should be decreased in size in this opera-
tion (Fig. 4-3).
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If the native breast tissue is larger, the skin has poor elasticity, or there is an excess of redun-
dant skin, the concentric circular technique can be used. The resulting scar will be primarily
within the areola, and it allows resection of redundant skin and repositioning of the NAC.
A concentric incision is drawn as a circle or ellipse around the NAC; this allows deepithe-
lialization of a specifi amount of skin horizontally or vertically.20,23 Thus the NAC complex
can be shifted based on the needs of the patient. Th s technique also leaves a well-preserved
pedicle to the nipple. The areolar diameter can also be adjusted with a purse-string suture.
Th s technique allows quite a bit of flex bility and adequate visualization during the mas-
tectomy. However, there is still limited correction of nipple ptosis and excess skin.28
Larger, more ptotic breasts with excess skin and a malpositioned NAC will require differ-
ent techniques. Various techniques have been described, including the extended concentric
circular technique. Th s requires one or two additional triangular excisions of skin and sub-
cutaneous tissue, in addition to the concentric circular technique. The scars are around the
areola with possible horizontal extensions onto the breast skin, depending on the amount
of skin requiring removal. Th s technique has fallen out of favor because of higher rates of
patient and surgeon dissatisfaction. It is also associated with a higher nipple necrosis rate
than even free nipple grafts 28
The free nipple graft technique is best used for patients with large and ptotic breasts.24,25,29,30
Th s technique requires the NAC to be harvested as a full-thickness skin graft, amputation
of the breast, and grafting of the NAC onto the chest wall. The incision can be placed hori-
zontally, 1 to 2 cm above the inframammary fold, and moved up laterally below the lateral
border of the pectoralis major muscle. The free nipple graft allows the more precise recon-
struction of the NAC and the most radical resection of excess skin. Reconstruction of the
NAC is an important component of achieving a masculine appearance of the chest. Male
NACs are more likely oval, and the longitudinal axes are more likely oblique and in line
with the pectoralis major muscle fibers.31 The NAC complex in patients born male tends
to be in the fourth intercostal space, with an average sternal notch-to-nipple distance of
20 cm. Both the nipple and areola tend to be smaller in males, and the nipple projection
should also be less for an ideal masculine aesthetic (Fig. 4-4). However, similar to the vari-
Fig. 4-4 Reconstruction of free nipple graft for chest reconstruction in the FTM transgender patient.
The nipple and areola should be made smaller with less nipple projection to achieve a more masculine
appearance.
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ability between female subjects, there is a quite a bit of variability between males in NAC
size. Therefore we recommend that the patient be positioned sitting up intraoperatively to
check the fi al nipple position.28 The advantages of the breast amputation and free nipple
graft technique are easy chest contouring, excellent exposure and rapid resection of tissue,
nipple reduction, and areola resizing/repositioning. In addition, the resected skin can be
used immediately for flap prelamination or neourethra construction if neophallus creation
is done concomitantly or can be banked if phalloplasty will be performed at a later date.
The disadvantages of breast amputation with free nipple grafting are the large, visible scars,
NAC hypopigmentation, decreased sensation and possibly insensate nipples, and risk of
incomplete graft ake, which can range from sloughing of the epidermis to complete loss
of the NAC.28
Results and Outcomes

D.G. is a patient who initially presented as a 14-year-old transgender male. He had been
living in his desired gender role for more than 2 years, had two letters from mental health
professionals diagnosing him with gender dysphoria, and had received cross-sex hormone
therapy for close to 2 years. His parents accompanied him to clinic visits and consented to
his undergoing combined chest reconstruction and TLH/BSO. His preoperative medica-
tions were fluoxetine, oxcarbazepine, and testosterone. On initial examination by the plastic
surgeon, he was 5 feet 9 inches, 180 pounds, with well-developed pectoralis major muscles
with grade 3 ptosis bilaterally, no breast masses, large NACs bilaterally, and evidence of
long-term breast binding. He was also seen by the gynecologist, who on examination de-
termined that he had normal, unremarkable external and internal female genitalia.
One year later, he presented to the plastic surgeon for surgical planning of concomitant total
mastectomy and TLH/BSO. D.G.’s hormone therapy was not discontinued before surgery.
Broad-spectrum antibiotic prophylaxis was administered on the day of surgery. The gyne-
cologic team performed the TLH/BSO fi st. The uterus and adnexa were removed vaginally,
and the vaginal cuff was closed laparoscopically. After uncomplicated TLH/BSO, the plastic
surgery team began chest reconstruction immediately after closure of trochar and port sites.
D.G.’s chest reconstruction was performed with a subcutaneous free nipple graft technique,
which is best suited for FTM transgender patients with large, ptotic breasts. The NACs were
harvested as full-thickness skin grafts, the breasts were amputated, and the NACs were
grafted onto the chest wall, allowing a more precise reconstruction to achieve a more mas-
culine appearance of the chest. The patient was placed in a sitting position intraoperatively
to check fi al nipple position. The chest reconstruction was performed without complica-
tion. A Xeroform dressing and cotton balls provided a bolster to each free nipple graft, and
as is standard practice after a mastectomy, a circumferential elastic bandage was placed
around the chest. D.G. was instructed to use this bandage for 4 to 6 weeks.
He was discharged after postoperative day 1. The nipple bolsters and drains were removed
1 week after surgery. Regular follow-up visits with both the plastic surgeon and gynecolo-
gist should occur frequently for the fi st 6 months, and D.G. was instructed to return to
both of his physicians several times within that time frame. One month after surgery, with
well-healed incisions, 100% surviving nipple grafts, and an intact, well-suspended vaginal
cuff, he was able to attend summer camp with minimal medical restrictions. Both he and
his parents were very satisfi d with the outcomes of these surgeries.
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A B
Fig. 4-5 A, Bilateral mastectomies, free nipple grafts, and a combined laparoscopic hysterectomy and
bilateral oophorectomy were planned for this 19-year-old transgender male. B and C, Eight months
postoperatively after TLH/BSO, in addition to chest reconstruction surgery with free nipple grafts.
One year after surgery, the patient remained extremely satisfi d with his surgeries. His
scars and nipple grafts had healed nicely, leaving him with excellent cosmetic results (Fig.
4-5). Because long-term postoperative care and follow-up after surgical treatments for
gender dysphoria are associated with good surgical and psychosocial outcomes, D.G. was
instructed to follow up with his plastic surgeon and gynecologist every 6 to 12 months.32
Th ee years later, the patient has integrated well into his school and is awaiting phallus
construction.
Problems, Complications, and Considerations

Total Laparoscopic Hysterectomy With Bilateral
Salpingo-oophorectomy
When comparing FTM transgender patients with cisgender counterparts, their uteruses
tend to weigh less, the patients are younger at procedure time, and they have lower par-
ity. These factors contribute to less blood loss and shorter operating times for transgender
patients.16 Complication rates are similar or lower than in nontransgender patients, and
generally only minor complications have been reported, even in cases combined with chest
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A B
Fig. 4-6 A, TAH/BSO in an FTM patient performed in conjunction with stage 1 of radial forearm phal-
loplasty (flap prelamination, urethral lengthening, and vaginectomy). This abdominal incision will be
used in stage 2 for epigastric vessel harvest before flap transfer. B, Uterus and adnexa after TAH/BSO in
an FTM patient. Uterine length and width are less than average when compared with adult, nulligravid
biologic females.
reconstruction. These minor complications include hematoma, urinary tract infection, al-
lergic reaction, and hypesthesia of the leg.3,16
Although TLH/BSO in transgender patients has similar outcomes to those in cisgender pa-
tients, there are some challenges to approaching this surgery in FTM patients that must be
considered. Nulliparity, never having receptive vaginal intercourse, and long-term testoster-
one exposure compound each other to cause signifi ant vaginal atrophy. Th s makes vaginal
access more challenging. Saridogan and Cutner33 reported that a laparoscopic hysterectomy
with a McCartney tube has been useful in overcoming the challenges of restricted vaginal ac-
cess. Another technique for removing the uterus and adnexa through a narrow vaginal open-
ing is to use a uterine morcellator before extraction.
Because the aesthetic result is so important in transgender patients, single-point access

techniques, both laparoscopic and robotic, are increasingly being used.34,35 However, no
long-term or postoperative data are yet available for these techniques in transgender pa-
tients. Laparoscopically assisted vaginal hysterectomy or total abdominal hysterectomy
(TAH) may be considered if a vaginectomy will be performed concomitantly. Although
laparoscopically assisted vaginal hysterectomy has not been extensively studied, combined
abdominal hysterectomy and vaginectomy may be associated with more blood loss than
if vaginectomy is performed at the time of subsequent phalloplasty.36 If a hysterectomy is
part of a staged phalloplasty procedure or a future phalloplasty is planned, an abdominal
approach can be used if care is taken to place the incision at an abdominal location that
can be used for harvesting vessels or creating a flap in subsequent surgery37-39 (Fig. 4-6).
An important discussion to have with FTM patients after TLH/BSO is whether they need
to have regular screening for cervical cancer. According to the American Society for Col-
poscopy and Cervical Pathology guidelines, there is no need to continue Pap screening
after hysterectomy unless the patient has a prior history of high-grade cervical dysplasia.40
If a patient has a history of cervical intraepithelial neoplasia 2 or 3, these guidelines state
that routine screening should continue for at least 20 years from the time of diagnosis.40
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FTM patients who are diagnosed with cervical cancer during preparation for hysterectomy
should be referred to a gynecologic oncologist for appropriate evaluation and treatment.
Chest Reconstruction
As with all reconstructive procedures, it is essential to have a preoperative discussion with
patients during the informed consent process about the risks of complications. All patients
will have a scar, and the technique required to avoid rippling of excess skin, contour abnor-
malities, adequate exposure, and acceptable NACs determines the extent of the scar. The
complication rate reported in the literature is relatively low, and most issues can be man-
aged nonoperatively. For example, Monstrey et al28 reported a 12.5 % complication rate, and
only 4.3% required reoperation. Common postoperative complications include hematoma,
seroma, superfic al wound dehiscence, partial or complete NAC necrosis, and abscess. It is
imperative that patients are also aware that although less than 5% require a second opera-
tion because of a complication, 25% will require a follow-up surgery to improve aesthetic
outcomes.28,41 Th s is particularly important in an obese patient with large breasts preopera-
tively, who will typically have prominent axillary folds/breast tails after surgery as a result
of breast removal. Secondary aesthetic surgery may include scar revision, liposuction, or
revision of the NACs and axillary folds. In extreme cases, partial or total nipple necrosis
may require a secondary nipple reconstruction. Also, tattooing of the areola may be per-
formed for depigmentation.28
Finally, it is important to discuss the persistent risk of breast cancer in the FTM patient after
chest reconstruction. There is now one reported case of breast cancer in this population.42
No studies have confi med the theoretical risk of hormone supplementation, but the aro-
matization of exogenous testosterone to estrogen may be a risk factor for the development
of breast cancer. Data from nipple-sparing mastectomies for women with a genetic risk fac-
tor for the development of breast cancer have been used to extrapolate to the transgender
population. The risk of breast cancer in women undergoing nipple-sparing mastectomy
who are BRCA positive has been reported to be 2% to 4%, and the risk for transgender
patients is likely less than 2%.43,44 WPATH does not currently have any recommendations
for breast examinations or mammograms in FTM patients who have undergone chest re-
construction. In the primary care protocol for prevention and screening for transgender
patients, the University of San Francisco recommends mammograms only for patients who
have undergone a reduction rather than complete chest reconstruction.45 It is unclear both
what is the actual risk of breast cancer in FTM patients after chest reconstruction and the
psychological implications of recommending that FTM patients continue breast cancer
screening postoperatively. However, it is certainly prudent to review the patient’s personal
risk factors for breast cancer as part of the preoperative discussion.
Combined Total Laparoscopic Hysterectomy With

Bilateral Salpingo-oophorectomy in Adolescents
The WPATH has published guidelines for the management of medical and surgical inter-
ventions in adolescents. These are divided into three categories: fully reversible, partially re-
versible, and irreversible. Fully reversible interventions are those that delay physical changes
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of puberty. Partially reversible interventions include hormone therapy, and irreversible

interventions refer to surgical procedures. WPATH recommends that adolescents do not
undergo surgery until they reach the legal age of majority for medical consent and have
lived continuously for 12 months in the gender role congruent with their gender identity.
Chest surgery can be performed earlier than the legal age of majority if the patient has lived
in his identifi d gender role and has been on hormone therapy for at least 1 year.1
Despite the WPATH recommendation that irreversible surgery, which would include
hysterectomy and oophorectomy, should not occur until the patient is 18 years old, they
acknowledge that different approaches may be warranted, depending on the individual
patient’s clinical situation, emotional support, and goals for gender identity expression.1
Limited data exist in the fi ld of GAS in adolescents, specifi ally the removal of female re-
productive organs, but published studies have shown that starting the gender reassignment
process, including surgery, before adulthood results in favorable postoperative functioning
and resolution of gender dysphoria.4,5 In addition, physicians and researchers with con-
siderable expertise in the fi ld of transgender health are urging health care providers to be
more open-minded about performing GAS in adolescents.46
In our case example and several other adolescent patients on whom we have performed
this procedure, the patients had identifi d as boys for many years, had received cross-sex
hormone therapy for more than 1 year, and had two letters of diagnosis from mental health
professionals confi ming gender dysphoria. In all cases, patients’ parents were willing to
consent to surgeries. We opted to perform combined TLH/BSO and chest reconstruction
in these patients. Combining these procedures serves to reduce the total number of surger-
ies for the patient and contributes even more signifi antly to resolving the patient’s gender
dysphoria by masculinizing his appearance and removing his female reproductive organs
in one operative setting. It also provides the additional benefit of reducing the total cost of
surgery for these patients and their families. As with any permanent modifi ation toward
gender affirmation, the decision to perform this surgery must be made in accordance with
the WPATH SOC, and only after extensive consultation with the patient or the adolescent
patient’s parents. These steps were always heeded carefully, and we were quite satisfi d not
only with the aesthetic and functional outcomes of the surgeries but also with the psycho-
logical benefits to our patients.
Conclusion
Performing chest reconstruction and TLH/BSO in the same operative setting can be a safe
and meaningful step toward gender affirmation in a gender dysphoric male patient who
desires removal of breasts and female reproductive organs, as well as cessation of endog-
enous production of feminizing hormones. Each surgery should be performed in adher-
ence with the WPATH SOC and after a thoughtful decision-making process undertaken by
the patient, surgeons, and mental health professionals. In the appropriate circumstances,
this combined procedure can be performed on adolescents, and in this case, the patient’s
parents should also be included in the presurgical planning process.
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References
1. Coleman E, Bockting W, Botzer M, et al. 14. Ott J, Kaufmann U, Bentz EK, et al. Incidence
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13:165, 2011. 15. Sehnal B, Sottner O, Zahumensky J, et al.
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3. Ott J, van Trotsenburg M, Kaufmann U, et al. 16. O’Hanlan K, Dibble S, Young-Spint M. Total
Combined hysterectomy/salpingo-oophorec- laparoscopic hysterectomy for female-to-male
tomy and mastectomy is a safe and valuable transsexuals. Obstet Gynecol 110:1096, 2007.
procedure for female-to-male transsexuals. J 17. Ergeneli M, Duran EH, Ozcan G, et al. Vagi-
Sex Med 7:2130, 2010. nectomy and laparoscopically assisted vagi-
4. Cohen-Kettenis P, van Goozen SH. Sex renal hysterectomy as adjunctive surgery for
assignment of adolescent transsexuals: a female-to-male transsexual reassignment:
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Psychiatry 2:263, 1997. prod Biol 87:35, 1999.
5. de Vries AL, McGuire JK, Steensma TD, et al. 18. Weyers S, De Sutter P, Hoebeke P, et al. Gyn-
Young adult psychological outcome after pu- aecological aspects of the treatment and
berty suppression and gender reassignment. follow-up of transsexual men and women.
Pediatrics 134:696, 2014. Facts Views Vis Obgyn 2:35, 2010.
6. Mueller A, Gooren L. Hormone-related tu- 19. Einarsson J, Suzuki Y. Total laparoscopic hys-
mors in transsexuals receiving treatment terectomy: 10 steps toward a successful pro-
with cross-sex hormones. Eur J Endocrinol cedure. Rev Obstet Gynecol 2:57, 2009.
159:197, 2006. 20. Hage J, Bloem J. Chest wall contouring for
7. Asscheman H, Giltay EJ, Megens JA, et al. female-to-male transsexuals: Amsterdam ex-
A long-term follow-up study of mortality in perience. Ann Plast Surg 34:59, 1995.
transsexuals receiving treatment with cross- 21. Richards CB. The case for bilateral mas-
sex hormones. Eur J Endocrinol 164:635, tectomy and male chest contouring for the
2011. female-to-male transsexual. Ann R Coll Surg
8. Perrone A, Cerpolini S, Cosimo N, et al. Ef- Engl 95:93, 2013.
fect of long-term testosterone administra- 22. Newfi ld E, Hart S, Dibble S, et al. Female-
tion on the endometrium of female-to-male to-male transgender quality of life. Qual Life
(FtM) transsexuals. J Sex Med 6:3193, 2009. Res 15:1447, 2006.
9. Baba T, Endo T, Honma H, et al. Association 23. Hage J, van Kesteren P. Chest-wall contour-
between polycystic ovarian syndrome and ing in female-to-male transsexuals: basic
female-to-male transsexuality. Hum Reprod considerations and review of the literature.
22:1011,2007. Plast Reconstr Surg 96:386, 1995.
10. Nelson JA, Chung CU, Fischer JP, et al. 24. Eicher W. Transsexualism. Rev Fr Gynecol
Wound healing complications after autolo- Obstet 85:507, 1990.
gous breast reconstruction: a model to pre- 25. Lindsay W. Creation of a male chest in female
dict risk. J Plast Reconstr Aesthet Surg 68:531, transsexuals. Ann Plast Surg 3:39, 1979.
2015. 26. Monstrey S, Selvaggi G, Ceulemans P, et al.
11. Pence BD, Woods JA. Exercise, obesity, and Chest-wall contouring surgery in female-
cutaneous wound healing: evidence from to-male transsexuals: a new algorithm. Plast
rodent and human studies. Adv Wound Care Reconstr Surg 121:849, 2008.
(New Rochelle) 3:71, 2014. 27. Webster J. Mastectomy for gynecomastia
12. Blakytny R, Jude E. The molecular biology of through a semicircular intra-areolar incision.
chronic wounds and delayed healing in dia- Ann Surg 124:557, 1946.
betes. Diabet Med 23:594, 2006. 28. Monstrey S, Cuelemans P, Hoebeke P. Sex
13. Glueck CJ, Richardson-Royer C, Schultz R, et reassignment surgery in the female-to-male
al. Testosterone, thrombophilia, and throm- transsexual. Semin Plast Surg 25:229, 2011.
bosis. Clin Appl Th omb Hemost 20:22, 2014.
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29. Hoopes J. Surgical construction of the male 38. Tsilchorodizou T, Conway GS. Uterus size
external genitalia. Clin Plast Surg 1:325, 1974. and ovarian morphology in women with
30. Kenney J, Edgerton MT. Reduction mammo- isolated growth hormone deficie cy, hypogo-
plasty in gender dysphoria. Principles nadotrophic hypogonadism, and hypopitu-
of transgender medicine and surgery. In itarism. Clin Endocrinol 61:567, 2004.
Bilowitz A, ed. Abstract Book of the Eleventh 39. Platt JF, Bree RL, Davidson D. Ultrasound
Symposium of the Harry Benjamin Interna- of the normal nongravid uterus: correlation
tional Gender Dysphoria Association, Cleve- with gross and histopathology. J Clinic Ultra-
land, 1989. sound 18:15, 1990.
31. Beer GM, Budi S, Seifer B, et al. Configur - 40. Massad LS, Einstein MH, Huh WK, et al;
tion and localization of the nipple- 2012 ASCCP Consensus Guidelines Confer-
areola complex in men. Plast Reconstr ence. 2012 updated consensus guidelines for
Surg 108:1947, 2001. the management of abnormal cervical can-
32. Monstrey S, Hoebeke P, Selvaggi G, et al. Pe- cer screening tests and cancer precursors. J
nile reconstruction: is the radial forearm flap Lower Genital Tract Dis 17:S1, 2013.
really the standard technique? Plast Reconstr 41. Beer G, Budi S, Seifert W, et al. Configur tion
Surg 124:510, 2009. and localization of the nipple-areola com-
33. Saridogan E, Cutner A. The use of McCart- plexes in men. Plast Reconstr Surg 108:1947;
ney tube during total laparoscopic hyster- discussion 1953, 2001.
ectomy for gender reassignment: a report of 42. Nikolic D, Djordjevic ML, Granic M, et al.
two cases. BJOG 111:277, 2004. Importance of revealing a rare case of breast
34. Lazard A, Cravello L, Poizac S, et al. Hyster- cancer in a female to male transsexual after
ectomy and bilateral adnexectomy by laparo- bilateral mastectomy. World J Surg Oncol
scopic single port access for female to male 28:280, 2012.
transsexualism. J Sex Med 10:1439, 2013. 43. Willemsen HW, Kaas R, Peterson JH, et al.
35. Bogliolo S, Cassani C, Babilonti L, et al. Ro- Breast carcinoma in residual breast tissue af-
botic single site hysterectomy with bilateral ter prophylactic bilateral subcutaneous mas-
salpingo-oophorectomy in female to male tectomy. Eur J Surg Oncol 24:331, 1998.
transsexualism. J Sex Med 11:313, 2014. 44. Paled AW. Total skin-sparing mastectomy in
36. Weyers S, Selvaggi G, Monstrey S, et al. Two- BRCA mutation carriers. Ann Surg Oncol
stage versus one-stage sex reassignment sur- 21:37, 2014.
gery in female-to-male transsexual individu- 45. General Prevention and Screening. Center
als. Gynecol Surg 3:190, 2006. of Excellence for Transgender Health, Uni-
37. Vergut J, Ameye L, Bourne T, et al. Norma- versity of California, San Francisco, 2013.
tive data for uterine size according to age Available at http://transhealth.ucsf.edu/
and gravidity and possible role for classi- trans?page=protocol-screening#S2X.
cal golden ratio. Ultrasound Obstet Gynecol 46. Cohen-Kettenis P, Klink D. Adolescents with
42:713, 2013. gender dysphoria. Best Pract Res Clin Endo-
crinol Metab 29:485, 2015.
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5
Male-to-Female Gender Affirmation
Skin-Flap Vaginoplasty
Miroslav L. Djordjevic,
Dusan Stanojevic, Marta Bizic
Key Points
❖❖ The penile inversion technique is one of the ❖❖ Fixation of the neovagina to the sacrospinous
best solutions to vaginal reconstruction in ligament is the key to successfully preventing
male-to-female transgender patients. postoperative prolapse. M
❖❖ The penile disassembly technique enables rad- ❖❖ Postoperative dilation of the neovagina is man-
ical removal of the corpora cavernosa, which datory in first 6 months after surgery.
prevents postoperative complications such as
postoperative erections, painful sexual inter-
course, and psychological disturbances.
❖❖ A vascularized urethral flap is a good option for
the mucosal part of the neovagina and should
be used to ensure better moisture of the neova-
gina postoperatively.
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Male-to-Female Gender Affirmation Skin-Flap Vaginoplasty
Vaginal absence has a devastating impact on a biologic woman or male-to-female trans-

gender patients. Thus, in such patients, it is essential to create a normal functioning neova-
gina with satisfactory sexual function and aesthetic appearance. Vaginal reconstruction is
inevitable in the case of vaginal agenesis, disorders of sexual development, transsexualism,
defects resulting from genital cancer surgeries, and trauma. There are many reports on vari-
ous surgical procedures, their outcomes after postoperative complications, and anatomic
and functional results.1-6 Some popular methods include split-thickness and full-thickness
skin grafts, ladder or buccal mucosa grafts, enile or penoscrotal skin flaps, local genital
flaps, and intestinal flaps.1-6 Skin grafts are used frequently because of their simplicity and
the fact that they are associated with fewer complications.
Clinical Evaluation
In transsexual patients with a preserved penis and scrotum, use of penile and penoscrotal
skin flaps remains the method of choice. However, these methods have certain disadvan-
tages, such as scarring, shrinkage, an insuffici t vaginal cavity, intravaginal hair growth,
the need for lubrication during intercourse, and permanent dilation. The debate on sur-
gical management of this condition with the very large number of techniques that have
been described continues, and considerable controversy still exists over which is the best
technique to choose. Surgical techniques should be classifi d by the type of flap or graft
that will be used for vaginal reconstruction. The types of flaps or grafts include penile/
penoscrotal skin grafts, pedicled penile/penoscrotal flaps, free skin grafts, bladder mucosa,
include intestinal segments.7,8

The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons
vary considerably in their techniques and skills, patients’ skin varies in elasticity and heal-
ing ability, previous surgery in the area can have an impact on results, and surgery can be
complicated by problems such as infections, blood loss, or nerve damage. However, in the
best cases, when recovery from surgery is complete, it is often very difficult for anyone, in-
cluding gynecologists, to detect women who have undergone vaginoplasty. Supporters of
colovaginoplasty argue that this method is better than the use of skin grafts, ecause the
colon is already mucosal, whereas skin is not. However, many transwomen report postop-
eratively that the skin used to line their vaginas develops mucosal qualities within months
to years after surgery. For others, lubrication during intercourse is necessary, and occasional
douching is advised to prevent the growth of bacteria and the resulting odors. Because
the human body treats the new vagina as a wound, any current technique of vaginoplasty
requires some long-term maintenance of volume (vaginal dilation) by the patient with
medical graduated dilators, dildos, or suitable substitutes to keep the vagina open. Sexual
intercourse is not always an adequate method of performing dilation. In our center for
transgender surgery, the inverted penile skin-flap technique still remains the fi st choice
for vaginoplasty in transsexual patients.9
In this chapter, we describe our technique of skin-flap vaginoplasty in male-to-female trans-

sexual patients. There are several advantages to penile skin-flap vaginoplasty. As a flap, pe-
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CHAPTER 5
nile skin has less tendency to contract, better local innervation and sensibility of the neo-
vagina, and yields a hairless and natural-colored neovagina.2,8,10-13 Many patients are able to
have a normal sex life postoperatively, although the level of satisfaction in this population
varies. Psychosocial and psychosexual outcomes lead us to understand the signifi ance of
surgical repair and the impact on the patient’s and partner’s life after surgery. Also, because
postoperative complications and pitfalls give rise to numerous physical and psychological
problems, it is important that they be recognized and corrected in a timely manner.

Before sex reassignment surgery, all patients must have complete Standards of Care for
Gender Identity Disorders (SOC) documentation. The most widespread SOC in this fi ld
is published by the World Professional Association for Transgender Health, previously
known as the Harry Benjamin International Gender Dysphoria Association.14A preopera-
tive assessment of all patients includes clinical examination of the external genitalia, echo-
sonography of the testicles, cystoscopy, and a full hormonal profile. Patients are admitted
to the hospital the day before surgery for mechanical bowel preparation with an enema;
2 g of ceftriaxone and 500 mg of metronidazole are administered intravenously with the
induction of anesthesia. Preoperative planning includes estimation of the proper size and
position of the neoclitoris based on the patient’s preferences. In the case of hairy penile skin,
preoperative laser epilation is recommended to prevent a hairy neovagina.
Surgical Techniques
To form the new vagina, several subprocedures must be performed: orchiectomy, removal
of the corpora cavernosa, creation of the neovaginal cavity, vaginoplasty, lining of the cav-
ity with the urethral orifice and vaginal introitus, clitoroplasty, and labioplasty.
After the usual bilateral orchiectomy, the penis is dissected into its anatomic components;
that is, the corpora cavernosa, the glans cap with the urethra and neurovascular bundle,
and the vascularized penile skin (Fig. 5-1, A and B). Th s principle, called the penile disas-
sembly technique, presents the main advantage, because it allows the ideal use of all penile
components (except the corpora cavernosa) in the construction of the new vulva, clitoris,
and vagina.15,16 The glans, with the neurovascular bundle dorsally and urethra ventrally, is
lifted from the tips of the corpora cavernosa together with Buck fascia, thus completely
preserving these components (Fig. 5-1, C).
As the glans cap is divided into two, the dorsal part of the glans is reduced by excising the
central ventral tissue, leaving the sides of the glans intact. Th s is used to create the neocli-
toris. Lateral excisions on the glans are not recommended to avoid injuring the neurovas-
cular bundle, which enters the glans cap lateroventrally. However, the sides are deepitheli-
alized and sutured to achieve a conical shape and appropriate size for the neoclitoris, with
preserved vascularization and sensitivity (Fig. 5-1, D). The penile disassembly also provides
ideal exposure of the corpora cavernosa for their removal at the level of attachment to the
pubic rami. Short remnants of the corpora cavernosa (erectile tissue) are also destroyed to
prevent any postoperative erection that could hinder sexual intercourse (Fig. 5-1, E).
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Fig. 5-1 A, Preoperative appearance of male genitalia. B, All penile structures are disassembled—the glans
with the neurovascular bundle dorsally and the urethra ventrally, corporeal bodies, and penile skin. C, Penile
skin is dissected with a long vascular pedicle to enable insertion of the neovagina into the perineal space.
D, The clitoris is created with the dorsal part of the glans, which is sutured after excising the central ventral
tissue. A hole at the base of the skin flap is created. The neoclitoris and male urethra are transposed dorsally.
E, Corporeal bodies are completely removed from the bones.
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The vascularized urethral flap is essential for the current vaginoplasty; it has adequate
length and therefore is never the limiting factor. With the penile disassembly technique,
the corpus spongiosum is completely preserved and ensures an excellent blood supply. The
bulbospongiosus muscle is removed from the bulbous part of the urethra; the dissection of
the bulbar urethra must be precise to avoid injury to the fascial sheath. The urethra is then
spatulated, including the bulbar part, and used to create the mucosal anterior part of the
neovagina. The urethral flap also allows a wider neovagina, especially the introitus. Any
bleeding in the bulbar urethra is controlled with hemostatic sutures. The extensive use of
electrocautery is not recommended, because urethral flap vascularization could be com-
promised. A female-type urethra is then formed, and the neoclitoris is fixed above the new
urethral meatus. In reconstructing the new vagina, the skin of the penile body and prepuce
(if present) is fashioned into a vascularized island tube flap. Because a long vascularized
pedicle must be obtained for the tube, the incision is made at less than 2 cm above the base
of the mobilized penile skin. The existing loose subcutaneous tissue permits formation of
a long vascularized pedicle. A hole is made at the base of the pedicle to transpose the ure-
thral flap and neoclitoris. On the dorsal side only of the skin tube flap, the skin is incised,
whereas the vascularized subcutaneous tissue remains intact. The urethral flap, which is
transposed through the pedicle hole, is embedded into the skin tube and sutured (Fig. 5-1,
F and G). The bottom of the tube is closed with the distal part of the urethra and/or the re-
maining ventral half of the glans cap after the deepithelialization of its inner side. The tube,
which consists of skin and the urethral flap, is inverted, thus forming the new vagina (Fig.
5-1, H). If there is insuffici t penile skin (a small and/or circumcised penis), the short skin
tube and long urethral flap will be disproportionate. If this is the case, the vagina can be
formed in two ways. The proximal part at the base of the vagina can be formed only from
the urethral flap, which initiates secondary epithelialization. If the tube pedicle is too short
F G H
Video
5-1
Fig. 5-1, cont'd F, A superficial incision is made at the dorsal part of penile skin, whereas the vascularized subcuta-
neous tissue remains intact. G, The urethra is spatulated up to its bulbar part. The urethral flap is embedded into the
skin tube and sutured to the skin edges. H, The vagina is fashioned by inversion of the penile skin and urethral flap.
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CHAPTER 5
to place the tube into the perineal cavity, the new vagina is created with the vascularized
urethral flap and free penile skin grafts. In this case the vascularized urethral flap plays the
key role in creating the new vagina.
The space for the new vagina is created in the perineum; two tunnels are made on both sides
on the arcus tendineus center; this and the rectourethral muscle are cut, allowing access to
the deep and wide perineal cavity between the urethra, bladder, and rectum. Particular care
should be taken to avoid injuring the rectum. Prolapse of the urethral part of the vagina,
which we observed when we used the Stamey fix tion procedure, is completely avoided
with vaginal fixation to the sacrospinous ligament, as is an exaggerated posterior vaginal
fourchette. Engorgement of the bulbar urethra during sexual arousal is moderate and does
not present a barrier to intercourse, contrary to transvaginal sacrospinous ligament fixa-
tion for treating vaginal prolapse in biological females.17 There are signifi ant difficulties in
using this procedure in male transsexual patients. Good exposure and direct visualization
of the sacrospinous ligament are crucial to prevent injury to the rectum, pudendal nerve,
and internal pudendal artery and vein; extensive experience with male pelvic surgery is
required. Transposing the vagina to the fi ed side has no clinical consequences in male
transsexual patients, because the distance between the sacrospinous ligaments is shorter
than in females. Using the ischial spine as a prominent landmark, the sacrospinous liga-
ment is palpated as it passes from the ischial spine to the lower part of the sacrum. After
exposing the ligament, a long-handled Deschamps ligature carrier preloaded with a 2-0
delayed absorbable suture is used to pierce the ligament medially to the ischial spine. The
surgeon must be careful not to place the suture close to the ischial spine to prevent injury
to the pudendal nerve and internal pudendal vessels. The suture must also not be placed
behind the ligament to prevent injury to the pudendal artery, because its course is vari-
able and may be at any distance from the ischial spine. Both ends of the suture are brought
out; one is passed through the skin part, whereas the other is passed through the urethral
part of the distal third of the neovagina, and the fix tion stitches are tied fi mly. We used
the right sacrospinous ligament in all patients; no bilateral fix tions were performed. It is
technically easier for a right-handed surgeon to use the right ligament. Vaginopexy to the
sacrospinous ligament is performed, and the neovagina is placed deep in the perineal cavity.
Th s provides good placement of the neovagina and ensures that prolapse will not occur.18
Vulvoplasty involves creation of the labia minora and labia majora. The remaining part of
the base of the penile skin is used to form the labia minora, which are sutured to the deepi-
thelialized area of the neoclitoris; thus the neoclitoris is hooded with labia minora. Excessive
scrotal skin is removed, and the remaining part is used to form the labia majora (Fig. 5-1, I).
A perivaginal Jackson-Pratt drain is left or 3 days. The patient is discharged on the fourth
day after surgery; an indwelling Foley catheter is left in place for the next 7 days. Antibiot-
ics (cephalosporins and metronidazole) are administered until 5 to 7 days postoperatively.
Vaginal packing (a condom filled with soft aterial and petrolatum gauzes) is placed in
the neovaginal cavity for 1 week after surgery and followed by vaginal stenting at night for
6 weeks. At discharge from the hospital, patients are instructed on how to maintain hygiene
and dilate the neovagina. Dilation of the neovagina is mandatory once a day for 6 months,
with a vaginal dilation set in five sizes (diameters ranging from 14 to 35 mm; lengths rang-
ing from 70 to 163 mm).
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CHAPTER 5
Fig. 5-1, cont'd I, Appearance at the end of surgery. The vagina is placed into the cavity and fixed to
the sacrospinous ligament. Labia minora and labia majora are created from the remaining penile and
scrotal skin.
Results
Depth and Diameter of Neovagina
The most important features of the new vagina are depth and width; the mean depth (range)
was 11.6 cm (9± 18), but a precise measurement of the vaginal width is difficult. These
measurements were estimated in current patients with a vaginal stent and were classifi d
as small, medium, and large with diameters of 2.7, 3.5, and 4.5 cm, respectively.
Moisture, Orgasm, and Sensitivity of the Neovagina

Another important characteristic of the new vagina is moisture. In the current vaginoplasty,
the vascularized urethral flap is essential for moisture and sensitivity of the neovagina. In-
formation on sensitivity and orgasm was obtained by interviewing our patients; good sen-
sitivity and full orgasm were reported in 96% and 83% of patients, respectively.
Aesthetic Appearance of External Genitalia and Voiding

Patients who answered the questionnaire noted their degree of satisfaction with the
aesthetic appearance of the external genitalia. Despite the high satisfaction with the fi-
nal outcomes after skin-flap vaginoplasty, some patients disapproved of the appearance
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CHAPTER 5
Fig. 5-2 Outcome 1 year later. A good aesthetic result was achieved.
of the clitoris, labia minora, and labia majora (Fig. 5-2). However, minor revisions re-
solved all of the presented problems.19 Postoperative voiding was satisfactory in all of our
patients. One of the main reasons for prevention of postoperative stenosis is the continuity
between the new urethral orifice nd urethral flap that was used for neovaginoplasty. In a
small number of patients, certain disturbances, such as the high position of the new meatus
or its lateralization, were fi ed through a minimally invasive approach.
Sexual Activity
Sexual intercourse could be resumed 6 to 12 months after vaginoplasty. We found that 79%
of our patients were capable of normal sexual intercourse, but despite an adequate vagina,
some patients refrained from intercourse. In sexually active patients, 81% reported satis-
factory sexual activity.
Patient Evaluation
There are reports of sexual satisfaction after vaginoplasty, which was evaluated predomi-
nantly by asking transwomen to defi e the degree of their sexual satisfaction. Only a few
published reports have presented functional questionnaire-based results of vaginoplasty
in patients with congenital vaginal agenesis.20-22 Borkowski et al23 evaluated the functional
outcome of Krzeski’s cystovaginoplasty and patients’ satisfaction with the use of 18 param-
eters. However, it is difficult to draw any comparison between studies, because different
inventories and surgical techniques were used within patient groups. We reported satis-
factory results in 79% of male-to-female transgender patients after vaginoplasty involving
penile skin combined with a urethral flap.8 However, those results were mostly based on
patients’ statements rather than the use of adequate and standardized parameters. They also
did not include long-term follow-up, because most were reported up to 1 year after surgery.
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CHAPTER 5
Box 5-1 List of Reported Complications After Male-to-

Female Surgery
Postoperative bleeding
Deep vein thrombosis
Wound infection
Urethral injury
Rectal injury—perforation
Skin (labial) necrosis
Vaginal necrosis
Clitoral necrosis
Vaginal shrinkage
Introital stenosis
Urethral stricture
Labial asymmetry
Vaginal prolapse
Remnants of the corpora cavernosa
Remnants of the urethral corpus spongiosum tissue
In addition to functional and aesthetic results, we think psychological and psychosocial

recovery, as well as quality of life, should be considered in a postoperative evaluation of
these patients.24 Psychological and psychosocial evaluation with a structured interview and
standardized questionnaires should be a part of this type of study. However, it may still be
difficult to identify a control group for any comparative study. The lack of standardized
methods for recording outcomes in long-term complications and sexual function limits
any possibility of direct comparison of our results. Therefore, although a consensus on the
ideal method of vaginal substitution may never be reached, current efforts should focus on
a consensus on the ideal way to follow these patients in the long-term.
Complications
Male-to-female surgery can be complicated by all the normal nonspecific complications of
major surgery. In a review of the literature, we compiled the main and most common post-
operative complications, which ranged from meatal stenosis to postoperative bleeding and
from clitoral necrosis to introital stenosis and neovaginal prolapse (Box 5-1).
We had only one major complication: a rectovaginal fistula caused by intraoperative in-
jury to the rectum. Other complications were vaginal shrinkage in two patients, which was
caused by a vaginal pedicle that was too short (vaginopexy under high tension) and was
resolved by rectosigmoid vaginoplasty. Introital stenosis and meatal stenosis were found in
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CHAPTER 5
A B
Fig. 5-3 A, Bulging of the bulbar urethra after primary skin-flap vaginoplasty. B, Appearance after exci-
sion of the excessive spongiosal tissue of the urethra.
seven and two patients, respectively. Excessive bulbar spongiosal tissue and urethral pro-
lapse was more frequent in the fi st years of our work and was solved by simple excision
(Fig. 5-3). Currently it is prevented by sacrospinous ligament fix tion of the neovagina.
We also had some rare complications, such as rupture of the posterior vaginal wall during
intercourse, but without rectal injury.
Conclusion
Reconstruction of female genitalia in male transgender patients generally presents a safe
and reasonable choice with acceptable complications and satisfactory results. Although a
consensus on the ideal method of vaginoplasty may never be reached, efforts should be
made to select the optimal method of long-term follow-up of these patients. Although pe-
nile skin-flap inversion vaginoplasty is largely standardized as a primary option, new re-
fi ements and improvements are needed to satisfy specific atient requests related to the
functioning of the neovagina and the ideal aesthetic outcomes.
Acknowledgment
Th s chapter was supported by the Ministry of Science, Republic of Serbia, Project No. 175048.
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References
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transsexuals by inversion of penile and scro- nous ligament fix tion for treatment of vagi-
tal skin. In Ehrlich RM, Alter GJ, eds. Recon- nal prolapse. J Urol 154:1008, 1995.
structive and Plastic Surgery of the External 18. Stanojevic DS, Djordjevic ML, Milosevic
Genitalia. Philadelphia: WB Saunders, 1999. A, et al. Sacrospinous ligament fix tion for
6. Djordjevic ML, Stanojevic DS, Bizic MR. neovaginal prolapse prevention in male-to-
Rectosigmoid vaginoplasty: clinical experi- female surgery. Urology 70:767, 2007.
ence and outcomes in 86 cases. J Sex Med 19. Hage JJ, Goedkoop AY, Karim RB, et al.
8:3487, 2011. Secondary corrections of the vulva in male-
7. Krege S, Bex A, Lümmen G, et al. Male-to- to-female transsexuals. Plast Reconstr Surg
female transsexualism: a technique, results 106:350, 2000.
and long-term follow-up in 66 patients. BJU 20. Lawrence AA. Patient-reported complica-
Int 88:396, 2001. tions and functional outcomes of male-to-
8. Perovic SV, Stanojevic DS, Djordjevic ML. female sex reassignment surgery. Arch Sex
Vaginoplasty in male transsexuals using pe- Behav 35:717, 2006.
nile skin and urethral flap. BJU Int 86:843, 21. De Cuypere G, T’Sjoen G, Beerten R, et al.
2000. Sexual and physical health after sex reassign-
9. Vujovic S, Popovic S, Sbutega-Milosevic G, ment surgery. Arch Sex Behav 34:679, 2005.
et al. Transsexualism in Serbia: a twenty-year 22. Weyers S, Elaut E, De Sutter P, et al. Long-
follow-up study. J Sex Med 6:1018, 2009. term assessment of the physical, mental, and
10. Amend B, Seibold J, Toomey P, et al. Surgical sexual health among transsexual women. J
reconstruction for male-to-female sex reas- Sex Med 6:752, 2009.
signment. Euro Urol 64:141, 2013. 23. Borkowski A, Czaplicki M, Dobronski P.
11. Karim RB, Hage JJ, Bouman FG, et al. Refi e- Twenty years of experience with Krzeski’s
ments of pre-, intra-, and postoperative care cystovaginoplasty for vaginal agenesis in
to prevent complications of vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome:
male transsexuals. Ann Plast Surg 35:279, anatomical, histological, cytological and
1995. functional results. BJU Int 101:1433, 2008.
12. Davies MC, Creighton SM, Woodhouse CR. 24. Labus LD, Djordjevic ML, Stanojevic DS,
The pitfalls of vaginal reconstruction. BJU Int et al. Rectosigmoid vaginoplasty in patients
95:1293, 2005. with vaginal agenesis: sexual and psychoso-
cial outcomes. Sex Health 8:427, 2011.
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CHAPTER
6
Male-to-Female Gender Affirmation Colon
Vaginoplasty: Total Laparoscopic
Sigmoid Vaginoplasty
Mark-Bram Bouman,
Wouter B. van der Sluis,
Marlon E. Buncamper,
Wilhelmus J.H.J. Meijerink
Key Points
❖❖ Total laparoscopic sigmoid vaginoplasty is a ❖❖ It is indicated for primary and revision vagino-
feasible and safe surgical technique for vaginal plasty in transgender and biologic women.
construction (reconstruction), if performed by ❖❖ The technique provides good surgical and M
an experienced team, with the right medical in- functional outcomes.
frastructure and laparoscopic equipment.
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MTF Gender Affirmation Colon Vaginoplasty: Total Laparoscopic Sigmoid Vaginoplasty
Vaginal reconstruction is of major importance for the psychological and sexual well-being
and quality of life in transgender women and biologic women with congenital or postab-
lative absence of the vagina.1 Different types of grafts can be used in vaginoplasty, each of
which has its own advantages and disadvantages.2 The advantages of intestinal vaginoplasty
are providing suffici t vaginal depth, self-lubricating, and a lesser tendency to shrink. 2.3
However, the disadvantages are the need for intestinal surgery and bowel anastomosis with
concomitant risks. In this chapter we will focus on the surgical technique for primary to-
tal laparoscopic sigmoid vaginoplasty. Secondary laparoscopic intestinal vaginoplasty will
also be discussed.

There are three distinct groups of patients with indications to undergo total laparoscopic
sigmoid vaginoplasty:
1. Transgender women with penoscrotal hypoplasia: These are transgender women who
cannot undergo penile-inversion vaginoplasty because of a lack of suffici t penile
skin. Penile and scrotal hypoplasia, which is potentially caused by puberty inhibition
and subsequent cross-sex hormonal treatment and/or previous circumcision, may
cause such a shortage.
2. Transgender women with a failed primary vaginoplasty: Th s group includes patients
who previously underwent vaginoplasty, which failed to provide suffici t neovaginal
depth; for example, as a result of total or partial neovaginal stenosis. These patients
are eligible to undergo laparoscopic sigmoid vaginoplasty as a revision or redo vagi-
noplasty.
3. Biologic women with either acquired or congenital absence of a functional vagina:
Genital trauma or vaginal surgery for malignancy can result in acquired vaginal ab-
sence. Congenital vaginal absence is observed in patients with Mayer-Rokitansky-
Küster-Hauser syndrome, androgen insensitivity syndrome, gonadal dysgenesis, blad-
der exstrophy, hermaphroditism, and common urogenital sinus syndrome.
Contraindications, although relative, include an inability to safely undergo general anes-

thesia, a history of intestinal malignancy, inflammatory bowel disease, extensive abdominal
surgery, smoking, and obesity (BMI greater than 30 kg/m2).
The Team and Infrastructure

If laparoscopic intestinal vaginoplasty is performed by an experienced team with the right
medical infrastructure and laparoscopic equipment, successful and reproducible results can
be achieved. Th s includes preoperative screening of patients by a specialized psychologist
in the gender fi ld. Th s approach requires two surgeons in different surgical fi lds, work-
ing simultaneously on the same patient. The laparoscopic portion can only be performed
by a surgical expert in advanced laparoscopy, and the genital portion is done by a gender
surgeon with vast experience in vaginoplasties.
For the laparoscopic procedure, we use basic laparoscopic instruments, including bowel
graspers and a needle driver. Regarding the devices, these should at least include an HD
camera and screen, 30-degree optics, and a range of laparoscopic staplers and a sealing de-
vice. Preferably, we use three-dimensional cameras/screens and goggles. An infrared cam-
era system in combination with a preoperative injection of indocyanine green can also be
of great help in identifying the vascular anatomy, especially in obese patients.
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In case of serious complications such as anastomotic leakage or graft necrosis, surgical ex-
pertise and easy access to an ICU or step-down unit are essential, preferably in the same
institution or at least in the vicinity.
Patient Evaluation
It is recommended that a specialized psychologist with experience in the gender fi ld per-
form an assessment of psychological eligibility for transgender women to undergo surgery.
Th s also includes sexual history to establish the patient’s postoperative sexual expectations
and desires. Sigmoid intestinal vaginoplasty is not indicated for patients who merely wish a
feminine genital appearance and do not desire penile neovaginal penetration. Both the plas-
tic surgeon and laparoscopic gastrointestinal surgeon assess surgical eligibility and obtain
informed consent for the procedure. If one third or less of the desired vaginal depth can be
covered with inverted penile skin, intestinal vaginoplasty is indicated. Patients should be
informed about the surgical alternatives with scrotal, abdominal, or groin full-thickness
skin grafts (FTGs). By overstretching the penile skin, extra neovaginal centimeters can be
achieved, but vulvoplasty with the labia minora and clitoral hood formation is more de-
manding or even impossible.
Most patients treated with puberty-suppressing hormones have had no preoperative sexual
experience. Preoperative consultation with a pelvic fl or physical therapist may facilitate
an easy postoperative dilation regimen.
If intestinal vaginoplasty is performed as a revision procedure, an in-depth analysis of the

reason for primary failure is important to prevent failure of the revision procedure. Co-
morbidities, intraoperative and postoperative complications, dilation regimen, and pelvic
fl or hypertonicity are assessed to prevent failure in revision procedures.

In selected cases, preoperative endoscopic examination of the sigmoid can be performed to
assess the health and mucosal integrity of the intestinal segment. Patients with inflamma-
tory bowel disease are not eligible for intestinal vaginoplasty. Also, patients with a familial
predisposition to colon cancer (Lynch syndrome) should be offered small bowel (ileum)
vaginoplasty. Laser depilation of the genital region must be performed before surgery. A
preoperative anesthetic assessment is performed, as is standard preoperative care for elec-
tive surgery. HIV-infected patients must have an adequate CD4 cell count and undetect-
able viral load to reduce the risk of postoperative complications.4 In colon vaginoplasty, full
bowel preparation is used to prevent stool spillage from the transposed sigmoid segment
into the perineal wound bed when the segment is opened.
Intraoperative Measures and Positioning

As is standard, intravenous antibiotics (750 mg of cefuroxime and 500 mg of metronidazole
for gram-negative bacteria) are administered 30 minutes before surgery. After general anes-
thesia is administered, the patient is placed on a surgical vacuum mattress in an extended
lithotomy-Trendelenburg position in stirrups. The right arm is positioned alongside the
body, sufficiently padded to prevent iatrogenic neuropathy and pressure-related physical
problems. The left rm is put on an armrest, so the intravenous catheter is easily accessible
to the anesthesiologist. In this way a simultaneous abdominoperineal approach is facilitated.
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A B
Fig. 6-1 Surgical construction of the female external genitalia. A, Design of the perineoscrotal flap. B, Dissection of the
neovaginal tunnel.
The bladder is catheterized. The gastrointestinal laparoscopic surgeon is positioned at the

patient’s right lateral side. The plastic surgeon is positioned between the legs.
Surgical Technique in Primary Cases

Perineal Phase and Vulvoplasty
Dissection of the Neovaginal Tunnel
The plastic surgeon begins by incising a caudally based perineoscrotal full-thickness
triangular skin flap measuring 2 by 4 cm, continuing in a cranially directed midscrotal
incision (Fig. 6-1, A). Th s opens the way to the perineal bottom. By dissecting the bulbo-
spongiosus muscle off the bulbar part of the urethra, a safe entrance to the pelvic fl or is
created. To check rectal wall integrity, a straight clamp with gauze is placed rectally. Th s
gauze directs the surgeon and prevents rectal injury during dissection of the perineal cav-
ity. With sharp dissection of the midline raphe, the loose plane of Denonvilliers fascia is
reached. To facilitate further dissection of the cavity, partial (diathermic) dissection of
the levator ani muscle is performed (Fig. 6-1, B). Th s provides suffici t width for the
neovaginal cavity. Next, blunt dissection above Denonvilliers fascia is carried out up to
the peritoneal fold. Gauze with epinephrine is placed in the newly formed cavity, until
the laparoscopic surgeon is ready to open the peritoneal fold. From the intraabdominal
approach, this gauze can be visualized through the parietal peritoneum and functions as
a guide for the laparoscopic surgeon to fi d the proper direction and plane to the neo-
vaginal cavity.
Surgical Construction of the Female External Genitalia

The blood supply of the corpus spongiosum is ligated, and a reduction of the corporeal body
is performed and oversewn. Bilateral orchiectomy is executed after careful ligation of the
vas deferens, ensuring that the stumps are freed and able to retract back into the inguinal
canal (Fig. 6-2, A). The urethra is shortened and spatulated. After circumcision, leaving
about 3 to 4 cm of the preputium to the corona, the penile skin is dissected off he penile
body with the avascular plane superfic al to Buck fascia, leaving it attached proximal to the
pubic region (Fig. 6-2, B).
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A B C
D E F
Fig. 6-2 A, Bilateral orchiectomy. B, Penile skin dissection. C, Sculpturing of the clitoris, clitoral hood, and labia minora.
D, Dissection of the neurovascular bundle. E, Measurement of the length of the sigmoid conduit by transillumination.
F, Resection of redundant scrotal skin to form the labia majora.
A clitoris, clitoral hood, and labia minora are sculptured from the preputium and part of
the glans penis (Fig. 6-2, C). By dissecting a pedicled dorsal penile neurovascular bundle off
the corporeal cavernous bodies, sensation and vascularization of the neoclitoris and labia
minora are well preserved (Fig. 6-2, D). In patients who have been treated with puberty-
suppressing hormones, penile hypoplasia may be so severe that the whole penile skin is
needed for labial construction.5,6 In these patients, the penile skin will serve as the outer
layer and the short preputial flap as the inner layer of the labia minora.
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CHAPTER 6
Subsequently, both corporeal bodies are dissected onto the pubic bone, ligated, discarded,
and fi ed together in the midline to form the “throne” of the neoclitoris. The exact place-
ment eventually determines the neoclitoral position and is chosen just below the level of the
origin of the upper leg adductor muscles. By fix ting the neoclitoris and spatulated urethra
together on the “throne,” a pink and natural-looking infundibulum is created.
The penile skin is then inverted. At the level of the future vulva, a vertical incision is made
in the inversion flap to bring out the clitoris, labia minora, infundibulum, and urinary me-
atus. They are sutured to the inversion flap. Depending on the length and width of the pe-
nile skin, a part can be inverted into the neovaginal canal. Th s forms a small skin bridge
between the caudal part of the neomeatus and the attachment of the intestinal vagina.
Redundant scrotal skin is trimmed to form the labia majora, and the neovaginal depth is
measured (Fig. 6-2, E and F). Scars are placed as inconspicuously as possible in the inguinal
fold. At this point in the operation, the simultaneous laparoscopic dissection and mobiliza-
tion of the sigmoid segment is completed.
Laparoscopic Isolation and Transposition

of the Sigmoid Segment
After open introduction of the fi st (umbilical) trochar, the pneumoperitoneum (12 to
14 mm Hg) is applied. After abdominal inspection for adhesions and unexpected fi d-
ings, a 5 mm right lateral trochar is positioned in the midclavicular line at the height of the
umbilicus. A third 12 mm trochar is then placed just lateral to the epigastric vessels in the
right lower quadrant.
Mobilization of the Sigmoid Segment

The procedure starts with mobilization of the sigmoid segment from the peritoneal lateral
adhesions (Fig. 6-3, A). The peritoneal fold is opened, and the mesosigmoid is mobilized
from lateral to medial. The vascular anatomy is identifi d, with special attention to the sig-
moid arteries and veins. A 6- to 7-inch sigmoid segment will be isolated for creation of the
neovagina. The distal part must be introduced through the neovaginal tunnel for suturing
at the level of the penile-inverted skin in the perineum. Vascular mobilization should al-
low this descent of the sigmoid. Because the anatomy of the vessels differs widely among
patients, careful perioperative mapping should be done to avoid damage to the sigmoid
arteries and the common branch of Drummond, because vascularization of the sigmoid
segment will depend on this branch. Near-infrared fluorescence angiography can be used
for intraoperative assessment of the adequacy of blood perfusion.
Just above the rectum at the height of the upper margin of the promontory, the sigmoid
artery is divided with a linear stapler/cutter (60 mm) (Fig. 6-3, B). The mesosigmoid is
transected to the base of the sigmoid arteries (Fig. 6-3, C). In most cases the fi st distal or
fi st and second distal arteries must be divided to obtain suffici t mobilization for the
sigmoid segment to descend safely and tension free to the perineal anastomosis. The distal
part is completely dependent on the arcade of Drummond. In some patients the arcade is
incomplete at the midsigmoid level (Sudeck point). In that case transection of the fi st or
fi st and second artery may lead to ischemia of the distal sigmoid. After complete mobili-
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CHAPTER 6
B C
Fig. 6-3 Intraabdominal isolation and relocation of the intestinal segment. A, The sigmoid segment is
mobilized from peritoneal lateral adhesions. B, The distal sigmoid is divided with a linear stapler. C, The
mesosigmoid is transected to the base of the sigmoid arteries.
zation of the sigmoid and mesosigmoid and transsection of the fi st and if needed second
vascular trunk, the distal sigmoid is checked for pulsations in the mesentery and transverse
arteries ascending to the bowel.
Passing the Sigmoid Through the Neovaginal Tunnel

The peritoneal fold that is between the rectum and bladder is opened above the level of De-
nonvilliers fascia (Fig. 6-4, A). The plastic surgeon has created the neovaginal tunnel onto
Douglas pouch and padded it with gauze. Th s gauze directs the dissection of the abdomi-
nal part of the tunnel, after which the pneumoperitoneum is lost. Careful inspection of the
lateral pillars is performed from both ends. If the tunnel is still too narrow at the level of
the levator muscles, they can easily be partly divided with diathermy by the laparoscopic
surgeon under direct visualization. The plastic surgeon introduces a Ballinger forceps and
grasps the sigmoid (Fig. 6-4, B). The sigmoid is now guided in an isoperistaltic way through
the neovaginal tunnel to the perineum, preventing vascular torsion (Fig. 6-4, C). If the seg-
ment is under tension, further dissection at the base of the vascular structures is performed.
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CHAPTER 6
B C
D E
Fig. 6-4 A, The peritoneal fold between the rectum and bladder is opened. B and C, The sigmoid seg-
ment is passed through the neovaginal tunnel to the perineal site. D and E, With the linear stapler the
proximal end of the neovaginal segment is transected at 6 inches.
Also, superfic al cuts in the peritoneum of the mesosigmoid can create extra length. The
distal suture line of the sigmoid segment is opened and fi ed with a few sutures to the ex-
ternal vaginoplasty. A dildo perspex is introduced into the sigmoid from the perineal side
(Fig. 6-4, D). The length of the neovagina is measured by perineal transillumination of
the dildo. A careful dissection just below the bowel and above the arcade of Drummond
is performed. With the linear stapler (60 mm), the bowel is transected at the proper level,
normally 6 inches from the introitus (Fig. 6-4, E).
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CHAPTER 6
After the sigmoid segment is passed through the neovaginal tunnel to the perineal site, the
intestinal segment is incised at the 12 o’clock and 6 o’clock positions over some centimeters.
The caudal perineoscrotal flap and anterior penile-inversion flap are set into the sigmoid
segment, thereby suturing it to the perineum in an exaggerated, interdigitated fashion to
prevent eventual future circumferential introital stenosis.
Neovaginopexy and Intracorporeal Anastomosis

The peritoneum at the level of the promontory is opened and the periosteum is exposed.
The surgeon should be careful not to damage the iliac vessels and hypogastric nerves. One
or two periosteal stitches of nonresorbable material (Mersilene 2-0 or Dacrofil 2-0) at the
top of the neovagina fix te it to the promontory. Th s will prevent neovaginal prolapse.
A functional side-to-side anastomosis between the proximal sigmoid and rectum is per-
formed. Two or three stay sutures are placed. A linear stapler (60 mm) is introduced
through the umbilical incision to facilitate the direction of stapling. The staple defect is
closed with a V-Loc suture (barbed suture) (Medtronic, Minneapolis, MN).
Surgical Technique in Secondary/Tertiary

Revision Cases
The use of direct laparoscopic visualization during revision vaginoplasty has several ad-
vantages. It enables the surgeon to prevent, check, and control possible damage to adjacent
structures. There is a great difference between revising a failed primary penile-inversion
vaginoplasty or a failed (secondary) vaginoplasty with FTGs.
Revision of Failed Primary Penile-Inversion Vaginoplasty

Parts of the skin of the performed penile-inversion vaginoplasty can be reused in most
cases. The neovagina is shortened up to 3 cm from the perineum, and the top of the
penile-inversion vaginoplasty is removed. Intraabdominal mobilization of the top is helpful
to prevent rectal perforation. If necessary, the neovaginal tunnel is widened by lateral inci-
sions at the 3 o’clock and 9 o’clock positions. Often the levator musculature and scar tissue
must be cleaved to create suffici t width. Lateral incisions help to suture the sigmoid seg-
ment in an exaggerated interdigitated fashion. The old obliterated neovagina is shortened
to facilitate easy dilation of the suture line of the sigmoid and penile skin postoperatively.
Revision of Failed (Secondary) Vaginoplasty

With Full-Thickness Grafts
Previously used skin grafts often leave residual tissue cranial to the obliterated neovagina,
consisting of shrunken and obliterated skin grafts nd including cystlike structures with
sebaceous content. Those cysts are sometimes closely attached to adjacent structures and
can be as large as several centimeters in diameter. Laparoscopic visualization allows the
surgeon to visualize and address these cysts. We strive to debride the old scarred surgical
fi ld and excise cysts and remnants of the former neovagina. Reconstruction of failed FTG
vaginoplasties with an intestinal segment requires an exceptionally experienced laparo-
scopic surgeon with knowledge of (secondary) vaginoplasty surgery. The surgical procedure
is time-consuming and can take as long as a primary vaginoplasty procedure.
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CHAPTER 6
Results and Outcomes of Primary Sigmoid

Vaginoplasty
Case Example: Primary Total Laparoscopic Sigmoid
Vaginoplasty
Video
6-1 A 19-year-old transgender woman of white origin presented to our clinic to discuss the
possibility of vaginoplasty as the final part of her male-to-female transition process. She
had no relevant medical history. She was fi st seen by psychologists of our gender team at
11years of age and had received puberty-suppressing hormones. At physical examination,
penile hypoplasia with a penile skin length of 4.5 cm and a diameter of 2 cm was observed,
in accordance with puberty inhibition with hormones. After considering and discussing
the surgical options and possible complications, we decided to perform a total laparoscopic
sigmoid vaginoplasty. Because of slight pelvic floor hypertonicity, she consulted a pelvic
fl or physical therapist to optimize the active relaxation of the pelvic fl or. We successfully
performed a total laparoscopic sigmoid vaginoplasty with a pedicled sigmoid segment of
15 cm. The procedure lasted 167 minutes and no intraoperative complications occurred.
There were no postoperative complications, and the patient was discharged on the fi h
postoperative day. At 1-year postoperative follow-up, the patient was able to engage in
penetrative sexual intercourse, have an orgasm, and was satisfi d with the achieved result.
Case Example: Secondary Total Laparoscopic Sigmoid

Vaginoplasty
A 44-year-old transgender woman of South American descent presented to our clinic to
discuss the possibility of secondary vaginoplasty. She underwent penile-inversion vagino-
plasty at 28 years of age in South America and secondary FTG vaginoplasty at 35 years of
age because of total neovaginal stenosis. Despite regular dilation, the neovagina had total
stenosis. The patient desired penetrative sexual intercourse, which was not possible with a
neovaginal depth of 3 cm. There were no signs of pelvic fl or hypertonicity. After consid-
ering the surgical options, such as revision FTG vaginoplasty under laparoscopic view or
laparoscopic sigmoid vaginoplasty, we successfully performed the latter. Redundant neo-
vaginal remnants, including two big cysts with sebaceous content adjacent to the rectal
wall, were laparoscopically removed and replaced by a pedicled sigmoid segment of 15 cm
without complications. The patient was discharged on the fi h postoperative day. At 2-year
postoperative follow-up, the patient was satisfi d with the surgical result and engaged in
penetrative sexual intercourse on a regular basis. Neovaginal depth was 15 cm. She was very
satisfi d with the surgical result.
Depth and Diameter

One advantage of an intestinal segment for vaginoplasty is that it has minimal or no ten-
dency to shrink. Long-term dilation is generally not recommended, especially not in sexu-
ally active patients. Even so, dilation of the skin-mucosa junction is recommended only
in the first postoperative year. The neovaginal depth depends, among other things, on
the length of the sigmoid segment. Excessive length of the sigmoid segment is prone to
neovaginal prolapse and excessive mucous production.7 In general an adequate neovagi-
nal depth is achieved with sigmoid vaginoplasty, easily facilitating neovaginal penetrative
sexual intercourse.5
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In our yet unpublished, comparative study of a consecutive series of 53 revision vaginoplas-

ties, 21 were total laparoscopic intestinal vaginoplasties (18 sigmoid and 3 ileal segments)
and 32 were FTG vaginoplasties without laparoscopy. Twice as many intraoperative per-
forations and rectal injuries (10% versus 20%) occurred in the FTG group. Length of hos-
pitalization did not differ signifi antly. A deeper neovagina was achieved with intestinal
vaginoplasty (15.9 ± 1.3 cm versus 12.5 ± 2.8 cm, p <0.01).8
Satisfaction, Quality of Life, and Sexual Function

In most transgender women, sexual intercourse and neovaginal penetration are possible
1 to 2 months after surgery. Approximately 75% of patients over 20 years of age who un-
derwent this surgery are sexually active; 85% report that their sex life is satisfactory.5 Stud-
ies focusing on the short-term and long-term postoperative quality of life in transgender
women are lacking. In a study by Morrison et al,9 21 transgender women who underwent
sigmoid vaginoplasty with a mean postoperative follow-up of 22.8 years were contacted.
All reported high satisfaction with the appearance, sexual function, postoperative recov-
ery, and the overall result.
In our yet unpublished, prospective series of 44 women after primary laparoscopic sigmoid
vaginoplasty, functionality was given a median score of 7 (range 1 to 10) and appearance a
score of 8 (range 3 to 10) of 10.10 Satisfaction and sexual health seemed high after intestinal
vaginoplasty, but more research is needed, especially on postoperative quality of life. Little
has been published about the satisfaction and quality of life after secondary vaginoplasty.
Problems and Complications

Intraoperative Injury to Adjacent Structures
The risk of intraoperative iatrogenic injury to adjacent structures is low during primary
laparoscopic vaginoplasty (0.4%, as estimated by a retrospective series).3 However, this risk
is higher for revision vaginoplasty procedures. The combination of scarring, fibrosis, and
local adhesions and the necessity to remove some of the redundant skin graft remnants
and inclusion cysts of the previous neovagina increase the chance for rectal perforation or
bladder injuries.
Colonic Conduit Necrosis

Inadequate vascularization from the supplying vascular pedicle leading to colonic conduit
necrosis is an uncommon but serious complication. Inadequate vascularization is likely
because of extensive mobilization of the mesosigmoid, too much tension on the pedicle,
or an incomplete arcade of Drummond. A combination of rapid diagnosis and immediate
surgical reintervention may prevent neovaginal necrosis. Near-infrared fluorescence an-
giography can be used for intraoperative assessment of the adequacy of blood perfusion.
Neovaginal Stenosis
Neovaginal stenosis can be subdivided into introital stenosis and diffuse stenosis. Both can
impede the possibility of neovaginal penetration. When compared with penile-inversion,
split-thickness, or FTG vaginoplasty, the intestinal tissue shows less of a tendency to shrink.
Lack of self-dilation, high pelvic fl or muscle tension, and sexual inactivity, however, are
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CHAPTER 6
predisposed to the development of introital stenosis. When stenosis occurs in approxi-

mately 8% to 10% of patients after intestinal vaginoplasty, conservative self-dilation is the
treatment of choice. If this does not provide the desired result, surgical correction with
transposition or interposition flaps (for example, V-Y advancement, double Z-plasty, and
“jumping man” plasty) is indicated.
Neovaginal Fistulas
Rectoneovaginal fistulas, often preceded by intraoperative rectal injury, may present with
symptoms of neovaginal passage of flatus or feces. To help the diagnosis and preoperative
fistula visualization, CT with rectal contrast or endoscopic examination of the intestinal
neovagina and proctosigmoid can be performed. Treatment options are fistulectomy with
primary closure in layers, local advancement flaps, pedicled flaps, and free flaps sometimes
in combination with a diverting colostomy or ileostomy. The role of low-residue diets as a
primary treatment option is disputed. Urethroneovaginal fistulas, often preceded by me-
atal stenosis, may present with neovaginal voiding, a splayed urinary stream, or recurrent
urinary tract infections and/or (position-dependent) urinary incontinence. To aid in the
diagnosis and preoperative fistula visualization, a voiding cystourethrogram can be per-
formed. In our series of 85 consecutive patients undergoing sigmoid vaginoplasty, two
patients developed a neovaginal fistula, both after revision vaginoplasty. One patient de-
veloped a rectoneovaginal fistula after intraoperative rectal injury. The other developed a
urethroneovaginal fistula after meatal stenosis.
Neovaginal Prolapse
Adequate intraoperative fix tion of the intestinal segment is key to prolapse prevention. The
neovaginal top can be fixed to the sacral promontory, uterosacral ligament, pelvic floor, or
connective tissue of the bladder, pelvic fl or muscle fascia, or pelvic cavity posterior wall.11
Total prolapse of the intestinal segment after intestinal vaginoplasty necessitating surgical
correction is uncommon.3 In these cases, (laparoscopic) neovaginopexy, such as fix tion to
the sacral promontory, is indicated.12 Minimal neovaginal mucosal prolapse, for which local
excision is suffici t, is observed more frequently and can be corrected with minor surgery.
Diversion Neovaginitis
Diversion colitis is colonic inflammation caused by a lack of luminal nutrients after surgi-
cal diversion from the fecal stream. It is commonly observed after colostomy surgery. A
shortage of luminal short-chain fatty acids, the most important nutrient of colonocytes,
supposedly leads to starvation, apoptosis, and subsequently to an inflammatory reaction
of the colonic mucosa. The precise incidence of diversion colitis of the sigmoid neovagina,
diversion neovaginitis, is unknown.13 Surgical reanastomosis or resection of the diverted
intestinal segment for diversion colitis is the treatment of choice. Local application of short-
chain fatty acids, 5-aminosalicylic acid, and/or topical corticosteroids has been suggested as
a treatment option. In most patients this is sufficient to resolve problems. If medical therapy
fails, severe refractory diversion colitis may even necessitate neocolpectomy. In our series,
this has not yet been the case.
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Cancer Risk
Cancer of the intestinal neovagina has only been described in case reports.14 Although rare,
carcinoma of the intestinal conduit is a defin te risk after its use in vaginal reconstruction. An
increase in the relative risk of developing an intestinal malignancy seems to be small or absent.
Follow-up Protocol
We advise regular follow-up consultation in the first postoperative year at 3 weeks,
3 months, and 6 months. Th s includes standard analysis of sexual and urogenital functions,
physical examination of the vulva, and speculum examination of the neovagina. The sur-
geon should be aware of meatal and introital stenosis and initially anticipate possible prob-
lems by ordering self-catherization and dilation, aided by a pelvic fl or physical therapist.
To prevent diversion neovaginitis, we collaborate with the gastroenterology department.
Yearly endoscopic follow-up of the neovagina with biopsies is performed.
Conclusion
Total laparoscopic sigmoid vaginoplasty is a safe procedure in the hands of an experienced
team with the right infrastructure and provides good surgical results. In selected patients
it is indicated for primary vaginoplasty and revision vaginoplasty.
References
1. Callens N, De Cuypere G, Wolffenbuttel KP, 7. Djordjevic ML, Stanojevic DS, Bizic MR.
Beerendonk CC, van der Zwan YG, van den Rectosigmoid vaginoplasty: clinical experi-
Berg M, Monstrey S, Van Kuyk ME, De Sut- ence and outcomes in 86 cases. J Sex Med
ter P; Belgian-Dutch Study Group on DSD, 8:3487, 2011.
Dessens AB, Cools M. Long-term psycho- 8. van der Sluis WB, Bouman MB, Buncamper
sexual and anatomical outcome after vaginal ME, Mullender MG, Meijerink WJ. Revision
dilation or vaginoplasty: a comparative study. vaginoplasty: a comparison of surgical out-
J Sex Med 9:1842, 2012. comes of laparoscopic intestinal versus peri-
2. Horbach SE, Bouman MB, Smit JM, et al. neal full-thickness skin graft vaginoplasty.
Outcome of vaginoplasty in male-to-female Plast Reconstr Surg (in press).
transgenders: a systematic review of surgical 9. Morrison SD, Satterwhite T, Grant DW, et
techniques. J Sex Med 12:1499, 2015. al. Long-term outcomes of rectosigmoid
3. Bouman MB, van Zeijl MC, Buncamper ME, neocolporrhaphy in male-to-female gender
et al. Intestinal vaginoplasty revisited: a re- reassignment surgery. Plast Reconstr Surg
view of surgical techniques, complications, 136:386, 2015.
and sexual function. J Sex Med 11:1835, 2014. 10. Bouman, MB, van der Sluis WB, van
4. Davison SP, Reisman NR, Pellegrino ED, et Woudenberg Hamstra LE, Buncamper ME,
al. Perioperative guidelines for elective sur- Kreukels BP, Meijerink WJ, Mullender MG.
gery in the human immunodeficie cy virus- Patient-reported esthetic and functional out-
positive patient. Plast Reconstr Surg 121:1831, comes of primary total laparoscopic intesti-
2008. nal vaginoplasty in transgender women with
5. Cohen-Kettenis PT, Delemarre-van de Waal penoscrotal hypoplasia. J Sex Med. 2016 Jul
HA, Gooren LJ. The treatment of adolescent 27. [Epub ahead of print]
transsexuals: changing insights. J Sex Med 11. Stanojevic DS, Djordjevic ML, Milosevic A,
5:1892, 2008. et al; Belgrade Gender Dysphoria Team. Sa-
6. Kreukels BP, Cohen-Kettenis PT. Puberty crospinous ligament fix tion for neovaginal
suppression in gender identity disorder: the prolapse prevention in male-to-female sur-
Amsterdam experience. Nat Rev Endocrinol gery. Urology 70:767, 2007.
7:466, 2011.
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12. Kondo W, Ribeiro R, Tsumanuma FK, et 13. van der Sluis WB, Neefjes-Borst EA, Bouman
al. Laparoscopic promontofix tion for the MB, et al. Morphological spectrum of neo-
treatment of recurrent sigmoid neovaginal vaginitis in autologous sigmoid transplant
prolapse: case report and systematic review patients. Histopathology 68:1004, 2016.
of the literature. J Minim Invasive Gynecol 14. Schober JM. Cancer of the neovagina. J Pedi-
19:176, 2012. atr Urol 3:167, 2007.
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CHAPTER
7
Female-to-Male Gender Affirmation
Metoidioplasty
Marci L. Bowers,
Borko Stojanovic, Marta Bizic
Key Points
❖❖ Metoidioplasty, as a single-stage gender affir- ❖❖ Advanced urethroplasty with a combined buc-
mation procedure, is a good and safe option for cal mucosal graft and labia minora flap offers a
female-to-male transsexual patients who want good result with a low complication rate.
to avoid complex and multistage phalloplasty. ❖❖ The length of the neophallus may be inade-
❖❖ Different types of metoidioplasty can be cho- quate for penetration during sexual intercourse.
sen, depending on anatomy and patient prefer- ❖❖ Most patients are satisfied with the final out-
ence. come of metoidioplasty as a consequence of
❖❖ The main goals of metoidioplasty are good achieving male-appearing genitalia with the
cosmesis, the ability to void in the standing po- ability to void while standing, in addition to
sition, and preservation and/or enhancement of preservation of sexual function.
sexual function.
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Female-to-Male Gender Affirmation Metoidioplasty
Gender affirmation surgery (GAS) for transmen typically includes top surgery (in excess
of 90%), but less commonly, genital surgery. For a variety of social, surgical, and fi an-
cial reasons, bottom surgery for transmen is not as commonly chosen, especially com-
pared with transwomen. Reasons for not accessing genital surgery include fear of complica-
tions, perceptions of less aesthetic surgical results, variable functionality of surgical results,
donor-site scarring, and cost. However, as national health plans and private insurers in-
crease coverage for transgender surgery (thereby reducing the individual’s cost), bottom
surgery is on the increase. In general, the goals of female-to-male (FTM) GAS are male ap-
pearance and, when selected, the ability to stand during urination. The ability to penetrate
during sexual contact is an important but secondary goal for some.1
Considerations
Patient Evaluation
The decision to move forward with genital surgery is driven by various factors and chang-
ing priorities within the transgender community. For some transmen, dysphoria with their
genitalia remains an important factor prompting surgery. These men want to completely
leave their female selves behind and consequently want all vestiges of female anatomy
gone: the uterus, ovaries, and vagina. Even the sight of the labia can generate dysphoria. On
the one hand, these individuals tend to choose phalloplasty, but not always. On the other
hand, many FTM patients are realistic about their genital surgery choices and opt for some
measure of affirmation, either a simple metoidioplasty (SM) alone or in combination with
other available surgeries, including hysterectomy (with gonadectomy), vaginectomy, and/
or scrotoplasty. Still others wish to retain their reproductive potential as “pregnant men.”
Although controversial, pregnancy in posttransition males remains an available option for
some, because metoidioplasty is the lone GAS that allows this possibility. Still other patients
choose surgery but with sexual considerations in mind. There are transmen or genderqueer
individuals who appreciate receptive penetration. Some have male partners and some do
not. They may like the sexual capacity of the vagina and wish to retain it after GAS. Finally,
there are logistical considerations when choosing a surgical option for transmen. Many men
are simply too bulky in the mons region or attain too little growth of the clitoral phallus to
allow for a satisfactory result to metoidioplasty. Th s is a delicate but important consider-
ation when making a fi al choice. Disappointment with a neophallus that may be techni-
cally excellent but functionally buried in mons fat is a costly and unsatisfactory outcome.
Monsplasty can subsequently be performed to remove fat above and around the neophallus,
but this has limitations, and the patient’s expectations must be realistic.

These varied choices for genital surgery for FTM patients refl ct the ever-changing demo-
graphics and complex needs of the transgender community and must be considered when
permanent surgical choices are made. No longer is one single surgical package ideal for
each candidate. Th s puts the onus on not only the surgeon but on the patient to devise the
right combination or single procedure that addresses these very personal concerns. Ad-
ditional controversy remains regarding vaginectomy in patients who seek urethral exten-
sion with their metoidioplasty. Many surgeons feel that vaginectomy allows a lower fistula
in those undergoing urethral extension, although this is not supported beyond anecdotal
evidence. We have not seen this increased risk of fistula; most fistulas occur distal to the
vagina, with no certain explanation for why those distal fistulas are adversely affected by
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CHAPTER 7
the lack of vaginectomy. As a result, we feel comfortable offering metoidioplasty with ure-
thral extension, regardless of whether a vaginectomy is done. Further study is indicated.
For patients in whom a resulting fistula is unacceptable, the SM without a vaginectomy can
be performed with zero chance of fistula formation.

Selection Criteria
It is recommended that all selections of potential transgender surgical patients follow the
Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming
People published by the World Professional Association for Transgender Health (WPATH).2
The standards are meant to be flex ble, although in general these standards include 1 year
of continuous hormone therapy and 1 year of living in the desired gender role. In addition,
two letters of psychological support are recommended before the patient undergoes FTM
genital surgery and GAS. Maximal clitoral growth from testosterone occurs during the fi st
2 years of testosterone therapy. Although growth is possible after metoidioplasty with the
use of pumping and/or testosterone, we recommend 2 years of therapy before moving for-
ward with metoidioplasty. As with any genital surgery, preoperative consultations with the
patient must emphasize the details of the surgery as well as a straightforward discussion of
expected outcomes and risks.
Clinical Evaluation
Of the bottom surgery choices for transmen, phalloplasty offers a larger, adult-sized penis,
and for some, can provide the ability to penetrate sexually and to stand while urinating.
Erotic sensation is also possible for some but not all who undergo phalloplasty. Penetration
relies on insertion or activation of an insertable or inflatable device episodically, or a device
that is permanently implanted within the neophallus. Signifi ant limitations of phalloplasty
include cost, donor-site scarring, a relative lack of spontaneity during sexual contact, and
the necessity of a multistaged procedure.1
Metoidioplasty, which was first described by Lebovic and Laub,3 provides an alternative to
phalloplasty as a single-stage procedure. Although the neophallus will be comparatively
small (range 3 to 8 cm), metoidioplasty can offer a realistic-appearing penis capable of en-
gorgement with no loss of erotic sensation and the ability to stand to urinate, if urethral
extension is chosen. The ability to penetrate is not typically attributed to metoidioplasty.
That said, in discussions with individual transmen, metoidioplasty is often preferred to
phalloplasty because of its organic, homegrown qualities, sexual spontaneity, and unal-
tered erotic sensation.4 Although engorged, the metoidioplasty erection is less rigid than
in cisgender males because of the absence of the tunica albuginea. However, for individuals
who choose metoidioplasty, penetration, where desired, is relatively possible, and by some
reports, quite possible. Sexual satisfaction in both phalloplasty and metoidioplasty groups
is high.5 Djordjevic and Bizic6 reported that metoidioplasty progressed to phalloplasty in
only 13.52% of patients. In general, metoidioplasty is ideal in thin- to medium-built men
who are relatively lacking in mons pubis adiposity. Signifi ant pelvic fat in the mons region
or a lack of clitoral hypertrophy in response to testosterone therapy will limit the apparent
length of the metoidioplasty. Pumping or suctioning of the neophallus both before and af-
ter metoidioplasty has been reported to be helpful in attaining maximal length. Similarly,
use of dihydrotestosterone, the active derivative of testosterone, although not widely avail-
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CHAPTER 7
able in the United States, has also been reported to be useful in maximizing phallic length.7
Monsplasty, a second-stage procedure, can be performed to reduce the fat around and above
the metoidioplasty, allowing the penis to project more and attain a more cephalad position.
In considering metoidioplasty, the surgeon must recognize the similarities and homolo-
gies associated with male and female anatomy. The clitoris, like the penis, is composed of
two paired corporeal bodies, a clitoral corona and a dorsal neurovascular sheath. Unlike
males, the ventral portion of the clitoris is made up of a short, wide urethral plate. With
testosterone hypertrophy, the clitoris can attain preoperative lengths of between 2 and
6 cm when measured from the coronal tip to the symphysis pubis. The head of the clito-
ris, although cleaved and attached to the labia minora inferiorly, can attain a size of nearly
2 cm in diameter. The shaft itself is bent downward as a result of its attachment to the labia
minora, the suspensory ligaments superiorly, and the chordae below the shaft. The urethral
plate is short and wide. All attachments effectively tether and curve the clitoris, limiting the
length of a potential neophallus.8,9
Metoidioplasty relies on straightening of the hypertrophied clitoris by dividing the chor-

dae, releasing the corpora bodies from their attachment to the labia minora, and if urethral
extension is chosen, elongating the short urethral plate. An SM can be selected, which al-
lows penis creation but without the ability to stand to urinate. In the SM, the urethral plate
is divided just above the original urethral opening. Metoidioplasty with urethral extension
includes various methods to elongate the urethral plate and proximal urethra. These options
include the buccal mucosa, labial mucosa, or the ring flap. The distal urethra is universally
derived from a labial mucosal island flap, except rarely, when the available mucosal mate-
rial is inadequate. The ventral portions of the urethra are derived proximally from a vaginal
pedicled flap and distally from the labial mucosa.10
Surgical Techniques
All metoidioplasty methods can be combined with a hysterectomy (and generally, bilateral
salpingo-oophorectomy), vaginectomy, and scrotoplasty (testicle implants) in a single-stage
procedure. Results are correlated with technique and experience, although the complica-
tions from an SM are negligible). Th ee types of metoidioplasty will be discussed.
Simple Metoidioplasty
An SM is performed on the testosterone-enlarged clitoris/phallus. The skin around the
clitoral corona is circumferentially incised, the clitoral body is degloved, and ideally, the
suspensory ligaments are transected. Oblique incisions toward the symphysis pubis from
the superior aspect of each labium minus transect the urethral plate, allowing access to the
chordae below the shaft while also allowing enough minora skin to later enable vertical clo-
sure of the neophallus ventrally. Excess tails of the labia minora skin inferiorly are discarded.
The chordae are divided transversely with electrocautery, and the levator musculature and
base of the shaft re bulked and closed vertically with interrupted 3-0 Vicryl sutures. The
midline approximation incorporating the levator musculature is carried superiorly to the
corpora. The subcutaneous labial skin is further brought together up the shaft long the
corpora until the corona is reached. The degloved corona is reattached to the minora/shaft
skin with running 5-0 PDS. Finally, the outer surface of the labia minora skin is closed
along the midline to form the ventral penile skin. Because the original urethral opening
remains intact, the surgeon must judge how low the midline closure is in allowing urine
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Fig. 7-1 Outcome after simple metoidioplasty. The

neophallus has a male appearance.
outfl w. The surgeon must also determine whether vaginectomy should be performed. A
14 Fr Foley catheter is typically placed to avoid urine contact with the raw surfaces. Simple
metoidioplasty can be combined with a vaginectomy, although patients must be cautioned
that residual mucosa and Skene glands can result in persistent secretions.
Complications of an SM develop only from the incisional closure; malunion or malrota-

tion is an uncommon occurrence (less than 5%, in our experience). As with all methods of
metoidioplasty, patients are in general satisfi d with the SM results5 (Fig. 7-1). Despite its
limitations, SM can provide complication-free GAS at a relatively low cost in an outpatient
setting with minimal recovery time and considerations.
Ring Metoidioplasty
The ring metoidioplasty (RM) is similar to the SM; in both, the chordae are released and
the suspensory ligaments are transected to straighten the phallus. The difference is in ex-
tending the urethral plate. In the RM, the additional dorsal urethral mucosa is derived from
the ring flap, an island flap incorporating a ring of introital vaginal mucosa distal to the hy-
men. Distally the ring flap retains its attachment to the underlying clitoral bodies, with its
edges dissected free along its length to allow tubularization distally. Its ring defect, which
is caused by circumscribing the vagina during dissection, is sewn closed with 5-0 PDS run-
ning suture. First described by Takamatsu and Harashina,11this technique allows a pedicled
mucosal flap to fill the posterior urethral plate extension, which is necessary to elongate
the urethra. The ventral portion of the urethra is closed with a vaginal skin flap measuring
4 to 6 cm in length and 2 to 3 cm in width. The vaginal flap is sewn to the proximal ring
flap, and the ring flap is tubularized along its length to the tip. As in all metoidioplasties,
the penile tube is closed with the outer surface of the labia minora to complete the ventral
penile skin tube (Fig. 7-2).
Complications include urethral fistula (range 10% to 26%) and stricture (range 3% to 5%).
Although RMs were performed in a single procedure, reoperation was necessary in nearly
30% of individuals in some series. Scrotoplasty was performed as a second-stage proce-
dure, which allowed closure in all but three individuals in our series. Recent experience
has shown improvement; the possibility of a leak-free urethral closure before completion
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CHAPTER 7
Fig. 7-2 Long-term result of ring metoidioplasty. Note

the good size of the penis and scrotum.
of skin closure appears to hold promise. Sexual satisfaction is high.5 The ability to stand
during urination was possible in some but not all individuals. Vaginectomy is offered but
not mandated in patients who opt for RM.
Belgrade Metoidioplasty
Although the ability to void in the standing position is imperative, advanced urethroplasty
with simultaneous use of buccal mucosal grafts nd genital flaps provides lengthening of
the native female urethra to reach the tip of the glans, as occurs in males. The masculine
appearance of the external genitalia is achieved with scrotoplasty and the insertion of two
testicular implants. Th s approach was fi st reported by a Belgrade team.12 The main advan-
tage of this technique is that all steps are performed in a single-stage procedure: removal of
the vaginal mucosa, metoidioplasty, and creation of the entire neourethra and scrotum.12
Vaginectomy is done by total removal of the vaginal mucosa (colpocleisis), except the part
of the anterior vaginal wall near the urethra that will be used for urethral reconstruction.
To straighten and lengthen the clitoris as much as possible, dorsal ligamentous components
must be completely released (Fig. 7-3, A). The wide and short urethral plate is also carefully
dissected from the clitoral bodies and divided at the level of the glanular corona, giving ad-
ditional length to the clitoris, but also creating a urethral plate defect. Urethroplasty starts
with reconstruction of the bulbar part. One of the main advantages of this technique is the
simultaneous removal of the vaginal mucosa and the use of an anterior vaginal wall flap
to create the bulbar urethra. The bulbar urethra has the highest urinary stream pressure
and therefore presents a high-risk point for postoperative fistula formation. The joining of
the clitoral bulbs over the neourethra and the additional covering with vascularized sur-
rounding tissue are considered keys to successful prevention of fistula. Additional urethral
reconstruction is performed with a buccal mucosal graft and vascularized genital skin
flaps6,10 (Fig. 7-3, B). Buccal mucosa is good grafting material for urethral reconstruction
because of its histologic and tactile similarity to urethral mucosa. It has a thick, hairless
epithelium and is tolerant of moisture.13 Harvesting of the graft s a safe procedure with a
high patient satisfaction rate.14,15 The graft is sutured to cover the urethral defect and quilted
to the corporeal bodies for better graft survival. A well-vascularized recipient site also pro-
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CHAPTER 7
A B
C D
Fig. 7-3 A, The clitoris is straight and 8 cm long after release of the dorsal ligaments and division of
the short urethral plate ventrally. B, The flap is harvested from the left labium minus, with preserved
blood supply. C, A buccal mucosal graft is quilted to the ventral side of the corpora. D, A labial flap is
joined with the buccal mucosal graft to create the neourethra.
vides a good blood supply and prevents shrinkage of the graft. rethral reconstruction is
completed either by use of a longitudinal dorsal clitoral skin flap buttonholed ventrally or
a flap harvested from the inner surface of the labia minora (Fig. 7-3, C). A labial flap (Fig.
7-3, D) combined with a buccal mucosal graft s reported as the best option, resulting in
a complication rate of less than 7%.6 Either a skin or labial flap is joined with the buccal
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E F
Video
7-1
Fig. 7-3, cont'd E, Malelike appearance of the genitalia is achieved 6 months after surgery. F, Normal
voiding in the standing position is obtained.
mucosal graft ver a 12 to 14 Fr catheter to form the neourethra. In both cases all suture
lines are covered with well-vascularized tissue, thus preventing fistula formation. The pe-
nile shaft is reconstructed with the remaining clitoral and labial skin. The labia majora are
joined in the midline to create the scrotal sac, and two silicone testicular prostheses are
inserted through the bilateral incisions at the top of the labia majora. A suprapubic urine
drain is placed in all patients for 3 weeks. The urethral stent is removed after 10 days. The
postoperative use of a vacuum pump, starting 3 weeks after surgery, is necessary to prevent
retraction of the neophallus.
Postoperative complications can be classifi d as minor (those that can be managed without
surgery) and major (those requiring additional surgery). Minor postoperative complications
include hematomas, wound infections, skin necrosis, urinary tract infections, and complica-
tions related to urethroplasty (dribbling, spraying, and urethral fistula). The reported minor
complication rate ranges from 17.5% to 35%, with spontaneous resolution in all cases. All
complications requiring secondary revision (flap necrosis, urethral fistulas, urethral stric-
tures, and testicular implant displacement) are considered major. Urethral fistulas occur
in 7% to 15% of all patients and are repaired by excision of the fistula and overlaying with
the available local vascularized flaps. Anastomotic or buccal mucosal graft u ethroplasty
is performed to repair urethral stricture in 2% to 3% of all patients. In the event of a dislo-
cated testicular implant, repositioning and fixation of the implant into the proper position,
along with the creation of a new capsule, are indicated.6,9,10,16,17
Th s complete, single-stage technique has a good aesthetic outcome, according to patients’

evaluations. Reconstruction of the neourethra enables voiding in the standing position in
all patients (Fig. 7-3, E and F). Although the length of the neophallus is mostly inadequate
for full penetration, most patients report satisfaction with the quality of erection, sensation
of the neophallus, and sexual arousal, confi ming good psychosexual outcome.
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Conclusion
Metoidioplasty has been established as the method of choice in FTM transsexual patients
who strive to have a malelike appearance of the genitalia without the creation of an adult-
sized phallus, which requires a complex and multistaged phalloplasty. Proper preoperative
planning and counseling in each patient, as well as a clear understanding of the female
genital anatomy and sexuality, are necessary for a successful outcome. Current techniques
of metoidioplasty provide a good aesthetic result, the ability to void in the standing po-
sition, and preserved sexual function in a single-stage procedure with a minimal rate of
postoperative complications. The main disadvantage of metoidioplasty is that it produces
a relatively short phallus compared with that of an adult cismale, which may disappoint
patients seeking the ability to penetrate. Patients must be advised of this before surgery.
References
1. Selvaggi G, Bellringer J. Gender reassign- 9. Vukadinovic V, Stojanovic B, Majstorovic M,
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2. Selvaggi G, Dhejne C, Landen M, et al. The World Journal 2014:437378, 2014.
2011WPATH Standards of Care and Penile 10. Djordjevic ML, Bizic M, Stanojevic D, et al.
Reconstruction in Female-to-Male Transsex- Urethral lengthening in metoidioplasty
ual Individuals. Adv Urol 2012:581712, 2012. (female-to-male sex reassignment surgery)
3. Lebovic GS, Laub DR. Metoidioplasty. In by combined buccal mucosa graft and labia
Ehrlich RM, Alter GJ, eds. Reconstructive minora flap. Urology 74:349, 2009.
and Plastic Surgery of the External Genitalia. 11. Takamatsu A, Harashina T. Labial ring flap:
Philadelphia: WB Saunders, 1999. a new flap for metoidioplasty in female-to-
4. Djordjevic ML, Stanojevic D, Bizic M, et al. male transsexuals. J Plast Reconstr Aesthet
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Sexual and physical health after sex reassign- 13. Bhargavas S, Chapple CR. Buccal mucosal
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two different methods for urethral lengthen- 14. Barbagli G, Vallasciani S, Romano G, et al.
ing in female to male (metoidioplasty) sur- Morbidity of oral mucosa graft harvesting
gery. J Sex Med 10:1431, 2013. from a single cheek. Eur Urol 58:33, 2010.
7. Kaya C, Bektic J, Radmayr C, et al. The effi- 15. Markiewicz MR, Lukose MA, Margarone JE,
cacy of dihydrotestosterone transdermal gel et al. The oral mucosa graft: a systematic re-
before primary hypospadias surgery: a view. J Urol 178:387, 2007.
prospective, controlled, randomized study. 16. Hage JJ, Turnhout WM. Long-term outcome
J Urol 179:684, 2008. of metoidioplasty in 70 female to male trans-
8. Stojanovic B, Djordjevic ML. Anatomy of sexuals. Ann Plast Surg 57:312, 2006.
the clitoris and its impact on neophalloplasty 17. Rohrmann D, Jakse G. Urethroplasty in fe-
(metoidioplasty) in female transgenders. Clin male to male transsexuals. Eur Urol 44:611,
Anat 28:368, 2015. 2003.
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CHAPTER
8
Phalloplasty: Radial Forearm Free Flap
Christopher J. Salgado, Harvey W. Chim,

Varsha R. Sinha, Piet Hoebeke,
Stan J. Monstrey
Key Points
❖❖ The radial forearm flap is the most commonly ❖❖ A metoidioplasty does not offer nearly all the
used technique for phalloplasty. benefits attributed to a phalloplasty, particu-
❖❖ The goal of penile construction is to create a larly a phallus long enough to allow penetration
functional and aesthetic phallus. during sexual intercourse, thereby avoiding the
use of a prosthesis. In addition, some patients
❖❖ The sequence of surgery is to first perform a
have problems voiding while standing.
subcutaneous mastectomy, followed by a hys-
❖❖ First-stage surgery consists of vaginectomy,
terectomy and oophorectomy, combined with a
vaginectomy, scrotoplasty, and reconstruction urethral lengthening, and prelamination of the
of the horizontal part of the urethra (similar to radial forearm flap.
a metoidioplasty) and later the actual phallo- ❖❖ Second-stage surgery consists of the microsur-
plasty. gical transfer of the radial forearm flap, tubular-
ization, and scrotoplasty.
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Female-to-Male Gender Affirmation Phalloplasty: Radial Forearm Free Flap
With a growing demand for female-to-male gender reassignment surgeries, more recon-
structive surgeons are learning the procedures necessary for gender affirmation bottom
surgery, and methods are becoming safer and more successful. Phalloplasty and metoid-
ioplasty are two of these procedures. Each technique has advantages and disadvantages.
Although less prone to complications and less costly, a metoidioplasty does not offer nearly
all the benefits attributed to a phalloplasty, particularly a phallus long enough to allow
penetration during sexual intercourse, thus avoiding the use of a prosthesis. In addition,
some patients have problems voiding while standing. Thus phalloplasty has become the
preferred procedure for patients wishing to live fully as a male. This chapter will focus on
the method of using a free flap from the radial forearm of the patient’s nondominant side
to create a neophallus.
The radial forearm free flap (RFFF) has become the most frequently used surgical technique
for a phalloplasty and is superior to all other techniques, because it effectively meets the goal
of creating a pleasing and sensate neophallus with a functioning neourethra to allow void-
ing from the distal end of the neophallus.1 Originally developed in 1981 by Yang et al for the
release of a cervical skin contracture in burn patients, the RFFF is now often used for both
head and neck and penile reconstruction.2 Although there is notable donor-site morbidity
and this multistage procedure can last anywhere from 5 to 12 hours, this technique makes
it possible for patients both to void while standing and have penetrative sexual intercourse;
bone can be added as an osteocutaneous flap or when a penile prosthesis is placed in the
flap at a later stage. Patients view this as a fair exchange that allows them to fully experi-
ence life as a male. Also, in terms of surgical positioning, the forearm donor site is far from
the groin, which enables two to three surgical teams to operate simultaneously (Fig. 8-1).
Fig. 8-1 Stage 2 gender affirmation RFFF phalloplasty with three surgical teams working concur-
rently. One team is performing left radial forearm free flap harvest, a second team is performing a vagi-
nectomy and scrotoplasty, and a third team is harvesting recipient vessels (an inferior epigastric artery
and vein).
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In this chapter we will highlight our surgical technique, donor-site morbidity, and outcomes
in an effort to elucidate this form of construction in the growing field of penile surgery. An
adequate preoperative evaluation to ensure realistic expectations, coupled with a dialogue-
based informed consent preferably through a multidisciplinary approach, enables success-
ful surgical outcomes in this patient population.
Justification for the Radial Forearm Flap

The ideal flap for penile reconstruction and construction should preferably be a one-stage
procedure that provides an aesthetically pleasing and functional phallus, has minimal
donor-site morbidity and functional loss, generates suffici t tactile and erogenous sensa-
tion, and has suffici t tissue to allow tubularization around the neourethra if not prelami-
nated. RFFFs can meet most of these prerequisites, with the advantage of providing thin,
malleable, and sensate tissue with a long pedicle that can easily be dissected and used for
free tissue transfer. The location of a forearm donor site away from the groin also allows an
effective two-team surgical approach.
The goal of penile construction is to create a functional and aesthetic phallus. Functional
goals include normal urinary function and phallic rigidity for penetrative sexual inter-
course. Normal urinary function may be achieved by the “tube-within-a-tube” method,
which allows voiding through the neourethra at the tip of the phallus while standing or with
our technique of urethra flap prelamination with mucosa and/or a skin graft. Sensation to
the shaft nd glans of the constructed penis should be adequate for protection sensation
and provide erogenous sensation helping with orgasm. The forearm donor site should leave
a well-accepted scar without functional or signifi ant sensory loss. These goals should be
met in a surgical procedure that is predictably reproducible.
Patient Evaluation
Female-to-male transgender patients are increasingly seeking gender affirmation surgery
to alleviate their gender dysphoria. Phalloplasty procedures, which enable the patient to
void while standing and achieve penetrative sexual intercourse, are certainly favored. Given
the potential morbidity associated with the complex phalloplasty procedure, an adequate
preoperative evaluation of these patients is essential. The need for an adequate gender
dysphoria evaluation and medical clearance is unique to this patient population. Gender
dysphoria, ICD-9-CM 302.85. Th s is distress caused by a discrepancy between the per-
son’s gender identity and external phenotype. According to the Standards of Care of the
World Professional Association of Transgender Health, a mental health assessment by two
different mental health professionals who treat transgender patients is necessary before
proceeding with a phalloplasty construction. Adequate social support is also encouraged
to facilitate a successful recovery. The surgeon should remain involved in all stages of the
preoperative evaluation by corresponding with the patient’s mental health provider and
the urogynecologist.
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Fig. 8-2 A 24-year-old transman with a radial forearm osteocutaneous flap for phalloplasty at 3-month
follow-up. He urinates in the standing position and has begun penetrative vaginal intercourse.
A clear and candid discussion regarding the patient’s desired goals from surgery, including
the length and circumference of the neophallus, allows the surgeon to determine whether
expectations are realistic given the patient’s anatomy. An osteocutaneous versus fascio-
cutaneous flap option is given to patients; the former will often allow a construction that
will not necessarily require an implant for rigidity, because a portion of the radius bone is
harvested with the flap (Fig. 8-2). Specific in ormation regarding previous infections and
the responsible microorganisms helps in selecting perioperative antibiotics, because post-
operative infections delay recovery and increase postoperative morbidity.
Microsurgical construction performed in an RFFF for phalloplasty requires several ad-

ditional preoperative assessments. Appropriate preoperative studies to ensure adequate
arterial infl w and venous outfl w of the surrounding vasculature of the genitalia are re-
quired, particularly if there has been any previous surgery or trauma. In these cases CT
angiography of the pelvis and groin may be performed. Intact sensation in the genital area
is vital, because the dorsal clitoral nerve, ilioinguinal nerve, and genitofemoral nerve are
used to achieve erogenous and protective sensation to the neophallus, respectively.3 A sur-
geon should have a clear answer regarding the patient’s ability to obtain an orgasm before
surgery, so that this can be matched after the construction.
If the patient has difficulty achieving an orgasm before the surgical stages, it will more than
likely be difficult for the patient to have one after surgery despite the anticipated reduction
in dysphoria. An Allen test is essential to guarantee that the vascularity of the hand will not
be compromised with harvest of the RFFF. In addition, a preoperative radiograph of the
donor forearm is indicated in patients in whom an osteocutaneous flap has been planned
to evaluate the radius bone stock.
Certain fi dings during the preoperative evaluation make the RFFF contraindicated in
some female-to-male transgender patients. Although an acceptable donor site in popular
opinion (Fig. 8-3), two of the main aesthetic contraindications to the RFFF are the occa-
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CHAPTER 8
Fig. 8-3 The forearm donor site of a 48-year-old transman after RFFF harvest with immediate bovine
collagen reconstruction, followed 3 weeks later by a partial-thickness autologous skin graft.
sional refusal of donor-site forearm scarring or the transfer of forearm tattoos to the neo-
phallus. An abnormal preoperative Allen test signifies poor vasculature, making the patient
an unfit candidate for an RFFF with that particular donor site. Because delicate vascular,
neural, and urethral microsurgical anastomoses are performed intraoperatively, patients
who do not stop smoking at least 4 weeks before surgery should not undergo an RFFF for
phalloplasty. In some European centers, surgeons want 1 year of smoking cessation before
phalloplasty procedures.
Preoperative Preparation
Preoperative depilation of the forearm is recommended when performing the tube-within-
a-tube technique for neourethra forearm flap design.4 In our practice we commonly per-
form forearm flap prelamination with mucosa and occasionally a skin graft,5 which obvi-
ates the need for depilation of the forearm tissue. In addition, from an aesthetic standpoint,
because of the abundant hair in the mons region of a transman taking testosterone, the
abrupt change from a mons full of hair to a hairless penile shaft does not lead to a smooth
transition, and thus we do not recommend electrolysis or depilation of the forearm tissues
for this reason. Depilation of both the mons region and penile shaft may be performed af-
ter surgery if desired.
Regarding hormonal therapy, our patients stop taking exogenous steroids 2 weeks before
surgery. Although we will not uncommonly use anticoagulation such as intravenous hepa-
rin during the microsurgical procedure, the risk of deep vein thrombosis is real given the
use of steroids and a concomitant long surgical procedure.6
A patient should also have had a hysterectomy and oophorectomy before beginning this
procedure. If he has not yet had these procedures, it is possible to perform this surgery
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CHAPTER 8
during the fi st stage of our approach to staged phalloplasty. If the patient is considering
harvesting of eggs before oophorectomy, this is performed before defin tive and irrevers-
ible hysterectomy and oophorectomy. Alternatively and in the earlier Belgian experi-
ence, a hysterectomy and oophorectomy were performed with bilateral chest reconstruc-
tion (mastectomy), in addition to scrotoplasty, fi ed urethra reconstruction, or urethral
lengthening and phalloplasty. Now the hysterectomy, oophorectomy, and bilateral mas-
tectomies are performed in the fi st stage, followed by later genital transformation. Cur-
rently in the Belgian group, a hysterectomy and oophorectomy are performed with the
top surgery and later genital transformation. Currently the Belgian groups perform only
subcutaneous mastectomy (top surgery/chest reconstruction) and later the entire geni-
tal transformation. Th s consists of a hysterectomy and oophorectomy combined with
a vaginectomy, scrotoplasty, and urethral lengthening (similar to a metoidioplasty) and
later the (entire) genital transformation.
The current sequence of surgery at the University of Miami Hospital is fi st a subcutaneous

mastectomy (at an early stage, because it is so important to them), followed by a hysterec-
tomy and oophorectomy combined with a vaginectomy, scrotoplasty, and reconstruction
of the horizontal part of the urethra (similar to a metoidioplasty) and later the actual phal-
loplasty. We think that this sequence allows patients to experience how “happy” they are
with the metoidioplasty, leading to a high rate of phallus transition. Although some patients
may not require a phallus and there are fewer complications such as a fistula and stenosis
with the fi al phalloplasty procedure, size limitations are considerably decreased with a
metoidioplasty, because only a micropenis is attainable, which is a disease according to the
International Classifi ation of Diseases (ICD).
Surgical Technique
Varied techniques of constructive phalloplasty have been performed, including innervated
gracilis flaps, anterolateral thigh flaps, tubed flaps from the abdomen, fibula flaps, RFFFs,
latissimus dorsi flaps, and vertical rectus abdominis myocutaneous flaps. All offer a distinct
approach to flap harvest and their associated morbidity.
Stage 1: Prelamination Technique

In this fi st stage of gender affirmation surgery, the three main goals are:
1. Vaginectomy (combined with a hysterectomy and oophorectomy if not already per-
formed)
2. Urethral lengthening
3. Radial forearm flap prelamination
Two to three teams operate simultaneously. One team is made up of an urogynecologist in

our case, who performs the vaginal mucosa harvest, harvest of the pedicled anterior vagi-
nal mucosal wall flap for urethral lengthening, and closure of the vaginal canal. He or she
will also perform the hysterectomy and oophorectomy if these were not already done pre-
viously; in select patients they can be performed concurrently. A second team will harvest
bilateral buccal mucosal grafts if vaginal mucosal length is insufficient for the neourethra
(Fig. 8-4). We have found that mucosal grafts (if available) are superior to autologous skin
grafts or neourethra prelamination. Th s has been concurrent with other studies avail-
able.7 If a metoidioplasty has been performed in the past, the vaginectomy will have com-
monly been done, and prelamination of the RFFF will be done with a skin graft and buccal
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CHAPTER 8
mucosal graft only if that is our preferred technique. In addition, the urethral lengthening
will have already been accomplished. In patients in whom no surgical intervention has
been performed on the transmen’s external genitalia, we have used an anterior vaginal flap
solely or to reinforce the external urethral lengthening, which is performed with the labia
minora tissues (Fig. 8-5).
A B
Fig. 8-4 A, A patient with intraoral retractors in place and buccal mucosa marked out; special atten-
tion is paid to not injure the parotid duct. B, A vaginal mucosal graft adjacent to two buccal mucosal
grafts used to line the neourethra around an 18 French Foley catheter in preparation for implantation in
the suprafascial plane of the RFFF.
A B
Fig. 8-5 A, Labia minora tissues and anterior vaginal flap used to lengthen the urethra in a stage I
phalloplasty for gender affirmation female-to-male surgery. B, Eight weeks after urethral lengthening
and RFFF prelamination. Patient is shown before stage 2 flap transfer.
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CHAPTER 8
Fig. 8-6 A 28-year-old patient is shown 3 weeks after forearm flap prelamination with a Foley catheter
in place.
The neourethra is placed along the ulnar aspect of the radial forearm donor site and secured
at both ends. A splint for immobilization is placed on the palmar aspect of the forearm,
and daily irrigation of the neourethra must be done after surgery until flap transfer (Fig.
8-6). Intravenous antibiotics are administered 1 hour before the incision to protect against
gram-positive and gram-negative organisms, in addition to anaerobes.
Stage 2: Radial Forearm Free Flap Transfer

We have commonly used the inferior epigastric artery as the donor artery, although the
branches off the femoral artery and an end-to-side anastomosis may also be used. The infe-
rior epigastric artery is a branch off the external iliac artery and the inferior arterial supply
to the rectus abdominis muscle. The artery is harvested through an extended Pfannenstiel
incision, and the dissection of the superior adipocutaneous flap is performed up to the level
of the umbilicus. The donor veins that are suitable for outfl w are the saphenous veins and
preferred vessels. All of these vessels may be pedicled into the groin region for vascular
anastomosis. A scrotoplasty is performed according to the technique of Selvaggi et al8; a
variation is to use a more transverse incision cephalad to the clitoral hood to avoid the ap-
pearance of a vaginal cleft n the RFFF inset at the dorsal aspect. The clitoris is denuded
of its epithelium in preparation for transposition, and the clitoral hood tissue is harvested
and preserved for coronaplasty.
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Working concurrently (see Fig. 8-1), the forearm flap is harvested from the nondominant
forearm after a normal Allen test is obtained. A tourniquet is used for flap harvest, in ad-
dition to a hand table. A separate surgical setup is used to avoid cross-contamination be-
tween the pelvic area and upper extremity. In addition, antibiotics, which protect against
gram-positive and gram-negative microorganisms, are used intravenously and administered
1 hour before the incision is made. A marking pen is used to mark the distal wrist crease
and proximal extent of the flap, which will commonly measure approximately 5.5 to 7 inches
in length and 5.5 to 6.5 inches in width. The marking is made so that the ulnar aspect is
overlying the ulnar aspect of the ulna and the radialmost aspect of the skin paddle is on
the lateral aspect of the radius. Placement of a Foley catheter in the neourethra before flap
harvest is benefic al to aid in identifi ation of the urethra. Flap elevation is started on the
ulnar side in a subfascial fashion, so that the neourethra is not entered during dissection.
Dissection proceeds to the fle or carpi radialis tendon for a fasciocutaneous RFFF.
With an osteocutaneous RFFF, dissection is carried deep and radial to the fle or carpi ra-
dialis tendon, and a cuff f fle or pollicis longus muscle is incised and preserved with the
bone segment that will be harvested. If an osteocutaneous flap is harvested, as a general
rule not more than one third of the radius diameter is taken with the soft issue. Flap el-
evation continues on the radial side of the flap, starting in a suprafascial fashion, to leave
some fascial tissue on the tendons, which may facilitate graft ake. Th s plane also allows
identifi ation and preservation of the superfic al branch of the radial nerve. All other sen-
sory nerves (medial and lateral antebrachial cutaneous nerves) are harvested with the flap.
If the tube-within-a tube technique is used, the flap extends more to the radial-dorsal side
of the arm. Dissection continues around the brachioradialis tendon in a subfascial fashion;
this forms the radial margin of the pedicle. After the flap is elevated on the ulnar and radial
sides, the osteotomy can be performed. If a long segment of bone will be harvested (more
than 8 cm), the insertion of the pronator teres tendon on the radius will have to be partially
disinserted and should be reattached to the remaining radius. We perform prophylactic
plating of the remaining radius bone to prevent fractures.
While the RFFF remains connected to its inherent blood supply, the flap is tubed into a
phallus and sutured so that the neourethra is buried within the tubed phallus. After vessel
preparation with a microscope and confi ming adequate outfl w from the artery and in- Video
fl w from the greater saphenous veins, the RFFF is transferred to the pubic area. The fi st 8-1
maneuver performed is to place the Foley catheter, which is located in the neourethra, di-
rectly into the patient’s bladder. The forearm donor site is covered with either an autologous
split-thickness skin graft, or the surgeon can choose to fi st apply a dermal substitute that
can be grafted later. The urethral anastomosis is performed fi st, followed by the arterial
anastomosis and venous anastomosis, all of which are often hand-sewn interrupted with
the use of a microscope. The venous anastomosis is performed between the cephalic and
great saphenous veins. In most patients it is possible to include the connection between the
deep comitant and superfic al cephalic veins at the level of the elbow to drain both systems
through one vein. Eventually a second venous anastomosis can be performed between a
deeper radial venous comitant vein, also with the great saphenous vein.
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B C
Fig. 8-7 A, The right ilioinguinal nerve is seen exiting the external inguinal ring and is used to anas
tomose to a sensory branch of the RFFF for tactile neophallus sensation. B, A patient is shown imme-
diately after RFFF microsurgical phalloplasty with bilateral saphenous veins for outflow veins, an ex-
tended Pfannenstiel incision for inferior epigastric artery harvest, and a Norfolk coronaplasty. Also note
the placement of the suprapubic catheter. C, The results are shown 6 months after surgery.
Two to three nerve anastomoses should be performed. The medial and lateral antebrachial
nerves are anastomosed to the ilioinguinal or genitofemoral nerve for protective sensation
and to one of the dorsal clitoral nerves for erogenous sensation. The ilioinguinal nerve is
commonly found exiting the external inguinal ring9 (Fig. 8-7, A). A suprapubic tube is
placed and used for urinary diversion and eventual phallus urinary training (Fig. 8-7, B
and C).
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CHAPTER 8
Fig. 8-8 A retrograde cystourethrogram 8 weeks after RFFF phalloplasty and just before discontinu-
ation of a penile Foley catheter. The patient will now have a suprapubic catheter clamped and bladder
training begun.
In an osteocutaneous forearm flap, the bone is anchored to the pubic symphysis by placing
a drill hole in the proximal aspect of the bone, and commonly a large braided (nonabsorb-
able) suture is anchored to the symphysis. Eventually an immediate gracilis flap can be per-
formed to buttress the urethral anastomosis and autoaugment the neoscrotum, avoiding
the use of testicular implants. The last step in the procedure is to perform a coronaplasty
at the distalmost aspect of the phallus. Commonly a Norfolk coronaplasty is used with ei-
ther a skin graft r labial graft btained from the clitoral hood region on denuding of the
clitoris before transposition.10
Patients are immediately transferred to the recovery room or intensive care unit for flap
monitoring and will remain on strict bed rest during a 1-week postoperative period. Subcu-
taneous heparin and aspirin are given after surgery to help avoid microvascular thrombosis.
Patients in whom the donor site was fi st covered with a dermal substitute are commonly
taken back to the operating room for skin grafting of the forearm at a later stage. After a
2- to 3-week hospital stay and discharge from the hospital, a pericatheter retrograde cys-
tourethrogram can be planned (Fig. 8-8).
If no extravasation of dye is encountered and there is no fistula, the penile Foley cather is
discontinued and the suprapubic catheter is clamped. Patients are encouraged to urinate
through their neophallus with the suprapubic tube clamped, or we check for residual urine
in the bladder. In most patients adequate voiding is achieved shortly thereafter, and the
suprapubic tube can be discontinued.
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Fig. 8-9 An RFFF donor-site tattoo for concealment.
Fig. 8-10 A 28-year-old transman with an elastic 3M Co-

ban wrap and a condom placed around the neophallus
for penetrative vaginal intercourse 3 months after surgery.
Tattooing of the glans and shaft ay be performed to enhance the aesthetic appearance
and should be performed before 1 year so that full tactile sensation has not been achieved
and the pain lessened. Similarly, donor sites may be tattooed to avoid the stigmata of the
skin graft (Fig. 8-9).
Because the RFFF without bone may be too soft to allow for vaginal or anal penetrative
intercourse, a penile prosthesis is sometimes necessary. Penile implants are commonly not
performed until protective sensation of the phallus is achieved to the penile tip, which is
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CHAPTER 8
about 12 months after surgery. A Tinel sign is often used to assess tactile sensation until
that time. Some patients have found an elastic 3M Coban wrap (3M, St. Paul, MN) and a
condom to be beneficial for penetrative intercourse before implant placement if no bone
has been used in the reconstruction (Fig. 8-10).
Postoperative Sequelae/Complications
Possible postoperative complications, which should be discussed in the informed consent
process, after this procedure are partial or total flap loss, hematoma of the donor or recipi-
ent site, an insensate flap, anorgasmia, skin graft lo s at either the donor or recipient site,
chronic pain, numbness, urinary complications, radius fracture (if an osteocutaneous flap
is harvested), hypertrophic scarring, infection, cold intolerance of the limb, vascular com-
promise requiring take back to the operating room, abdominal wall hernia or weakness,
bone or implant extrusion, implant infection, dyspareunia in the patient or recipient of
vaginal or anal penetrative intercourse, tendon exposure, decreased hand function, implant
malfunction, inability to use the constructed phallus, and less commonly persistent gender
dysphoria.11 The management of these unfavorable sequelae will be discussed in another
chapter; however, complications directly related to free tissue transfer are managed in the
same fashion as any free tissue transfer revision procedure. There have been some reports
of impaired venous return in revisions of both arterial and venous anastomoses.
For this reason there may be indications to dissect the distal ends of the radial artery and
cephalic vein at the time of flap harvest; an arteriovenous anastomosis can be easily per-
formed at the time of flap revision to improve venous return. Th s ateriovenous fistula can
be easily taken down without the use of any anesthetic after a 6-week to 3-month period.
Potential Drawbacks of the Radial Forearm Free

Flap Phalloplasty
Urinary complications such as urethrocutaneous fistulas or urinary strictures are signifi-
cant after an RFFF phalloplasty and have reached up to 41%12 and even 80% in other stud-
ies. Initial urinary fistulas typically develop at the penoscrotal junction and can usually
be managed conservatively without surgical intervention. Because the urethral skin graft
tends to retract, prelamination with mucosal grafts may reduce the chances of stenosis in
patients in whom a tube-within-a-tube reconstruction of the urethra is not used. However,
mucosal grafts are not always available, and urethral meatal stenosis may occur, which re-
quires prompt treatment with dilation to avoid later fistula formation resulting from the
backpressure of urine this can create. Th s usually occurs later than fistulas and requires
treatment with dilation. Advances in urethroplasty, including labia minora flaps and small
U-shaped flaps from the anterior wall of the vagina for the cylindrical-shaped urethra in
urethral lengthening, which are often used, have resulted in a decreased occurrence of ure-
thral fistula to 22%.13
Sexual intercourse is typically a goal for most female-to-male transgender patients; how-
ever, phallic rigidity is difficult to create without the natural erectile tissue of the penis. The
need for a penile prosthesis or bone graft s a stiffener may be seen as a disadvantage be-
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CHAPTER 8
cause of potential complications.14 Explantation rates can reach 20% or higher as a result
of technical failure and infection of the implant device.15 The available erection devices are
conceived to be used (mostly) in aged individuals, who have a normal male anatomy and a
lesser need for sexual intercourse in contrast with most young transmen. A constantly erect
neophallus may lead to embarrassment for the patient but can be concealed with restric-
tive undergarments under regular clothing. Ultimately, a penile prosthesis or bone allows
penetrative sexual intercourse, an option that is not feasible with other surgical methods.
Recent Advances in Phalloplasty

Interestingly, the RFFF has also been described for penile reconstruction with a nonmicro-
surgical technique.16 In this research an osteocutaneous RFFF was elevated as a reverse-flow
island flap and transferred to the recipient site as a distal flap while maintaining its vascular
connection with the forearm. The pedicle was then divided, and reconstruction was com-
pleted during a second stage, approximately 3 weeks later.
In recent years, perforator flaps have become popular for phallic reconstruction because
of the obvious advantages, including a concealed donor site, a large reservoir of tissue, and
a potentially easier vascular anastomosis.17 The most promising perforator flap for phallo-
plasty is the anterolateral thigh flap, which has been used as both a free flap and pedicled
flap, thus avoiding the problems related to microsurgical free flap transfer.18 One challenge
of using the anterolateral thigh flap in the construction of a phallus is maintaining a well-
vascularized neourethra because of the increased thickness of the entire flap, resulting in a
higher incidence of urinary complications compared with other techniques.19 Nonetheless,
this flap may become an alternative to the superior RFFF, particularly because it may be
used as a pedicled flap. Th s flap will be discussed in more detail in Chapter 9.
Advances in tissue engineering portend novel options for penile reconstruction. Although
research has not been translated beyond animal studies, remarkable progress has been made
in recent years. Acellular corporeal collagen matrices seeded with autologous cells have
been used to replace entire pendular penile corporeal bodies in a rabbit model.20 Remark-
ably, the engineered tissue was similar both structurally and functionally to native tissue,
because male rabbits were still able to successfully impregnate females.
Tissue-engineered cartilage rods have also been used as a substitute for synthetic penile im-
plants. Autologous chondrocytes seeded on a polymer lattice rod were implanted into the
corporeal spaces of the same rabbits, and explantation after 2 months showed well-formed
cartilage structures, with animals able to copulate and impregnate female partners.21 An
additional study implanted human chondrocytes into the subcutaneous spaces of rats for
2 months to produce cartilaginous rods of comparable size and mechanical properties to
silicone prostheses.22 Stem cells may also serve as a novel treatment option in the future.
One study reported differentiating rat muscle-derived stem cells into corporeal smooth
muscle cells to replace these in situ.23 Another study by Song et al24 observed the differen-
tiation of human mesenchymal stem cells into smooth muscle cells or endothelial cells on
transplantation into rat corpus cavernosum.
Two penile transplantations have been performed worldwide, with a 50% success rate over
6 months. Penile transplantation is in its infancy. However, a number of disadvantages
make this an unenthusiastic venture at this point in time. Immunosuppression is required
for the transplant when evidence is lacking that it will lead to fewer urinary complications.
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In addition, a smaller construct is created with autologous flaps. Also, it is more likely that
an implant will be required for rigidity.
Conclusion
Female-to-male transgender patients requesting phalloplasty have multiple goals. The ability
to void in the standing position, adequate sensation, and considerable rigidity of the neo-
phallus for penetrative sexual intercourse are signifi ant challenges, but all can be achieved
through the use of the RFFF. The primary goals, however, in these constructions are to help
alleviate the patient’s gender dysphoria and to allow penetrative intercourse without the use
of a prosthetic device. All other goals are secondary. An extensive preoperative evaluation
to ensure realistic expectations and stable mental health, coupled with a multidisciplinary
approach between skilled reconstructive surgeons, urologists, and gynecologists, enables
successful surgical outcomes for female-to-male transgender patients. Continued long-
term follow-up of this patient population will allow further refi ements in functional and
aesthetic surgical techniques.
References
1. Garaffa G, Christopher NA, Ralph DJ. To- 10. Gilbert DA, Jordan GH, Devine CJ Jr, et
tal phallic reconstruction in female-to-male al. Microsurgical forearm “cricket bat-
transsexuals. Eur Urol 57:715, 2010. transformer” phalloplasty. Plast Reconstr
2. Loeffelbein DJ, Al-Benna S, Steinsträßer L, et Surg 90:711,1992.
al. Reduction of donor site morbidity of free 11. Salgado CJ, Garrido DE, Eidelson SA, et al.
radial forearm flaps: what level of evidence is Reconstruction of the penis. In Salgado CJ,
available? Eplasty 12:e9, 2012. Redett R, eds. Aesthetic and Functional Sur-
3. Salgado CJ, Chim H, Tang JC, et al. Penile re- gery of the Genitalia. Hauppauge, NY: Nova
construction. Semin Plast Surg 25:221, 2011. Science Publishers, 2014.
4. Monstrey S, Hoebeke P, Selvaggi G, et al. Pe- 12. Hu ZQ, Hyakusoku H, Gao JH, et al. Penis
nile reconstruction: is the radial forearm flap reconstruction using three different operative
really the standard technique? Plast Reconstr methods. Br J Plast Surg 58:487, 2005.
Surg 124:510, 2009. 13. Kim SK, Moon JB, Heo J, et al. A new
5. Song C, Wong M, Wong CH, et al. Modifi a- method of urethroplasty for prevention of
tions of the radial forearm flap phalloplasty fistula in female-to-male gender reassign-
for female-to-male gender reassignment. J ment surgery. Ann Plast Surg 64:759, 2010.
Reconstr Microsurg 27:115,2011. 14. Doornaert M, Hoebeke P, Ceulemans P, et al.
6. Salgado CJ, Moran S, Mardini S. Flap moni- Penile reconstruction with the radial forearm
toring/patient management. Plast Reconstr flap: an update. Handchir Mikrochir Plast
Surg 124(6 Suppl):e295, 2009. Chir 43:208, 2011.
7. Zhang YF, Liu CY, Qu CY, et al. Is vaginal 15. Monstrey S, Hoebeke P, Dhont M, et al.
mucosal graft the excellent substitute mate- Radial forearm phalloplasty: a review of 81
rial for urethral reconstruction in female- cases. Eur J Plast Surg 28:206, 2005.
to-male transsexuals? World J Urol 33:2115, 16. Mutaf M. Nonmicrosurgical use of the radial
2015. forearm flap for penile reconstruction. Plast
8. Selvaggi G, Hoebeke P, Ceulemans P, et al. Reconstr Surg 107:80, 2001.
Scrotal reconstruction in female-to-male 17. Lin CT, Chen LW. Using a free thoracodorsal
transsexuals: a novel scrotoplasty. Plast Re- artery perforator flap for phallic reconstruc-
constr Surg 123:1710, 2009. tion—a report of surgical technique. J Plast
9. Salgado CJ, Sinha V, Sanchez P, et al. Penile Reconstr Aesthet Surg 62:402, 2009.
scrotal and perineal anatomy. In Salgado CJ, 18. Felici N, Felici A. A new phalloplasty tech-
Redett R, eds. Aesthetic and Functional Sur- nique: the free anterolateral thigh flap phal-
gery of the Genitalia. Hauppauge, NY: Nova loplasty. J Plast Reconstr Aesthet Surg 59:153,
Science Publishers, 2014. 2006.
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19. Ceulemans P. The pedicled antero-lateral 22. Kim BS, Yoo JJ, Atala A. Engineering of hu-
thigh (ALT) perforator flap: a new technique man cartilage rods: potential application for
for phallic reconstruction. Presented at the penile prostheses. J Urol 168(4 Pt 2):1794,
XIX Biennial Symposium of the Harry Ben- 2002.
jamin International Gender Dysphoria Asso- 23. Nolazco G, Kovanecz I, Vernet D, et al. Effect
ciation (HBIGDA), Bologna, Italy, Apr 2005. of muscle-derived stem cells on the restora-
20. Chen KL, Eberli D, Yoo JJ, et al. Bioengi- tion of corpora cavernosa smooth muscle
neered corporal tissue for structural and and erectile function in the aged rat. BJU Int
functional restoration of the penis. Proc Natl 101:1156, 2008.
Acad Sci USA 107:3346, 2010. 24. Song YS, Lee HJ, Park IH, et al. Potential dif-
21. Yoo JJ, Park HJ, Lee I, et al. Autologous engi- ferentiation of human mesenchymal stem cell
neered cartilage rods for penile reconstruc- transplanted in rat corpus cavernosum to-
tion. J Urol 162(3 Pt 2):1119, 1999. ward endothelial or smooth muscle cells. Int
J Impot Res 19:378, 2007.
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CHAPTER
9
Anterolateral Thigh Flap Phalloplasty
Stan J. Monstrey, Salvatore D’Arpa,

Britt Colebunders, Nicolaas Lumen,
Piet Hoebeke
Key Points
❖❖ A pedicled anterolateral thigh flap can be a ❖❖ The flap is tunneled underneath the rectus
valuable alternative to a radial forearm flap femoris and sartorius muscles and then sub-
phalloplasty to avoid the typical scar in the cutaneously to reach the pubis. In rare cases a
forearm. short pedicle makes conversion to a free flap
❖❖ The flap is planned with the aid of preoperative necessary.
CT angiography to locate the best perforator. ❖❖ Urethral reconstruction can rarely be accom-
❖❖ Two nerves are always taken with the flap. One plished with the same flap, because the thigh
is sutured to an ilioinguinal nerve for restoration fat is too thick most of the time. A second skin
of protective sensation, and the other is su- flap is the best way to reconstruct the urethra.
tured to one of the dorsal clitoral nerves. ❖❖ A free radial forearm flap and pedicled super-
ficial circumflex iliac artery perforator are the
methods of choice for urethral reconstruction.
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The anterolateral thigh (ALT) flap was introduced as an alternative flap for phalloplasty in
2006 by Felici and Felici1 as a free flap and by Mutaf et al2 as a pedicled flap. Since then, 52
cases have been published to date,3-13 of which the largest series was 13 cases.14
The ALT flap phalloplasty was introduced as an alternative to the standard phalloplasty
technique: the radial forearm flap (RFF). The RFF is considered the method of choice for
several reasons:
1. No other flap has been used so extensively in phalloplasty; the RFF is the only flap
that has been proved effective and safe in large series.14,15
2. It is thin and pliable enough to allow a tube-within-a-tube reconstruction of a (skin-
lined) urethra with one flap, and even in large series patients managed to void while
standing in all cases.14
3. At least two sensory nerves can be included in the flap, and sensory innervation is of
good quality.
4. It effectively accommodates an erectile prosthesis, making satisfactory sexual inter-
course possible.16
5. The flap can be easily shaped to reproduce a penis.
6. Morbidity is acceptable.17
Despite all these advantages, there are reasons to look for an alternative technique. Phallo-
plasty with an RFF is a microsurgical operation that requires close postoperative monitor-
ing and potentially necessitates anastomotic revision, increasing the workload of an already
complex surgery. Furthermore, skin grafting of the donor site—covering a large part of the
forearm—is a well-known stigmata of the surgery that not all patients are willing to accept.
To avoid a forearm scar, many alternative techniques for phalloplasty have been described.
Sporadic reports with other types of free flaps such as the fibula flap,18-21 the latissimus
dorsi,22 the deltoid flap,23 and the thoracodorsal artery perforator flap24 can be found in the
literature. All these flaps share some common drawbacks:
❖❖ Urethral reconstruction is not performed or achieved with multiple flaps or
skin/mucosal grafts, which increase the risk of strictures and fistulas.
❖❖ Sensation is rarely restored or is of low quality, making implantation of an erectile
prosthesis less safe.
❖❖ It is difficult to shape the neophallus appropriately.
❖❖ Only small series are published, and subsequently the techniques cannot be stan-
dardized.
The only theoretical advantage of these other free flaps is the absence of the forearm scar,
but because the goal of surgery is to reconstruct a penis that is as functional and aesthetic
as possible, these various techniques thus far have not met either the standards or the qual-
ity of an RFF phalloplasty. Furthermore, the complexity of the procedure is not reduced,
because these are also microsurgical techniques.
To avoid the additional complexity of a microsurgical procedure, pedicled flap phalloplas-

ties have also been described with the use of abdominal skin,25 groin flaps,26 or gracilis
flaps.27 However, these techniques also share some of the previously mentioned drawbacks
regarding urethral reconstruction, decreased or absent sensation, less aesthetic appearance,
and a small nonstandardized series.
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The only advantages of these pedicled techniques are the avoidance of microsurgery and
forearm scar. Similar to the alternative free flap phalloplasties, these advantages come at
the expense of functionality, aesthetics, and reliability of the reconstructed penis, and for
these reasons they have never had a large consensus.
Taking all these factors into consideration, the ideal alternative to the RFF phalloplasty
should have the following characteristics:
❖❖ Be safe and reliable
❖❖ Allow reconstruction of an aesthetically acceptable phallus
❖❖ Allow reconstruction of a competent penile urethra with a single tube, minimizing
risks of strictures and fistulas so that patients are able to void while standing
❖❖ Be sensate and allow implantation of an erectile prostheses to have satisfactory sex-
ual intercourse
❖❖ Be pedicled to reduce the complexity of a free flap phalloplasty
❖❖ Have an acceptable or better concealed donor-site scar
The ALT flap seems a promising alternative to the RFF because:

❖❖ It is one of the most commonly used flaps and is safe and reliable.
❖❖ It can be shaped into an acceptable phallus.
❖❖ It can be reinnervated by branches of the lateral femoral cutaneous nerve.
❖❖ It lies close to the recipient site and can subsequently be used as a pedicled flap.
❖❖ The donor site can be concealed under men’s clothing.
Although it has all these positive qualities, the ALT phalloplasty has not gained popularity
so far, and at best only sporadic case reports or small series can be found in the literature.
The main reason is that urethral reconstruction in an ALT phalloplasty is not easy to ac-
complish, because the flap is seldom thin enough to reconstruct it with the tube-within-a-
tube technique. Only a few case reports have been published on how to solve this problem,
and most only have a short follow-up or report unclear outcomes regarding urinary func-
tion.1-13How to effici tly reconstruct the urethra when using an ALT flap is still unclear,
and this has greatly limited its application to patients in whom urethral reconstruction was
not needed, such as patients with bladder exstrophy. These patients usually have a perma-
nent urinary diversion. When these patients need urethral reconstruction, which are typi-
cally young male patients, the subcutaneous fatty layer of the thigh is often thin enough
to allow a urethral reconstruction with the tube-within-a-tube technique. Unfortunately,
these patients are only a small number of those seeking phalloplasties, because fortunately
bladder exstrophy is quite rare. The largest demand for phalloplasty is from female-to-male
transsexual patients seeking sex reassignment surgery (SRS). The difference between these
patients and biologic males seeking phallic reconstruction after bladder exstrophy or am-
putation is that female-to-male patients have withstood the influence of female hormones;
these patients have a gynoid habitus with thicker thighs. In this patient population urethral
reconstruction with the tube-within-a-tube technique is almost never possible with an ALT
flap because of excess flap thickness.
The fi st report of the lateral thigh as a donor site for phalloplasty was that of Santanelli and
Scuderi,28 who used a pedicled tensor fasciae latae (TFL) flap. Urethral reconstruction was
accomplished in three stages by (1) flap prelamination, (2) tissue expansion at the second
stage, and (3) fi ally flap transfer with tubing of the urethra. The outcomes of urethral re-
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CHAPTER 9
construction were unclear, and eventually only one patient maintained the reconstructed
urethra after 2 years. Th s technique has been used in five cases, and no further reports can
be found in the literature afterward. The reconstructed phallus lacked a glans and corona,
and thus although functionally acceptable, cosmetically it was not ideal. Furthermore, the
flap needed defatting of the pedicle in the groin, adding up to a total of four procedures.
Another increasing patient group are those who have previously undergone a phalloplasty
with or without urethral reconstruction and again request penile reconstruction of a shriv-
eled penis or after an inadequate phalloplasty. These patients can be ideal candidates for
an ALT phalloplasty.
The ALT phalloplasty seems the most promising alternative to the free RFF if an effective
way for urethral reconstruction is found. In this chapter we will describe the technique of
ALT flap phalloplasty and the different methods for reconstructing the urethra to accom-
plish an aesthetic and a functional penile construction.
Anatomy
The ALT flap is named based on its nourishing artery, the descending branch of the lateral
circumflex femoral artery (DBLCFA) perforator flap.29 Flaps such as the TFL perforator flap
can be harvested from the ALT, thus confusing the nomenclature. However, for the pur-
pose of simplicity and adherence to the most commonly used nomenclature, the DBLCFA
perforator flap will still be referred to as the ALT flap.
Perforators to the ALT flap originate at various distances from the DBLCFA, which travels
in the septum between the vastus lateralis and rectus femoris muscles and then lies on the
medial margin of the vastus lateralis,30,31 in close proximity to the motor nerve to the vastus
lateralis. It gives off, early after its origin, one or two short branches that nourish the rec-
tus femoris and cross its motor nerve. The anatomy of the DBLCFA perforators can vary
considerably; they are most frequently found in the middle third of the thigh, just lateral
to the intermuscular septum. Myocutaneous perforators are more commonly encountered
than septocutaneous perforators. The position of the perforator and its course influence
pedicle length: the more distal and lateral the perforator, the longer the pedicle. A septocu-
taneous perforator warrants a faster dissection, because it avoids intramuscular dissection,
ligation of several intramuscular branches, and identifi ation and preservation of small
intramuscular motor nerves. With free flaps the position of the perforator has little influ-
ence, because pedicle length has lesser importance, and a suitable perforator can always be
found by eventually switching to an anteromedial thigh flap32 or a TFL flap33 if no suitable
“ALT” perforator is found. When a pedicled flap is planned that should reach the pubic
area, pedicle length becomes of paramount importance. Because perforator anatomy is un-
predictable, accurate preoperative perforator localization is mandatory to plan these flaps.
Sensory nerves to the lateral thigh skin come from the lateral femoral cutaneous nerve,
and like anywhere else in the body, they constantly run across the largest perforators that
nourish them on their course to the skin. Th s implies that in a conventional freestyle ALT
flap, the nerves can guide the surgeon to the best perforator; in an ALT flap phalloplasty,
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in which the best perforator is determined before surgery by CT angiography, the nerves
will be found running close to the perforator. The main nerve branches usually run in the
loose plane between the fascia and subscarpal fat and are accompanied by large perineural
vessels, branches of the perforator, throughout their whole length.34 Sometimes only one
large nerve is found. In these cases the two fascicles of the nerve are separated to obtain
two branches for nerve coaptation.
The skin of the ALT is thicker than that of the forearm. The skin usually has hair, and mainly
the subcutaneous fat is much thicker and divided in two layers by Scarpa fascia; several
vertical septa are needed to hold the skin and fat against gravity, making it more rigid and
less pliable compared with a forearm flap.
Preoperative Planning
There are various perforators nourishing the lateral thigh skin coming from the DBLCFA
that travel either through the muscle or septum and reach the skin at different levels on
the thigh. As previously mentioned, their position is unpredictable. With a free flap, a ret-
rograde freestyle approach can be used.35 After simple preoperative Doppler localization,
the perforators are identifi d through an exploratory incision; the best one is chosen dur-
ing surgery and further dissected out until its source vessel is reached. The dissection of an
ALT free flap does not require preoperative knowledge of the best perforator, which side
has the best perforator, which perforator is septocutaneous, and pedicle length, but with a
pedicled flap, all these details are fundamental.
In pedicled ALT flap phalloplasty, this freestyle retrograde approach, in which there is no
information on position, course, and pedicle length of the perforator, is not advisable, be-
cause there is a risk that the wrong side was chosen, the best perforator or a septocutaneous
perforator was missed, or eventually the pedicle is too short. Preoperative CT angiography
is needed to investigate perforator anatomy of both thighs to identify the “best” perforator,
which is a big perforator (not necessarily the biggest), long enough to comfortably reach the
pubic area without undue traction, and preferably a septocutaneous perforator or one with
a short intramuscular course. Furthermore, as mentioned previously, the accurate choice
of the perforators guarantees that the sensory nerves lie in close proximity. We have started
using a CT scan after we encountered problems in a patient in whom, after preoperative
tissue expansion of the thigh at the time of surgery, we found no perforators to harvest an
ALT. We had to stop the operation and change the surgical plan; we performed an RFF
phalloplasty 2 weeks later. The additional benefit of CT angiography is that it also allows
measurement of flap thickness to estimate the circumference of the neophallus and subse-
quently the required flap dimensions. Preoperative perforator location becomes especially
useful when preoperative expansion with a medial and lateral expander is planned. In these
cases an exact location of the best-suited perforator is an absolute requirement. Recently
noncontrast MRI has been introduced for preoperative perforator mapping.36
The point where the perforator pierces the fascia will be measured starting from the line
connecting the anterior superior iliac spine (ASIS) and the upper lateral angle of the patella.
Th s line corresponds to the septum between the rectus femoris and vastus lateralis muscles.
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Patient Preparation
No specific patient preparation is needed for the actual phalloplasty.
Preoperative CT angiography is absolutely necessary for perforator location, as discussed

previously, and is obtained before surgery for two reasons:
1. Complete flap epilation is ideally completed before surgery. If this is not possible,
at least the urethral part (for tube-within-a-tube phalloplasties) of the flap will be
hairless. When urethral reconstruction is not planned, the outer part of the flap can
undergo defin tive epilation after surgery. The part that must undergo epilation can
be decided only after the perforator is chosen with the CT scan.
2. If preoperative expansion is planned to avoid skin grafting of the donor site, CT an-
giography is performed fi st to locate the perforator. Two expanders are then placed
in the suprafascial plane at the lateral and medial borders of the flap. The skin lateral
and medial to the flap, not the actual flap, is expanded so that the flap and the perfo-
rator are not affected by expansion. To accomplish this, the surgeon must know the
exact perforator location and flap size based on the measurements obtained from the
CT angiogram.
Perioperative antibiotic prophylaxis is administered starting on the day of surgery.37
Preoperative Markings
The ASIS is marked on the chosen side, and a line is drawn that connects it to the upper lat-
eral angle of the patella. The position of the perforator is marked precisely on the thigh skin
based on the X and Y coordinates provided by the CT scan, and the flap is drawn around it
with the perforator lying along its midline axis and close to its proximal border (Fig. 9-1).
The length of the flap is usually 14 cm. The width is determined based on flap thickness as
measured on the CT scan. Because the reconstructed phallus can be considered a cylinder,
with its cross-section a circumference, the estimated outer circumference, which corre-
sponds to the transverse axis of the flap, can be calculated with the following formula: 2πr,
where r corresponds to thickness of the ALT flap in millimeters as measured on the CT
scan plus the thickness of the planned urethra in millimeters plus 5 (this latter to compen-
sate for the presence of the urinary catheter and postoperative edema). Th s means that a
20 mm thick ALT combined with a 5 mm thick superfic al circumflex iliac artery perfora-
tor (SCIAP) (see Fig. 9-1) will be
2 × 3.14 × (20 + 5 + 5) = 188.4 mm
wide. If these rules are not respected, closure may be too tight, and a ventral skin graft will
be needed to avoid flap compression. It is not infrequent that the flap is wider than it is long.
Th s can potentially mislead the surgeon, who may tend to think that the longer side is the
longitudinal axis, thus causing rotation and malpositioning of the flap. The nerves always
allow correct flap orientation, because they always enter the flap from the proximal side.
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Fig. 9-1 Preoperative markings of an ALT/SCIAP phalloplasty. The ALT is drawn based on the CT angi-
ographic findings, with the perforator placed on the proximal edge of the flap and approximately along
its midline. The SCIAP is drawn along the iliac crest. This latter marking frequently leads to intraopera-
tive adjustment after the required pedicle length is known.
Surgical Technique
The patient lies in the supine position. The proximal margin of the flap is incised first to
the level of Scarpa fascia. In the plane between the subscarpal fat and deep fascia, the sen-
sory nerves, branches of the lateral femoral cutaneous nerve are identifi d. Two nerves are
needed, and the best ones are located close to the midline of the flap and subsequently to
the perforator. Because the nerves usually run deep in the flap, the flap cannot be thinned
in the area in which the nerves run. If the nerves are located close to the midline, the flap
can be thinned in the periphery. After the two nerves are identifi d, the skin is incised
proximally toward the groin to allow pedicle exposure and creation of the tunnels. The skin
flaps are elevated, and the nerves are harvested as long as possible. The nerves will only be
shortened at the end, after flap transfer. After the nerves are harvested, they are marked in
blue to allow easier identifi ation later on, and they are kept on the proximal margin of the
flap and moistened throughout the whole procedure.
At this point the lateral margin and lateral half of the distal margin are incised to the level
of the dermis. To thin the flap, the dissection continues in the subdermal plane, leaving ap-
proximately 5 mm of fat below the dermis, until the most lateral nerve is reached and not
closer than 3 cm from the perforator. At this point the dissection is deepened to the supra-
fascial layer, and the flap is elevated until the perforator is identifi d.
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Subsequently, the hole in the fascia through which the perforator comes out is widened
proximally and distally to expose the subfascial perforator course. If the perforator runs in-
tramuscularly, minor motor branches that cross it on its medial side may occasionally need
to be divided. In this case it is better to resuture them immediately. Dissection is carried
out until the vascular pedicle for the rectus femoris muscle is reached, close to the origin of
the descending branch from the lateral circumflex femoral artery itself. The branch for the
rectus femoris can usually be spared. If additional pedicle length is needed, it occasionally
must be sacrific d. Sometimes two branches are found going to the rectus femoris muscle
that can similarly be spared or sacrific d, depending on the pedicle length needed. The
nerve to the rectus femoris muscle is always spared.
After the dissection of the perforator is completed, the rest of the flap is incised and elevated
as previously described. A tunnel underneath the rectus femoris and sartorius muscle is
created. Medial to the sartorius the tunnel becomes subcutaneous and reaches the pubic
area. The tunnel should be wide enough to allow easy passage of the flap and then accom-
modate the pedicle without any tension or compression, compensating for postoperative
swelling and allowing visualization of the entire pedicle to check it before the end of surgery.
At this point hemostasis and flap perfusion are checked. The two distal corners of the flap
are temporarily sutured together with a Vicryl 0 suture to cone the flap for easier tunnel-
ing. The suture is left l ng to allow pulling on the flap during passage through the tunnel.
While the assistant pulls on the muscle or skin with a retractor to hold the tunnel open, the
surgeon holds the flap with one hand and gently pulls on the suture with the other hand.
Th s movement is gentle and a careful combination of gentle pull with the suture and push-
ing the flap with the other hand. With the aid of some sterile gel, the flap is tunneled to its
recipient site; the surgeon is careful not to injure the motor nerves to the vastus lateralis,
intermedius, and rectus femoris muscles. The surgeon must also be careful not to pull on the
sensory nerves to the flap. Tunneling is not done all at once but step by step: fi st through
the vastus lateralis if the perforator was myocutaneous, then underneath the rectus femoris,
next underneath the sartorius muscle, and fi ally through the subcutaneous tunnel. During
tunneling, the pedicle and sensory nerves will always be under vision. With this maneuver,
the flap is not rotated to avoid torsion of the pedicle.
After the flap has reached the recipient site, the pedicle is checked once again to rule out
torsion, kinking, traction, or compression, and vascularity is ultimately checked. At this
point the flap is sutured around the urethral flap or closed on itself if the flap is prelami-
nated, if a tube-within-a-tube procedure is planned, or if no urethral reconstruction is
needed. The sensory nerves are sutured to one of the ilioinguinal nerves and to one of the
dorsal clitoral nerves.
A coronaplasty is always staged and usually performed 7 days after the fi st surgery, which
is different from RFF phalloplasty and is a result of the differences in flap vascularization
between the ALT and RFF. Although the RFF has multiple perforators reaching the skin
from the axial radial artery and the dermis can be divided between them, creating mul-
tiple skin islands, the ALT has only one perforator reaching the skin and relies totally on
the subdermal plexus originating from it. A coronaplasty may theoretically increase the
risk of distal necrosis, which is why we prefer to stage the coronaplasty after 7 to 10 days.
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Urethral Reconstruction
The importance of urethral reconstruction should never be underestimated. The ability to
void while standing is a very distinctive male feature, and in patients who have lost this abil-
ity or who have never had a penis, this often becomes the single most important factor for
considering a phalloplasty.14 In this section we will discuss the best procedures for urethral
reconstruction, the advantages and disadvantages of each technique, and how we arrived
at our current methods of choice (SCIAP or RFF urethral reconstruction).
Tube-Within-a-Tube Technique
The tube-within-a-tube technique is the simplest and best way to reconstruct a urethral
tube, similar to a skin-lined urethral reconstruction in a free RFF phalloplasty. Unfortu-
nately most of the time, especially in SRS, it cannot be performed because of excess flap
thickness. Th s technique is only feasible when the subcutaneous fat of the thigh and sub-
sequently the flap is very thin, which often occurs in biologic (young) males after bladder
exstrophy but is only very rarely encountered in (biologic female) transmen who undergo
SRS. In these patients, a thick ALT cannot be thinned like in other reconstructive proce-
dures, because the nerves lie on the deep surface of the flap and thinning would jeopardize
sensation.
If the tube-within-a-tube technique is feasible, the flap is designed similar to a conventional

free RFF phalloplasty, with a longer and narrower skin island for urethral reconstruction
lying medially and a shorter and broader skin island for the outside lining, separated by a
narrow deepithelized strip of skin.
Tissue Expansion
As previously discussed, because a thick ALT cannot be radically thinned when sensation
must be maintained, tissue expansion was initially used in an attempt to decrease the thick-
ness of the flap. Th s attempt failed, because the expanders had to be placed in the periphery
of the flap at a distance from the perforator to prevent damage to it. With expansion, some
limited thinning was achieved at the edges of the flap, but the remaining fat was squeezed
in the middle toward the perforator, counterbalancing the peripheral thinning with a cen-
tral thickening of the flap and making the little thinning obtained useless. Today we use
tissue expansion outside the flap’s area as a way to allow primary closure of the flap’s donor
site. After CT angiography has been obtained and the perforator located, the flap is drawn
on the patient’s thigh, and two rectangular tissue expanders are placed just laterally and
medially to the flap margins. During the following weeks and months, the expanders are
gradually inflated. After a minimum of 4 months from completion of expansion, a phal-
loplasty is performed, and the donor site is closed with the expanded skin flaps instead of
a skin graft. This confers the double benefit of avoiding the depression and patch effect of
a skin graft at the ALT donor site and a second donor site for the skin graft. When the de-
pression persists, fat grafting can be used to improve contour.
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Flap Prelamination
Flap prelamination involves creating an inner lining on the deep surface of the flap with a
skin graft. After the skin graft has taken, the flap is raised, and the skin graft is tubed inside
of it to create the neourethra. Initially we used a full-thickness skin graft (FTSG), which
was tubed inside to create the neourethra. The FTSG (usually taken from the groin) was
sutured around a wide silicone tube and introduced between the flap and deep fascia. After
3 months the flap was elevated and phalloplasty was performed. Despite the use of FTSGs,
fistulas and strictures complicated this procedure, and it was abandoned in favor of wider
sleeve prefabrication with a split-thickness skin graft (STSG). The STSG was used as follows:
After CT planning of the flap and marking on the skin, one side of the flap (medially) was
lifted, and a 7 cm wide STSG was sutured to the undersurface of the flap and to the bot-
tom on the muscle fascia. The flap was then put back in place, creating a wide skin-grafted
sleeve that could easily be cleansed and inspected through the (wide) proximal and distal
opening. Th ee to 6 months later, the flap was harvested and transferred as one single tube
with a skin-grafted neourethra inside and thigh skin on the outside. Although a rather wide
urethra could be reconstructed with this technique, the quality of the (grafted) skin inside
the urethra was not as good as with a tube-within-a-tube RFF.
Currently the indications for urethral reconstruction with a skin graft are limited to cases
for which no other option is available.
Peritoneal Flap
Another attempt at urethral reconstruction was inspired by the potentially interesting peri-
toneal flap described by Winters et al.38 Th s flap can be harvested based on the deep infe-
rior epigastric vessels, the well-known pedicle of the deep inferior epigastric artery perfora-
tor flap, and it is easily transferred to the pubis. The serosal nature of the peritoneal lining
seemed ideal because of the like-with-like replacement of the mucosal lining of a urethra.
However, despite the theoretical advantages of this flap, this technique failed, because the
peritoneal flap easily collapsed, and the two surfaces adhered, eventually resulting in an
obliteration of the urethra after catheter removal.39
Narrow Free Radial Forearm Flap

As mentioned previously, the RFF has proved to be the safest and most effective flap for
phalloplasty. Outcomes of urethral reconstruction are well known and unparalleled to date
with any other flap. When the RFF is used for urethral reconstruction alone, just a narrow
strip is harvested on the palmar side of the forearm. The residual scar is much less con-
spicuous and better concealed for two reasons. First, the forearm is usually pronated, and
the palmar side mostly faces downward. Second, the glabrous region is already grafted, and
thus the skin graft is less evident than when placed in a hairy region of skin.
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A narrow radial strip is harvested in the radial forearm, 4 cm wide and 16 cm long. Usu-
ally one nerve is included and used for sensory coaptation with an ilioinguinal nerve. Ex-
ceedingly hairy forearms need preoperative epilation. The flap is anastomosed to the ves-
sels contralateral to the ALT: end-to-side to the femoral artery or end-to-end to one of its
branches and the vein end-to-end to the great saphenous vein as in an RFF phalloplasty.
The advantage of this technique is that it provides the safest and most effective urethral
reconstruction, similar to a free RFF without the distinctive scar in the forearm. The dis-
advantage is that it adds complexity to the procedure, because a free flap and pedicled per-
forator flap must be performed.
Previous Inadequate Phalloplasty

A new emerging population is seeking phalloplasty surgery with increasing frequency. This
population is made up of patients with a shriveled phalloplasty caused by atrophy of the
subcutaneous fat or with an inadequate phalloplasty, that is, nonsensate and nonfunctional
phalloplasties (for example, a single-tube groin flap phalloplasty).40
In many patients, suffici t skin of good quality covering the outside of an inadequate
phallus is present and can be used to reconstruct the new urethra by raising it as a laterally
and medially (or even distally) based flap and tubing it to reconstruct the penile urethra.
Th s reconstructed urethra is then covered with the ALT flap wrapped around it as a tube.
Superficial Circumflex Iliac Artery Perforator Flap

The SCIAP flap is gaining increasing popularity in many fi lds of reconstructive microsur-
gery, because it is always very thin, glabrous, and allows primary donor-site closure in a
very well-concealed area. It has been described for nonsensate phalloplasty by Koshima et
al41 as a pedicled flap and may become our first choice for urethral reconstruction in com-
bination with an ALT flap.
Th s flap is based on perforators of the superfic al circumflex liac artery, a branch of the
femoral artery that travels upward and laterally toward the ASIS, parallel to the inguinal
ligament.
The perforator is usually located approximately at the level of the ASIS. The flap is then
drawn with its axis lying along the iliac crest. A V-shaped proximal end is drawn to elongate
the urethral suture line, increasing circumference to compensate retraction and prevent
strictures (see Fig. 9-1). The distal tip can also be V-shaped to widen the external urethral
meatus, but this is usually not necessary. The proximal end of the flap lies over the perfora-
tor. The pedicle usually travels from the femoral vessels to the ASIS. A line is drawn con-
necting them, and the position can be confi med with a handheld Doppler probe. Th s line
is the exploratory incision, done right over the pedicle. The pedicle is isolated underneath
Scarpa fascia and dissected proximally and distally before the flap is incised.
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A wide space for pedicle tunneling is created between the femoral vessels and recipient ure-
thra. The pedicle is carefully dissected to its origin, preserving a superfic al vein for drainage
if needed, which sometimes serves the flap better than the venae comitantes. The last part
of the dissection is always tricky, but the pedicle must be isolated until its origin is reached,
because every millimeter is important to allow tensionless transfer.
After the whole pedicle is dissected, the length needed is measured, and pedicle dissection
proceeds distally at a subdermal level until the desired length is reached. The pedicle gives
off everal branches to the skin and the most distal is chosen. After an adequate length is
reached, the drawing is checked or redone according to the perforator position. The per-
forator is kept at the medial edge of the flap (Fig. 9-2, A).
In rare cases the pedicle ends up being too short, and the flap must be converted to a free
flap (Fig. 9-2, B). The superfic al epigastric vein needs to be routinely divided. Lymph nodes
in this area lie in close proximity to the pedicle, and sometimes, especially if enlarged, they
can be difficult to separate from it. Vascular branches to the lymph nodes must be identi-
fied and ligated before division. If dissection is difficult, it is preferable to take the lymph
nodes with the flap rather than risking damage to a very delicate pedicle.
After pedicle dissection is completed and the flap is isolated, perfusion is checked. The flap
is tubed with simple dermal-only Vicryl 3-0 sutures and then a continuous subcuticular
suture again with Vicryl 3-0 sutures. If needed, the flap can be thinned before tubing almost
to the subdermal level with the help of loupe magnifi ation to avoid damage to the pedicle.
At this point the flap is transferred, the urinary catheter is passed inside of it, and the flap
is sutured to the pars fixa of the urethra with dermal-only bites (Fig. 9-2, C). The ALT (Fig.
9-2, D) is tunneled and wrapped around the flap (Fig. 9-2, E). After nerve anastomoses are
performed (Fig. 9-2, F), the wound is closed (Fig. 9-2, G and H), and coronaplasty is de-
layed after 1 week (Fig. 9-2, I).
A B
Fig. 9-2 A, The SCIAP flap is isolated and vascularity is checked. A superficial vein can be seen lying
above the green background. B, Before tubing, the flap’s arc of rotation is checked. If there is any ten-
sion, it is better to convert the flap to a free flap, because with postoperative swelling, the pedicle may
be stretched and vascularity impaired.
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CHAPTER 9
C D
E F
Fig. 9-2, cont'd C, The SCIAP is tubed and transferred and urethral anastomosis is performed. A Pen-
rose drain is left in the groin, but a suction drain can also be safely placed laterally, far from the pedicle.
Meanwhile, the ALT flap is raised. D, The left ALT pedicle is dissected free from the muscle, and the
nerves are left intact. The flap will pass through the vastus lateralis without interrupting muscle continu-
ity and then underneath the rectus femoris (held by the retractor), sartorius, and afterward subcutane-
ously. E, After the ALT flap is tunneled, the pedicle is checked for torsion or rotation. If tension is sus-
pected, conversion to a free flap can be considered. F, The two sensory nerves taken with the flap are
sutured to one ilioinguinal nerve and one dorsal clitoral nerve (green backgrounds).
Continued
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CHAPTER 9
G H
Fig. 9-2, cont'd G, The ALT flap is eventu-

ally tubed around the SCIAP. Coronaplasty is
staged. H, Closure is obtained without any ten-
sion. If there is any doubt, the sutures are re-
leased, and a skin graft should be used to relieve
the tension. I, The results are shown 1 year after
surgery.
Final Considerations and Future Perspectives

Construction of an aesthetic and functional penis is a challenge for reconstructive surgeons.
There is no donor tissue with similar features in the body, and the cosmetic and functional
requisites are extremely high. A functioning urethra is needed for unhindered voiding while
standing, the phallus must be sensate to allow safe implantation of an erectile device and
erogenous stimulation, and fi ally the patient needs an acceptable aesthetic appearance.
The standard RFF phalloplasty seems to be the technique that meets most of these goals.
Dissatisfaction with the appearance of the donor site on the arm has lead us to seek an al-
ternative technique that provides results comparable with the RFF and possibly avoid the
need for microsurgery to make this technique usable by nonmicrosurgeons. This latter as-
pect must also be considered, because the request for phalloplasty procedures is steadily
increasing, and worldwide many centers are beginning to perform phalloplasties.
The fi ld of phalloplasty is in continuous development, and improvement must always be

pursued to offer these long-suffering patients a penis that is as close to normal as possible.
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References
1. Felici N, Felici A. A new phalloplasty tech- lateral thigh flap for total phalloplasty: the
nique: the free anterolateral thigh flap phal- mushroom flap. Ann Plast Surg 72(Suppl
loplasty. J Plast Reconstr Aesth Surg 59:153, 1):S22, 2014.
2006. 14. Monstrey S, Hoebeke P, Selvaggi G, et al. Pe-
2. Mutaf M, Isik D, Bulut O, et al. A true one- nile reconstruction: is the radial forearm flap
stage nonmicrosurgical technique for to- really the standard technique? Plast Reconstr
tal phallic reconstruction. Ann Plast Surg Surg 124:510, 2009.
57:100, 2006. 15. Baumeister S, Sohn M, Domke C, et al.
3. Lumen N, Monstrey S, Selvaggi G, et al. Phal- [Phalloplasty in female-to-male transsexuals:
loplasty: a valuable treatment for males with experience from 259 cases] Handchir Mikro-
penile insuffici cy. Urology 71:272, 2008. chir Plast Chir 43:215, 2011.
4. Lumen N, Monstrey S, Ceulemans P, et al. 16. Hoebeke P, de Cuypere G, Ceulemans P, et al.
Reconstructive surgery for severe penile Obtaining rigidity in total phalloplasty: expe-
inadequacy: phalloplasty with a free radial rience with 35 patients. J Urol 169:221, 2003.
forearm flap or a pedicled anterolateral thigh 17. Selvaggi G, Monstrey S, Hoebeke P, et al.
flap. Adv Urol 2008:704343, 2008. Donor site morbidity of the radial forearm
5. Descamps MJ, Hayes PM, Hudson DA. Phal- free flap after 125 phalloplasties in gen-
loplasty in complete aphallia: pedicled an- der identity disorder. Plast Reconstr Surg
terolateral thigh flap. Plast Reconstr Aesthet 118:1171, 2007.
Surg 62:e51, 2009. 18. Sengezer M, Ozturk S, Deveci M, et al. Long-
6. Lee GK, Lim AF, Bird ET. A novel single-flap term follow-up of total penile reconstruction
technique for total penile reconstruction: the with sensate osteocutaneous free fibula flap
pedicled anterolateral thigh flap. Plast Recon- in 18 biological male patients. Plast Reconstr
str Surg 124:163, 2009. Surg 114:439, 2004.
7. Rubino C, Figus A, Dessy LA, et al. Inner- 19. Hage JJ, Winters HA, Van Lieshout J. Fibula
vated island pedicled anterolateral thigh flap free flap phalloplasty: modifi ations and
for neo-phallic reconstruction in female-to- recommendations. Microsurgery 17:358,
male transsexuals. J Plast Reconstr Aesthet 1996.
Surg 62:e45, 2009. 20. Schaff J, Papadopulos NA. A new protocol for
8. Rashid M, Aslam A, Malik S, et al. Clini- complete phalloplasty with free sensate and
cal applications of the pedicled anterolateral prelaminated osteofasciocutaneous flaps: ex-
thigh flap in penile reconstruction. J Plast perience in 37 patients. Microsurgery 29:413,
Reconstr Aesthet Surg 64:1075, 2011. 2009.
9. Sinove Y, Kyriopoulos E, Ceulemans P, et al. 21. Sadove RC, Sengezer M, McRobert JW, et al.
Preoperative planning of a pedicled antero- One-stage total penile reconstruction with a
lateral thigh (ALT) flap for penile reconstruc- free sensate osteocutaneous fibula flap. Plast
tion with the multidetector CT scan. Hand- Reconstr Surg 92:1314, 1993.
chir Mikrochir Plast Chir 45:217, 2013. 22. Vesely J, Hyza P, Ranno R, et al. New tech-
10. Liu CY, Wei ZR, Jiang H, et al. Preconstruc- nique of total phalloplasty with reinnervated
tion of the pars pendulans urethrae for latissimus dorsi myocutaneous free flap in
phalloplasty with digestive mucosa using female-to-male transsexuals. Ann Plast Surg
a prefabricated anterolateral thigh flap in a 58:544, 2007.
one-arm patient. Plast Reconstr Surg Glob 23. Harashima T, Ionque T, Tanaka I, et al. Re-
Open 1:e53, 2013. construction of penis with free deltoid flap.
11. Holzbach T, Giunta RE, Machens HG, et Br J Plast Surg 43:217, 1990.
al. [Phalloplasty with pedicled anterolateral 24. Lin CT, Chen LW. Using a free thoracodorsal
thigh flap (“ALT-Flap”)] Handchir Mikrochir artery perforator flap for phallic reconstruc-
Plast Chir 43:227, 2011. tion—a report of surgical technique. J Plast
12. Hasegawa K, Namba Y, Kimata Y. Phallo- Reconstr Aesthet Surg 62:402, 2009.
plasty with an innervated island pedicled 25. Hage JJ, Bouman FG, de Graaf FH, et al.
anterolateral thigh flap in a female-to-male Construction of the neophallus in female-to-
transsexual. Acta Med Okayama 67:325, 2013. male transsexuals: the Amsterdam experi-
13. Morrison SD, Son J, Song J, et al. Modifi a- ence. J Urol 149:1463, 1993.
tion of the tube-in-tube pedicled antero-
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26. Koshima I, Nanba Y, Nagai A, et al. Penile 34. D’Arpa S, Claes KE, Stillaert F, et al. Vascu-
reconstruction with bilateral superfic al cir- larized nerve “graft ”: just a graft or a worth-
cumflex iliac artery perforator (SCIP) flaps. J while procedure? Plast Aesthet Res 2:183,
Reconstr Microsurg 22:137, 2006. 2015.
27. Kolehmainen M, Suominen S. Functional 35. Wei FC, Mardini S. Free-style free flaps. Plast
phalloplasty? Pyrenean Lodge in Plastic Sur- Reconstr Surg 114:910, 2004.
gery, Kitzbühel, Austria, Jan 28, 2011. 36. Masia J, Navarro C, Clavero JA, et al. Non-
28. Santanelli F, Scuderi N. Neophalloplasty in contrast magnetic resonance imaging for
female-to-male transsexuals with the island preoperative perforator mapping. Clin Plast
tensor fasciae latae flap. Plast Reconstr Surg Surg 38:253, 2011.
105:1990, 2000. 37. Toia F, D’Arpa S, Massenti MF, et al. Periop-
29. Blondeel PN, Van Landuyt KH, Monstrey SJ, erative antibiotic prophylaxis in plastic sur-
et al. The “Gent” consensus on perforator flap gery: a prospective study of 1,100 adult pa-
terminology: preliminary defin tions. Plast tients. J Plast Reconstr Aesthet Surg 65:601,
Reconstr Surg 111:13 78; discussion 1384, 2003. 2012.
30. Toia F, D’Arpa S, Brenner E, et al. Segmental 38. Winters HA, Bouman MB, Boom F, et al. The
anatomy of the vastus lateralis: guidelines for peritoneal free flap: an anatomic study. Plast
muscle-sparing flap harvest. Plast Reconstr Reconstr Surg 100:1168, 1997.
Surg 135:185e, 2015. 39. Hage JJ, Winters HA, Kuiper IA. The super-
31. Cordova A, D’Arpa S, Di Lorenzo S, et al. thin peritoneum free flap: not to be used for
Prophylactic chimera anterolateral thigh/ urethra reconstruction. Plast Reconstr Surg
vastus lateralis flap: preventing complications 100:1613, 1997.
in high-risk head and neck reconstruction. 40. Bluebond-Langner R, Redett RJ. Phalloplasty
J Oral Maxillofac Surg 72:1013, 2014. in complete aphallia and ambiguous genita-
32. Yu P. Inverse relationship of the anterolateral lia. Semin Plast Surg 25:196, 2011.
and anteromedial thigh flap perforator anat- 41. Koshima I, Nanba Y, Nagai A, et al. Penile
omy. J Reconstr Microsurg 30:463, 2014. reconstruction with bilateral superfic al cir-
33. Contedini F, Negosanti L, Pinto V, et al. Ten- cumflex iliac artery perforator (SCIP) flaps. J
sor fascia latae perforator flap: an alternative Reconstr Microsurg 22:137, 2006.
reconstructive choice for anterolateral thigh
flap when no sizable skin perforator is avail-
able. Indian J Plast Surg 46:55, 2013.
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CHAPTER 9
Expert Commentary: Anterolateral Thigh Flap Phalloplasty
EXPERT COMMENTARY

Curtis Crane, Klara Sputova
A variety of flaps are available for gender reassignment surgery in female-to-male (FTM)
transgender patients. Therefore both the specific psychological implications and the patient’s
demands must be considered when making a donor-site choice. Many patients who are not
open about being transgender fear that the radial forearm donor-site scar will “brand” them
as a free flap phalloplasty recipient. Thus some prefer the anterolateral thigh (ALT) phallo-
plasty compared with that of the radial forearm because of the less obvious donor-site scar
on the leg. In addition, some patients may choose the ALT flap because they prefer a phallus
length that cannot be achieved with the radial forearm flap. Regardless of the reason, in our
practice, of 175 phalloplasties, approximately 30% of the patients chose the ALT donor site.
One drawback of the ALT donor site is the amount of adipose tissue in the thigh. Although
taking testosterone, many patients still carry a female body habitus and have more fat in
their medial and lateral thighs than in the truncal region. As a result, the ALT phallus has
a substantial girth. To include branches of the lateral femoral cutaneous nerve and appro-
priately identify the septal or intramuscular perforators of the descending branch of the lat-
eral circumflex femoral artery, the dissection plane is typically just superfic al to the rectus
femoris and vastus lateralis fascia and includes all subcutaneous adipose of the thigh. When
a urethra is included in the flap, the tissue must be folded over itself four times. As a result,
small increases in flap thickness exponentially increase the circumference of the phallus.
The best way to estimate the circumference of the ALT phallus is by measuring the thigh
skinfold pinch thickness. The pinch test involves the patient’s extending his lower leg to fle
the quadriceps muscles, and the examiner pinches the skin and subcutaneous fat over the
vastus lateralis and rectus femoris muscles. It is important to consider not only the pinch
thickness but also adipose density. Some patients have less-dense adipose tissue that is more
easily compressible, making it easier to fold a urethra within the phallus compared with
patients with dense, fi m subcutaneous fat. The ideal patient has a thigh skin pinch thick-
ness of less than a few centimeters with very soft, compressible adipose tissue.
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However, even in this ideal situation, the phallus will likely have a circumference of greater
than 6.5 inches. It is possible to thin the flap medially and laterally, superfic al to Scarpa
fascia. Any central thinning in the area of the lateral femoral cutaneous nerve could jeop-
ardize sensation to the flap or damage the perforator artery, thus causing flap necrosis. Pa-
tients who still desire a smaller girth can undergo liposuction of the phallus but no earlier
than 3 months after phalloplasty. On occasion, it is necessary to skin graft he base of the
phallus, if primary closure increases the risk of venous congestion. Unfortunately, if skin
grafting is necessary, there is a much higher rate of fistula formation.
Furthermore, hair removal from the ALT flap is required before surgery. Permanent meth-
ods of hair removal such as electrolysis and/or laser therapy are preferred, because part of
the donor site becomes the urethra and should be initiated at least 6 to 12 months before
surgery. However, despite preoperative hair removal, some men may require additional hair
removal after surgery for cosmetic reasons. It is very difficult to perform laser hair removal
in the urethra after surgery.
Some centers advocate the use of the radial forearm flap to construct the urethra within
the ALT flap. The skin and adipose tissue of the forearm are much thinner than that of the
thigh. However, patients must be able to tolerate the 3 to 4 cm skin graft on the ventral
forearm, because we have not found that the defect can be closed primarily. Another option
is to delay the urethral reconstruction either as a two-stage Johanson urethroplasty with
buccal mucosa or a full-thickness skin graft r with open flap thinning at least 3 months
after surgery.
The larger girth of the ALT phallus allows placement of both cylinders of either the inflat-
able or semirigid penile implant. Not only does the girth accommodate both cylinders,
but the patient will fi d it necessary for rigidity, given the larger fat content of the flap. Pa-
tients who choose ALT phalloplasty because they prefer an exceptionally long phallus must
be counseled that their desired length may exceed standard implant sizes. The cylinders
should be placed in two separate dissection planes to limit cylinder contact, friction, and
premature breakdown of the prosthesis. Urethral perforation is easier to avoid than with
ALT phalloplasty because of the larger girth.
In our practice we have noticed a similar urethral stricture rate between 10% and 12% in
both the radial forearm and ALT phalloplasties. However, the urethral fistula rate approxi-
mately doubles for the ALT (20%) compared with the radial forearm (10%) flap. Th s is
likely the result of ischemia and fat necrosis in the ALT flap, with a higher volume of adi-
pose tissue. Infection, hematoma, necrosis, and partial loss have similar rates between the
radial forearm and ALT phalloplasties. At this point we have not experienced total flap loss
with either technique.
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The following are examples of FTM transgender patients who have chosen to pursue ALT
phalloplasty.
Th s 38-year-old FTM patient (Fig. 9-3) had undergone a hysterectomy and simple mastec-
tomy as a chest masculinizing procedure, had been on testosterone for several years, and
had the support of his mental health team. His BMI was 26, and his pinch test revealed ap-
proximately 2 cm of tissue superfic al to his vastus lateralis. A vaginectomy was performed
in one stage in conjunction with scrotoplasty, urethral lengthening, suprapubic tube place-
ment, and ALT phalloplasty. The donor site was covered with a split-thickness skin graft
and a wound vacuum was applied. The patient recovered without incident and will be
scheduled for glansplasty and penile and testicular implant in 9 months.
Fig. 9-4 shows another patient 6 months after glansplasty.
Fig. 9-3 ALT phalloplasty with one-stage

urethral reconstruction before glansplasty.
Fig. 9-4 Six months after glansplasty in a pa-

tient receiving ALT phalloplasty.
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CHAPTER 9
B C
Fig. 9-5 A, ALT flap donor-site scar with the implanted tissue expander. B, Perioperatively, excision of
the skin graft scar and advancement of expanded tissue. C, Postoperatively, excision of 50% of the skin
graft scar and advancement of expanded tissue.
Th s 31-year-old FTM patient (Fig. 9-5) had right ALT phalloplasty. The patient disliked the
appearance of his donor-site scar and was self-conscious wearing shorts above the knee. Ap-
proximately 3 years after his ALT phalloplasty, he desired tissue expansion and removal of
as much skin graft scar as possible. His insurance only covered one 800 cc tissue expander,
which was placed lateral to the skin graft car. Intraoperatively the expander was filled to
250 cc and over the next 9 weeks was expanded to 850 cc of normal saline solution. On re-
turn, approximately 50% of his skin graft was removed, and his expanded skin was advanced
over the defect. He will likely pursue additional expansion at a later date.
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CHAPTER
10
Phalloplasty: Latissimus Dorsi Flap
CHA
Miroslav L. Djordjevic,
Sinisa Kojic, Borko Stojanovic
Key Points
❖❖ The myocutaneous latissimus dorsi free flap is ❖❖ Both labia minora and dorsal hairless clitoral
a reliable alternative to the radial forearm flap skin are harvested with the preserved blood
for neophalloplasty in female-to-male transgen- supply for use in urethral lengthening.
der patients. ❖❖ The neophallus is placed just above the top of
❖❖ A synchronous two-team approach could be the labia majora, creating a good relationship
used (team one, harvesting of the flap; team between the phallus and newly created scro-
two, dissection of the recipient area and recipi- tum.
ent blood vessels for later microvascular anas- ❖❖ The neophallic urethra is reconstructed as a
tomosis). staged procedure with buccal mucosal and skin
❖❖ It is possible to remove the vagina and recon- grafts.
struct the scrotum with insertion of silicone tes-
ticle implants in the same stage.
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CHAPTER 10
Female-to-Male Gender Affirmation Phalloplasty: Latissimus Dorsi Flap
Reconstruction of the neophallus is one of the most difficult elements in the surgical treat-
ment of female transsexual patients. Although a variety of surgical techniques are avail-
able, their results are not equally acceptable to all patients. Overall the patient chooses the
preferred surgical technique after he has been completely informed regarding all treatment
options, the advantages, and possible complications.1
For patients requiring an adult-sized phallus, the myocutaneous latissimus dorsi free flap
is a good option for phallic reconstruction. Various flaps (vaginal, labial, and clitoral flaps)
and grafts (buccal mucosal graft) are recommended for urethral lengthening, whereas im-
plantation of a penile prosthesis in the second stage enables penetration and sexual inter-
course. However, the lack of erogenous sensitivity of the neophallus remains problematic.

Metoidioplasty is a technically demanding and challenging surgical procedure that is used
in female-to-male (FTM) transgender patients who want gender reassignment surgery
without undergoing a complex, multistaged surgery to create an adult-sized phallus. Th s
technique creates a neophallus from a hormonally hypertrophied clitoris in FTM patients
who do not wish to have sexual intercourse.2,3 In patients who want a larger phallus, many
different surgical techniques have been reported that use available local vascularized tissues
or microvascular tissue transfers. An ideal phalloplasty includes one surgical stage, pro-
tective and erogenous sensitivity, good aesthetic appearance, a volume sufficient to place a
protected prosthesis, suffici t rigidity to allow sexual intercourse, patency of the neoure-
thra, and low donor-site morbidity.4-10
The most widely used flap for total neophalloplasty is the radial forearm flap.8 However,
it has many drawbacks, such as an unsightly donor-site scar, very frequent urethral com-
plications, and a small penis that does not allow the safe insertion of a penile prosthesis in
most patients. These were the main reasons we developed a new technique with the myo-
cutaneous latissimus dorsi free flap, which was based on favorable experimental and clini-
cal experience.11-13Th s flap has a reliable and suitable anatomy to meet the aesthetic and
functional needs of phallic reconstruction. Because of its workable size, ease of identifi a-
tion, long neurovascular pedicle, and minimal functional loss after removal, the latissimus
dorsi flap has been used for various reconstructions.14,15
The main advantage of this flap is its large surface area, allowing an excellent penile size
(length and circumference), large enough to allow urethroplasty and implantation of a pe-
nile prosthesis. Moreover, the penis can be constructed to the size desired by the patient.
Neophallus retraction seems less likely with muscle-based grafts than with fasciocutaneous
forearm flaps, because denervated, well-vascularized muscle is less prone to contraction
than connective tissue. Sexual function of this neophallus remains problematic, because
the flap lacks orgasmic sensitivity; it is restricted to the glans, with a preserved dorsal nerve
bundle incorporated at the base of the neophallus. Strong motivation and excellent coop-
eration of the partner are mandatory for successful sexual intercourse.11,12
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Surgical Technique: Main Procedure

Our present technique includes the removal of internal female genitalia, including hysterec-
tomy, adnexectomy, and vaginectomy, the creation of a neophallus from the myocutaneous
latissimus dorsi free flap, its fix tion in the pubic region and anastomosis with the blood ves-
sels of the right leg, and reconstruction of the scrotum. The second and third stages of phal-
loplasty (urethral reconstruction and penile prosthesis implantation) are performed several
months after the fi st stage. Our phalloplasty can be performed as a separate surgery after
or before metoidioplasty or at the same time as metoidioplasty as a one-stage procedure.
Preoperative Assessment
Patients should receive hormonal treatment for a minimum of 1 year before surgery. The
donor-site region must be treated with professional massage, which will improve skin elas-
ticity and thus direct closure of the donor site after harvesting of the flap. The massage is
performed regularly for at least 3 months before surgery. The donor site is defi ed as the
nondominant side of the latissimus dorsi muscle region.
Clitoral Anatomy
A clear understanding of the anatomy of the clitoris is important for this surgical recon-
struction. The clitoris consists of erectile bodies (paired bulbs and paired corpora, which
are continuous with the crura), the glans clitoris, the neurovascular bundle dorsally, and
the wide urethral plate ventrally. The glans is a midline, densely neural, nonerectile struc-
ture that is the only external manifestation of the clitoris. The distribution and course of
the neurovascular bundle of the clitoris are similar to those of the penis; the blood supply
of the clitoris comes from the deep artery and dorsal artery of the clitoris, which branch off
from the internal pudendal artery. The wide urethral plate with well-developed spongiosal
tissue is adherent to the corporeal bodies, forming a ventral chordee. The clitoris has fun-
diform and suspensory ligaments, as in penile anatomy. However, the clitoral ligaments are
more developed and make it hidden and curved.16,17
Removal of Female Reproductive Organs

Removal of female reproductive organs (that is, hysterectomy and bilateral salpingo-
oophorectomy) can be performed either before or at the same time as phalloplasty. The
vaginal mucosa is completely removed by colpocleisis, except for the part of the anterior
vaginal wall close to the native urethral orific , which is used for reconstruction of the bul-
bar urethra (Fig. 10-1).
Clitoral Lengthening and Repositioning

Lengthening of the clitoris begins with a circular incision beneath the clitoral glans at the
border between the inner and outer layers of the clitoral prepuce and continues around the
urethral plate and native urethral orific . After total degloving, fundiform and suspensory
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CHAPTER 10
Fig. 10-1 Female-to-male patient. A hysterectomy, bilateral salpingo-oophorectomy, and vaginec-

tomy were performed through a vaginal approach.
clitoral ligaments are detached from the pubic bone to advance the clitoris, mobilizing it
to enable its fix tion in a new position at the base of the neophallus.
Urethral Lengthening
In FTM patients, the gap between the neourethra and female urethral meatus always ex-
ceeds 10 cm. Reconstruction of the neourethra begins with the reconstruction of its bulbar
part. A vaginal flap is harvested from the anterior vaginal wall, with its base close to the
female urethral meatus.18 Th s flap is joined with the remaining part of the divided ure-
thral plate, which forms the bulbar part of the neourethra. Further urethral reconstruction
includes using all available vascularized hairless tissue to lengthen the neourethra to the
maximum extent, which prevents postoperative complications. In this way the new urethral
opening is placed in the fi st half of the neophallus, minimizing the requests for longer neo-
phallus urethroplasty. Both varieties of flaps, clitoral and labial, have fi e supportive tissue
that prevents fistula formation and yields satisfactory aesthetic results (Fig. 10-2).
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CHAPTER 10
A B
Fig. 10-2 A, Proximal urethra created with the urethral plate and a vaginal flap. A very long flap from
both the labia minora and clitoral skin is dissected on a well-vascularized pedicle. B, The flap is tubular-
ized, allowing an additional increase in urethral length.
Reconstruction of the Perineum and Creation of the Scrotum

The vaginal space is closed, and the perineum is fashioned to resemble that of males. Both
labia majora are joined in the midline over the neourethra, creating a one-sac scrotum.
Silicone testicle prostheses are inserted into the labia majora, completing the scrotoplasty.
Flap Design and Marking

The patient is placed in the lateral position (the upper torso is placed in a full lateral position
at 90 degrees, and the pelvis is at a 30-degree angle) to provide access to the groin. The flap
is marked on the latissimus dorsi donor site; it consists of two parts: a rectangular part for
the neophallic shaft and a circular component for glans reconstruction (Fig. 10-3, A). Flap
dissection starts with an incision of the anterior skin margin down to the deep fascia. The
plane is developed between the latissimus dorsi and serratus anterior muscles with sharp
and blunt dissection. The flap is divided inferiorly and medially, cauterizing the large pos-
terior perforators of the intercostal vessels, and then lifted to expose the neurovascular ped-
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CHAPTER 10
B C
Fig. 10-3 A, Design of the myocutaneous latissimus dorsi flap. B, The flap is harvested on the thoracodorsal artery and
vein. C, The flap is tubularized, creating the neophallus.
icle. The pedicle, which is surrounded by fatty tissue, is identified and dissected proximally
up to the axillary vessels. The thoracodorsal nerve is identifi d and isolated proximally for
3 to 4 cm, which preserves its vascularization. The flap is elevated completely except for the
neurovascular bundle, which is not transected until the recipient vessels and nerve have
been prepared for microanastomosis (Fig. 10-3, B). The latissimus muscle is fi ed to the
edges of the skin at several points to prevent layer separation during further dissection. The
flap is tubularized, creating the neophallus while still perfusing on its vascular pedicle (Fig.
10-3, C). The circularized terminal part is rotated back over the distal body and sutured to
create a neoglans. Thus a completely constructed neophallus is detached from the axillary
region after clamping and dividing the subscapular artery, vein, and thoracodorsal nerve
at their origins to achieve maximal pedicle length.
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CHAPTER 10
Fig. 10-4 A, Microvascular anastomosis is performed between the blood vessels of the neophallus
and the recipient area. B, Appearance at the end of surgery. The neophallus is placed in the proper po-
sition. The urethral opening is placed in the proximal part of the neophallus.
Recipient Site: Dissection of the Blood Vessels

Dissection of the recipient area is performed together with the dissection of the femoral
artery, saphenous vein, and ilioinguinal nerve. A Y incision is made on the mons pubis,
and a wide tunnel is created between the incisions to receive the pedicle. After all neuro-
vascular structures are identified at the recipient site, the thoracodorsal vessels and nerve
are divided, the neophallus is transferred to the pelvic region, and a microsurgical vascular
anastomosis is performed immediately. The neophallic base is fi ed to the skin at the recipi-
ent site. The stabilizing recipient skin site is further approximated and closed (Fig. 10-4).
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CHAPTER 10
Fig. 10-5 The donor site is closed by approximation and grafting with a split-thickness skin graft.
Donor-Site Closure
The donor site is approximated and closed directly after adjacent undermining of wound
edges, if possible. Otherwise, if signifi ant tension is present that may compromise healing
and lead to donor-site necrosis, a split-thickness skin graft is used (Fig. 10-5).
Surgical Technique: Subsequent Procedures

Penile Prosthesis
Because erectile dysfunction occurs after total phalloplasty from the lack of erectile tissue,
penile prosthesis implantation is a suitable option. Its use has frequently been associated
with complications, sometimes in as many as 50% of cases.19 Two types of penile prosthe-
ses, semirigid and inflatable, available in various lengths and diameters, are usually used
after total phalloplasty (see Chapter 11). Only two surgical approaches, the infrapubic and/
or the penoscrotal, are suitable for implanting a penile prosthesis into the neophallus.
A longitudinal or transverse incision is made below the pubis, just above the base of the
neophallus. Hegar dilators are used to create the space for insertion of the prosthesis (Fig.
10-6, A and B). The prosthesis is covered with vascular grafts imitating the tunica albuginea
to prevent protrusion through the glans. The prosthesis is also fi ed to the periosteum of
the inferior pubic rami (Fig. 10-6, C and D). The disadvantages of the infrapubic approach
include possible damage to the neurovascular bundle of the neophallus and limited expo-
sure for prosthesis insertion. It is also impossible to transfer the tubes between cylinders
and the pump located in the scrotum. The pump of the inflatable prosthesis is inserted into
the scrotum with a small incision above the scrotum.
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A B
C D
Fig. 10-6 A, Good appearance of the neophallus 3 weeks later. B, Hegar dilators are used to create
the space for penile prosthesis implantation. C, An inflatable tricomponent penile prosthesis is inserted
into the neophallus. The pump is inserted into the left side of the scrotum. D, Appearance after surgery,
including glansplasty.
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CHAPTER 10
With the penoscrotal approach, a vertical or transverse incision is made ventrally at the pe-
noscrotal junction. Initially there was concern that this approach might be associated with
a higher infection rate than the infrapubic approach. However, this has been shown not to
be the case. The advantages of the penoscrotal approach include avoidance of injury to the
vascular supply, better exposure for prosthesis insertion, insertion of the pump without an
additional incision, and the ability to anchor the prosthesis to the pubic bones. Fixation
of the cylinder bases to the periosteum of the inferior pubic rami stabilizes the prosthesis
and discourages cylinder protrusion through the neoglans. With the vertical penoscrotal
approach, all layers are opened longitudinally, allowing good visualization of all structures,
especially the urethra. The scar produced by this incision is barely visible and is hidden
between two hemiscrota.
For a long time, conventional wisdom dictated that if penile prosthesis revision surgery is
necessary, it should be performed with the same approach that was used for the initial im-
plant. When a patient presents for explantation of a semirigid prosthesis that was implanted
through the infrapubic approach and implantation of a tricomponent inflatable prosthesis
in its place, we go through the infrapubic scar and remove the malleable implants. The new
prosthesis is then implanted with the described technique.
Staged Neophallic Urethral Reconstruction

Staged neophallic urethral reconstruction is the most promising technique for the recon-
struction of the neophallic urethra, based on a two-stage procedure. Th s principle, intro-
duced by Johanson in the 1950s, is still used today, directly or indirectly. 20 The first stage
includes the creation of a new “urethral plate” with a buccal mucosal graft (Fig. 10-7). The
use of buccal mucosal grafts that was fi st described seven decades ago has been the bench-
mark for urethral reconstruction. Th s graft s tough, elastic, simple to harvest, and easy
to handle and leaves no noticeable scar at the donor site. It is also an attractive option in
patients in whom the available genital skin is insufficient, such as after multiple failed ure-
thral reconstructions. With Johanson’s principle, a buccal mucosal graft presents the opti-
mal option in staged urethroplasty.21
The principles of harvesting and transfer are the same as previously described.22 Buccal
mucosal grafts (e ther pairs or single, depending on the required width and length of the
neourethra) are placed on the ventral side of the penis. When the healed grafts are ready
for fi al-stage tubularization and closure, the surgeon must incise the underlying tissue that
will support the neourethra and avoid ischemia at the neourethral suture line. A second
layer should be created from the surrounding tissue to cover and support the newly cre-
ated urethra (Fig. 10-7, C and D). The key to successful repair is waiting long enough until
the skin is supple. The classic mistake is to perform the second stage too early. The second
stage should be performed when the urethral plate has matured enough to be supple and
thus more easily mobilized for tubularization. If necessary, additional buccal mucosal graft
can be used for urethral plate augmentation and easier tubularization.
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CHAPTER 10
A B
C D
Fig. 10-7 A, Second stage: glansplasty and urethroplasty. B, The glans is reconstructed by the Nor-
folk technique, which involves the use of a full-thickness skin graft from a non-hair-bearing area. The
buccal mucosal graft is positioned in the distal half of the neophallus, forming the new urethral plate.
C, The urethral plate is dissected from the penile skin and tubularized. D, Final appearance after ure-
thral reconstruction.
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CHAPTER 10
Postoperative Care
Broad-spectrum antibiotics are recommended to prevent infection after any stage. In the
fi st stage of phalloplasty, a special dressing and fix tion of the neophallus in an elevated
position are used to prevent pedicle kinking. Urethral reconstruction is followed with su-
prapubic urine derivation for a period of 3 weeks to allow satisfactory healing of the neo-
urethra. Special care should be taken after penile prosthesis implantation to prevent infec-
tion and its rejection; broad-spectrum antibiotics (cephalosporins, metronidazole) should
be given for 7 days and sexual intercourse restricted for 3 months.
Results
Material
Between 2007 and 2014, 112 transgender patients underwent microvascular latissimus
dorsi phalloplasty at our center. In 76 patients phalloplasty was performed as a primary
procedure, whereas in 27 patients, we performed phalloplasty after a previous metoid-
ioplasty. Nine additional patients underwent the same procedure as a reversal surgery
(Fig. 10-8).
A B
Fig. 10-8 A, Appearance of the genitalia after male-to-female surgery in a regretful patient. B, Reversal
surgery included removal of all female genitalia, scrotoplasty with testicle implants, and latissimus dorsi
phalloplasty.
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CHAPTER 10
Size of the Neophallus

The neophallic size in these patients was 15 cm (range 12 to 21 cm) and 13 cm (range 12 to
15 cm) in circumference. In six patients, a split-thickness skin graft w s used to cover the
ventral side of the neophallus.
Donor-Site Closure
The donor-site was closed by direct approximation in 87 patients, whereas a split-thickness
skin graft w s used to cover the defect in the remaining 25. Scar appearance was accept-
able in almost all patients. No one required additional surgery to correct donor-site scars.
Sensitivity
Although an anastomosis was performed between the thoracodorsal and ilioinguinal nerves
as a standard part of the phalloplasty, less than 20% of patients reported tactile sensation
of the neophallus, confi ming one of the main disadvantages of this procedure. Th s issue
remains problematic because of poor sensitivity of the neophallus, with most sensation
restricted to the clitoris (with a preserved sensitivity), incorporated at the base of the neo-
phallus. Strong motivation and a good relationship with the partner are crucial in achiev-
ing a successful sex life.
Urethral Reconstruction
The total length of the reconstructed urethra in the fi st stage was measured during surgery
and ranged from 12.1 to 19.7 cm (median 13.8 cm). In 91 patients, the urethral opening was
located in the distal third of the neophallus. In seven patients, the neourethral opening was
placed in the distal half of the neophallus. In the remaining 14 patients, the newly created
urethra was opened at the base of the neophallus, because there was not enough vascular-
ized genital hairless skin for more lengthening. Neophallic urethral reconstruction by either
one-stage or two-stage buccal mucosal graft tubularization was performed in 82 patients.
Penile Prosthesis Insertion

Two types of penile prostheses were used in 48 of 112 patients. Malleable prostheses were
implanted in 29 patients, and tricomponent inflatable prostheses were used in the remain-
ing 19. Other patients had an interest in penile implants, but the costs were a limiting fac-
tor for them.
Patient Evaluation
All patients were evaluated by either a psychologist or psychiatrist and reported that they
were very satisfi d with their surgery (see Figs. 10-6 and 10-7). According to patients’ self-
reports, most were pleased with the aesthetic appearance of their genitalia (97 were “com-
pletely satisfi d” and 15 were “somewhat satisfi d”). Nevertheless, erogenous sensation based
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CHAPTER 10
on clitoral stimulation was reported from all 112 patients. None of the patients reported
problems or difficulties in sexual arousal, masturbation, or orgasms. In all patients who
had penile implants, sexual intercourse with full penetration of partners was completely
adequate. Ultimately 9 patients requested reversal surgery (see Fig. 10-8).
The preference for a specific urgical technique mostly depends on the patient’s desires
and expectations. Nevertheless, it is the surgeon’s duty to fully inform patients about all
associated advantages and disadvantages, as well as any postoperative complications and
their potential severity. The surgeon may even need to talk patients out of a desired surgi-
cal technique if there are contraindications.1
Complications
Complications that may occur after this type of sex reassignment surgery can be classifi d
as minor (those that can be managed nonoperatively) and major (those requiring addi-
tional surgery) (Table 10-1).
Hematomas can be avoided by meticulous hemostasis during surgery and afterward by the
application of self-adherent dressing. In most patients, postoperative hematomas resolve
spontaneously, and surgical exploration is rarely necessary. Partial skin necrosis, which may
occur even after careful handling, usually heals spontaneously merely by treating with fi-
brinolytic ointment. Prolonged suprapubic drainage precludes urinary retention.
Postoperative complications related to urethroplasty include dribbling and spraying dur-

ing voiding, which disappear during the fi st 3 months after surgery. Urethral fistulas and
Table 10-1 Complications After Total Phalloplasty

Minor Major
Hematoma Hematoma
Wound infection Wound dehiscence
Partial skin necrosis Partial flap necrosis
Urinary retention Complete flap necrosis
Urinary tract infection Urethral fistula
Dribbling Urethral stricture
Spraying Loss and dislocation of the testicle implant
Fistula Penile prosthesis infection
Stricture Penile prosthesis rejection
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CHAPTER 10
strictures are the main problems after total phalloplasty. The reasons may be insuffici t
vascular supply of the local flaps and inappropriate width of the neourethra, causing in-
creased pressure on the bulbar part of the urethra and anastomotic sites, infection, or
external pressure to the neourethra produced by testicle prostheses. The development of
fistulas can be prevented by covering the anastomosis with an additional layer of subcuta-
neous tissue. In some patients with a urethral fistula, leaking resolves spontaneously, with
no need for surgical repair. Most temporary urethral strictures can be managed by periodic
dilation for a 3-month period.
Major postoperative complications include all complications requiring secondary revision

Urethral fistulas requiring surgical intervention are repaired by simple excision of the fis-
tula and covering with the available local vascularized flaps. Urethral strictures should be
confi med by a voiding cystourethrogram, feeble urine stream, and urine retention. Most
of the strictures are located at the anastomotic site between the native urethra and neoure-
thra. Repair of the stricture can include anastomotic or buccal mucosal graft urethroplasty.
Strictures located in the neophallic urethra can also be repaired by urethroplasty with a
buccal mucosal graft. No complications were related to the buccal mucosal harvesting site,
flap necrosis, or postoperative infections.
Loss of a testicular implant may be related to wound dehiscence, wound infection, or in-
fection of the testicular capsule resulting from urine leakage. The testicle implants can be
dislocated upward or downward. The surgical repair always consists of repositioning of the
implant and its fix tion into the proper place and new capsule creation.
Protrusion of the penile prosthesis can occur as a result of wound dehiscence, infection, or
prosthesis rejection from an allergic reaction. The surgical repair consists of repositioning
the prosthesis, sometimes requiring its removal and implantation in another stage. If penile
prosthesis revision surgery is necessary, it should be performed with the same approach
that was used for the initial implant.
Conclusion
As a multistage surgical procedure in FTM patients, phalloplasty poses considerable chal-
lenges. The goal of phalloplasty is to create male-like genitalia of an adult male that will al-
low voiding in the standing position, have a satisfactory aesthetic appearance, and provide
good sexual function. The myocutaneous latissimus dorsi flap phalloplasty is an acceptable
choice for transsexual patients and gives an excellent penile size, allowing urethral recon-
struction and penile prosthesis implantation. Although radial forearm flap phalloplasty is
largely accepted as the benchmark, new refi ements and improvements of all techniques
are needed to satisfy specific atients’ requests related to functional and aesthetic results
of neophalloplasty.23
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Acknowledgment
Th s chapter is supported by the Ministry of Science, Republic of Serbia, Project No. 175048.
References
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J Urol 177:1112, 2007. prosthesis implantation in total phalloplasty.
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9. Bettocchi C, Ralph DJ, Pryor JP. Pedicled pu- intact epithelium tube. Acta Chir Scand 176:1,
bic phalloplasty in females with gender dys- 1953.
phoria. BJU Int 95:120, 2005. 21. Barbagli G, Palminteri E, De Stefani S, et al.
10. PeroviĆ S. Phalloplasty in children and ado- Penile urethroplasty. Techniques and out-
lescents using the extended pedicle island comes using buccal mucosa grafts. Contemp
groin flap. J Urol 154:848, 1995. Urol 18:25, 2006.
11. Djordjevic ML, Bumbasirevic MZ, Vukovic 22. Markiewicz MR, Margarone JE, Barbagli G,
PM, et al. Musculocutaneous latissimus dorsi et al. Oral mucosa harvest: and overview of
free transfer flap for total phalloplasty in chil- anatomic and biologic considerations. EAU-
dren. J Pediatr Urol 2:333, 2006. EBU Update Series 5:179, 2007.
12. Perovic SV, Djinovic R, Bumbasirevic M, et 23. Leriche A, Timsit MO, Morel-Journel N, et
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13. Ninkovic M, Stenzl A, Schwabegger A, et
al. Free neurovascular transfer of latissi-
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CHAPTER
11
Testicular and Erectile Implants
in Transmen After Phalloplasty
CHA
Piet Hoebeke, Nicolaas Lumen
Key Points
❖❖ Testicular and erectile implants complete the ❖❖ Erectile implants have a high complication rate
reconstruction in transmen after phalloplasty. because of the limited durability of the implant
❖❖ A delay of 12 months between phalloplasty and the often high frequency of use. T
and implants is recommended. ❖❖ Implants in transmen should be performed in
❖❖ The ideal phalloplasty implant is not yet avail- high-volume centers.
able, and implants available to biologic men are
still used today.
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CHAPTER 11
Testicular and Erectile Implants in Transmen After Phalloplasty
After phalloplasty and scrotoplasty, the neophallus is flaccid and the scrotum is empty.1,2
To make the newly constructed genitals look and function as natural as possible, scrotal
and penile implants are needed.3 Most often these implant procedures are the last stage of
reconstruction, preferably performed 1 year after phalloplasty. At that time most urethral
complications will have been resolved, sensitivity will be present, and vascular integration
of the phallus should be maximal, decreasing the risk of vascular complications during
implantation.
Testicular Implants
The testicular implants used after phalloplasty do not differ from those used in biologic
males. Most often silicone gel–filled implants are used; they are available off he shelf in
small, medium, and large sizes. The size used depends on the available space in the neo-
phallus. If an inflatable erectile device is chosen, there must be extra space to accommodate
the device’s pump. In most cases, the pump is large enough to fill half of the scrotum. As
a consequence, most patients who choose an inflatable erectile device will need only one
testicular prosthesis.
With semirigid erectile devices, two testicular prostheses will be implanted, one along the
incision used for the erectile implant and one by the contralateral inguinal incision. An
inguinal incision in which to place the testicular prosthesis is recommended, because the
scrotum often has many scars from the reconstruction. Reopening a scarred area increases
the risk of wound infection and delayed or impaired wound healing in general. Th s in turn
increases the risk of prosthesis infection and/or perforation.
The space for the prosthesis is developed bluntly, starting at the inguinal incision. Testicu-
lar implants can dislocate from their original position, especially if too big a size is chosen
for the area. Capsule formation and retraction are rare but can happen. Published reports
on the clinical outcomes of testicular implant surgery in transmen are scarce. Some plastic
surgeons tend to use tissue expanders in the labia majora to create space for the implants. 4
In the technique of scrotoplasty described by Selvaggi et al,1 the surgeon performing the
scrotal reconstruction tries to bring the scrotum in front of the legs (that is, the “natural”
position). When the labia are preserved in their anatomic position and just closed in the
midline, the patient will have problems with the testicular implants while sitting, and the
chance of dislocation of the implants will increase.
Erectile Implants
Rigidity of the neophallus is required to engage in sexual intercourse. However, obtaining
rigidity after phalloplasty remains a real challenge, and many complications are reported.2,5,6
Different possibilities are available to obtain rigidity. When the phallus is constructed by
use of a fibula flap or a radial forearm flap, theoretically part of the fibula or radius could
be transplanted with the flap, thus allowing rigidity. Unfortunately, the limited amount of
bone that can be taken from the distal radius or fibula can never function as a real rigidity
device, and the risk of donor-site complications is substantially increased.7-9 In addition,
bone or cartilage grafts ay absorb or render a pointed deformity to the distal part of the
penis, where the extra skin can glide around the end of the bone. Moreover, a phallus with
a permanent erection can be an embarrassment that cannot be easily concealed.
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CHAPTER 11
Fig. 11-1 A 53-year-old transgender man

after failed abdominal tubed flap and radial
forearm free flap phalloplasty without urethral
lengthening 8 months earlier. (Courtesy of
Christopher J. Salgado, MD.)
Fig. 11-2 A 53-year-old man 1 week afer dual-rod semi-

rigid penile prosthesis in radial forearm free flap phallo-
plasty. This patient had tactile sensation three fourths of
the way down the penile shaft. (Courtesy of Christopher J.
Salgado, MD.)
Commercially available erectile implants have the advantage of being readily available in
many formats, lengths, and sizes, and their use in biologic males has been very successful
in terms of the implant’s survival time and the patient’s quality of life after implantation
(Figs. 11-1 n
a d 11-2).
One of the major complications while implanting an erectile device is infection. With an
antibiotic-impregnated prosthesis, the infection rates in large groups of biologic males was
reduced to approximately 1%.10 However, there is an important difference when comparing
implantation in biologic males with implantation in a male with a neophallus. In biologic
males the prosthesis is implanted in the corporeal bodies, which serve as extra protection
against protrusion and in which some blood fl w is preserved, enhancing the effect of the
local antibiotics. In transmen, the prosthesis is implanted in fatty tissue with low blood sup-
ply and without the protection of corporeal bodies. Garaffa et l11 described ways to over-
come the lack of corporeal bodies by inserting the devices in covers of either Gore-Tex or
Dacron. These covers are also used to anchor the prosthesis to the pubic bone.11
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CHAPTER 11
Other options for rigidity are the use of external devices such as silicone condoms, which
can be used over the phallus. However, no studies have been published on the use of these
devices.
At our center we have much experience with erectile devices. Our strategies have changed
over time based on experience.
In general, we have found that inflatable devices have limited survival time. There are many
reasons why they tend to fail more compared with the series that have been published on
biologic males. Biologic males receive their implant to treat erectile dysfunction. These
patients usually are older and have a lower libido and thus have a lower frequency of us-
ing their implant. Transmen are younger, receive testosterone therapy, and usually have a
high libido, so they tend to use the prosthesis more often and much longer. In addition to
frequency of use, there is also the unlimited space for expansion of the prosthesis, because
it is not contained in the corporeal bodies.
Initially, a one-piece hydraulic prosthesis was used (Dynaflex, American Medical Systems
[AMS], Minnetonka, MN), fully covered with Dacron, usually in combination with two
testicular prostheses. In that series we had a high amount of leakage from rubbing of the
silicone against the Dacron, causing wearing of the silicone sheath of the cylinder and sub-
sequent leakage.3 After this implant became unavailable, we switched to the three-piece
AMS CX prosthesis. In this device, the pump replaced one testicular prosthesis. Good re-
sults were initially reported with this prosthesis; however, we encountered an increase in
technical failure because of leakage, probably because there was no limit to the amount of
fluid that could be pumped into the cylinders. In a three-piece system, there is a reservoir
containing 65 ml of saline solution. Thus we switched to the two-piece device (Ambicor,
AMS), a system that limits the amount of fluid available, because the reservoir is integrated
at the base of the cylinder and thus contains less saline solution. With this two-piece sys-
tem, the initial results were good, but with longer follow-up, the problems of leakage and
malposition and lack of rigidity were observed. Because of the absence of tunica albuginea
in the neophallus, there is no limit to the expansion of the erectile device, so patients tend
to overpump the prosthesis, and over time the limited amount of saline solution is insuffi-
cient for stiffening the cylinder. In the fi st long-term follow-up study, reintervention was
observed in about one in four patients. However, more than 80% of the patients were able
to have normal sexual intercourse with penetration.3
In an observational study on the quality of patients’ sex lives, patients with erection pros-
theses attained their sexual expectations compared with those without prostheses, although
the group with prostheses more often reported pain during intercourse.12
In 2010 we reported a longer follow-up on erectile implants; 129 transmen who received
implants between March 1996 and October 2007 were evaluated.2 The mean follow-up
was 30.2 months (range 0 to 132 months). A Dynaflex prosthesis was initially implanted in
9 patients, a three-piece hydraulic device (AMS CX or AMS CXM) in 50 patients, and a CX
InhibiZone (AMS, Boston Scientific, Marlborough, MA), Ambicor (AMS), and Coloplast/
Mentor prosthesis (Coloplast, Minneapolis, MN) in 17, 47, and 6 patients, respectively. Of
the 129 patients, 76 (58.9%) still had their original implant in place. Fifty-three patients
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CHAPTER 11
Fig. 11-3 Newly developed implants for patients undergoing phalloplasty. A, Semirigid device. B, In-
flatable device. (Courtesy of Zephyr Surgical Implants, Geneva, Switzerland.)
(41.1%) needed to undergo either removal or revision of the prosthesis because of infec-
tion, erosion, dysfunction, or leakage. Forty-one patients underwent a replacement of the
prosthesis, 9 needed a second revision, 5 needed a third revision, and 1 patient needed a
fourth revision of the prosthesis. Malposition of the prosthesis was corrected by surgical
repositioning so that removal could be avoided. Of the 185 prostheses used in 129 patients,
108 (58.4%) were still in place, with a total infection rate of 11.9%, a total protrusion rate
of 8.1%, a total prosthesis leakage rate of 9.2%, a total dysfunction rate of 13%, and a total
malposition rate of 14.6%. 2
Because of the higher complication rates with longer follow-up, we started to propose the
use of semirigid implants in transmen. We used a Spectra semirigid prosthesis (AMS) in
a Gore-Tex sleeve. Th s is a titanium-based prosthesis, which has the advantage of being
concealed when it is bent downward. The results of this prosthesis have not been evaluated
until recently, but malfunction as a result of leakage is impossible with this device. We ob-
served some infection problems and some malposition, but in general, we think that the
semirigid device is more durable.
Some new developments in erectile implants are expected in the near future; for example,
a Swiss company (Zephyr Surgical Implants, Geneva, Switzerland) is developing a specific
implant for transmen after phalloplasty. They are working on a device that meets the re-
quirements of an ideal erectile device after phalloplasty—either an inflatable or a semirigid
system that has one larger cylinder (greater than a 20 mm diameter) with a soft glans cap
and is easy to affi at the level of the pubic bone. The prototype is seen in Fig. 11-3.
Conclusion
Implantation of scrotal and penile implants is part of the reconstructive procedures that can
be offered to patients undergoing female-to-male sex reassignment surgery. Both patients
and surgeons must be aware that these procedures have high complications rates, but that
for some patients, these procedures are important to obtain a good quality of life.
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CHAPTER 11
References
1. Selvaggi G, Hoebeke P, Ceulemans P, et al. 7. Koshima I, Tai T, Yamasaki M. One-stage re-
Scrotal reconstruction in female-to-male construction of the penis using an innervated
transsexuals: a novel scrotoplasty. Plast Re- radial forearm osteocutaneous flap. J Recon-
constr Surg 123:1710, 2009. str Microsurg 3:19, 1986.
2. Hoebeke PB, Decaestecker K, Beysens M, et 8. Biemer E. Penile construction by the radial
al. Erectile implants in female-to-male trans- arm flap. Clin Plast Surg 15:425, 1988.
sexuals: our experience in 129 patients. Eur 9. Cavadas PC. Secondary free fibular flap for
Urol 57:334, 2010. providing rigidity in a radial forearm phallo-
3. Hoebeke P, de Cuypere G, Ceulemans P, et al. plasty. Plast Reconstr Surg 122:101e, 2008.
Obtaining rigidity in total phalloplasty: expe- 10. Carson CC III, Mulcahy JJ, Harsch MR.
rience with 35 patients. J Urol 169:221, 2003. Long-term infection outcomes after original
4. Sengezer M, Sadove RC. Scrotal construction antibiotic impregnated inflatable penile pros-
by expansion of labia majora in biological thesis implants: up to 7.7 years of followup.
female transsexuals. Ann Plast Surg 31:372, J Urol 185:614, 2011.
1993. 11. Garaffa G, Raheem AA, Ralph DJ. Penile
5. Hage JJ, Bloem JJ, Bouman FG. Obtaining fracture and penile reconstruction. Curr Urol
rigidity in the neophallus of female-to-male Rep 12:427, 2011.
transsexuals: a review of the literature. Ann 12. De Cuypere G, T’Sjoen G, Beerten R, et al.
Plast Surg 30:327, 1993. Sexual and physical health after sex reassign-
6. Leriche A, Timsit MO, Morel-Journel N, et ment surgery. Arch Sexual Behav 34:679,
al. Long-term outcome of forearm free-flap 2005.
phalloplasty in the treatment of transsexual-
ism. BJU Int 101:1297, 2008.
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CHAPTER
12
Management of Unfavorable Urologic
Sequelae After Phalloplasty
in Transgender Patients
CHA
Yuka Yamaguchi,
Jamie P. Levine, Lee C. Zhao
Key Points
❖❖ Urinary fistula and urethral stricture are com- S
mon after neophallus reconstruction.
❖❖ Fistulas commonly occur at sites of anastomo-
sis.
❖❖ Reconstruction must be tailored to the patient’s
anatomy.
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CHAPTER 12
Management of Unfavorable Urologic Sequelae After Phalloplasty in Transgender Patients

One goal of neophallus construction in female-to-male transgender surgery is to give a pa-
tient the ability to void while standing. Although some patients use external “urinary assist”
devices to facilitate urination from the native urethra while standing,1-3 many undergo neo-
urethra construction, because the ability to stand to void is a high priority among female-
to-male transgender individuals. More than 98% of patients reported a desire to stand to
void.4 The management of urologic sequelae is important after neourethra construction,
because fistulas and strictures are common complications.
The urethra of the male-to-female transgender patient after phalloplasty can be divided
into distinct segments3,5 from proximal to distal: native (female) urethra, fi ed urethra,
anastomotic urethra, phallic urethra, and meatus. The fi ed urethra is the portion of the
urethra formed after lengthening the native urethra through local vaginal or labial flaps,
extragenital flaps, and grafts of skin or mucosa.3,6 The phallic urethra can be constructed by
a variety of techniques, including prelamination, prefabrication, tube-in-tube techniques,
and pedicled flaps.3,6
Urethrocutaneous fistula is the most common urethral complication. The fistula rate of ra-
dial forearm free flap phalloplasty ranges from 22% to 75%.7-10 Urethral fistulas commonly
occur at points of anastomosis—between the phallic urethra and fi ed urethra and between
the fi ed urethra and native urethra, although fistulas can occur anywhere along the neo-
urethra.11 Fistulas occur most commonly at the anastomosis between the phallic urethra
and fi ed urethra8 as a result of vascular insuffici cy of the flap and the decreased lumen
of the phallic urethra. The change in caliber of the lumen from fi ed to phallic urethra may
cause a relative obstruction of the urinary stream distal to the site of the fistula.8 The small-
caliber lumen of the phallic urethra may be the result of tissue shrinkage or insuffici t
size of the urethra at the time of construction. Spontaneous closure of the fistula tract has
been reported; Fang et al12 reported spontaneous closure of the fistula within 2 months in
as many as 35.7% of patients.
Urethral stricture is another common urologic complication, with reports of incidences

varying from 25% to 58%.8,13,14 Although stricture can occur in any segment of the urethra,
the most common location of stricture formation is at the anastomosis of the fi ed and
phallic portion of the neourethra (Fig. 12-1).
Lumen et al5 characterized stricture formation after phalloplasty and determined that ure-
thral stricture occurred at the anastomosis in 40.7%, phallic portion in 28%, the meatus
in 15.3%, fi ed segment in 12.7%, and multifocal in 7.6%. Ischemia is considered the cause
of strictures at all levels. Fistula formation may also contribute to dense scar formation
and kinking of the tissues, especially at the anastomosis of the phallic to fi ed portions.5,13
At the meatus, contracture of the anastomosis between the skin of the glans and urethral
tissue can lead to meatal stenosis. Mean stricture length in this series was 3.6 cm (range
0.5 to 15 cm).5 Fistula and urethral stricture may occur simultaneously. In a series of one-
stage urethroplasty by Rohrmann and Jakse,8 40% of patients developed a fistula and stric-
tures, with the fistula usually proximal to the stricture.
Proper management of urologic sequelae of phalloplasty is mandatory, given that urinary

fistulas and urinary obstruction caused by urethral stricture can have grave consequences,
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CHAPTER 12
Native urethra
Fixed
urethra
Anastomosis
Phallic
Urethral urethra
stricture
Meatus
Fig. 12-1 Retrograde urethrogram of the neourethra, showing the urethral stricture at the anastomo-
sis between the phallic and fixed urethra.
such as chronic infection, sepsis, and renal failure, as well as compromised quality of life. If
a patient is in urinary retention, urinary drainage must be performed with the placement
of a suprapubic catheter. The extent of subsequent urinary reconstruction will depend on
the individual’s health and preferences.
Patient Evaluation
A patient with urologic sequelae after phalloplasty will often present with voiding com-
plaints. Th s may include increased difficulty with urination, whether with a decreased
stream or an increased need to strain to void or a complete inability to void. If a urethro-
cutaneous fistula has formed, a patient may complain of urine or purulent drainage at a
location other than the meatus. The drainage may occur at the time of micturition but may
also occur afterward because of pooling of urine in the urinary tract. A patient may also
complain of dysuria or suprapubic pain.
The fi st step in patient evaluation is a careful physical examination. The suprapubic area
and neophallus should be examined for evidence of infection such as erythema and indu-
ration. The areas are also palpated for fluctuance to determine if any fluid collections re-
quire drainage. Ultrasound examination may be performed to evaluate for the presence of
an abscess. All areas are evaluated for fistulous openings, and the urethral meatus itself is
examined for patency.
Treatment of infections should be performed before surgery. Cellulitis should be treated. If

there is concern about a urinary tract infection, a urine sample may be sent for urinalysis
and urine culture. If a patient has a suprapubic tube, the urine sample may be sent from the
tube. However, indwelling catheters are often colonized, and organisms grown from these
cultures may not be representive of infections. If the urine culture fi dings return positive
with a clinical indication of infection, culture-specific antibiotics should be given.
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CHAPTER 12
Suprapubic tenderness and flank pain can be the result of urinary retention and an overly
distended bladder. A postvoid residual can be determined with a bladder scanner. If a pa-
tient is in urinary retention, drainage of the bladder should performed. Because a patient
typically has a urethral stricture that precludes urethral catheterization, a suprapubic tube
should be placed to ensure adequate urinary drainage and to prevent renal damage.
Further anatomic evaluation can be performed with a retrograde urethrogram or voiding

cystourethrogram to help to delineate the location of the stricture or fistula. Examination
under anesthesia is frequently useful given the complex urinary anatomy of a patient’s sta-
tus after phalloplasty. A suprapubic tube can be placed at that time of this examination if a
patient does not already have one in place.

A notation should be made regarding a patient’s previous surgeries and what potential flaps
and grafts are available for use for urologic reconstruction.
The fi st step in managing a urinary fistula or stricture causing urinary obstruction is to

ensure that a patient’s urine is adequately diverted with a suprapubic catheter of adequate
size. The suprapubic catheter should be placed 2 to 4 cm above the pubis. Placement of a
16 Fr or larger catheter facilitates the use of the suprapubic channel for antegrade cystoure-
throscopy to delineate the proximal urethra. Antegrade cystourethroscopy is easiest when
the suprapubic tube is at the midline. The surgeon must be careful to avoid the vascular
anastomosis to the neophallus.
The standard preoperative evaluation for urethral strictures and fistulas includes a ret-
rograde urethrogram combined with endoscopic evaluation to determine the extent of
stricture and level of fistulization if present. The patient is brought to the operating room
and is placed in the low lithotomy position and prepped and draped to allow access to the
perineum and suprapubic region. A layer of complexity is added to the patient’s status af-
ter phalloplasty, because the neourethra created may have a smaller caliber than the native
urethra and may be unable to accommodate a standard 16 Fr flex ble cystourethroscope.
At our institution, we use a flex ble ureteroscope to navigate the neourethra. The retro-
grade urethrogram can be performed by injecting contrast through the ureteroscope. Th s
technique has the advantage of allowing direct visualization of the neourethra rather than
attempting to blindly pass a catheter into a possibly tortuous neourethra. A guidewire is
used to gradually advance the ureteroscope. After contrast is injected, fluoroscopic images
are obtained to delineate the anatomy of the stricture and fistulas. If the suprapubic tract is
mature, antegrade cystoscopy may be performed to delineate the anatomy proximal to the
stricture point. Location, length, and caliber of the stricture, as well as location of any fistu-
las, are key factors to determine. Any fluid collections or abscesses, which have formed as
a result of obstruction, should be adequately drained. If a fistula does not heal on its own,
excision of the fistula tract with closure and coverage with a flap is often required.
Surgical Technique
The patient is placed under general anesthesia. The surgeon carefully positions the endotra-
cheal tube to the side opposite the potential side of graft harvest if a buccal graft is planned.
Positioning a patient in the lithotomy position allows access to the genitalia, suprapubic
area, and thighs as needed for flap harvest.
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CHAPTER 12
A B
Fig. 12-2 A, A patient with stricture of the anastomosis between the phallic segment of the neourethra. The neourethra
has been opened. A perforator-based fasciocutaneous flap is used. B, The fasciocutaneous flap is rotated to cover the ure-
thral defect.
All procedures are performed with the assistance of antegrade and retrograde cystoure-
throscopy for delineation of the anatomy. Because of the absence of normal landmarks
within the neourethra, identifi ation of the fistula site often requires simultaneous cysto-
urethroscopy with exposure of the cutaneous fistula tract. A needle or guidewire inserted
from the opening of the fistula into the urethral lumen is then visualized with the cysto-
scope and can be further used to identify the approximate distance and trajectory of the
urethra from the skin surface. A “cut to the light” procedure can be performed, in which
the fistula tract is dissected toward the light of the cystoscope. The fistula tract is excised,
and the opening to the urethra is closed. The surgeon must consider flap coverage of the
site to decrease the risk of fistula recurrence. We generally use a fasciocutaneous groin flap
to cover the anastomosis (Fig. 12-2). If a distal stricture is associated with the fistula, the
stricture must be repaired. Otherwise high-pressure voiding caused by obstruction will
result in fistula recurrence.
Management of urethral strictures in the female-to-male patient can be quite challeng-

ing. Endoscopic management with dilation and direct visualization internal urethrotomy
(DVIU) has been prone to failure; Levine and Elterman13 reported a restricture rate of 87.5%
in patients who underwent endoscopic urethrotomy. The relative decrease in the success
rates of endoscopic management in neophalluses when compared with native urethras is
likely because of a lack of corpus spongiosum and otherwise poor blood supply. However,
Lumen et al15 reported that DVIU would be a reasonable fi st-line approach for shorter
strictures that are less than 3 cm in length. First-time DVIU was successful in 43.8%, with
an additional 12.5% patent with a second DVIU at a median follow-up of 51 months (range
8 to 95 months). Th ee or more endoscopic interventions were not successful. In their series
Foley catheters were left in lace for 2 weeks after DVIU to allow healing of the epithelium
lining the urethra. A shorter time to stricture formation was a significant risk factor for
failure of the endoscopic intervention.15
In patients with longer or multifocal strictures or in whom endoscopic management fails,

urethroplasty must be performed. The approach to urethroplasty depends on the location
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CHAPTER 12
of the stricture and length of the affected segment. Different types of urethroplasty used
for the treatment of urethral strictures after phallic reconstructions include meatotomy, the
Heineke-Mikulicz principle, excision and primary anastomosis, free graft urethroplasty,
pedicled flap urethroplasty, two-stage urethroplasty, and perineal urethrostomy, which
may be followed by urethral reconstruction.5 If a penile prosthesis is present, the urethra
is opened ventrally.5
Shorter segments of urethral stricture may not require additional graft or flap material.
Meatal stenosis may be treated with meatotomy if the stenotic segment is short. This may
result in a hypospadiac meatus. At our institution, we prefer to cut the meatus both ven-
trally and dorsally to reduce the appearance of hypospadias. However, the hindered mobil-
ity of the urethral and glans tissue limits the applicability of this technique. Another option
for short strictures is the Heineke-Mikulicz approach, in which the strictured segment is
incised longitudinally and closed transversely to augment the size of the urethral lumen 5
(Fig. 12-3, A). Excision and primary anastomosis (EPA), in which the strictured segment is
excised and the healthy ends are spatulated and anastomosed, is the benchmark for short
urethral strictures in native male urethras16 (Fig. 12-3, B). However, the applicability of
EPA is notably limited in the transgender patient because of the lack of tissue mobility and
good blood supply.13 The successful use of EPA has been described for short strictures up
to 2 to 3 cm long, particularly at the anastomosis when excision of dense scar is required.5,8
Fig. 12-3 A, Heineke-Mikulicz repair of a urethral stricture. The narrowed urethral segment is incised
longitudinally and closed horizontally. B, EPA; the narrowed segment is excised, and the urethra is spat-
ulated and anastomosed.
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CHAPTER 12
For longer segments of stricture, a pedicled flap or graft can be performed in a one-stage
or two-stage approach. A dorsal inlay approach17 has been described for one-stage proce-
dures,15 and skin, bladder mucosa, and buccal mucosal grafts have been used.13,15For this
approach, a ventral urethrotomy is made to expose the dorsal aspect of the strictured ure-
thra. A vertical incision is made in the dorsal surface of the urethra, and a graft is placed
into this dorsal urethrotomy to increase the lumen of the strictured urethra (Fig. 12-4, A).
A buccal mucosal graft has become the graft of choice for urethral reconstruction. It has a
panlaminar vascular plexus ideal for engraftment and a thick, nonkeratinized epithelium
compatible with a wet environment. It is also readily available and has a hidden harvest
site. Given the lack of corpus spongiosum, the vascularity and coverage of the ventral tis-
sues are unreliable, making the dorsal position of the graft favorable.
The urethra is opened ventrally, and a dorsal inlay is placed because of better vascularity of
the backing tissue on the dorsal aspect. Although in the urethroplasty literature the dorsal
onlay approach with circumferential mobilization is performed in native pendulous ure-
thras, we do not recommend circumferential mobilization of the neourethra, because this
likely results in disruption of the vascular supply. If the vascular supply is tenuous on the
recipient site, a fasciocutaneous or muscular flap may be used to support a ventral onlay
graft. In a two-stage urethroplasty, the ventral urethrotomy is made through the strictured
segment. The existing urethral plate can be augmented with graft material, and the lateral
edges of the new urethral plate are sutured to the borders of the skin incision. After the new
urethral plate has matured, which is typically 6 months later, the new augmented urethral
plate is tubularized and the neophallus is closed. This is the preferred technique for long
or refractory strictures.5
A Ventral
Dorsal
B C
Fig. 12-4 A, The dorsal inlay approach, in which an urethrotomy is made on the ventral aspect of the
urethral stricture. An incision is made on the dorsal aspect of the urethra, and the graft is placed into the
dorsal incision. After the graft is placed, the ventral urethrotomy is closed. B, The dorsal inlay approach
as viewed intraoperatively. C, Holding stitches are placed to retract the ventral urethrotomy, the graft is
placed dorsally, and the urethrotomy is closed.
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CHAPTER 12
A C
Urethra
Fig. 12-5 A, Patient with a urethral stricture repaired by placing a graft dorsally. B, A fasciocutaneous
flap was used for urethral coverage. C, Final result on postoperative follow-up.
Perineal urethrostomy is also an option if multiple reconstructive efforts fail or if it is a

patient’s preference. The segment of fi ed urethra can be opened and approximated to the
perineum to expose the native urethral meatus. Th s may also be used as a temporary treat-
ment until defin tive reconstruction can take place. A combination of several of the recon-
structive approaches may be required for multifocal stricture. Regardless of the approach
to urethral reconstruction, stricture recurrence rates after treatments are as high as over
60%,5 with many patients requiring repeated intervention.8
Results
At our institution we select the technique of reconstruction based on a patient’s anatomy.
For example, the retrograde urethrogram in Fig. 12-1 shows a patient with a 4 cm urethral
stricture of the anastomotic urethra extending proximally into the fi ed urethra and distally
into the phallic urethra. A stricture of this length cannot be reconstructed by the Heineke-
Mikulicz approach or excision and primary anastomosis. The urethra was opened, and a
buccal mucosal graft w s placed dorsally (Fig. 12-5, A). The ventral urethra was covered
with a buccal mucosal graft, and the fasciocutaneous flap was sutured to the graft (Fig.
12-5, B). The fasciocutaneous flap was incorporated into the neophallus, and the patient
was able to void well after surgery (Fig. 12-5, C).
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D E
Bladder
Urethral
diverticulum
G
Diverticulum
Fig. 12-5, cont'd D, CT scan demonstrating a urethral diverticulum in an incompletely resected vagina. E, View
of the diverticulum when viewed from the peritoneal cavity. F, First-stage urethroplasty with a buccal mucosal
graft. G, Perineal urethrostomy performed in a patient with an obliterated phallic urethra, who was unwilling to un-
dergo more extensive urethroplasty.
In another patient with a stricture of the anastomotic urethra and phallic urethra, the
obstruction resulted in a urethral diverticulum at the location of the previously resected
vagina (Fig. 12-5, D). The urethral diverticulum was resected with a transabdominal ro-
botic-assisted laparoscopic approach (Fig. 12-5, E). Because the patient had a long urethral
stenosis, a fi st-stage urethroplasty with a buccal mucosal graft w s performed (Fig. 12-5,
F). Th s patient is currently awaiting second-stage reconstruction.
Although many patients prefer to void while standing, a patient may elect to undergo a
perineal urethrostomy as a temporizing measure (Fig. 12-5, G). Further reconstruction to
allow a patient to stand while voiding may be performed in the future.
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CHAPTER 12
Problems and Complications

There are several challenges to urinary reconstruction after phalloplasty in the female-to-
male transgender patient.5 There is no native corpus spongiosum to cover the urethral re-
construction. Preputial and penile skin flaps commonly used in standard penile urethral
reconstruction are not available in these individuals, and therefore extragenital grafts and
flaps must be used.13 Dense scar tissue may be present after the phalloplasty. Furthermore,
the neophallus is made up of skin, fat, and fascia, which may not be the ideal vascularized
graft recipient site.12
Even after successful reconstruction, urinary incontinence is prevalent in the female-to-

male transgender population because of trapping of urine in the fi ed and phallic parts of
the urethra.18 The long-term effect of a neourethra on bladder function is unknown, and
given the high propensity for recurrence of strictures and urinary fistulas, lifelong urologic
follow-up is of paramount importance.14
References
1. Dubin BJ, Sato RM, Laub DR. Results of 8. Rohrmann D, Jakse G. Urethroplasty in
phalloplasty. Plast Reconstr Surg 64:163, 1979. female-to-male transsexuals. Eur Urol 44:611,
2. Puckett CL, Montie JE. Construction of male 2003.
genitalia in the transsexual, using a tubed 9. Leriche A, Timsit MO, Morel-Journel N, et
groin flap for the penis and a hydraulic infla- al. Long-term outcome of forearm free-flap
tion device. Plast Reconstr Surg 61:523, 1978. phalloplasty in the treatment of transsexual-
3. Hage JJ, Bloem JJ. Review of the literature ism. BJU Int 101:1297, 2008.
on construction of a neourethra in female- 10. Kim SK, Moon JB, Heo J, et al. A new
to-male transsexuals. Ann Plast Surg 30:278, method of urethroplasty for prevention of
1993. fistula in female-to-male gender reassign-
4. Hage JJ, Bout CA, Bloem JJ, et al. Phallo- ment surgery. Ann Plast Surg 64:759, 2010.
plasty in female-to-male transsexuals: what 11. Blaschke E, Bales GT, Thomas S. Postopera-
do our patients ask for? Ann Plast Surg tive imaging of phalloplasties and their com-
30:323, 1993. plications. AJR Am J Roentgenol 203:323,
5. Lumen N, Monstrey S, Goessaert AS, et al. 2014.
Urethroplasty for strictures after phallic re- 12. Fang RH, Kao YS, Ma S, et al. Phalloplasty in
construction: a single-institution experience. female-to-male transsexuals using free radial
Eur Urol 60:150, 2011. osteocutaneous flap: a series of 22 cases. Br J
6. Rashid M, Tamimy MS. Phalloplasty: the Plast Surg 52:217, 1999.
dream and the reality. Indian J Plast Surg 13. Levine LA, Elterman L. Urethroplasty fol-
46:283, 2013. lowing total phallic reconstruction. J Urol
7. Rashid M, Sarwar SU. Avulsion injuries of 160:378, 1998.
the male external genitalia: classifi ation and 14. Monstrey SJ, Ceulemans P, Hoebeke P. Sex
reconstruction with the customised radial reassignment surgery in the female-to-male
forearm free flap. Br J Plast Surg 58:585, 2005. transsexual. Semin Plast Surg 25:229, 2011.
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CHAPTER 12
15. Lumen N, Oosterlinck W, Decaestecker K, et 17. Asopa HS, Garg M, Singhal GG, et al. Dorsal
al. Endoscopic incision of short (<3 cm) ure- free graft urethroplasty for urethral stricture
thral strictures after phallic reconstruction. by ventral sagittal urethrotomy approach.
J Endourol 23:1329, 2009. Urology 58:657, 2001.
16. Morey AF, McAninch JW. When and how to 18. Hoebeke P, Selvaggi G, Ceulemans P, et al.
use buccal mucosal grafts in adult bulbar ure- Impact of sex reassignment surgery on lower
throplasty. Urology 48:194, 1996. urinary tract function. Eur Urol 47:398, 2005.
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CHAPTER
13
Unfavorable Results and Complications
in Phalloplasty Surgery
CH
Salvatore D’Arpa, Nicolaas Lumen,
Piet Hoebeke, Christopher J. Salgado,
Vishal K. Sinha, Natalie R. Joumblat,
Stan J. Monstrey
Key Points
❖❖ Prevention and treatment of complications and ❖❖ Early complications include insufficient venous
failures of a phalloplasty are discussed. outflow in patients with a free radial forearm
❖❖ Failure to achieve the goals of correct penile flap, vascular insufficiency, partial necrosis, and
reconstruction despite a “successful operation” a fistula.
is also discussed. Sometimes these cases re- ❖❖ Delayed complications include strictures.
quire a redo. ❖❖ Late complications are atrophy, dyspareunia,
❖❖ Immediate or perioperative complications are erectile implant exposure, an unaesthetic
a short pedicle, arterial thrombosis, arterio- donor-site scar, and compression neuropathy.
venous shunts (radial forearm flap), and tight ❖❖ In cases of shriveled or incomplete phallo-
closure. plasty, redos must be considered.
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CHAPTER 13
Unfavorable Results and Complications in Phalloplasty Surgery
Th s chapter on unfavorable results in phalloplasty surgery provides not only a compre-

hensive list of possible bad results and their management but also useful tricks and tools to
prevent—or at least minimize—the incidence of complications.
Potential unfavorable results will be classifi d according to a chronologic order of imme-

diate, early, delayed, and late “complications.” Solutions and preventive measures will be
described case by case.
We will defi e what “an unfavorable result” is. A phalloplasty is a complex surgical proce-
dure that requires different reconstructive steps and the use of one or more sensate-free and/
or pedicled flaps to obtain an aesthetic and functional penile construction. An unfavorable
phalloplasty result includes all flap-related complications and all cases that have failed to
achieve the ideal goals of a phalloplasty as described by Hage and de Graaf 1 and Monstrey
et al.2 Even with the substantial progress in phalloplasty, a single technique that produces
an ideal neophallus without complications has not yet been found, and given its complex-
ity, it is unlikely that there will be a procedure in which revision surgery is never needed.
Thus part of this chapter will discuss the actual handling of untoward events, but part will
also detail the functional and aesthetic improvement of previously performed phalloplas-
ties that have failed to achieve these goals. An example of this category is an “uncompli-
cated” phalloplasty that was performed without urethral reconstruction. Thus, although
no complications occurred in the initially performed procedure, the goal of voiding while
standing has not been achieved. Because the population of these often rightfully demand-
ing patients seeking revision or improvement is constantly increasing, we will also describe
possible ways of improving previous incomplete or unfavorable phalloplasties. Th s latter
category will be named redo-phalloplasties.
In a transgender individual the ideal penile construction should achieve the following
goals3:
❖❖ Decrease the individual’s gender dysphoria
❖❖ Avoid the need for a prosthesis for penetrative vaginal or anal penetration, thus al-
lowing sexual intercourse with the construction
❖❖ Have the ability to achieve orgasm during the sexual experience
❖❖ Allow voiding while standing
❖❖ Have tactile and erogenous sensation
❖❖ Have a normal-looking scrotum and be aesthetically pleasing
❖❖ Cause little morbidity and scars at the donor site
Based on the experience in our centers, we will consider only phalloplasty surgery with the
radial forearm flap (RFF) and the anterolateral thigh (ALT) flap.
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CHAPTER 13
Immediate or Perioperative Complications

Short Pedicle
There can be a problem with the vascularity of both a free and pedicled flap phalloplasty
with a short pedicle. Very short pedicles do not pose any decisional dilemma, because ob-
viously such pedicles will not reach far enough for adequate tissue transfer. Sometimes the
pedicle is just long enough to reach the femoral vessels (or one of its side branches) for a free
flap reconstruction or the recipient site in the pubic area for a pedicled flap. In those cases
a little tension may cause vascular occlusion and subsequent revision for vascular insuffi-
ciency. If there is any doubt, we advocate taking one of the measures that will be described
instead of waiting for the problem to occur and needing to do a revision.
If a pedicled (ALT) flap phalloplasty has a short pedicle, the surgeon should convert it to a
free flap without hesitation. Postoperative swelling can only worsen a borderline scenario.
If the pedicle is still too short, adequate measures should be taken as will be described for
free flaps.
To prevent this unlucky scenario in an ALT flap phalloplasty, we always perform an an-
giographic CT scan preoperatively4 to identify the best thigh and pedicle both in diameter
and distance from the groin area. Thus the need to use a short or small-sized pedicle can
be avoided. Perforators located less than 20 cm below the anterior superior iliac spine are
at risk of being too short.
In an RFF phalloplasty, pedicle shortness is a problem that normally only affects the arte-
rial side. In the dissection of an RFF, the cephalic vein is harvested until after the conflu-
ence between the superfic al and deep venous systems, resulting in a draining vein that is
always longer than the artery. Furthermore, on the venous recipient side, many long veins
can always be found. If this is not the case, the great saphenous vein can always be har-
vested to a suffi ent distal length and then divided and transposed cranially to allow a safe,
large-caliber, and tension-free venous anastomosis. The drawback is that a longer vein is
more prone to kinking if not appropriately positioned. The surgeon should always double
check vein position before closing. If the saphenous vein is used, positioning of a coupler
may be difficult. The saphenous vein tends to be thick walled and not easy to bend over the
circular ring of the coupler.
A short arterial pedicle will not reach the femoral artery (common or superfic al) and its
branches below the inguinal ligament, which are sometimes too small to allow a safe anas-
tomosis. If this is the case, two options are available: arterial transposition or arterial in-
terposition graft.
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CHAPTER 13
Arterial Transposition (Deep Inferior Epigastric Artery)

If the gap to be filled is less than 4 cm (pedicle to femoral vessels), the deep inferior epi-
gastric artery (DIEA) can be identifi d and used for vascular anastomosis. In this situation
DIEA vessels can be harvested either through an extension of the existing groin incision
(Fig. 13-1) or an extended Pfannenstiel incision (Fig. 13-2). The superior adipocutaneous flap
is raised as needed with cephalad traction, and an incision is made just medial to the lateral
border of the rectus abdominis muscle. The anterior rectus sheath fascia is incised, and the
deep inferior epigastric vessels are isolated from the posterior rectus sheath posteriorly and
the rectus muscle anteriorly. The artery and venae comitantes are harvested cranially until
the desired length is reached; the surgeon must be careful to preserve the motor intercostal
nerve branches. The vessels are then divided distally and transposed to the recipient site
through the opening in the fascia (Fig. 13-3) that will be sutured completely except for a
hole for the vessels. Although the artery maintains an adequate caliber, the veins may be so
small that the discrepancy with the flap’s vein is too big. In this latter case the transposed
saphenous vein or one of its branches can be used for outfl w (see Fig. 13-2).
After the desired length of the pedicle is obtained, the artery is ligated, divided, and trans-
posed caudally. Letting the artery come out of the abdominal wall from the lowest point of
the fascial incision usually allows suffici t length to almost reach the pubis. Tunneling the
pedicle underneath the inguinal ligament to bring it below provides additional length but
at the expense of a longer, deeper, and more complicated dissection. Th s is almost never
necessary, because extending the dissection cranially is usually easier and as effective; this
is because the inferior epigastric vessels do not reduce much in their caliber in their course
underneath the rectus abdominis muscle. Furthermore, the proximal part of the artery lying
underneath the ligament is rather tortuous, whereas the distal part underneath the rectus
muscle is straight and easier to position. When closing the abdomen, the surgeon should
carefully reapproximate the two layers of fascia that are encountered without arterial com-
pression. Some surgeons reinforce the anterior rectus sheath with a mesh graft o avoid a
postoperative bulge. However, preservation of the intercostal motor branches and careful
reapproximation of the fascial layers prevent any bulging.
Fig. 13-1 The DIEA and venae comitantes (green backgrounds) are isolated through the prolonged
groin incision. A microvascular clamp is placed on the vessels before division.
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CHAPTER 13
Fig. 13-2 The deep inferior epigastric artery and vein are tunneled into the defect after an extended
Pfannenstiel incision is used to harvest the vessels. Two saphenous veins as outflow vessels, the left
ilioinguinal nerve, and the denuded clitoris are also shown.
Fig. 13-3 The transposed DIEA and venae comitantes almost reach the recipient site. It is not always
necessary to take such a long stump. The shorter the stump, the bigger the caliber.
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CHAPTER 13
Fig. 13-4 The left descending branch of the lateral circumflex femoral artery is dissected and tun-
neled in the defect for recipient vessels when inferior epigastric arteries were not useful and femoral
arteries had extensive scarring.
Arterial Interposition Graft (Deep Inferior Epigastric Artery/Descending

Branch of the Lateral Circumflex Femoral Artery)
An alternative to arterial transposition can be an arterial interposition graft. n arterial
(and venous) interposition graft an be harvested from the deep inferior epigastric ves-
sels as previously described or from the DIEA/descending branch of the lateral circumfle
femoral artery, which is the ALT flap pedicle, accessed through an incision at the septum
between the vastus lateralis and rectus femoris muscles and deepened until the pedicle is
encountered lying on the medial edge of the vastus lateralis (Fig. 13-4). As long as the mo-
tor nerve to the vastus lateralis is spared, this donor site provides easy access to a very long
graft ith no functional loss and through a linear scar in a thigh that is usually already
scarred to harvest either an ALT flap and/or a split-thickness skin graft sed to cover the
ALT or RFF donor site. In ALT phalloplasties the graft an be harvested from the vessels
distal to the perforator or from the contralateral thigh. We prefer to avoid a vein-to-artery
graft. n artery-to-artery graft reserves a more physiological situation, better tolerates
high-pressure regimens, and maintains the pulsatile fl w.
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CHAPTER 13
Arterial Thrombosis
Immediate arterial thrombosis is a very rare event, but it can sometimes complicate a
phalloplasty procedure intraoperatively or (very) shortly after surgery. These early arte-
rial thrombi are normally white and easy to remove. The problem with this complication
is not only that the anastomosis (either end-to-end on a side branch or end-to-side on the
femoral artery) must be redone, but there is not too much room for vessel shortening in the
fi st case or for a change in anastomotic site in the second case. When a thrombosis occurs
at an end-to-side anastomosis, the surgeon should preferably not remove the anastomosis
and close the femoral artery, because leakages or breakdowns may occur. The flap’s artery
is normally divided while leaving the stump (ligated or clipped) attached to the femoral
vessels. A new recipient vessel must be found, eventually requiring an arterial interposition
as previously described for short pedicled flaps. In this case the inferior epigastric artery is
an excellent choice for a recipient artery.
If the thrombosis is not explained by a technical mistake, thromboprophylaxis is started

with a bolus of an antiplatelet drug (dipyridamole, lysine salicylate, and piracetam) at the
completion of the arterial anastomosis before clamp release. Antiaggregation is continued
postoperatively as a continuous infusion for 24 hours and then orally for 7 days. Th s regi-
men is only used in patients with an otherwise unexplained arterial thrombosis. Alterna-
tively, low-molecular-weight heparin and aspirin—discontinuing heparin on discharge and
aspirin after 1 month—can be used.
Arteriovenous Shunts (Radial Forearm Flap)

Although rare, an arteriovenous fistula that causes a steal phenomenon to the flap may exist
between the radial artery and venae comitantes. In these cases the anastomoses are patent,
there is venous return in the vein, and the flap is pale; there is neither bleeding nor capil-
lary refill. The clue to diagnosis is a pedicle that is well pulsatile until a certain point with
venous return through the flap’s vein (this latter case rules out a pedicle thrombosis). On
suspicion the pedicle is examined starting from the anastomosis and carefully isolating the
artery from the vein until the communication is found and ligated or clipped. Sometimes
there can be multiple shunts. In these latter cases the fl w will progress a little further and
then stop again. After all the fistulas are closed, the flap will again be well perfused.
Tight Closure
If the subcutaneous fatty layer in the forearm or thigh is too thick (or the dimensions of the
flap are not designed large enough), closure under tension, which is often combined with
postoperative swelling, can cause a compartment syndrome within the flap, jeopardizing
vascularization of the urethra, the outer flap, or both. Every time tension is observed, the
flap should not be sutured to itself but left pen in its ventral part and the residual defect
grafted. Th s is often required only in the proximal two thirds of the flap, but if any doubt
exists, it is safer to place a small skin graft over the complete ventral side of the flap (which
will not be visible long-term) rather than risking partial flap necrosis. The same applies to
revisions for venous congestion, hematomas, or intraflap arteriovenous loops (Fig. 13-5),
which result in additional flap congestion and increased swelling. In these cases the cylin-
der of the penis should not be closed but left pen and grafted.
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CHAPTER 13
A B
Fig. 13-5 A, A ventral view of an ALT plus superficial circumflex iliac artery perforator (SCIAP) phal-
loplasty. The skin graft (covered with SurfaSoft) was placed on the ventral side (thus on the SCIAP) to
avoid tension while closing. B, One year after surgery, the skin graft on the ventral side is not always vis-
ible and has an acceptable appearance.
Th s occurrence may be prevented by accurate preoperative planning. Not every patient has
the same subcutaneous fat thickness, and applying a standard template for flap planning
to all patients may not always be adequate. The thicker the subcutaneous tissue, the larger
the radius and circumference of the phallus. The surgeon can measure subcutaneous flap
thickness with a pinch test or a CT scan to approximately calculate the necessary circum-
ference, and the flap’s width can be adjusted accordingly.
Early Complications
Insufficient Venous Outflow in a Free Radial Forearm Flap
To guarantee good venous drainage in a free RFF phalloplasty, both the superfic al and deep
systems are used. The cephalic vein is anastomosed after the deep and superfic al systems
are joined together, possibly including additional superfic al tributaries of the cephalic vein
that drain the flap.
Sometimes in an RFF, venous congestion may occur with a patent venous anastomosis be-
cause of slow venous return. If such an otherwise unexplainable venous congestion is ob-
served or there is insuffici t venous drainage after an anastomotic revision, the capillary
connections between the radial artery (somewhat pulsating against a “wall” at the end of the
flap) and the venules may be insuffici t to drain such a large flap alone and may need extra
fl w rate. Therefore during flap dissection, a superfic al vein (usually the cephalic) and the
radial artery are routinely dissected out distally 1 to 2 cm longer to preserve a long stump
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CHAPTER 13
A B
Fig. 13-6 A, When an arteriovenous loop is created, the phallus looks congested. This is normal.
B, After closure of the fistula, the skin color returns to normal.
in the distal portion of the flap that will be used to create an arteriovenous anastomosis in
cases of impaired venous outflow. The augmented venous return that is created by directly
connecting the distal stump of the radial artery to the distal stump of the superfic al vein
will create a Venturi effect that sucks blood out of the flap. The flap will swell, and coun-
termeasures such as those mentioned previously for tight closure should be considered.
After 5 to 6 weeks, in the outpatient clinic and even without a local anesthetic (the penis is
still insensate), the arteriovenous loop can be exposed through a small incision and simply
ligated (Fig. 13-6).5
Strict monitoring of microsurgical phalloplasty is performed in the ICU; here the vascular
infl w is monitored with the use of a pencil Doppler probe. Two of the authors (C.J.S. and
V.K.S.) have commonly used the implantable Doppler probes around the recipient vein to
detect early obstruction. The free flaps are monitored every 30 minutes for 24 hours, fol-
lowed by every hour for 24 hours, followed by every 2 hours on the third day.6 The patient
is then transferred from the ICU to the hospital fl or, where the phalloplasty is monitored
every 4 hours until discharge. Th s has allowed very early detection of vascular compro-
mise, and no incidences of flap death have occurred after any reexploration procedure.
The other authors monitor the flap every hour in the postoperative ICU until the morning
after surgery, and on the fl or early reexploration is the key to maintain a low (less than
1%) flap loss rate.
Vascular Insufficiency
Arterial or venous thrombosis is quite infrequent, because big vessels with a strong fl w
are used. If arterial or venous anastomoses are revised, a change in recipient vessels can be
contemplated.
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CHAPTER 13
Fig. 13-7 A, A rectus sheath hematoma after inferior epigastric flap harvest for RFF phalloplasty. B, A
CT scan confirmed the findings. The patient was taken to the operating room on an emergency basis to
avoid vascular compromise of the flap.
If, after redoing the anastomoses, there is little or no refl w, intraarterial thrombolysis
should be administered to dissolve thrombi that may have formed in the microcirculation
of the flap. We routinely use urokinase (100,000 IU in 10 ml of saline solution) or tissue
plasminogen activator (10 mg in 50 cc of normal saline solution) as an intraarterial bolus
administered either directly into the artery or through one of its side branches. To avoid
drug circulation in the bloodstream, the flap’s vein is left pen to drain the drug, or if the
anastomosis has already been done, it is clamped upstream from the anastomosis, and one
of its branches is left pen to let the drug fl w out. Thus there is no risk of bleeding or drug
overdose, and multiple boluses can be administered until the circulation is restored.7 If the
take-back procedure required continued heparin administration, the risk of a hematoma
is increased, and the patient is closely monitored. Because the posterior rectus sheath may
be pliable, a signifi ant hematoma may occur with minimal clinical fi dings (Fig. 13-7).
In a free RFF phalloplasty, because the venous pedicle is usually longer than the arterial
one, the surgeon should avoid kinking of the vein, which can cause venous occlusion. In a
pedicled ALT, vascular insuffici cy may occur because of a short pedicle. In these cases
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CHAPTER 13
Fig. 13-8 A pedicled ALT flap for a phalloplasty converted to free flap on day 1 because of vascular in-
sufficiency, resulting from tension on the pedicle. The pedicle is divided and anastomosed to the groin
vessels (femoral artery and great saphenous vein; see text for details).
the flap should be converted to a free flap without hesitation as previously described (Fig.
13-8). To relieve tension, the patient is routinely placed in bed with slight hip flexi n.
A compartment syndrome caused by tight closure and postoperative swelling or a hema-

toma inside the flap can be the cause of vascular insuffici cy. In these cases the ventral
sutures should be opened and the wound grafted to release pressure. To prevent hemato-
mas, meticulous hemostasis of the flap is imperative. Any bleeding at the undersurface of
the flap must be located and coagulated.
Most slow-developing vascular insuffici cies that involve only the distal parts of the flap
and cannot be surgically corrected may result in a skin slough or even partial necrosis, as
will be discussed.
Partial Necrosis
To maximize flap vascularization, the circulation of the flap is left o settle after flap har-
vest. Before tubing or transferring the flap, we usually wait 20 minutes for any spasm of the
blood vessels to resolve and for the circulation to be restored.
Unfortunately, if skin slough or a partial flap necrosis occurs, it always involves the dis-
talmost parts of the flap around the glans of the penis or at the side of the base of the flap
furthest away from the radial artery. In both scenarios the surgeon should wait until the
necrosis is demarcated. A skin slough is normally treated conservatively, and partial flap
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CHAPTER 13
A B
Fig. 13-9 A, Partial necrosis in an RFF phalloplasty. After escharotomy the healthy dorsal flap is used
(like a dorsal preputial flap is used in hypospadias repair) to reconstruct a glans and a meatus. B, The
ventral side can be skin grafted.
necrosis can usually be handled with a local plasty (Fig. 13-9) or skin grafting. If vascular
compromise is suspected during flap transfer, the coronoplasty is usually delayed for an-
other operation.
Large partial necroses that involve the ventral side and the urethra need debridement and
flap repair. If only the ventral part of the urethra and its skin cover are lost, the urethra is
partially reconstructed with a full-thickness skin graft covered with a pedicled SCIAP flap.
To keep the graft in place, we use an intraurethral mold made by a plastic sleeve filled with
gel (Fig. 13-10).
If the whole urethra needs to be reconstructed, two surgical options are available: a free
RFF8 or a pedicled SCIAP.9
The free RFF allows harvesting of enough skin to provide the urethral tube and a narrow
strip of skin for outer coverage. The flap is designed as in a conventional phalloplasty, with
a smaller outer skin island designed according to the defect size (Fig. 13-11).
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A B
Fig. 13-10 A, After partial failure of urethral reconstruction, the missing half can be reconstructed
with a skin graft. B, A sterile sleeve, such as the one used for gamma probes, is filled with gel and in-
serted to hold the graft in place.
A B
Fig. 13-11 A, Frontal view of an RFF used to reconstruct the whole urethra. B, An external skin island
is left after tubing to reconstruct the ventral side.
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CHAPTER 13
A pedicled SCIAP flap only allows reconstruction of the urethral tube (see Chapter 9). A
skin graft s used for the outer lining that is better delayed through preliminary allograft
coverage until the wound granulates and a better graft take can be obtained.
Fistulas
Urinary fistulas are not an infrequent complication after phalloplasties in transmen, and
thus many surgeons do not even try to reconstruct the urethra and perform an incomplete
phalloplasty. These fistulas are more frequent when urethral anastomoses are proximally
located. If a fistula occurs as a result of wound dehiscence or partial necrosis, the surgeon
should not attempt an immediate repair. Direct closure will inevitably fail. Any immedi-
ate flap closure may have the potential to fail and will sacrifice a potentially useful tool for
future use regardless of whether it has been used successfully, particularly if infection has
also occurred (Fig. 13-12). Two of the authors (C.J.S. and V.K.S.) advocate the use of local
flaps for urethroplasty in conjugation with the RFF or urethral prelamination with mucosa
tissue to reduce fistula rates.
Most fistulas will close spontaneously over weeks or months. The patient will receive ad-
equate preoperative instructions about the possible occurrence of this complication.
A B
Fig. 13-12 A, This patient developed a penoscrotal fistula and infection 3 weeks after RFF phallo-
plasty and was treated with debridement and an immediate gracilis flap to the defect within 1 week.
B, The patient urinated well 3 months after phalloplasty.
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Delayed Complications
Stricture
A fistula that heals secondarily may result in a stricture of the urethra because of wound
contraction. Strictures should be evaluated by antegrade voiding cystourethrography. In
addition, suprapubic catheters can be used to avoid damage to the neophallus from Foley
catheters. The stricture should be treated by an expert urologist.10-13 Dilations or urethroto-
mies usually have a temporary effect only; for correction of a recurrent or extensive stric-
ture, urethroplasty must be performed. Various types of urethroplasties can be used to treat
these strictures, such as meatotomy, free graft u ethroplasty, pedicled flap urethroplasty,
and Heineke-Mikulicz. For short urethral strictures less than 3 cm, endoscopic incisions
are recommended.
Flap prelamination with mucosa may decrease stricture rates.14 Two of the authors encour-
age meatal maintenance with a meatal dilator to avoid both strictures at the external ure-
thral meatus and more proximal fistulas (Fig. 13-13).
Fig. 13-13 Cook meatal dilator (Cook Medical, Bloomington, IN).
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CHAPTER 13
Fig. 13-14 RFF phalloplasty that permitted successful vaginal penetration and orgasm with the abil-
ity to urinate in the standing position, following 1 year with a dual-rod inflatable penile prosthesis in
place. However, softening of the neoglans caused a ptotic glans. A 30 cc lipoinjection was performed
to correct the deformity and avoid implant exchange for a longer implant, which can have a high risk of
extrusion.
Late Complications
Atrophy
In the long term, especially in cases of RFF phalloplasty, the penis may atrophy substan-
tially and assume a fl ppy appearance or clearly show the erection prosthesis. The softening
of the phallus can occur as a result of soft tissue resorption. Penile shaft circumferences in
various patients decreased signifi antly 1 year after surgery. Th s could be caused by de-
creased metabolism, friction, or blood supply changes. A solution to this problem can be
lipofilling, artific al dermal grafts, or silicone rod insertion. With lipofilling the fat may be
resorbed and require additional injections (Fig. 13-14). A redo can also be considered. An
ALT flap phalloplasty usually has less atrophy.
Dyspareunia
Erectile rigidity, which is essential to engage in sexual intercourse, is an issue in patients
undergoing RFF phalloplasty. Penile prostheses are required that can cause genital pain as-
sociated with sexual intercourse. When phalloplasty is performed with an osteocutaneous
fibula flap, pain can be alleviated with the creation of pseudojoints within the bone graft
resulting in segmental osteotomies. By harvesting the tensor fascia lata for interposition
between bone segments, the neophallus can maintain semirigidity and allow pain-free vagi-
nal intercourse.15 Two of the authors (C.J.S. and V.K.S.) also advocate a free scapular flap
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CHAPTER 13
along with a malleable penile prosthesis. Th s method has shown promise by maintaining
a hairless flap, which eliminates the issue in urethral reconstruction. A free scapular flap
also has a greater quantity of tissue available than the free RFF.
Erectile Implant Exposure

Erectile implant exposure is not uncommon and can occur if the penile prosthesis cylin-
der extrudes through the skin during or after implantation. Because of the lack of the tu-
nica albuginea, the cylinders created are less protected from trauma. Even a well-placed
erectile implant in a sensitive penis can be extruded because of infection or pressure that
causes skin ulceration. More commonly the extrusion occurs ventrally or laterally and in
patients with aggressive distal dilation or decreased distal penile sensation. In these cases
the implant should be removed, and later replacement should be carefully considered. It is
difficult to repair the extrusion, because the process of fi ding adequate tissue for closure
and the reduced blood supply in the area impede the process. Furthermore, the presence
of periprosthetic fluid, exudate, and erosions contraindicates immediate repair.
Unaesthetic Donor-Site Scar

There is little room for improvement of the scar in a free RFF flap, because the forearm skin
has been almost entirely used. To optimize healing, we always harvest the flap suprafascially,
keeping the paratenon intact. By preserving the fascia, tenting is prevented, along with ad-
hesion of the fle or myotendinous structures. Th s reduces complications associated with
range-of-motion abnormalities. The wound edges are meticulously approximated to the
underlying muscles to reduce a step deformity; dermal substitutes can be used to provide
some additional thickness underneath the skin graft.
Lipofilling or tattooing is the only available solution to improve a scar after surgery.
Conversely, in ALT phalloplasty, sufficient thigh skin is left to allow expansion. Expansion
can be performed before surgery to immediately close the wound at the time of phalloplasty
(see Chapter 9) or after surgery to improve an unsightly donor site.
A modifi d version of the RFF flap has had better outcomes regarding donor-site morbidity
compared with the classic RFF flap in phalloplasty. This method, known as radial artery–
based free flap urethroplasty, incorporates a 4 cm wide tubularized free flap based around the
radial artery with a preexisting infraumbilical flap to create a neourethra. Th s minimizes
donor-site scarring on the forearm while maintaining a sensate neourethra.
Compression Neuropathy
Sometimes a persistent compression neuropathy is observed affecting the superfic al branch
of the radial nerve in the forearm. Patients may complain of pain in the region of the ana-
tomic snuffbox. Alternatively, a cut branch of the superfic al branch of the radial nerve can
also result in a painful neuroma that may need to be surgically removed.
Several patients have complained of tenderness at the knee level after an ALT phalloplasty.
Lipofilling around the affected nerve may alleviate the symptoms in these cases.
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CHAPTER 13
Fig. 13-15 A shriveled phalloplasty.
Redos
Shriveled or Incomplete Phalloplasty
Because we are now starting to see patients with long follow-ups, we are seeing an increas-
ing population with a shriveled phalloplasty (Fig. 13-15) or an incomplete phalloplasty. The
treatment for these cases is a redo phalloplasty. This has not been seen in patients who have
undergone osteocutaneous flaps but commonly occurs in patients who have not undergone
penile implant insertion. Such cases are simplifi d by the already existing penis. The skin
of the present penis will be incised and tubed on itself to provide for a urethral tube. If the
urethral tube needs lengthening, the skin of the previous phalloplasty can also be used as
a distally based flap. The outer coverage will be provided by a pedicled ALT or free RFF.
Nonsensate phalloplasties also fall into this category.
References
1. Hage JJ, de Graaf FH. Addressing the ideal 5. Hage JJ, Monstrey S. Free-flap distal arterio-
requirements by free flap phalloplasty: some venous fistula: when to close it? J Reconstr
refl ctions on refi ements of technique. Mi- Microsurg 14:407, 1998.
crosurgery 14:592, 1993. 6. Salgado CJ, Moran SL, Mardini S. Flap moni-
2. Monstrey S, Hoebeke P, Selvaggi G, et al. Pe- toring and patient management. Plast Recon-
nile reconstruction: is the radial forearm flap str Surg 124(6 Suppl):e295, 2009.
really the standard technique? Plast Reconstr 7. D’Arpa S, Cordova A, Moschella F. Pharma-
Surg 124:510, 2009. cological thrombolysis: one more weapon for
3. Salgado CJ, Monstrey S, Hoebeke P, et al. Re- free-flap salvage. Microsurgery 25:477, 2005.
construction of the penis after surgery. Urol 8. Tchang LA, Largo RD, Babst D, et al. Second
Clin North Am 37:379, 2010. free radial forearm flap for urethral recon-
4. Sinove Y, Kyriopoulos E, Ceulemans P, et al. struction after partial flap necrosis of tube-
Preoperative planning of a pedicled antero- in-tube phalloplasty with radial forearm flap:
lateral thigh (ALT) flap for penile reconstruc- a report of two cases. Microsurgery 34:58,
tion with the multidetector CT scan. Hand- 2014.
chir Mikrochir Plast Chir 45:217, 2013.
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9. Koshima I, Nanba Y, Nagai A, et al. Penile construction: a single-institution experience.

reconstruction with bilateral superfic al cir- Eur Urol 60:150, 2011.
cumflex iliac artery perforator (SCIP) flaps. J 13. Lumen N, Oosterlinck W, Decaestecker K, et
Reconstr Microsurg 22:137, 2006. al. Endoscopic incision of short (<3 cm) ure-
10. Lumen N, Vierstraete-Verlinde S, Oosterlinck W, thral strictures after phallic reconstruction. J
et al. Buccal versus lingual mucosa graft in Endourol 23:1329, 2009.
anterior urethroplasty: a prospective com- 14. Zhang YF, Liu CY, Qu CY, et al. Is vaginal
parison of surgical outcome and donor site mucosa graft the excellent substitute material
morbidity. J Urol 195:112, 2016. for urethral reconstruction in female to male
11. Lumen N, Oosterlinck W, Hoebeke P. Ure- transsexuals? World J Urol 33:2115,2015.
thral reconstruction using buccal mucosa 15. Salgado CJ, Rampazzo A, Xu E, et al. Treat-
or penile skin grafts: systematic review and ment of dyspareunia by creation of a pseu-
meta-analysis. Urol Int 89:387, 2012. dojoint in rigid bone following total penile
12. Lumen N, Monstrey S, Goessaert AS, et al. reconstruction with fibular osteocutaneous
Urethroplasty for strictures after phallic re- flap. J Sex Med 5:2947, 2008.
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K24940_Book.indb 208 8/22/2016 7:16:40 AM
CHAPTER
14
Medical Treatment of Adolescent
Transgender Patients
CHA
Daniel E. Shumer, Norman P. Spack
Key Points
❖❖ Treatment of gender dysphoria with hormonal ❖❖ Cross-sex hormones (17 beta-estradiol and
interventions in carefully assessed adolescents testosterone) can be used to support the devel-
can reduce dysphoria, prevent development of opment of desired secondary sex characteris-
unwanted secondary sex characteristics, and tics in older adolescents with persisting gender
support development of desired secondary sex dysphoria.
characteristics. ❖❖ Treatment of adolescents with hormonal inter-
❖❖ Treatment requires collaboration between ex- ventions has unique surgical considerations.
perienced mental health providers and medical Medical providers caring for this patient popu-
providers. lation should familiarize themselves with the
❖❖ Pubertal suppression, a fully reversible inter- surgical options available to adolescents and
vention, can be considered at sexual maturity adults with gender dysphoria.
rating 2 (early puberty). This intervention can
reduce dysphoria, prevent development of un-
wanted secondary sex characteristics, improve
future gender attribution (“passability” as the af-
firmed gender), and obviate the need for some
surgical interventions.
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CHAPTER 14
Medical Treatment of Adolescent Transgender Patients
Gender identity refers to a person’s internal sense of gender (for example, boy, girl; man,
woman; or a nonbinary identifi ation such as genderqueer). A transgender person feels
discordance between assigned biologic sex at birth and gender identity. Gender dysphoria
refers to the discomfort felt as a result of this discordance.1 Gender dysphoria in childhood
and gender dysphoria in adolescents and adults are defi ed separately in the Diagnostic and
Statistical Manual of Mental Health Disorders, edition 5 (DSM-5), and in the previous edi-
tion was referred to as gender identity disorder.2,3 Children and adolescents are diagnosed
with gender dysphoria if they have a signifi ant difference between their experienced and
assigned gender that has persisted for at least 6 months and causes signifi ant distress or
impairment in functioning. The change in terminology removes the stigmatizing word
“disorder” and highlights that the dysphoria can improve with a variety of interventions,
including counseling, cross-sex hormones, and gender affirmation surgery (GAS). Although
there is an evolving deemphasis on the pathology of gender dysphoria and acceptance of
gender identity diversity, transgender adolescents continue to be disproportionately affected
by mental health comorbidities, such as anxiety, depression, self-harm, and suicidality. 4
The World Professional Association for Transgender Health (WPATH) and the Endocrine
Society provide clinical standards of care for treatment of the transgender adolescent.5,6
The Transgender Child

Children are born into a gendered world, where boys and girls are often dressed differ-
ently and encouraged to participate in different types of play, and where men and women
may traditionally assume different familial or occupational roles. In addition, stereotypical
gender roles and gender behavior vary among different cultures and also change over time.
Children 2 to 3 years of age are able to label themselves as boy or girl; by ages 4 to 5, they
can understand the stability and lasting nature of gender.7 Gender-specific oy preference
emerges as young as 12 months, and children can use gender labels (boy, girl) by 2 years
of age.8 As young children begin to develop preferences in play and dress, these behaviors
may appear very gender conforming, very gender nonconforming, or somewhere within
this spectrum. Some gender nonconforming children may state a desire to be the other
gender or express a feeling that they are the other gender, even by 3 years of age. 9 Young
children with cross-gender identifi ation may become transgender adolescents; however,
the evidence suggests that a larger percentage will not be transgender, and that individuals
with a cross-gender identity in young childhood that later desists have high rates of iden-
tifi ation as gay or lesbian.10,11
Sex hormones, chiefly testosterone and estrogen, are steroids produced by the testes and
ovaries that cause a multitude of effects that result in biologic differences between males and
females. In fetal life and also in the fi st 6 to 12 months of postnatal life, there are signifi ant
differences in sex hormone levels in male and female fetuses and infants. The absence of
testosterone production in fetal life results in normal female genitalia, whereas testoster-
one produced in the fetal testes is converted to dihydrotestosterone in the genital tissue,
resulting in virilization of the external tissues into normal male genitalia.12 Differences in
sex hormone levels during fetal life and infancy between the biologic sexes also likely play
an important role in sexual differentiation in brain organization. These differences may be
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CHAPTER 14
an important contributor to group differences in behaviors observed between males and

females later in life.13,14
In later childhood, as gender identity begins to manifest, the testes or ovaries have entered
a quiescent stage with very little sex hormone production, and therefore there is little dif-
ference in the hormonal milieu between prepubertal male and female children (Figs. 14-1
through 14-3). Therefore hormonal intervention is not indicated for prepubertal children.
Instead, the child and family can focus on mental health and logistical issues, such as ad-
dressing mental health comorbidities (for example, anxiety or depression) and deciding
whether to make a social transition to the affirmed gender in young childhood. Although
there is consensus that prepubertal children with gender dysphoria should be seen by a
mental health professional with gender experience, there is not a consensus among mental
health providers with respect to the goals of treatment.15 Some argue that because of the fre-
quency of desistance later in adolescents, the therapeutic goals should focus on reduction in
dysphoria through acceptance of the biologic sex.16 Another strategy focuses less on gender
identity but rather on emotional, behavioral, and family problems that are co-occurring.17
Finally, affirmative approaches help families to support the child’s identifi d gender and as-
sist children and families in making a social transition.18 When prepubertal children make
a social transition, presenting themselves as their affirmed gender, their ability to “pass” as
their affirmed gender is aided by the fact that they have not yet developed secondary sexual
characteristics. Th s process of “passing” is also known as gender attribution, the process an
observer undertakes when deciding what gender they believe another person is.15
Fig. 14-1 Transgender children, all expressing a gender incongruent with their biologic sex. Before
production of sex hormones, children are quite passable as either gender. (Courtesy of Sarah Wong
from Inside Out: Portraits of Cross-gender Children, 2011.)
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CHAPTER 14
Fig. 14-2 A prepubertal transgender boy. (Courtesy of Sarah Wong from Inside Out: Portraits of Cross-
gender Children, 2011.)
Fig. 14-3 A prepubertal transgender girl. (Courtesy of Sarah Wong from Inside Out: Portraits of Cross-
gender Children, 2011.)
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CHAPTER 14
Normal Puberty
Puberty, the life stage characterized by the development of secondary sexual character-
istics, begins with the activation of the gonadotropin-releasing hormone (GnRH) pulse
generator in the hypothalamus, which results in pulsatile luteinizing hormone (LH) and
follicle-stimulating hormone (FSH) production within the anterior pituitary and secretion
into the systemic circulation. LH in turn causes the production of testosterone in testicular
Leydig cells and androgens in ovarian Theca cells, which are converted to estrogen within
the ovary (Fig. 14-4). FSH causes germ cell maturation and testicular enlargement in males
and the growth and recruitment of ovarian follicles in females.19,20 In males, testosterone
and dihydrotestosterone cause the development of male secondary sexual characteristics
and musculoskeletal changes, such as enlargement of the phallus, enlargement of the laryn-
geal prominence and deepening of the voice, development of facial hair, an increase in lean
muscle relative to fat, widening of the shoulders, and masculinization of the facial bones
and jaw. Testosterone production during puberty also causes accelerated growth within
skeletal growth plates, the effect of which results in taller stature among men compared
with women. In females, estrogen production causes the development of glandular breast
tissue. Th s is followed by maturation of the vulva and vaginal epithelium, proliferation of
the uterine lining with subsequent menstruation, distribution of body fat to the hips and
buttocks, and skeletal growth, followed by closure of epiphyseal growth plates.21
Hypothalamus
GnRH
Anterior pituitary
Luteinizing
hormone
Testes
Ovaries
• Growth and Testosterone Estrogen • Breast

development of development
phallus • Regulation of
• Voice deepening menstrual cycle
• Body/facial hair • Closure of growth
growth plates
• Height growth
acceleration
Fig. 14-4 The hypothalamic-pituitary-gonadal axis.
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CHAPTER 14
The hallmark physical examination fi ding heralding the start of central puberty in males
is testicular enlargement and in females development of breast buds. These early findings
defi e testicular and breast sexual maturity rating (Tanner stage) 2. Pubic hair develop-
ment, which may develop before central puberty as a result of adrenal androgen production,
is not a reliable marker of activation of the hypothalamic-pituitary-gonadal axis.22,23 Th
average timing of pubertal initiation has historically been age 10 to 11 years in females and
age 11 to 12 years in males, with precocious puberty defi ed as initiation before age 8 years
in females and age 9 years in males; however, new evidence suggests that normal central
puberty may occur in the absence of pathology at ages younger than previous estimates.24
Peak height velocity occurs about 21∕2 years after the start of pubertal growth acceleration.25
In males, characteristics that signifi antly affect gender attribution, such as facial hair de-
velopment, completion of voice change, and masculinization of facial bones, occur later
compared with genital development. The lateness of these changes within normal male
puberty provides an incentive for pubertal suppression in transgender males who present
in late puberty. In females, breast development typically progresses from sexual maturity
rating 2 to 5 (fully developed) within 4 to 5 years, and menses typically begins 2 to 21∕2 years
after breast budding.21
Overview of Medical Management

Both WPATH and the Endocrine Society standards of care suggest that the diagnosis of
gender dysphoria should be made by a mental health professional before consideration of
hormonal intervention.5,6 Some pediatric centers perform mental health evaluations as
part of a multidisciplinary gender team, emphasizing the role of mental health assessment
and support in concert with medical treatment.26 The goals of hormonal treatment include
prevention of the development or progression of unwanted secondary sex characteristics of
the biologic sex and the induction of desired secondary sex characteristics of the affirmed
gender. Broader goals of treatment include a reduction in dysphoric feelings, enhanced
ability to “pass” as the affirmed gender, resulting in improved integration into society, and
reduction in comorbid mental health outcomes such as anxiety, depression, and suicidal-
ity. Long-term outcome data from the Dutch group suggest improvement in psychological
function in carefully selected adolescents treated with pubertal suppression followed by
cross-sex hormones and a multidisciplinary team throughout treatment.27,28
Pubertal Suppression
The management sequence of treating early pubertal children with GnRH agonist medica-
tion to suppress puberty, followed by cross-sex hormones later in adolescence (Fig. 14-5),
was fi st described by Cohen-Kettenis and colleagues29,30 at the Vrije University Medical
Center in Amsterdam. Pubertal suppression allows a transgender child in early puberty
the time to explore his or her gender identity without the continued influence of sex hor-
mones, which can cause dysphoria and permanent changes to the body. Not only can pu-
berty suppression reduce dysphoria, it can result in enhanced gender attribution later in
adolescence and adulthood. It also can obviate the need for future surgical interventions.
For females, if pubertal suppression is initiated at pubertal stage 2 breast development, mas-
culinizing chest reconstruction may be avoided. If suppression occurs later but before full
breast development with an inframammary fold, a less invasive chest surgery (for example,
through an areolar incision rather than an inframammary incision) may be successful. For
males, pubertal suppression before development of facial hair, voice deepening, and facial
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CHAPTER 14
At sexual maturity rating 2 (males, testicular

enlargement; females, breast budding):
• Affirmation of diagnosis of gender dysphoria
• Consideration of pubertal suppression Consideration of initiation of cross-sex hormones
Age in years: 8 9 10 11 12 13 14 15 16 17 18 19
Consideration of gender affirmation surgeries;

chest masculinization surgery can be considered
at a younger age.
Fig. 14-5 General sequence for medical and surgical management of transgender adolescents. The
mental health provider supports the child and family, treats comorbid mental health conditions, and
helps with the logistics of social transition throughout adolescence.
and skeletal masculinization can dramatically enhance gender attribution. The need for
such interventions as facial and chest electrolysis, vocal cord surgery or voice therapy, and
facial feminization surgery can be eliminated. In addition, blunting of the testosterone-
dependent growth acceleration with pubertal suppression in males can mitigate tall stature
in transgender women.
Both WPATH and the Endocrine Society guidelines recommend initiation of GnRH ago-
nist after the start of puberty (sexual maturity rating 2).5,6 In an effort to prevent puberty
from beginning, treatment before the start of puberty is not recommended. Th s is likely
because the persistence of gender dysphoria in the setting of exposure to early pubertal
levels of sex hormones is an important diagnostic consideration.
GnRH agonist medications have been used extensively in this age group for the treatment
of precocious puberty for more than 25 years and are considered safe and reversible.31 In
the transgender population, theoretical risks include reduced bone mineral density accrual
while the patient is receiving treatment (this has been found to improve after treatment
with cross-sex hormones) and the unknown impact on brain maturation while the patient
is on suppression.30 The concern about brain maturation may be overstated, given that this
is not a signifi ant concern for children with constitutional delay of puberty.
GnRH agonist medications work by inhibition of pulsatile LH and FSH secretion from the
anterior pituitary gland. It can be administered as an injectable drug administered every
1 or 3 months (intramuscular leuprolide acetate) or as a subcutaneous implant recom-
mended for replacement annually (histrelin acetate). Use of intranasal preparations of
GnRH agonist for transgender patients has not been reported in the literature. In our ex-
perience, histrelin acetate administered in either the pediatric preparation (delivering 65 μg
per day of active medication) or adult preparation (delivering 50 μg per day of active medi-
cation) is effective at suppressing puberty in transgender adolescents and remains effective
longer than 1 year and usually more than 2 years. The choice of preparation is based on pa-
tient and family preference and can be affected by availability and insurance coverage. We
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CHAPTER 14
have found that in patients in whom insurance coverage is denied, the most cost-effective
method of administration is to use the adult preparation of histrelin acetate. Use of GnRH
agonist for pubertal suppression in transgender adolescents is considered off- abel in the
United States, because the Food and Drug Administration has not listed gender dyspho-
ria as a clinical indication for use, despite the fact that this is the current standard of care.
In addition to GnRH agonists, other medications that reduce sex hormone production or
action are often used in transgender adolescents. Progestins, such as medroxyprogesterone
acetate or norethindrone (administered as a daily oral tablet or an intramuscular injection
every 3 months), reduce the pulsatile release of LH and FSH from the anterior pituitary
and also directly inhibit sex hormone production in the gonads. Progestins can be used
in a menstruating FTM patient to suppress menses if the menses are causing signifi ant
dysphoria. In this patient group, which has often completed breast development, full sup-
pression of puberty with a GnRH agonist is not required to achieve menstrual suppression.
Instead, the less expensive progestins are a good alternative to minimize dysphoria. MTF
patients can be similarly treated with progestins if GnRH agonists are unavailable or unaf-
fordable. Treatment of MTF patients with progestins in early puberty can lower testosterone
production and in late adolescence can allow lower, safer doses of estrogen to be used for
a similar effect.32 As opposed to GnRH agonists, progestins may cause acne, nausea, and
weight gain or bloating.
Spironolactone, an oral medication also used as a weak diuretic, is an androgen receptor

antagonist used by MTF adolescents to reduce androgen effects.32 We commonly prescribe
spironolactone when there is a desire to reduce growth of problematic facial and body hair
in MTF patients who have already progressed to late male puberty. With treatment, hair
becomes fi er and more amenable to removal by electrolysis.
Cross-Sex Hormones
Cross-sex hormones, 17 beta-estradiol in MTF patients, and testosterone in FTM patients,
are used to induce the development of gender-affirming secondary sex characteristics in
the transgender adolescent. The WPATH standards of care do not specify an age at which
cross-sex hormones can be administered but suggest that obtaining parental consent is
preferred.5 The Endocrine Society suggests that cross-sex hormones can be considered at
about 16 years of age.6 However, there is potential physical and psychosocial risk to patients
who wait until age 16 to start cross-sex hormones if the patients are otherwise stable in their
transgender identity. Therefore it is our practice and the practice of similar institutions to
consider the initiation of cross-sex hormone treatment as young as age 14 years.32,33
MTF patients are treated with 17 beta-estradiol to induce female secondary sex char-
acteristics, specifically breast development and feminine body habitus (Fig. 14-6). The
medication is most commonly available in oral, sublingual, transdermal, and intramus-
cular preparations. We commonly use oral or transdermal 17 beta-estradiol, depending
on patient preference. For the MTF patient, adequate suppression of intrinsic testoster-
one is important for optimal breast development. In our practice, adolescent patients
receiving GnRH agonist therapy concurrent with 17 beta-estradiol are able to achieve
normal breast development without the need or desire for later breast modifi ation sur-
gery. In suppressed patients, we start oral 17 beta-estradiol at 0.5 mg daily and gradu-
ally increase to 2 mg daily, with dose increases every 4 to 6 months (or transdermal
17 beta-estradiol starting at 25 μg weekly). Similar results may be possible with a
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CHAPTER 14
Fig. 14-6 A transgender young woman who was treated

with estrogen. (Courtesy of Sarah Wong from Inside Out:
Portraits of Cross-gender Children, 2011.)
Fig. 14-7 A transgender young man who was treated with

testosterone. (Courtesy of Sarah Wong from Inside Out: Por-
traits of Cross-gender Children, 2011.)
combination of a progestin and 17 beta-estradiol. Without suppression, patients re-

quire higher doses of estrogen to suppress testosterone production and overcome
its androgenic effects on the breast tissue. Cosmetic results may be less favorable,
and a higher dose of 17 beta-estradiol carries a thrombogenic risk. In addition, if an
MTF patient undergoes gonadectomy as part of GAS, higher suppressive doses of
17 beta-estradiol are not required.
FTM patients develop male secondary sex characteristics from the effects of testosterone
therapy (Fig. 14-7). Testosterone for pubertal induction has classically been given as an in-
tramuscular preparation (as testosterone cypionate or testosterone enanthate), starting at
25 mg every 2 weeks, with gradual dose increases to 100 to 200 mg every 2 weeks. Our cen-
ter and others have successfully used the same preparations administered as a subcutaneous
weekly dose of 12.5 to 25 mg, increasing to 50 to 100 mg weekly with a 3 ml syringe and a
5
∕8-inch 25-gauge needle.32 Smaller-gauge needles, such as insulin syringes, are too narrow
to draw up the viscous testosterone medication. The subcutaneous method allows home
administration of testosterone after a brief in-office ducation on subcutaneous adminis-
tration. Doses are adjusted to keep the testosterone level in the normal male range for age,
and based on clinical response.
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Transgender adolescents considering treatment with cross-sex hormones should be coun-

seled about potential fertility impairment before initiation. If a patient has progressed far
enough into natal puberty so that cryopreservation of sperm or oocytes is possible, this
option should be discussed.
Surgical Considerations
Medical providers who treat adolescents should be familiar with the gender affirmation
surgical options available to their patients and should help with referrals. Genital surger-
ies are typically not recommended until the patient has reached the legal age of majority;
however, individual considerations, such as performing surgery at least 1 year before leav-
ing home for college, may result in better compliance to postoperative care, such as vaginal
dilations. Chest surgery in MTF patients can be considered earlier.5
The sequence of pubertal suppression followed by cross-sex hormone administration has

specific surgical implications. What is most evident is the potential elimination of the need
for some surgical interventions. An FTM patient starting pubertal suppression at breast
maturity rating 2 may not require a masculinizing chest surgery. A slightly later initiation
of pubertal suppression (breast maturity rating 3 or 4) may facilitate a smaller procedure,
such as a chest surgery through a periareolar incision instead of an inframammary incision.
An MTF patient treated with 17 beta-estradiol concurrent with a GnRH agonist may not
require breast augmentation surgery to achieve a fully developed chest. She also would not
require facial or body electrolysis, facial feminization surgery, or vocal surgery or therapy.
An MTF patient who starts taking pubertal suppression treatments at sexual maturity
rating 2 and proceeds to the age of majority without exposure to testosterone will have a
much smaller scrotum and phallus than the typical MTF patient presenting for feminizing
vaginoplasty. Therefore the surgeon may need to use tissue expansion or other techniques
as part of the surgical planning. An FTM patient may require 1 year or more of testoster-
one treatment to achieve the clitoral enlargement necessary for masculinizing phalloplasty.
Case Examples
An 11-year-old biologic male with gender dypshoria presented for a well-child check; the
child was determined to have a sexual maturity rating of 2, with testicular enlargement to
6 ml bilaterally. The patient had identifi d as female from a young age, and the parents, in
coordination with a child psychologist versed in gender dysphoria, allowed her to make a
complete social transition to female at 8 years of age. The development of testicular enlarge-
ment and impending puberty had caused anxiety and decline in school performance. The
child was referred to a multidisciplinary gender center, where a mental health professional
confi med the diagnosis of gender dysphoria. The pediatric endocrinologist, confi ming the
sexual maturity rating 2 and early pubertal levels of LH, FSH, and testosterone, prescribed
the GnRH agonist histrelin acetate. Bone health was supported with vitamin D supplemen-
tation to keep 25-hydroxyvitamin D within the normal range and with adequate dietary
calcium intake. The histrelin acetate implant was replaced at 13 years of age at the fi st sign
of measurable testosterone production. At 14 years of age, after a repeated psychological
assessment, the patient started therapy with 17 beta-estradiol (0.5 mg per day orally). The
dose was increased to 1 mg daily after 6 months and 2 mg daily after 12 months from initia-
tion. The histrelin implant was replaced again at 15 and 17 years of age. Breast development
progressed to sexual maturity rating 5 over 4 years. When she was 18 years old, the patient
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CHAPTER 14
was referred for feminizing vaginoplasty. A tissue expander was placed in the scrotum as
part of the surgical planning. The gonads were removed during surgery, and the histrelin
acetate implant was also removed. Treatment with 17 beta-estradiol continues as the pa-
tient’s care is transitioned to an adult provider.
A 15-year-old biologic female presented to the pediatric endocrinologist with her parents
for consultation. The patient reported that she had always felt more male than female;
however, she had tolerated the dysphoria until the recent development of menses. Over
the past 6 months since menarche, she had become depressed and withdrawn and initi-
ated arm-cutting behaviors. The patient began treatment with norethindrone to suppress
menses and connected with a mental health professional to begin exploration of gender
identity in more detail. Over the next 12 months, the patient’s menses remained adequately
suppressed. The patient made a complete social transition to the new gender, male. At
16 years of age, he began treatment with 25 mg per week of subcutaneous testosterone en-
anthate, which was increased to 80 mg per week subcutaneously over 9 months. Noreth-
indrone was discontinued on initiation of testosterone, and menses did not recur. At this
dosage, the testosterone level was maintained in the middle of the normal male range for
age. Within 12 months of starting testosterone, there was a noticeable voice change, hair
growth on the face and chest, increase in strength, and a subtle masculinization of the fa-
cial bones. At 17 years of age, the patient elected to have masculinizing chest surgery. He
had a hysterectomy, including removal of the cervix, at age 18 years, and is contemplating
a future masculinizing phalloplasty.
A 10-year-old biologic female presented for evaluation to a gender clinic. She was always
described as a “tomboy” with stereotypically masculine interests. However, recently she
had expressed a male gender identity, and she was distressed about the new development
of breast buds. Her parents were concerned about progression into puberty, given her new
declaration of male identity. After a comprehensive assessment by a psychologist versed in
gender, a diagnosis of gender dysphoria was made. She was treated with leuprolide acetate
every 3 months, with adequate suppression of puberty and slight regression of breast buds.
The child and her family connected with a local therapist, who helped them to explore her
gender identity in greater detail during weekly sessions. Over 9 months, she was able to
identify that she has a sexual attraction to females and identifies as a lesbian. Her gender
identity lies somewhere on a spectrum between male and female but is more closely aligned
with a female identity. She refers to herself as genderqueer and embraces the use of female
pronouns when referring to herself. The decision was made to discontinue treatment with
leuprolide acetate, and she continues through a normal female puberty.
A 15-year-old male presented to a gender clinic for evaluation with his mother. The child
had announced a female gender identity to both parents at age 8 years. The announcement
met with disapproval from the patient’s father, and the child was not allowed to present as
female or attend therapy. Over the next 5 years, the child became anxious and depressed
and had attempted suicide twice, prompting several inpatient psychiatric hospitalizations.
At 13 years of age, the patient’s parents divorced, and the mother retained sole custody of the
child. Over the past 2 years, the child has had extensive counseling and has made a social
transition to female. The transition resulted in reduced symptoms of depression and anxi-
ety; however, continued progression through male puberty has been extremely upsetting.
The child was especially distressed about his changing voice, development of facial hair, and
masculinization of the face. On examination he was found to be at sexual maturity rating
4, with incomplete development of facial and body hair and facial masculinization. After
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CHAPTER 14
receiving a letter of support from his treating therapist and undergoing a comprehensive
gender assessment in the clinic, he was treated with histrelin acetate to suppress continued
masculinization and spironolactone to reduce facial and body hair growth. Th ee months
later, he began treatment with 17 beta-estradiol in a 25 mg transdermal patch weekly, which
was increased to 100 mg weekly over 1 year. He continues to receive treatment with histre-
lin acetate, spironolactone, and 17 beta-estradiol into early adulthood and is considering
feminizing vaginoplasty.
Conclusion
Gender dysphoria in children and adolescents should be managed thoughtfully, with
attention to current best practices and standards of care. Adolescents with persisting gen-
der dysphoria in early puberty can be treated with medications to suppress pubertal devel-
opment. In older adolescents, cross-sex hormones can be considered. The timing of these
interventions has important ramifi ations for future gender affirmation surgery. Provid-
ers in the fi ld of gender affirmation surgery must understand the treatment options for
adolescents and partner with pediatric clinics to help patients transition into surgical care
programs as needed.
References
1. Institute of Medicine. The Health of Les- 8. Fausto-Sterling A. The dynamic development
bian, Gay, Bisexual, and Transgender People: of gender variability. J Homosex 59:398, 2012.
Building a Foundation for Better. Washing- 9. Shechner T. Gender identity disorder: a liter-
ton, DC: The National Academies Press, 2011. ature review from a developmental perspec-
2. American Psychiatric Association. Diagnos- tive. Isr J Psychiatry Relat Sci 47:132, 2010.
tic and Statistical Manual of Mental Disor- 10. Drummond K, Bradley S, Peterson-Badali
ders, ed 5. Arlington, VA: The Association, M, et al. A follow-up study of girls with gen-
2013. der identity disorder. Dev Psychol 44:34,
3. American Psychiatric Association. Diagnos- 2008.
tic and Statistical Manual of Mental Disor- 11. Wallien MS, Cohen-Kettenis PT. Psychosex-
ders, ed 4. Arlington, VA: The Association, ual outcome of gender dysphoric children. J
2000. Am Acad Child Psychiatry 47:1413, 2008.
4. Reisner SL, Vetters R, Leclerc M, et al. Men- 12. Witchel SF, Lee PA. Differentiation of exter-
tal health of transgender youth in care at an nal genital structures. In Sperling MA, ed.
adolescent urban community health center: Pediatric Endocrinology, vol 3. Philadelphia:
a matched retrospective cohort study. J Ado- Saunders Elsevier, 2008.
lesc Health 56:274, 2015. 13. Berenbaum SA, Beltz AM. Sexual differentia-
5. Coleman E, Bockting W, Botzer M, et al. tion of human behavior: effects of prenatal
Standards of Care for the Health of Transsex- and pubertal organizational hormones. Front
ual, Transgender, and Gender-Nonconform- Neuroendocrinol 32:183, 2011.
ing People, version 7. Int J Transgenderism 14. Jordan-Young RM. Hormones, context, and
13:165, 2012. “brain gender”: a review of evidence from
6. Hembree WC, Cohen-Kettenis P, Delemarre- congenital adrenal hyperplasia. Soc Sci Med
van de Waal HA, et al. Endocrine treatment 74:1738, 2012.
of transsexual persons: an Endocrine Society 15. Shumer DE, Spack NP. Current management
clinical practice guideline. J Clin Endocrinol of gender identity disorder in childhood and
Metab 94:3132, 2009. adolescence: guidelines, barriers and areas of
7. Kohlberg LA. A cognitive-developmental controversy. Curr Opin Endocrinol Diabetes
analysis of children’s sex role concepts and at- Obes 20:69, 2013.
titudes. In Maccoby E, ed. The Development 16. Zucker KJ, Wood H, Singh D, et al. A de-
of Sex Differences. Stanford, CA: Stanford velopmental, biopsychosocial model for the
University Press, 1966.
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treatment of children with gender identity 26. Tishelman AC, Kaufman R, Edwards-Leeper
disorder. J Homosex 59:369, 2012. L, et al. Serving transgender youth: chal-
17. de Vries AL, Cohen-Kettenis PT. Clinical lenges, dilemmas, and clinical examples. Prof
management of gender dysphoria in children Psychol Res Pr 46:37, 2015.
and adolescents: the Dutch approach. J Ho- 27. de Vries AL, Steensma TD, Doreleijers TA, et
mosex 59:301, 2012. al. Puberty suppression in adolescents with
18. Hill DB, Menvielle E, Sica KM, et al. An af- gender identity disorder: a prospective fol-
fi mative intervention for families with gen- low-up study. J Sex Med 8:2276, 2011.
der variant children: parental ratings of child 28. de Vries AL, McGuire JK, Steensma TD, et al.
mental health and gender. J Sex Marital Ther Young adult psychological outcome after pu-
36:6, 2010. berty suppression and gender reassignment.
19. Hughes IA. Puberty and the testis. In Sper- Pediatrics 134:696, 2014.
ling MA, ed. Pediatric Endocrinology, vol 3. 29. Cohen-Kettenis PT, van Goozen S. Pubertal
Philadelphia: Saunders Elsevier, 2008. delay as an aid in diagnosis and treatment of
20. Rosenfi ld RL, Cooke DW, Radovick S. De- a transsexual adolescent. Eur Child Adolesc
velopment of the female reproductive system. Psychiatry 7:246, 1998.
In Sperling MA, ed. Pediatric Endocrinology, 30. Delemarre-van de Waal HA, Cohen-Kettenis
vol 3. Philadelphia: Saunders Elsevier, 2008. PT. Clinical management of gender iden-
21. Marcell AV. Adolescence. In Kliegman RM, tity disorder in adolescents: a protocol on
Behrman RE, Jenson HB, et al, eds. Nelson psychological and paediatric endocrinology
Textbook of Pediatrics, ed 18. Philadelphia: aspects. Eur J Endocrinol 155(Suppl 1):S131,
Saunders Elsevier, 2007. 2006.
22. Marshall WA, Tanner JM. Variations in pat- 31. Boepple PA, Mansfi ld MJ, Wierman ME,
tern of pubertal changes in girls. Arch Dis et al. Use of a potent, long acting agonist
Child 44:291, 1960. of gonadotropin-releasing hormone in the
23. Marshal WA, Tanner JM. Variations in the treatment of precocious puberty. Endocr Rev
pattern of pubertal changes in boys. Arch Dis 7:24, 1986.
Child 45:13,1970. 32. Rosenthal SM. Approach to the patient:
24. Herman-Giddens ME, Slora EJ, Wasserman transgender youth: endocrine considerations.
RC, et al. Secondary sexual characteristics J Clin Endocrinol Metab 99:4379, 2014.
and menses in young girls seen in offic prac- 33. Spack NP, Edwards-Leeper L, Feldman HA,
tice: a study from the Pediatric Research in et al. Children and adolescents with gender
Offic Settings network. Pediatrics 99:505, identity disorder referred to a pediatric med-
1997. ical center. Pediatrics 129:418, 2012.
25. Abbassi V. Growth and normal puberty. Pe-
diatrics 102(2 Pt 3):507, 1998.
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CHAPTER
15
Adult Hormone Therapy
in Transgender Patients
CHA
Melany Castillo, Roy E. Weiss
Key Points
❖❖ The treatment and care of transgender indi- ❖❖ The significant consequences of male-to-
viduals are now common practice in medicine, female and female-to-male treatment affect car-
which requires medical personnel trained and diovascular disease, hormone-related cancers,
experienced in the health needs of the trans- and bone health.
gender population. ❖❖ Perioperative management of patients may re-
❖❖ Hormone treatment should be administered to quire brief cessation of hormone therapy.
maximize the safest and most effective transi- ❖❖ Reproductive function should be discussed
tion of desired sexual characteristics. with the patient and planned for appropriately.
❖❖ Data on the effectiveness of cross-hormonal
therapy protocols in the adult transgender pop-
ulation are limited and based on a few, nonran-
domized studies.
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CHAPTER 15
Adult Hormone Therapy in Transgender Patients
The influence of the composition of the hormonal milieu and the timing of exposure on
the establishment of gender identity are not fully understood. Most agree that there is a
complex interaction between the genetic blueprint and hormonal regulation of genetic
expression that influences psychological elements, resulting in self-perception of gender.
Hormones, and specifi ally sex hormones (androgens and estrogens), can have a profound
effect on the perception of one’s gender. For example, intrauterine androgen exposure of
XX females may predispose to gender identity disorders.1 In addition, XY males exposed to
male-typical prenatal androgen have a high likelihood of declaring a male sexual identity,
even when raised as female. However, inappropriate prenatal androgen exposure demon-
strated unpredictable sexual identifi ation.2 The prevalence of disorders of sex develop-
ment is estimated at 0.1% to 2% of the global population, and of those, 8.5% to 20% present
with gender dysphoria.3 Gender dysphoria is a psychiatric diagnosis, which should only
be made after a careful endocrine evaluation and other disorders of sexual differentiation
have been excluded.
Many syndromes affecting sexual development present at an early age, which prompt evalu-
ation by the pediatrician. The clinical manifestations include clitoromegaly, penile agenesis,
bilateral or unilateral cryptorchidism, posterior labial fusion, and hypospadias. Obtaining
a thorough family history of maternal virilization during gestation, prenatal exposure to
androgens, infertility, miscarriages, or consanguinity is important in understanding the
etiologic factors for defi able causes of gender dysphoria.
The initial assessment of any patient should include a thorough clinical history, physical
examination, determination of sex chromosomes, pelvic/abdominal ultrasonography, mea-
surement of 17-hydroxyprogesterone, testosterone, gonadotropins, anti-Müllerian hormone,
serum electrolytes, and urinalysis.4 According to the International Consensus Conference,
disorders of sex development can be categorized as 46,XX or 46,XY or a mixed sex chro-
mosome pattern5,6 (Table 15-1).
Hormonal Sex Reassignment

Initiation
As stated in the “World Professional Association for Transgender Health Standards of Care
(WPATH SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming
People,” transgender/transsexual patients need to fulfill eligibility and readiness criteria
before proceeding with cross-sex hormone therapy.7 Patients undergoing sex reassignment
therapy must understand the reversible and irreversible effects of cross-sex hormones. A
comprehensive discussion of the patient’s expectations should be done by the treating en-
docrinologist before the patient starts treatment.7
The criteria suggested for transgender hormone therapy for transgender adults are as follows:
1. The treating physician should confi m that the Diagnostic and Statistical Manual of
Mental Disorders, fi h edition (DSM-5), or the tenth revision of the International
Statistical Classification of Diseases and Related Health Problems (ICD-10) criteria for
gender identity disorder or transexualism are present.
2. The patient should have an understanding of what hormonal sex reassignment ther-
apy can and cannot accomplish and the social benefits and risks.
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CHAPTER 15
3. There is an absence of psychiatric comorbidities that would interfere with the diag-
nostic workup or treatment.
4. Documented real-life experience should be undertaken for at least 3 months before
the administration of hormones or a period of psychotherapy of a duration specifi d
by the mental health professional after the initial evaluation (usually a minimum of
3 months).
After the eligibility criteria have been fulfilled, the readiness of the transgender patient for
hormonal therapy should be evaluated. The WPATH SOC document three key elements:
1. The patient has had further consolidation of gender identity during the real-life ex-
perience or psychotherapy.
2. The patient has been evaluated for other mental health conditions (for example, so-
ciopathy, substance abuse, psychosis, and suicidality).
3. Hormones are likely to be taken in a responsible manner.
As outlined by the 2009 Endocrine Society guidelines on endocrine treatment of transgen-

der individuals, adverse mental health events can be prevented, if the transgender patient
undergoing hormonal sex reassignment has a clear understanding of the mental and physi-
cal changes that will follow after hormonal therapy is initiated.8
It is also essential for the caregiver to provide counseling with regard to the effects of cross-
sex therapy on fertility and the available options to preserve fertility for the future. It has
been our experience that patients, because of economic reasons or inaccessibility of proper
endocrinologic consultation, frequently seek to obtain the hormones without physician
supervision through various sources (for example, Internet purchasing). Although this is
illegal in most locales, some patients fi d that this is the only way to obtain hormones. Un-
fortunately, the quality of the hormone preparations is questionable, and there is no moni-
toring of the patient for adverse events. We think that it is better for the patient to obtain
the medications through a physician rather than without physician supervision, even if it
means that not all the previous criteria are met.
Hormone Therapy
Transgender patients seek hormone therapy to achieve anatomic and psychological changes
that will make them feel and appear more like members of their aspired-to-be gender. Using
the same principle for hormone replacement therapy in the hypogonadal patient, the main
objectives of hormonal therapy are to induce the development of secondary sex character-
istics of the reassigned gender and to suppress the individual’s genetic sex characteristics
by reducing and replacing endogenous hormones. Hormone treatment can be acceptably
safe and provide improvement in the quality of life and mental well-being.9
Areas that should be covered before the initiation of cross-sex hormone therapy by the
treating endocrinologist are the risks and benefits of hormone therapy, the presence of co-
morbidities that can be exacerbated by hormonal treatment, and the relative contraindi-
cations to hormonal therapy (liver disease, diabetes, and metabolic syndrome). Smoking
cessation is highly recommended to avoid an increased risk of cardiovascular disease and
thromboembolism.
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CHAPTER 15
Table 15-1 Disorders of Sex Development

Disease Etiologic Factors Suggested Workup
46,XX Congenital Adrenal Hyperplasia

Most common cause of female 21-alpha-hydroxylase (CYP21A2) Basal measurement of serum
fetal virilization deficiency 17-hydroxyprogesterone,
Steroid biosynthetic is detected, 11-beta-hydroxylase deficiency 11-deoxycortisol, DHEA, and
leading to excessive or deficient 17-delta-5-hydroxypregnenolone
Aldosterone synthase deficiency
production Serum electrolytes
17-alpha-hydroxylase deficiency
Salt-wasting type causes ACTH stimulation test
hyponatremia with hyperkalemia 3-beta-hydroxysteroid dehydroge-
nase deficiency Genetic testing
and hypotension
High risk for adrenal crisis and its Lipoid hyperplasia
complications
Gestational Hyperandrogenism
Exposure to maternal androgen Luteoma Pelvic ultrasound
or synthetic progestational agent Theca lutein cysts If a mass is identified, consider
History of virilization of the Placental aromatase deficiency laparoscopic biopsy
mother during pregnancy Maternal serum testosterone
Exogenous progestin or androgen
administration androstenedione
Miscellaneous ovarian tumors cell Cell-free fetal DNA to determine

tumor fetal sex; if male there is no
concern for virilization
Sertoli-Leydig tumors
Krukenberg tumors (gastrointesti-
nal cancer metastatic to ovaries)
Polycystic ovary syndrome
Adrenal tumors
Other Causes
Dysgenetic testis or ovotestis; SOX9 duplication Pelvic ultrasound
female or ambiguous; Müllerian Müllerian structure abnormalities Peripheral karyotype
structures can be present or not (Rokitansky-Mayer-Küster-Hauser
present FISH and SRY probe
syndrome)
Ovotesticular Disorder of Sex Development

Unusual condition characterized SOX9 duplication Pelvic ultrasound
by histologically confirmed Müllerian structure abnormalities Peripheral karyotype
testicular and ovarian tissue; (Rokitansky-Mayer-Küster-Hauser
formerly known as true hermaph- FISH and SRY probe
syndrome)
roditism
ACTH, Adrenocorticotropic hormone; DHEA, dehydroepiandrosterone; FISH, fluorescence in situ hybridization; SRY, sex-determining
region Y protein.
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CHAPTER 15
Disease Etiologic Factors Suggested Workup
46,XY Uncommon Causes of Congenital Adrenal Hyperplasia

Produce undervirilization of StAR protein deficiency Basal measurement of delta-
46,XY individual 3-beta-hydroxysteroid dehydroge- 5-pregnenolone after ACTH
nase deficiency stimulation
17-alpha-hydroxylase deficiency Basal measurement of ACTH

(increase), corticosterone,
11-deoxycorticosterone, and
18-hydroxy-deoxycorticosterone
Cortisol, DHEA, androstene-
dione, testosterone, estradiol,
11-deoxycortisol, and 17-alpha-
hydroxyprogesterone (reduced)
Swyer Syndrome or 46,XY Pure Gonadal Dysgenesis

Phenotypically female with SRY translocation (most common) Pelvic ultrasound
functional female genitalia and Mutations in NR5A, DHH, NR0B1, Peripheral karyotype
futile ovaries caused by lack of and DAX1 genes
proper ovarian development; FISH and SRY probe
affected women do not undergo
puberty given the lack of sex
hormones
Testicular Regression Syndrome

Female phenotype with atrophic Irreparable damage to the testis Pelvic ultrasound
Müllerian ducts at a critical stage in fetal develop-
ment
Vanishing Testes Syndrome

Phenotypically males with male Defeat of testicular function late in Pelvic ultrasound
genitalia, anorchia, and absent fetal life Peripheral karyotype
Müllerian ducts
FISH and SRY probe
Persistent Müllerian Duct Syndrome

Phenotypically male with normal Mutations in the AMH or AMHR2 Pelvic ultrasound
external genitalia, persistent gene Serum levels of AMH
Müllerian ducts, and variable
cryptorchidism Sequence analysis of AMH or
AMHR2
Abnormal Androgen Synthesis/Androgen Insensitivity

Phenotype of affected males usu- 17-beta-hydroxysteroid dehydro- Measure androstenedione levels,
ally consists of female-appearing genase type 3 deficiency FSH, and LH
external genitalia, blind vaginal 5-alpha-reductase deficiency Measurement of serum testos-
pouch, and cryptorchidism terone and DHT before and after
LH receptor defects
stimulation with hCG
Androgen insensitivity
Androgen receptor sequencing
AMHR2
Prenatal exposure to phenobarbi-
tal and phenytoin
ACTH, Adrenocorticotropic hormone; AMH, anti-Müllerian hormone; AMHR2, anti-Müllerian hormone receptor type 2; DHEA, dehydro-
epiandrosterone; DHT, dihydrotestosterone; FISH, fluorescence in situ hybridization; FSH, follicle-stimulating hormone; hCG, human
chorionic gonadotropin; LH, luteinizing hormone; SRY, sex-determining region Y protein; StAR, steroidogenic acute regulatory protein.
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CHAPTER 15
Table 15-2 Hormone Therapy Options for Female-to-Male Patients

Hormone Therapy Dose Comments
Testosterone enanthate or cypionate 100-200 mg IM every 2 wk or Monitor levels midway between

50-100 mg IM weekly injections
Testosterone undecanoate 1000 mg IM every 12 wk or Monitor levels midway between
160-240 mg PO daily injections
Not available in the U.S.
Testosterone gel 2.5-10 mg daily Higher incidence of breakthrough
bleeding
Testosterone patch 2.5-7.5 mg daily Patch can cause skin irritation
Testosterone nasal (Natesto) 5.5 mg per pump actuation; 1 pump Monitor before next dose
actuation in each nostril TID
Most of the treatment recommendations are based on opinion and experience10-12 without
large studies to support many of the recommendations. In an extensively researched consen-
sus statement by committees and members of the the Endocrine Society (United States), Eu-
ropean Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson
Wilkins Pediatric Endocrine Society (United States), and the WPATH, the recommenda-
tions were based on “very low quality” or “low quality evidence” except in three instances.8
The need to confi m the diagnostic criteria of transsexualism, the medical conditions that
can be exacerbated by cross-sex hormone therapy, and the effects on bone mineral density
(BMD) were based on “moderate quality” evidence.8 Much of our knowledge regarding
the use of cross-sex hormones is based on the supraphysiologic dosing of these hormones
in same-sex individuals and extrapolated to the transgender community. Th s is obviously
imperfect, and prospective studies are needed to make defin tive recommendations.
Female-to-Male Transgender Patients

The goal for female-to-male (FTM) transgender individuals is to induce virilization. To
achieve this objective, there are different formulations and routes of administration of tes-
tosterone, including percutaneously administered gel, injectable intramuscular prepara-
tions, buccal tablets, and a nasal spray8,13 (Table 15-2). The main goal is to maintain a total
serum testosterone level in the normal male range (350 to 1000 ng/dl).
There are several initiation protocols for androgen therapy, ranging from high doses of
parenteral testosterone, with subsequent titration based on serum testosterone, or vice
versa. Testosterone enanthate or cypionate can be delivered at doses of 100 to 200 mg every
2 weeks intramuscularly, or 1000 mg of testosterone undecanoate (not available in the
United States) can be given every 12 weeks, with titration according to serum testosterone
levels. After the desirable serum testosterone level is achieved, the patient can be switched
to testosterone gel (25 to 50 mg/day).
Other protocols start with a lower dose of testosterone (for example, 100 mg of testosterone
enanthate every 2 weeks) with subsequent adjustment. Therapy can also be initiated directly
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CHAPTER 15
Table 15-3 Masculinization Effect of Cross-Sex Hormones in Female-to-Male

Outcome Onset Maximum Comments
Fat redistribution 1-6 mo 2-5 yr

Skin oiliness/acne 1-6 mo 1-2 yr
Cessation of menses 2-6 mo Irregular menstrual periods may require evaluation for
uterine fibroids or other abnormalities
Clitoral enlargement 3-6 mo 1-2 yr
Vaginal atrophy 3-6 mo 1-2 yr
Facial and body hair redistribution 6-12 mo 4-5 yr
Increased muscle mass/strength 6-12 mo 2-5 yr
Scalp hair loss 6-12 mo Prevention and treatment as recommended for
biologic men
Decline in breast size 6-12 mo Variability between individuals
Deepening of the voice 6-12 mo 1-2 yr Voice training can be pursued
with testosterone gel, although one caveat is that the virilization achieved with transdermal
methods is slower, given the lower serum levels achieved with this route. On the other hand,
the risk of having a supraphysiologic serum concentration of testosterone is less common
with this approach, thus decreasing the theoretical risk of adverse reactions.
The physical changes induced by androgen therapy include male pattern hair growth, in-
creased muscle mass, an increase in fat mass, clitoromegaly, increased libido, deepening of
the voice, and cessation of menses. However, permanent cessation of menses may require
high doses of testosterone, which is rarely achieved with testosterone gel. If breakthrough
uterine bleeding continues, concomitant therapy with a progestational agent may be needed,
or endometrial ablation may be considered if hysterectomy is not desired. Recommended
regimens include medroxyprogesterone acetate, 5 to 10 mg daily, or 17 alpha-ethinyl-3-
desoxy-19-nortestosterone (Lynestrenol), 5 mg/day, which is not available in the United States.
Other treatment options include depot medroxyprogesterone, 150 mg intramuscularly every
3 months, or a gonadotropin-releasing hormone (GnRH) agonist (for example, goserelin,
3.6 mg once every 4 weeks or 10.8 mg once every 12 weeks). The use of leuprolide and na-
farelin has not been established for hormone reassignment therapy.
The estimated time for physical changes with testosterone therapy occurs in the first 3 to
6 months of treatment, although the maximum effect can take as long as 2 to 5 years for
some patients8,14 (Table 15-3).
Routine Follow-up: Recommended Clinical Practice

The Endocrine Society recommends maintaining testosterone levels in the normal adult male
range to prevent long-term side effects from therapy, such as erythrocytosis or transient eleva-
tion of liver enzymes. For this purpose, monitoring should be done every 3 months during
the fi st years of therapy, and then once or twice a year thereafter8 (Table 15-4).
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Table 15-4 Monitoring Female-to-Male Transgender Patients Receiving Hormone

Therapy
Evaluation Frequency Comment
History Baseline Specifically assess family history of dia-

betes, osteopenia, smoking, and previous
bone fractures
Physical examination (blood Baseline and every 2 to 3 mo in the Look for appropriate signs of masculiniza-
pressure, weight) first year and then yearly tion and possible complications
Serum total testosterone Every 2 to 3 mo until levels are Adjust dose
between 350 and 1000 ng/dl See Table 15-2 regarding when to mea-
sure based on preparation used
Serum estradiol Every 2 to 3 mo during first 6 mo or Usually serum estradiol <50 pg/ml in first
until cessation of menses 3 mo
Liver function tests and CBC, lipid Baseline; every 3 mo in the first year Family history of diabetes should prompt
profile and then 1 to 2 times per year A1c
BMD measurement Baseline and at 60 yr of age If risk factors are identified
Yearly If cervical tissue is present
Pap smear Per American Cancer Society If mastectomy is not performed
Mammogram recommendations
Monitoring of weight, blood pressure, and physical changes, and asking routine health
questions regarding new risk factors focusing on cardiovascular risk and new medications
should be done at each visit. In addition, periodic monitoring of CBC, renal function, liver
enzymes, and lipid and glucose profiles is also recommended.
Cardiovascular Risk
The metabolic effect of testosterone on the lipid profile is mainly on the increase of serum
triglycerides and reduction of high-density lipoprotein levels15 with central fat redistribu-
tion for FTM patients. However, there is uncertainty regarding the degree of increase of
cardiovascular risk with chronic testosterone use in FTM patients given the dearth of medi-
cal evidence in this matter. On the contrary, data from a meta-analysis of randomized clini-
cal trials assessing the risks of adverse events associated with testosterone replacement in
older men found no increased incidence of cardiovascular events in the treated group.16,17
Furthermore, data available from a university practice in The Netherlands with a median
follow-up of 181∕2 years showed that for FTM transgender patients, total mortality and cause-
specific mortality were not signifi antly different from those of the general population, and
that for MTF transgender patients, the main increase in mortality was from non-hormone-
related causes.18 Nevertheless, cardiovascular risk factors should be prevented and assessed
according to available guidelines.19
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CHAPTER 15
Based on the available evidence, there is no increased risk of developing venous throm-
boembolism during cross-sex hormone treatment in FTM transgender patients receiving
androgen treatment.20
Bone Health
Sex steroid exposure has been found to influence bone metabolism.21-23 Prior studies in
FTM transgender patients have shown that in the fi st 2 years of hormonal sex reassign-
ment therapy, testosterone administration could prevent bone loss resulting from estrogen
deficie cy.24 Cortical bone is the most affected by androgen replacement therapy, showing
higher BMD. During the fi st year of cross-sex hormonal therapy with testosterone, there
is an increase in bone turnover markers.25
At the molecular level, testosterone can affect bone physiology in an indirect or direct
fashion. The use of exogenous testosterone lowers the receptor activator of nuclear factor
kappa B ligand (RANKL) levels but does not change osteoprotegerin levels, resulting in an
increased osteoprotegerin/RANKL ratio, which may be benefic al to the bone by inhibit-
ing osteoclastogenesis. Furthermore, aromatization of testosterone to estradiol affects the
bone directly by increasing BMD.26 In addition, chronic testosterone exposure has an im-
pact on body composition by increasing muscle and decreasing fat mass. Moreover, there
is a direct effect on the adult skeleton,25 with larger bone and lower volumetric BMD at the
radius and tibia, in FTM transgender patients when compared with age-matched females.
Overall, the available evidence shows preserved BMD in the transgender population. Thus
an adequate level of serum testosterone (300 to 1000 ng/dl) must be maintained to preserve
the benefic al effect of androgen therapy in the bones. For this purpose, luteinizing hor-
mone can be used as a marker of adequate hormone dosing, of which the goal is to keep
its level in the normal range. Th s recommendation is based on the inverse correlation be-
tween luteinizing hormone or follicle-stimulating hormone and BMD.27 Suffici t intake
of vitamin D and calcium initiated and maintained as indicated in the standard guidelines
for the general population is recommended.
Cancer Screening
The effects of lifelong administration of testosterone therapy on cancer remain to be deter-
mined; however, some evidence indicates that prolonged exposure to androgen can lead
to increased endogenous estrogen levels mostly by partial aromatization of testosterone to
estradiol, which triggers endometrial hyperplasia and possible estrogen receptor–positive
breast cancer. However, a large cohort study of adverse events on a transgender population
showed no increase in hormone-related cancers.28
Ovarian Cancer
Th ee cases of ovarian cancer in FTM transgender patients have been reported.29,30 Im-
munohistochemical studies done in ovarian and endometrial tissue of FTM transgender
patients receiving long-term treatment with testosterone therapy have shown an increase
in androgen receptors, resembling those changes found in the ovarian tissue of patients
with polycystic ovary syndrome,31 which may lead to androgen receptor–related ovarian
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CHAPTER 15
cancer. To prevent the risk of female reproductive tract diseases and cancer, the Endocrine
Society recommends total hysterectomy and oophorectomy for FTM transgender patients
receiving cross-sex hormone therapy. Although a seemingly prudent recommendation, this
is based on very low evidence of support.8
Cervical Cancer
Currently there are no data regarding the prevalence of cervical cancer or cervical cancer
screening among FTM transgender patients. Yet the American College of Obstetricians and
Gynecologists recommends that an FTM transgender patient who has not undergone hys-
terectomy should follow the same screening guidelines as nontransgender females (Ameri-
can Society for Colposcopy and Cervical Pathology guidelines: www.ascp.org/guidelines).
In brief, the recommendations are as follows:

❖❖ Women younger than 21 years of age should not be screened, regardless of age at
sexual initiation and other behavior-related risk factors.
❖❖ Women 21 to 29 years of age should have a Papanicolaou (Pap) test every 3 years.
❖❖ Women 30 to 65 years of age should have a Pap test and human papillomavirus test
(co-testing) every 5 years (preferred); it is acceptable to have a Pap test alone every
3 years.
Breast Cancer
In one of largest studies in the transgender population, the estimated incidence of breast
cancer in FTM transgender patients was signifi antly lower than in biologic women (5.9 per
100,000 person-years versus 154.7 per 100,000 person-years for biologic women).32 Today
there are eight cases of breast cancer in the FTM transgender population published in the
literature.32,33 Th s low incidence seems to be related to the high prevalence of mastectomy
and testosterone therapy in the FTM transgender population. Th s estimation was based on
a relatively small number of cases of breast cancer, and thus there should be cautious inter-
pretation of these data.
The breast tissue of FTM transgender patients receiving long-term treatment with andro-
gen therapy shows decreased glandular and increased fibrotic tissue. Based on the premise
that exogenous testosterone is partially aromatized to estradiol and that the endogenous
levels of estradiol do not decrease signifi antly in a treated FTM transgender patient, it is
reasonable to link testosterone therapy with increased risk of breast cancer, especially in
those patients who have not undergone total mastectomy. Conversely, breast cancer may
develop in residual tissue after mastectomy. As a prevented intervention, a breast exami-
nation should be performed before initiation of cross-sex hormone therapy, with further
assessment of family history for breast cancer. The Endocrine Society guidelines recom-
mend following the same breast cancer screening guidelines for the general population.8,34
Male-to-Female Transgender Patients

Treatment Protocols
The hormone treatment needed to achieve phenotypic feminization of MTF transgender
patients has two major components. The fi st is to decrease the virilization effect of endog-
enous testosterone with the use of antiandrogen agents, and the second is to promote femi-
nization with estrogens. The main goal of using progestational agents (cyproterone acetate,
not available in the United States), GnRH analogs (leuprolide, nafarelin, or histrelin), and
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CHAPTER 15
Table 15-5 Hormone Therapy Options for Female-to-Male Patients

Therapy Dose Comments
Estrogen
Oral estradiol 2-8 mg/dl Metabolized via the cytochrome P450 enzyme system; thus a
potential drug-drug interaction can exist
Transdermal patch 0.1-0.4 mg twice weekly Transdermal estradiol produces fewer changes in hemostatic
estradiol variables
Parenteral estradiol 5-30 mg IM every 2 wk Transdermal estradiol produces fewer changes in hemostatic
variables
Antiandrogen Therapy
Progesterone 20-60 mg PO daily Progesterone affects lipid profile and BMD
Spironolactone 100-200 mg PO daily Use off-label
GnRH agonist (leuprolide) 3.75-7.5 mg IM monthly
Cyproterone acetate 50-100 mg PO daily Not available in the U.S.
Finasteride 1 mg PO daily
other medications that suppress androgen action is to obtain a reduction in serum testos-
terone levels similar to the ones found in adult women (less than 55 ng/dl).
GnRH agonists are mostly used in adolescent patients in Europe. Testosterone secretion
is suppressed by inhibiting the release of gonadotropins; this mirrors the effects achieved
by bilateral gonadectomy, which reduces testosterone to minimal levels. The downside of
these medications is the high cost, and that it is not covered by health insurance in the
United States. A second, much less expensive drug, spironolactone, which inhibits testos-
terone secretion and androgen effects by inhibiting its binding to the androgen receptor,
can be used. In addition, it has some weak estrogenic activity 8 (Table 15-5). After orchi-
ectomy is performed, antiandrogen therapy is no longer recommended or needed. Estro-
gen is available in oral, transdermal, and parenteral formulations as conjugated estrogens,
17 beta-estradiol, and estrogen ester.
Testosterone production is diminished by estrogen treatment by suppressing gonadotro-

pin output; however, it is more effective when used in addition to other antiandrogen
treatments. In general, estrogen should be used in conjunction with antiandrogen agents,
especially in patients who have not undergone orchiectomy, because otherwise the doses
needed to suppress testosterone levels to the minimal range and to maximize feminization
will be four to eight times greater than in a biologic woman, increasing the risk for adverse
events, namely, thromboembolic events.13 The Endocrine Society guidelines recommend
keeping serum estradiol at the mean level for premenopausal woman (less than 200 pg/ml)
and testosterone level lower than 55 ng/dl. These levels should be measured every 3 months
after cross-hormonal therapy has been initiated.8
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CHAPTER 15
Table 15-6 Feminization Effect of Cross-Sex Hormones in Male-to-Female

Outcome Onset Maximum Comments
Decreased libido 1-3 mo 3-6 mo

Decreased spontaneous erection 1-3 mo 3-6 mo
Fat redistribution 3-6 mo 1-2 yr
Breast growth 3-6 mo 2-3 yr Size varies from Tanner 1 to 4
Decrease in muscle mass and 1-2 yr
strength
Softening of the skin/decreased 3-6 mo Unknown
oiliness
Decreased testicular volume 3-6 mo 2-3 yr
Decrease in sperm production Unknown >3 yr
Decrease in terminal hair growth 6-12 mo >3 yr Complete male pattern hair removal requires laser
treatment, electrolysis, or both
Scalp hair No effect
Voice changes No effect Voice treatment by a speech pathologist is the most
effective
A serum estradiol level is a good marker to monitor cross-sex hormone therapy in MTF
patients who receive estradiol or its ester in the transdermal, oral, or parenteral form. The
exceptions to the rule are conjugated or synthetic estrogens (ethinyl estradiol), whose lev-
els are not detectable by a blood test. Ethinyl estradiol should be avoided, given the asso-
ciation with signifi ant increased risk of venous thromboembolic disease and death from
cardiovascular events.35
A treatment protocol used in the United States includes spironolactone, 100 to 200 mg/day,
plus transdermal 17 beta-estradiol, 100 to 400 μg twice a week, or in oral form in a dose of
2 to 6 mg/day. In Europe cyproterone acetate, 100 mg/day, plus oral 17 beta-estradiol valer-
ate, 2 to 4 mg daily, is the most common cross-sex hormone therapy used.
Physical Changes
The feminization effect of estrogen and antiandrogen therapy includes decreased facial and
body hair, redistribution of fat mass, decreased oiliness of the skin, decreased libido, ces-
sation of morning erections, and breast tissue growth. Physical changes start in about 3 to
6 months but can take up to 2 to 3 years to have its full effect8,12,36,37 (Table 15-6).
Breast development is one of the most important feminization features desired by MTF
transgender patients. The increase in breast size usually begins within 2 to 3 months after
the start of cross-sex hormone treatment and progresses over 2 years with the develop-
ment of an A cup, which corresponds to Tanner stages 2 and 3 in most MTF transgender
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Table 15-7 Monitoring Male-to-Female Transgender Patients Receiving Hormone

Therapy
Evaluation Frequency Comment
History Baseline Specifically assess family history of diabetes,

osteopenia, smoking, previous bone fractures,
and breast, colon, and prostate cancer
Physical examination (blood Baseline and every 2-3 mo in the Look for appropriate signs of feminization and
pressure, weight, genital first year, then yearly possible complications
examination)
Serum total testosterone Baseline and every 2-3 mo until Within normal female range
levels are <55 ng/dl
Serum estradiol Baseline and every 2-3 mo during Adjust dose of estrogen preparation so that serum
first 6 mo and then every 6 mo levels are not greater than 100-200 pg/ml
Serum electrolytes Every 2-3 mo in first year and then Only if taking spironolactone
1 to 2 times per year
BMD measurement Baseline and at 60 yr of age If risk factors identified
Serum prolactin Baseline; yearly during transition To monitor lactotroph hyperplasia
period, then biannually thereafter Colon, breast, and prostate
Routine cancer screening
Per American Cancer Society
recommendations
patients. Th s may explain the high percentage (60% to 70%) of MTF subjects pursuing
surgical augmentation. The available evidence suggests no association between the type or
dosage of estrogen therapy, including a protocol with progestational properties, on fi al
breast size.37 At the initiation of hormone therapy, it is essential that MTF transgender pa-
tients have realistic expectations regarding the physical changes that will follow cross-sex
hormone therapies, especially on breast development. Testicular and prostate gland atro-
phy will occur over a long period (about 3 years) on hormonal sex reassignment therapy.
Routine Follow-up: Recommended Clinical Practice

The Endocrine Society guidelines recommend maintaining estradiol and testosterone levels
in the mean values found in premenopausal woman (less than 200 pg/ml of estradiol and
less than 55 ng/dl of testosterone), avoiding supraphysiologic doses and levels of estradiol
to prevent increased risk of liver dysfunction, the development of hypertension, and of
critical importance, thromboembolic events. For this purpose, monitoring should be done
every 3 months during the first years of therapy and then once or twice a year thereafter
(Table 15-7).
As in FTM transgender patients, weight, blood pressure, physical changes, routine health
questions, new risk factors focusing on cardiovascular risk, and new medications should be
assessed during routine visits, including periodic monitoring of CBC, renal function, liver
enzymes, lipids, glucose, and electrolytes, especially in patients receiving spironolactone. In
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CHAPTER 15
addition, patients receiving estrogens, gonadotropin suppression, or antiandrogen therapy

should have a prolactin level check before and during cross-hormone therapy, given the
stimulatory effect of estrogen on pituitary lactotrophs.8 However, the risk of an estrogen-
induced prolactinoma in MTF transgender patients seems low based on available evi-
dence.38 If elevation of prolactin develops, estrogen therapy can be reduced or discontinued.
Cardiovascular Risk
Cross-hormonal therapy is well tolerated and has been associated with few side effects.28,39
However, the MTF transgender population has more cardiovascular pathology than FTM
transgender subjects receiving androgen therapy. Despite favorable changes seen in the lipid
profile of MTF transgender patients taking estrogen and antiandrogen therapy, such as an
increase in high-density lipoprotein cholesterol and a decrease in low-density lipoprotein
cholesterol levels, there is no reduction of cardiovascular events in this particular popula-
tion. Moreover, there is an increase in triglycerides, blood pressure, subcutaneous fat, and
visceral fat, which are features of metabolic syndrome.40
There is a strong association between the use of ethinyl estradiol and cardiovascular events.18
In an MTF transgender population between the ages of 40 and 65 years, a threefold increase
in cardiovascular mortality was found in those patients who had taken ethinyl estradiol or
oral contraceptives compared with those who used another type of estrogens; the adverse
effect was confi med only for patients actively taking ethinyl estradiol. However, during
the past 40 years, there has been a decrease in the prevalence and incidence of thrombo-
embolic disease, probably because of the use of transdermal estradiol and other forms of
estrogen preparation (transdermal patches or gel, oral estradiol, or conjugated equine es-
trogens).20 Therefore preexisting cardiovascular risks should be taken into consideration
when deciding on the type and route of administration for estrogens and antiandrogenic
therapy,41 with special emphasis on avoiding the use of ethinyl estradiol.
Bone Health
Available evidence suggests that estrogens are a major regulator of bone turnover in both
men and women and that serum estradiol levels in elderly men have a positive correlation
with BMD.38,42,43
In the MTF transgender population, the use of estrogen therapy decreased bone turnover
markers and preserved and increased BMD at the level of the femoral neck and lumbar
spine after 12 and 24 months of continued use of cross-sex hormone therapy.43 However,
the effect was no longer observed after a longer follow-up period (32 to 63 months).
During treatment with antiandrogen therapy, MTF transgender patients experience a state
of hypogonadism, which constitutes a substantial risk factor for bone loss. However, the
concomitant use of estrogen seems to be able to maintain bone mass in the male skeleton in
the absence of testosterone.27 Therefore, to preserve the benefic al effect of estrogen, cross-
hormonal therapy should be continued, even after gender affirmation surgery. As outlined
by the Endocrine Society, BMD measurements should be taken if there are risk factors for
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CHAPTER 15
osteoporosis (for example, previous fractures, family history, glucocorticoid use, and pro-
longed hypogonadism) at 60 years of age in patients with a low risk for osteoporosis or in
those who are noncompliant with hormone therapy.
Cancer Screening
The incidence of hormone-related cancers is not higher in the MTF transgender population
in short- and medium-term follow-up studies. Yet the duration of exposure to cross-sex hor-
mones may influence susceptibility to certain cancers, although there are insuffici t data.
Breast Cancer
In a biologic man, the incidence of breast cancer is approximately 1 in 100,000. The peak
incidence occurs at 68 to 71 years of age, representing a much older population when com-
pared with the peak age of breast cancer in women. The epidemiology of breast cancer in
the MTF transgender population resembles the pattern seen in men,32 with only 11 cases
reported in the literature, and in those, 3 were likely not related to estrogen use.44
Studies such as the Women’s Health Initiative have suggested that estrogen therapy does
not increase the risk of breast cancer in the short-term.8 However, one concern regarding
long-term estrogen treatment is the induction of carcinomas of estrogen-sensitive tissues,
such as the breast.
The usefulness of screening mammography is still to be determined. The Endocrine Society

recommends that MTF transgender individuals who have increased risk factors for breast
cancer follow the screening guidelines as recommended for biologic women.34
Prostate Cancer
The incidence of prostate cancer in transgender patients is rare, with only six cases reported
in the literature.45-48 Commonly, prostate cancer expresses androgen receptors; however,
after testosterone depletion, as in the case of MTF transgender patients, androgen receptor
levels are increased, which may suggest a greater sensitivity to androgens.
The long-term effects of estrogen in the prostate are unknown. Estrogen therapy does not
induce hypertrophy or premalignant changes in the prostate, and castration early in life
protects against prostate cancer.49 The same principle could be applied to MTF transgender
individuals who undergo antiandrogen therapy or orchiectomy at a young age.
MTF gender reassignment surgery generally does not include prostatectomy,47 and therefore
the risks and benefits of prostate cancer screening should be discussed with MTF transgen-
der patients, as is done in biologic men, especially for those with risk factors for prostate
cancer and in those who started cross-hormone therapy later in life. After the patient agrees
to screening, rectal or transvaginal (neovaginal) examination of the prostate should be per-
formed.50,51 The use of prostate-specific antigen levels as a screening tool is not straightfor-
ward, given that it could be falsely low in the presence of prolonged exposure to estrogen. In
the MTF population, 1 ng/ml should be used as the upper limit of normal and not 4 ng/ml
as is used in biologic men.46 However, the rate of increase in prostrate-specific antigen is
a signifi ant predictor of malignancy in both XY men and MTF transgender individuals.
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CHAPTER 15
Special Topics in Hormone Replacement Therapy

Hormone Therapy Before Sex Reassignment Surgery
Surgical sex reassignment is viewed as the fi al step to provide relief from the dichotomy
between the body habitus and gender identity, and thus a careful preoperative evaluation
of the transgender patient should be done in line with available guidelines.52 Preoperative
management should take into consideration that MTF patients receiving estrogen treat-
ment can be predisposed to venous thrombosis, leading to serious complications, such as
pulmonary embolism, chronic venous insuffici cy with edema, or chronic leg ulcers. In
addition, this treatment also carries a risk of serious bleeding.53 Fortunately, there are no
reports of venous thrombosis in FTM patients receiving testosterone treatment. Without
any data or evidence to the contrary, it is recommended that cross-sex hormonal therapy
should be discontinued 2 weeks before sex reassignment surgery or other elective surgery.
Hormonal Therapy After Sex Reassignment Surgery

Hormonal therapy should be restarted after sex reassignment surgery to guarantee a pa-
tient’s general well-being and to prevent the consequences of sex steroid deficie cy, such
as osteoporosis, although in MTF transgender patients, the dose of antiandrogen agent can
be reduced by more than half or even discontinued after oophorectomy. After surgery the
risk of venous thromboembolism decreases slowly over 2 weeks.54 In the absence of data,
it seems prudent to recommend that hormonal treatment should be delayed 3 to 4 weeks
after surgery, or at least until full mobilization has been achieved.
Aging Transgender Population and Hormonal Sex

Reassignment Therapy
Information regarding the management of hormones in the aging transgender population
is very limited. A recent publication by Gooren and Lips28 addressed several important
questions, such as the age at which cross-sex hormone therapy should be discontinued
and whether transgender persons older than 50 to 60 years of age should be accepted for
cross-sex hormone treatment. Rather than providing a cutoff age, a summary of goals was
concluded based on the available evidence of the hormonal effects on the transgender and
cisgender population: (1) The dose of hormonal therapy should be adjusted in the aging
transgender population to maintain the sex characteristics of the new sex, and (2) blood
levels of sex hormones should be kept within the normal range to preserve BMD in both
sexes. With aging there is a known increased risk for malignancies and cardiovascular mor-
tality,41 and thus there should be a discussion of the risks with the transgender individual
who has decided to continue lifelong cross-sex hormone therapy.
Although there may be an increase in the side effects of cross-sex hormone therapy in el-
derly patients, there is no strong evidence to suggest that it is harmful. Many transgender
individuals are unwilling to surrender the sexual characteristics of the new sex achieved
with hormone therapy, even after aging.28
Reproduction in the Transgender Population

The WPATH SOC and the clinical practice guidelines of the Endocrine Society state that
transgender individuals should be encouraged to consider their fertility options before
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CHAPTER 15
starting cross-sex hormone treatment. Therefore transgender patients should be referred

to a reproductive specialist, with whom a detailed exploration of the available options is
discussed, preferably before initiation of hormone therapy.
Cross-sex hormone therapy has some irreversible actions on the reproductive male ap-
paratus, with a direct effect on spermatogenesis and sperm motility and density, leading
to hypospermatogenesis, azoospermia, and atrophy of the testis.55,56 Cryopreservation of
sperm or preservation of testicular tissue are alternatives to preserved fertility in MTF trans-
gender patients, although it should be done before initiation of feminization hormones.
Preserved gametes can be used for insemination of a female partner, in vitro fertilization,
or intracytoplasmatic sperm injections.57 In 2014 the fi st live birth after uterus transplanta-
tion in a biologic woman was reported,58 which opens the window for possible use of this
technology in the MFT population. However, it seems impossible for MTF transgender
patients to become pregnant.
For the FTM population, the possibilities of pregnancy are wider, because testosterone ther-
apy does not deplete primordial follicles or affect its capacity for development. Also, because
some FTM transgender patients retain the ovaries and uterus, this makes pregnancy more
feasible.57 However, androgen therapy can affect reproductive capacity, as seen in patients
with hyperandrogenism, such as in polycystic ovary syndrome.59 There are several reports
of FTM transgender individuals who have had successful pregnancies after temporary dis-
continuation of androgen therapy.60 Currently there are no available published guidelines.
Conclusion
The main goal of hormone therapy in the transgender population is to provide a safe and
effective hormonal regimen that will result in the development of the physical characteris-
tics of the desired gender. The caregiver should maintain hormone levels close to the physi-
ologic range and minimize the potential long-term risk of these regimens. Unfortunately,
more work is needed in prospective studies to evaluate these hormone therapies and their
long-term effects. Careful monitoring by the endocrinologist within a multidisciplinary
team approach will provide the best outcome for the patient.
References
1. Reiner WG, Reiner DT. Thoughts on the na- 5. Houk CP, Levitsky L. Evaluation of the infant
ture of identity: disorders of sex development with ambiguous genitalia. 2013.
and gender identity. Child Adolesc Psychiatr 6. Lee PA, Houk CP, Ahmed SF, et al; Interna-
Clin N Am 20:627, 2011. tional Consensus Conference on Intersex or-
2. Öcal G, Berberoğlu M, Şiklar Z, et al. Clinical ganized by the Lawson Wilkins Pediatric En-
review of 95 patients with 46,XX disorders of docrine Society and the European Society for
sex development based on the new Chicago Paediatric Enocrinology. Consensus statement
classifi ation. J Pediatr Adolesc Gynecol 28:6, on management of intersex disorders. Proceed-
2015. ings of the International Consensus Conference
3. Furtado PS, Moraes F, Lago R, et al. Gender on Intersex. Pediatrics 118:e488, 2006.
dysphoria associated with disorders of sex 7. Coleman E, Bockting W, Botzer M, et al.
development. Nat Rev Urol 9:620, 2012. Standards of Care for the Health of Transsex-
4. Massanyi EZ, Dicarlo HN, Migeon CJ, et al. ual, Transgender, and Gender-Nonconform-
Review and management of 46,XY disorders ing People, version 7. Int J Transgenderism
of sex development. J Pediatr Urol 9:368, 13:165, 2011.
2013.
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8. Hembree WC, Cohen-Kettenis P, Delemarre- Guidelines. 2013 ACC/AHA guideline on the

van de Waal HA, et al. Endocrine treatment assessment of cardiovascular risk: a report of
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clinical practice guideline. J Clin Endocrinol can Heart Association Task Force on Practice
Metab 94:3132, 2009. Guidelines. Circulation 129(25 Suppl 2):S49,
9. Murad MH, Elamin MB, Garcia MZ, et al. 2014.
Hormonal therapy and sex reassignment: a 20. Asscheman H, T’Sjoen G, Lemaire A, et al.
systematic review and meta-analysis of qual- Venous thrombo-embolism as a complica-
ity of life and psychosocial outcomes. Clin tion of cross-sex hormone treatment of male-
Endocrinol (Oxf) 72:214, 2010. to-female transsexual subjects: a review. An-
10. Meriggiola MC, Gava G. Endocrine care drologia 46:791, 2014.
of transpeople part I. A review of cross-sex 21. Turner RT, Riggs BL, Spelsberg TC. Skeletal
hormonal treatments, outcomes and adverse effects of estrogen. Endocr Rev 15:275, 1994.
effects in transmen. Clin Endocrinol (Oxf) 22. Orwoll ES, Klein RF. Osteoporosis in men.
83:597, 2015. Endocr Rev 16:87, 1995.
11. Meriggiola MC, Gava G. Endocrine care of 23. Watts NB, Adler RA, Bilezikian JP, et al.
transpeople part II. A review of cross-sex Osteoporosis in men: an Endocrine Society
hormonal treatments, outcomes and ad- clinical practice guideline. J Clin Endocrinol
verse effects in transwomen. Clin Endocrinol Metab 97:1802, 2012.
(Oxf) 83:607, 2015. 24. Lips P, van Kesteren PJ, Asscheman H, et al.
12. Moore E, Wisniewski A, Dobs A. Endocrine The effect of androgen treatment on bone
treatment of transsexual people: a review of metabolism in female-to-male transsexuals. J
treatment regimens, outcomes, and adverse Bone Miner Res 11:1769, 1996.
effects. J Clin Endocrinol Metab 88:3467, 25. Van Caenegem E, Wierckx K, Taes Y, et al.
2003. Bone mass, bone geometry, and body com-
13. Spack NP. Management of transgenderism. position in female-to-male transsexual per-
JAMA 309:478, 2013. sons after long-term cross-sex hormonal
14. Nakamura A, Watanabe M, Sugimoto M, et therapy. J Clin Endocrinol Metab 97:2503,
al. Dose-response analysis of testosterone 2012.
replacement therapy in patients with female 26. Gooren LJ, Giltay EJ. Review of studies of
to male gender identity disorder. Endocr J androgen treatment of female-to-male trans-
60:275, 2013. sexuals: effects and risks of administration of
15. Elamin MB, Garcia MZ, Murad MH, et al. androgens to females. J Sex Med 5:765, 2008.
Effect of sex steroid use on cardiovascular 27. van Kesteren P, Lips P, Gooren LJ, et al. Long-
risk in transsexual individuals: a systematic term follow-up of bone mineral density and
review and meta-analyses. Clin Endocrinol bone metabolism in transsexuals treated with
(Oxf) 72:1, 2010. cross-sex hormones. Clin Endocrinol (Oxf)
16. Fernández-Balsells MM, Murad MH, Lane 48:347, 1998.
M, et al. Clinical review 1: adverse effects of 28. Gooren L, Lips P. Conjectures concerning
testosterone therapy in adult men: a system- cross-sex hormone treatment of aging trans-
atic review and meta-analysis. J Clin Endo- sexual persons. J Sex Med 11:2012, 2014.
crinol Metab 95:2560, 2010. 29. Hage JJ, Dekker JJ, Karim RB, et al. Ovarian
17. Calof OM, Singh AB, Lee ML, et al. Adverse cancer in female-to-male transsexuals: report
events associated with testosterone replace- of two cases. Gynecol Oncol 76:413, 2000.
ment in middle-aged and older men: a meta- 30. Dizon DS, Tejada-Berges T, Koelliker S, et al.
analysis of randomized, placebo-controlled Ovarian cancer associated with testosterone
trials. J Gerontol A Biol Sci Med Sci 60:1451, supplementation in a female-to-male trans-
2005. sexual patient. Gynecol Obstet Invest 62:226,
18. Asscheman H, Giltay EJ, Megens JA, et al. 2006.
A long-term follow-up study of mortality in 31. Pache TD, Fauser BC. Polycystic ovaries in
transsexuals receiving treatment with cross- female-to-male transsexuals. Clin Endocri-
sex hormones. Eur J Endocrinol 164:635, nol (Oxf) 39:702, 1993.
2011. 32. Gooren LJ, van Trotsenburg MA, Giltay EJ, et
19. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. Breast cancer development in transsexual
al; American College of Cardiology/Ameri- subjects receiving cross-sex hormone treat-
can Heart Association Task Force on Practice ment. J Sex Med 10:3129, 2013.
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33. Gooren LJ, Kreukels B, Lapauw B, et al. transsexual persons treated with oestrogens.
(Patho)physiology of cross-sex hormone ad- Andrologia 46:1156, 2014.
ministration to transsexual people: the po- 47. Miksad RA, Bubley G, Church P, et al. Pros-
tential impact of male-female genetic differ- tate cancer in a transgender woman 41
ences. Andrologia 47:5, 2015. years after initiation of feminization. JAMA
34. US Preventive Services Task Force. Screen- 296:2316, 2006.
ing for breast cancer: U.S. Preventive Services 48. Thurston AV. Carcinoma of the prostate in a
Task Force recommendation statement. Ann transsexual. Br J Urol 73:217, 1994.
Intern Med 151:716, W-236, 2009. 49. van Kesteren P, Meinhardt W, van der Valk
35. Gooren L. Is there a hormonal basis for hu- P, et al. Effects of estrogens only on the pros-
man homosexuality? Asian J Androl 13:793, tates of aging men. J Urol 156:1349, 1996.
2011. 50. Epstein JI. PSA and PAP as immunohisto-
36. Tangpricha V, Ducharme SH, Barber TW, et chemical markers in prostate cancer. Urol
al. Endocrinologic treatment of gender iden- Clin North Am 20:757, 1993.
tity disorders. Endocr Pract 9:12, 2003. 51. Unger CA. Gynecologic care for transgen-
37. Wierckx K, Gooren L, T’Sjoen G. Clinical der youth. Curr Opin Obstet Gynecol 26:347,
review: breast development in trans women 2014.
receiving cross-sex hormones. J Sex Med 52. Fleisher LA, Fleischmann KE, Auerbach
11:1240, 2014. AD, et al; American College of Cardiology;
38. Mueller A, Gooren L. Hormone-related tu- American Heart Association. 2014 ACC/
mors in transsexuals receiving treatment AHA guideline on perioperative cardiovas-
with cross-sex hormones. Eur J Endocrinol cular evaluation and management of patients
159:197, 2008. undergoing noncardiac surgery: a report of
39. Leinung MC, Urizar MF, Patel N, et al. En- the American College of Cardiology/Ameri-
docrine treatment of transsexual persons: can Heart Association Task Force on practice
extensive personal experience. Endocr Pract guidelines. J Am Coll Cardiol 64:e77, 2014.
19:644, 2013. 53. Palareti G, Cosmi B. Bleeding with anticoag-
40. Elbers JM, Asscheman H, Seidell JC, et al. ulation therapy—who is at risk, and how best
Long-term testosterone administration in- to identify such patients. Th omb Haemost
creases visceral fat in female to male trans- 102:268, 2009.
sexuals. J Clin Endocrinol Metab 82:2044, 54. Sweetland S, Green J, Liu B, et al. Dura-
1997. tion and magnitude of the postoperative
41. Gooren LJ, Wierckx K, Giltay EJ. Cardiovas- risk of venous thromboembolism in middle
cular disease in transsexual persons treated aged women: prospective cohort study. BMJ
with cross-sex hormones: reversal of the tra- 339:b4583, 2009.
ditional sex difference in cardiovascular dis- 55. Lubbert H, Leo-Rossberg I, Hammerstein J.
ease pattern. Eur J Endocrinol 170:809, 2014. Effects of ethinyl estradiol on semen quality
42. Amin S, Zhang Y, Felson DT, et al. Estradiol, and various hormonal parameters in a eugo-
testosterone, and the risk for hip fractures nadal male. Fertil Steril 58:603, 1992.
in elderly men from the Framingham Study. 56. Th agaraj D, Gunasegaram R, Loganath A,
Am J Med 119:426, 2006. et al. Histopathology of the testes from male
43. Müller R. Long-term prediction of three- transsexuals on oestrogen therapy. Ann Acad
dimensional bone architecture in simulations Med Singapore 16:347, 1987.
of pre-, peri- and post-menopausal micro- 57. T’Sjoen G, Van Caenegem E, Wierckx K.
structural bone remodeling. Osteoporosis Transgenderism and reproduction. Curr
International 16(Suppl 2):S25, 2005. Opin Endocrinol Diabetes Obes 20:575, 2013.
44. Sattari M. Breast cancer in male-to-female 58. Brannstrom M, Johannesson L, Bokstrom H,
transgender patients: a case for caution. Clin et al. Livebirth after uterus transplantation.
Breast Cancer 15:e67, 2015. Lancet 385:607, 2015.
45. Turo R, Jallad S, Prescott S, et al. Metastatic 59. Hunter MH, Sterrett JJ. Polycystic ovary syn-
prostate cancer in transsexual diagnosed drome: it’s not just infertility. Am Fam Physi-
after three decades of estrogen therapy. Can cian 62:1079, 2000.
Urol Assoc J 7:E544, 2013. 60. Light AD, Obedin-Maliver J, Sevelius JM, et
46. Gooren L, Morgentaler A. Prostate cancer in- al. Transgender men who experienced preg-
cidence in orchidectomised male-to-female nancy after female-to-male gender transi-
tioning. Obstet Gynecol 124:1120, 2014.
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CHAPTER
16
Mental Health Care for Transgender
and Gender Nonconforming Children,
Adolescents, and Adults
CHA
Walter O. Bockting, Amir Adam Tarsha,

Yasmina Zoghbi, Clara Alvarez-Villalba
Key Points
Me
❖❖ Mental health professionals can play a key role ❖❖ Mental health professionals can help to facili-
in assisting transgender and gender noncon- tate identity development and improve quality
forming persons to explore and actualize their of life. Medical providers and surgeons are en-
gender identity. Surgeons should discuss the couraged to coordinate care with mental health
various medical interventions available to affirm professionals.
gender identity and support these patients in ❖❖ Transgender and gender nonconforming chil-
coping with the psychosocial challenges many dren, adolescents, and adults can benefit from
continue to face. an interdisciplinary approach to the promotion
❖❖ The social stigma attached to nonconformity in of transgender health.
gender identity and expression negatively im-
pacts mental health. Factors associated with
resilience include family support, transgender
community connectedness, and identity pride.
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Mental Health Care for Transgender and Gender Nonconforming Children, Adolescents, and Adults
Role of the Mental Health Professional

According to the “Standards of Care for the Health of Transsexual, Transgender, and Gen-
der Nonconforming People” (TGNC), set forth by the World Professional Association for
Transgender Health (WPATH),1 mental health professionals may serve TGNC people and
their families in a various ways, depending on individual needs. The roles include asses-
sor or evaluator, counselor, psychotherapist, educator, and advocate. Psychological assess-
ment or evaluation typically covers three domains: gender dysphoria, mental health, and
psychosocial adjustment. Based on this assessment or evaluation, counseling and psycho-
therapy follow an individualized treatment plan. Counseling may include assisting TGNC
individuals and their families in making an informed decision about interventions to affirm
gender identity. These interventions may include changes in gender role and expression,
voice therapy, hormone therapy, and/or surgery. Psychotherapy may include exploration
of gender and sexual identity but also treatment of mental health concerns. TGNC people
may be extra vulnerable to mental health concerns because of the stress associated with be-
ing differently gendered and the social stigma attached to gender nonconformity. Mental
health concerns, whether or not related to gender nonconformity, may also exacerbate the
psychosocial challenges TGNC people face as they explore and seek to affirm their gender
identity. Education may include providing information and facilitating access to commu-
nity resources so that TGNC people and their families can make informed choices and can
benefit from peer support. It may also include educating the environment (for example,
schools, workplaces, organizations, and institutions) and policy makers about gender di-
versity and the needs of TGNC people. Finally, mental health professionals can play a key
role in advocating for transgender rights on an individual, interpersonal, and sociocultural
level. Th s may include supporting changes in identity documents, advocating for sexual
and reproductive rights, and supporting antidiscrimination legislation.
Competency in mental health care for TGNC people and their families varies based on
the mental health professional’s role. All mental health professionals should be culturally
competent in transgender care. Cultural competence can be defi ed as the process in which
the health professional continuously strives to achieve the ability to effectively work within the
cultural context of the patient.1,2 Th s includes awareness of one’s own biases and prejudices,
knowledge about the patient’s belief system and worldview, the skills to conduct a cultural
assessment while avoiding stereotypical judgments and assumptions, cultural encounters
with patients from diverse backgrounds, and the desire to engage in the ongoing process of
building cultural competence. In transgender care this includes ensuring a clinic environ-
ment that refl cts gender diversity in posters, brochures, registration and intake forms, the
use of preferred names and pronouns, and access to all-gender bathrooms. It also includes
open communication between provider and patient about gender identity and gender af-
fi mation to the extent that it is relevant to the presenting concern. Clinical competence in
the assessment and treatment of gender dysphoria goes a step further, because it requires
specialty training and supervision.1 In addition, mental health professionals working with
TGNC children and adolescents should have training in developmental psychology. More-
over, mental health care for TGNC people and their families is best provided in consulta-
tion with providers of other disciplines (for example, medicine, education, and social work)
involved in the patient’s care.
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CHAPTER 16
Assessment of Gender Dysphoria

Mental health professionals are often the fi st health care providers that TGNC patients will
seek out. Although some patients will present with gender dysphoria as their chief com-
plaint, others may desire treatment for other related or unrelated mental health concerns.
Before addressing gender dysphoria, the mental health professional should first perform a
complete psychosocial history. If patients wish to further explore their gender identity and
any associated dysphoria, the clinician can move forward with the assessment and treat-
ment of gender dysphoria.
Gender dysphoria refers to discomfort with the sex and gender role assigned at birth.
Gender dysphoria is also a diagnosis in the Diagnostic and Statistical Manual of Mental
Disorders, fi h edition (DSM-5),3 where it is defi ed as a marked incongruence between a
person’s experienced/expressed gender and assigned gender of at least 6 months’ duration
and requires that the patient present with at least two of the following:
❖❖ A strong desire to be rid of his or her primary or secondary sex characteristics (or
in young adolescents, to prevent the development of the anticipated secondary
characteristics)
❖❖ A strong desire for the primary or secondary sex characteristics of the other gender
❖❖ A strong desire to be of the other (or some alternative) gender
❖❖ A strong desire to be treated as the other (or some alternative) gender
❖❖ A strong conviction of having the typical feelings and reactions of the other (or
some alternative) gender
In children, the desire to be the other gender must be present and verbalized. For the di-
agnosis to be applicable, the incongruence must cause clinically signifi ant distress or im-
pairment in social, occupational, or other important areas of functioning.
Mental health professionals must recognize that some patients and transgender commu-
nity members may take umbrage to the idea that their gender identity issues deserve a
DSM classifi ation. Th s is a response that the clinician should be prepared for and able to
deal with thoughtfully, professionally, and empathetically.4 Although some patients may
enter the therapeutic relationship with a mature grasp on their gender identity, others may
be less clear and have questions about their gender identity. Mental health professionals
should explore with compassion and cultural competence the gender with which the pa-
tient identifies and avoid any assumptions before proceeding with a formal assessment and
treatment of gender dysphoria.
The main approach to the assessment of gender dysphoria is the clinical interview. TGNC
adolescents or adults are asked to describe their gender identity, how they feel about their
current gender role and expression, how they feel about their body (particularly their pri-
mary and secondary sex characteristics), and what if any changes they have made or would
like to make in gender identity, gender expression, and/or sex characteristics. Subsequently,
a history of their experience with gender identity is obtained. TGNC children are asked
whether they feel like a boy, girl, or other gender (for example, boygirl). Parents of TGNC
children and adolescents are interviewed about their perceptions, observations, and the
reports received about their child or adolescent regarding their gender identity, gender ex-
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CHAPTER 16
pression, and sexual development. For many of these domains, structured questionnaires
have been developed that are either self-administered or interviewer-administered. These
include the Gender Identity Interview for Children,5 the Gender Identity/Gender Dyspho-
ria Questionnaire for Adolescents and Adults,6,7 and the Utrecht Gender Dysphoria Scale.8
The assessment of gender dysphoria also includes other key components of sexual identity
and sexual development. Most patients presenting with gender dysphoria report normative
development of primary and secondary sex characteristics before gender-affirming medi-
cal interventions. However, some children born with ambiguous genitalia develop gender
dysphoria. Many patients with gender dysphoria report a history of childhood gender role
nonconformity (for example, feminine boys and masculine girls), and yet a substantial
number of patients (particularly among those assigned male at birth) were not gender role
nonconforming in childhood. Thus gender identity and gender expression are two distinct
components of sexual identity that are not necessarily congruent. Sexual orientation, an-
other key component of sexual identity, is also distinct from gender identity. TGNC ado-
lescents and adults may be attracted to boys or men, girls or women, or both, as well as to
other TGNC individuals. In assessing the patient’s sexual development, all these compo-
nents should be considered, along with other aspects of sexuality, such as sexual fantasy,
sexual expression, attachment, and love. The development of gender identity and gender
dysphoria should be understood in the context of overall sexual and human development.
Mental Health
TGNC children, adolescents, and adults are at increased risk for mental health concerns,
including anxiety, depression, nonsuicidal self-injury, suicidal ideation and attempts, symp-
toms of posttraumatic stress disorder, and substance abuse.9-14 When patients present to
a mental health professional with questions about their gender identity or complaints of
gender dysphoria, it is the responsibility of the clinician to also screen for and assess comor-
bid mental health conditions. Before fi ally deciding to see a mental health professional,
patients with gender dysphoria have often dealt with years of social stigma, microaggres-
sions, and social isolation resulting from their status as a gender and/or sexual minority.15
TGNC individuals may also experience physical violence.16
In a U.S. national survey of transgender women and men, 44% reported depression and
33% reported anxiety.9 These high rates of psychological distress have been attributed to
the social stigma attached to nonconformity in gender identity and expression.9,13,20 Ac-
cording to the minority stress model,21,22 TGNC people experience minority stress, which
negatively impacts mental health. Minority stress processes include enacted stigma (actual
experiences of rejection and discrimination), felt stigma (perceived rejection and expecta-
tions of being stereotyped or discriminated against), and internalized transphobia (discom-
fort with one’s own transgenderism as a result of internalizing society’s normative gender
expectations).23 Indeed in the U.S. national survey previously cited,9 participants reported
high rates of housing discrimination (12%), sexual abuse or assault (15%), physical abuse
(24%), employment discrimination (38%), and verbal abuse or harassment (70%). Protec-
tive factors included family support and identity pride, and peer support and community
connectedness buffered the negative impact of enacted stigma on mental health.9,24 Research
is needed to better understand the mechanism of how stigma affects mental health and to
develop tailored interventions.13 While exploring the history of the patient’s gender dys-
phoria, clinicians should be cognizant of the often hostile cultural environment in which
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CHAPTER 16
their TGNC patients came of age. The cumulative impact of this negative culture and its
rejecting and sometimes violent attitude toward gender nonconformity and the subsequent
trauma can have a serious impact on mental health. When caring for patients with gender
dysphoria, the clinician should be vigilant for psychiatric comorbidities and prepared to
apply the appropriate assessment tools to diagnose them.
TGNC adolescents are also more likely to have autism spectrum disorder compared with
the general population. In a clinical sample of 204 children presenting with gender dys-
phoria, 16 (7.8%) had autism spectrum disorder compared with 0.6% to 1% of the general
population.9 Similar higher rates of autism spectrum disorder traits have been found in
an adult clinical sample,17 and in clinical samples of children and adolescents with autism
spectrum disorder, a higher prevalence of gender dysphoria was found compared with the
general population.25,26 The explanation for these fi dings remains unclear. However, men-
tal health professionals working with TGNC patients should screen for autism spectrum
disorder and incorporate the results in the care they provide.27
A standard psychological evaluation can assess mental health and psychosocial adjustment.
For TGNC children, adolescents, and adults, this evaluation should include an assessment
of the impact of enacted stigma, felt stigma, and internalized transphobia on mental health
and the resilience that they developed over time. Existing strengths and potential assets
should be identified, which may include support from friends, family, and community.
The evaluation should also include screening for suicidal ideation, substance abuse, and
sexual risk behavior (for example, HIV risk behavior, hazards associated with sex work,
and sexual violence), for which TGNC people have a heightened vulnerability. When indi-
cated, a psychiatric consultation may be obtained (for example, in patients with symptoms
of severe mental illness or when pharmacotherapy may be helpful to alleviate symptoms
of depression or anxiety).
Given the disparities in mental health documented thus far, a comprehensive screen and
assessment of identifi d mental health concerns resulting in a differential diagnosis is war-
ranted for most individuals presenting with gender dysphoria. This will allow incorporating
treatment of mental health comorbidities in an individualized treatment plan. Generally
speaking, treatment is best provided in parallel, that is, mental health issues are addressed
during the course of treatment of gender dysphoria. Effective management of mental health
comorbidities will facilitate social changes to alleviate gender dysphoria, and progress with
gender affirmation will improve self-esteem and self-care, foster a positive future outlook,
and motivate the patient to sustain optimal adaptation.
Transgender Identity Development

Transgender identity development is a lifelong process.28 In the context of social stigma
attached to gender nonconformity, transgender identity development has been described
as a coming out process.29-31 Bockting and Coleman29 describe five developmental stages:
1. Pre-coming out
2. Coming out
3. Exploration
4. Intimacy
5. Integration
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CHAPTER 16
Individuals do not necessarily go through these stages in this particular order. Rather, these
stages refl ct developmental tasks commonly observed in clinical practice. The pre-coming
out stage is characterized by feeling different. TGNC children and adolescents who are out-
wardly gender role nonconforming (for example, a feminine boy or masculine girl) are rec-
ognized as such by the people in their environment and are vulnerable to enacted stigma,
which may take the form of rejection, harassment, and abuse. In the face of this adversity,
they develop early resilience with the help of supportive others (for example, family mem-
bers, friends, school, and mental health professionals). TGNC children and adolescents
who are outwardly gender role conforming often conceal their gender identity in an effort
to avoid enacted stigma. However, concealment is often accompanied by felt stigma (an-
ticipated rejection and fear of discrimination), which may take a different emotional toll
and contribute to anxiety, depression, and substance use.
The developmental task of the coming out stage is to acknowledge one’s transgender feel-
ings to self and others. The mental health professional may be the fi st person the individ-
ual comes out to. Needless to say, a nonjudgmental, accepting attitude is critical without
foreclosing what may be a process of exploring (avoid premature labeling), giving the indi-
vidual permission to have an ongoing conversation about their gender identity and related
concerns. Telling others involves taking calculated risks, starting with those who are close
and most likely to accept. The mental health professional can coach and support the in-
dividual during this process. Family and friends often need time to understand and come
to terms with the news that their loved one is transgender. The mental health professional
can assist by putting reactions into perspective and referring both the patient and family
to information and support resources. The exploration stage is a time of learning as much
as possible about gender diversity, connecting with the transgender community, and ex-
perimenting with gender expression. In this stage individuals often make decisions about
changes in gender role and gender-affirming medical procedures (hormones and surgery).
Also, in this stage, individuals explore their sexuality and begin to defi e or redefi e their
sexual orientation. The mental health professional plays an important role in normalizing
this process of exploration at any chronologic age, facilitating access to peer support, and
assisting the individual in making fully informed decisions about changes in gender role,
hormone therapy, changes in identity documents, and surgery.
In the intimacy stage, the emphasis on identity development shifts rom a focus on self to
a focus on establishing and maintaining intimate relationships. Th s often involves facing
fears of abandonment and learning when and how to communicate about one’s gender
identity and sexuality in the context of dating relationships. It also involves developing an
identity as a couple and how to deal with society’s heteronormative and homonormative
expectations. Mental health professionals can assist by helping patients clarify and com-
municate their needs for intimacy and sexuality to their (potential) partners and by help-
ing partners cope with felt and enacted stigma and the questions partners may have about
their own identity. Finally, integration involves grief over lost time and missed opportunities
and an appreciation of the added value of living life as a transgender person. In this stage
individuals are often able to tolerate greater ambiguity in gender identity and expression,
and being transgender is no longer necessarily the most defini g aspect of their overall
identity. During this time, many TGNC people give back to their community and contrib-
ute to making the world a better place for the next generation. During this stage mental
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CHAPTER 16
health professionals can facilitate grief, address internalized transphobia, witness personal
growth, and learn a great deal from the patient’s deeper insights into what it means to be a
person of transgender experience.
Working With Children and Adolescents

TGNC children and adolescents present at younger and younger ages with gender dys-
phoria and for assistance in making informed decisions about changes in gender role and
the available options for early, gender-affirming medical interventions. In childhood, non-
conformity in gender identity can be hard to distinguish from nonconformity in gender
role; the former is an indication of gender dysphoria. Moreover, the majority of gender
role nonconforming children do not grow up to be transgender, and any gender dyspho-
ria they may experience does not necessarily persist into adolescence.32 During puberty
(ages 10 to 13 years), changes in social environment (with respect to gender roles among
peers), anticipated and actual physical changes, and fi st experiences of sexual attractions
and falling in love appear to contribute to critical changes in the intensity and persistence
of gender dysphoria.33 Because the outcome is hard to predict, the approach to treatment
is to provide a supportive environment in which the child’s gender identity development
can unfold without trying to bring about any particular outcome. Th s requires tolerating
ambiguity and uncertainty, and care must be taken not to foreclose identity development.
For children with a history of intense gender dysphoria who have a strong adverse reaction
to the onset of puberty, puberty suppression with gonadotropin-releasing hormone analogs
is available. Th s allows monitoring of gender identity development and gender dysphoria
for a period of time beyond 12 years of age before initiation of cross-sex hormone therapy
(in case dysphoria persists) or discontinuation of suppression (in case dysphoria desists),
so that puberty can continue congruent with gender identity. The role of the mental health
professional is to counsel patients and families with information on what is known and not
known about the benefits and risks of the various treatment options (including the potential
harm of doing nothing); it is also to support them during this period of uncertainty and
address any adjustment issues the child may face, regardless of whether these issues are re-
lated, or not to the presenting complaint of gender dysphoria. Thus far, follow-up research
has shown favorable outcomes for youth treated with this approach.34
Even before the age of puberty, gender nonconforming children may consider making a so-
cial transition in gender role (from female to male or male to female), including at school.
Although such a social transition may alleviate gender dysphoria, caution is warranted,
because qualitative research has shown that children for whom gender dysphoria does not
persist may struggle significantly with the stress of reverting back to the original gender
role.33 Moreover, some TGNC youth develop a gender identity outside of the gender bi-
nary (not male, not female, but an alternative gender such as genderqueer), revealing the
limits of the concept of “transition,” whether social, medical, or both. What is known is
that children with gender dysphoria are more vulnerable to poor peer relations and general
behavioral problems35 and that these adjustment challenges, in addition to the gender dys-
phoria, could benefit from social and behavioral interventions. Mental health profession-
als can work with the child, family, school, and other health and social service providers to
develop and implement an individualized, coordinated care plan.
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The WPATH “Standards of Care”1 provide the following minimum criteria for puberty-
suppressing hormones:
1. There is a long-lasting and intense pattern of gender nonconformity or gender dys-
phoria.
2. Gender dysphoria emerged or worsened with the onset of puberty.
3. Any coexisting psychological, medical, or social problems that could interfere with
treatment have been addressed.
4. The adolescent has given informed consent, and particularly when the adolescent has
not reached the age of medical consent, the parents or other caretakers or guardians
have consented to the treatment and support the adolescent throughout the treat-
ment process.
Facilitating Changes in Gender Role and Expression

Transgender coming out is fi st and foremost a psychosocial process. Just because a patient
presents with gender dysphoria and may meet the criteria for a formal DSM-5 diagnosis of
gender dysphoria does not mean that social and medical “transition” is indicated. Rather,
today’s approach to care develops and implements an individualized treatment plan requir-
ing coordination of care across providers of various disciplines (psychology, psychiatry, so-
cial work, endocrinology, surgery, and voice therapy) and various support resources (online
and offl e transgender community resources, legal assistance) tailored to the needs of pa-
tients and their family. In consultation with their health providers, patients make decisions
among the various available options for intervention. Thus a patient assigned male at birth
may decide to change gender role and expression and take feminizing hormones but not
opt for surgery, or a patient assigned female at birth may opt for chest surgery without tak-
ing masculinizing hormones. These patients may identify as female or male, a transgender
woman or man, or as genderqueer. Others, however, will pursue a more traditional path
and take hormones, change gender roles (including a change in identity documents), and
have gender-affirming surgery (breast/chest, genital, and/or facial surgery). In addition, the
treatment plan may include treatment of other identifi d mental or physical health issues.
Patients go about this process at their own pace, and the plan is often adjusted along the
way. Mental health professionals can assist in the development and implementation of this
individualized treatment plan, consult with the other providers and stakeholders involved
in the patient’s care, and provide support along the way.
For many patients, changes in gender role and expression are the most frightening part of
the process. It involves informing others who need to know, including family, friends, and
typically after that employers and coworkers, teachers, and schoolmates. Th s involves tak-
ing calculated risks, putting the reactions of others into perspective, and recognizing that
others need time to adjust. Particularly when family and friends are adjusting, a process
that has been described as their own coming out or transition process,36,37 support from
other transgender individuals who have gone through a similar process can be extremely
helpful. Patients may include their families and friends in psychotherapy. Family therapy is
useful, especially when the patient is a child or adolescent.31,38,39 Many support groups are
available to TGNC individuals at all stages of coming out and to family members.40 Mental
health professionals should be familiar with and can refer families and friends to available
local and national support networks and services.
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In addition to fears of rejection and abandonment by families and friends, changes in gen-
der role and expression involve facing stigma and discrimination by society at large. Indeed,
experiences of actual discrimination are more common among those who openly express
their transgender identity, and yet peer support and transgender community connected-
ness can buffer the negative impact of these experiences on the patient’s mental health.7,24
TGNC individuals who identify as genderqueer or nonbinary and who may have a more
ambiguous gender expression are extra vulnerable to social stigma and struggle with the
fact that society is not yet very adept at accommodating their gender identity and expres-
sion. Mental health professionals can assist patients to navigate these challenges, access
peer support, consult on gender role changes in the workplace, support changes in identity
documents, and advocate on behalf of their patients or more generally for antidiscrimina-
tion and transgender rights, policies, and legislation.
Preparation and Referral for Hormone Therapy

According to version 7 of the “Standards of Care,”1 TGNC people can access hormone ther-
apy without a referral by a mental health professional, particularly when the physician pre-
scribing the hormones is appropriately trained in behavioral health and competent in the
assessment of gender dysphoria. However, patients may want to obtain a consultation and
work with a mental health professional to make a fully informed decision about hormone
therapy and its psychosocial implications. Moreover, mental health professionals can play
a key role in preparing the patient for hormone therapy.
The decision to feminize or masculinize the body through hormone therapy is first and
foremost a very personal decision for the patient. However, mental health professionals
working with TGNC individuals and their families are often called on to support this deci-
sion. Coordination of care with the other providers involved in the patient’s care is critical,
whether or not the mental health professional is an integral member of a multidisciplinary
specialty team. Progress in meeting the goals of the patient’s individualized treatment plan
to alleviate gender dysphoria and address any other identifi d mental health issues is what
should guide the timing of the onset of hormone therapy.
Preparation should include having realistic expectations and understanding the impli-
cations of hormone therapy for psychosocial adjustment and mental health. Discussing
these expectations and implications with other TGNC persons who have the relevant ex-
perience can be extremely helpful in this regard. Preparation also includes establishing
and maintaining social support from family and/or friends. With the help of readings
and consultation with a physician (preferably one with experience in providing gender-
affirming hormone therapy), the patient should be made aware of the risks and benefits
of hormone therapy for physical health, taking into account overall health and chronic
disease. Finally, preparation includes discussion of the implications of hormone therapy
for sexual and reproductive health, with an explicit discussion of the available options
for preservation of fertility.
The WPATH “Standards of Care”1 recommends that the mental health professional’s referral
for feminizing or masculinizing hormone therapy includes a summary of the psychosocial
assessment and diagnoses, duration and progress made in counseling or psychotherapy, a
clinical rationale for hormone therapy and the patient’s standing in meeting the criteria,
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documentation of informed consent, and a statement about the availability of coordination

of care. The WPATH “Standards of Care” criteria for hormone therapy are:
1. There is persistent, well-documented gender dysphoria.
2. The patient has the capacity to make a fully informed decision and to consent for
treatment.
3. The patient has reached the age of majority in a given country (if younger, see “Work-
ing With Children and Adolescents”).
4. If signifi ant medical or mental health concerns are present, they must be reasonably
well controlled.
Preparation and Referral for Surgery

According to the WPATH “Standards of Care,”1 for gender-affirming breast/chest and gen-
ital surgery, referrals from one or two mental health professionals are needed to initiate
surgical treatment. The mental health professional can assist the patient to make a fully
informed decision about the various options for surgery and their timing, to have realistic
expectations, and to understand the implications of surgery for psychosocial adjustment.
Discussing these expectations and implications with other TGNC individuals who have
experience in this regard is extremely helpful. The mental health professional should en-
courage the patient to obtain accurate information about surgical procedures, including
their risks and benefits, through readings and consultation with qualifi d surgeons. Social
support and the development of an aftercare plan are critical.
One referral from a qualifi d mental health professional is needed for breast/chest sur-
gery (mastectomy, chest reconstruction, or breast augmentation); two referrals are needed
for genital surgery (hysterectomy, salpingo-oophorectomy, orchiectomy, or genital recon-
structive surgery). The referral letter (or letters) should include a summary of the patient’s
psychosocial assessment and diagnoses, duration, and progress made in counseling or
psychotherapy; a clinical rationale for surgery and the patient’s standing in meeting the
criteria; documentation of informed consent; and a statement regarding the availability for
coordination of care. Others have recommended that the letter include information about
how well the patient has adhered to the WPATH’s “Standards of Care” and the likelihood
of future compliance and that the letter (or letters) provide a holistic picture of the patient,
including a description of the patient’s socioeconomic status, functional status, and social
history.41 Although this model of referral by mental health professionals is currently the
accepted standard of practice, some members of the transgender community think that
this creates an adversarial relationship in which the mental health professional serves as a
“gatekeeper,” perceived as standing in the way of the transgender patient’s goals for transi-
tion. Rather, clinicians should do their best to act as a facilitator, working with the patient
to achieve the highest quality of life possible.42
The WPATH “Standards of Care” criteria for breast/chest surgery are:

treatment.
3. The patient has reached the age of majority in a given country.
well controlled.
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For breast augmentation, patients who are taking feminizing hormones are encouraged to
give hormone therapy suffici t time before breast augmentation surgery.
The criteria for genital surgery are:

treatment.
3. The patient has reached the age of majority in a given country.
well controlled.
5. The patient has received 12 continuous months of hormone therapy unless hormones
are not clinically indicated.
6. For genital reconstructive surgery (vaginoplasty, metoidioplasty, or phalloplasty), the
patient must live for 12 continuous months in a gender role that is congruent with the
patient’s gender identity.
The rationale for this last criterion (criterion 6) is to provide ample opportunity for patients
to experience and socially adjust to the gender role congruent with their identity before
they undergo irreversible surgery.
After the patient has been referred for surgery, psychiatrists should collaborate with the
surgeon and anesthesiologists to clarify the risks of the various psychotropic medications
their patients may take. The psychiatrist may opt to adjust various medications before sur-
gery. Although some psychotropic drugs may be safe during surgery, others may interact
dangerously.43,44 Before surgery, psychiatrists should be aware of a number of other drug-
drug interactions, especially if their patients are taking multiple psychotropic medications
for comorbidities.
Postoperative Tasks of Mental Health Professionals

After the surgery has been completed, patients must check in regularly with their mental
health providers. Postoperative care is fundamental for patients’ psychological well-being.
During the postoperative stages of care, the three broad categories of tasks for the mental
health professional are:
1. Immediate postoperative mental health and behavioral health care
2. Facilitating postoperative adjustment
3. Continuation of long-term mental health care
In the immediate postoperative period, TGNC patients, like all surgical patients, may pre
sent with uncontrollable pain, confusion, agitation, and delirium. The mental health pro-
fessional can aid the patient by ensuring that an appropriate support network will be at the
bedside during the initial recovery period. Th s may be a challenge. Although patients may
be pleased with the completion of much sought-after surgery and have improved body im-
age, and decreased gender dysphoria, these feelings are not always shared by their families
and loved ones.45 Patients may be faced with shock or confusion rather than support and
may experience a wide range of reactions from acceptance and celebration to rejection and
violence.31,46 Thus adjustment during the fi st postoperative year may be far from what one
may consider a honeymoon, and mental health professionals must provide the appropriate
support and therapy. It also underscores the potential benefit from including family mem-
bers and loved ones early on in treatment.
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In the months after surgery, patients may face adjustment challenges. As patients recover
and become more comfortable with their body, many wish to resume sexual function. Most
function well from a social and sexual standpoint and are able to achieve orgasm.47-50 Oth-
ers, however, may have difficulty finding sexual partners or may have lost interest in sex
altogether.51 These issues can be addressed through sex therapy.
Regarding overall quality of life, multiple studies have demonstrated that treatment of gen-
der dysphoria is benefic al for both transgender women and men.34,45,47,52-55 Among adoles-
cents, more stable psychological function was found after surgery. Smith et al45 confi med
that treatment is effective, with regrets of transition being extremely rare. One transgender
woman conveyed regrets and stated that her transition would have been more bearable had
she had professional guidance through the adverse consequences she experienced, includ-
ing intolerance of society, family, and her own children. As such, good aftercare and post-
operative follow-up cannot be overstressed.56 Research is limited, however, to cohorts of
patients who have followed a traditional path of psychological evaluation, hormone therapy,
a change in gender role from male-to-female or female-to-male, and surgery, and typically
in that order. Studies have not refl cted the diversity in gender identity, gender expression,
and treatment options that TGNC individuals exercise today. Future research is needed to
evaluate the outcomes of today’s heterogeneous approaches to care, including the specific
interventions delivered by mental health professionals, and on comfort with gender iden-
tity and role, mental and physical health, and quality of life.28,57
Although quality of life tends to improve after surgery, patients must regularly see their
primary care physician and mental health provider.47 Surgery, although a crucial compo-
nent of gender affirmation for some, cannot teach patients how to live life as a transgender
woman or man. Mental health professionals are responsible for providing their patients
with adequate preparation for the challenges they can expect with transition, in addition
to the rewards and satisfaction they may experience.58
Postoperative psychotherapy in groups or individually should be part of the available care

to support patients in their adjustment and life goals.59 Questions about gender identity
may remain or resurface, providing the opportunity to accept one’s identity as a person of
TGNC experience on a deeper level. Some issues may not arise until some time after a gen-
der role transition or surgery, such as worries and apprehensions about daily life related to
gender (for example, facing questions about past gender markers on identity documents or
disclosure of identity and background to a new health care provider) and issues regarding
dating, relationships, and sexuality.58
Conclusion
Mental health professionals play an important role in the care of TGNC people and in the
interdisciplinary assessment and treatment of gender dysphoria. Transgender coming out
is fi st and foremost a psychosocial process in which coping with social stigma attached to
gender nonconformity is a recurring theme. Mental health professionals can facilitate iden-
tity development and resilience. Mental health professionals can also assist TGNC people
in making a fully informed decision about the various treatment options available, in pre-
paring patients for changes in gender role and/or medical interventions, and in providing
support to TGNC persons, their families, and communities along the way. Finally, mental
health professionals can advocate for better accommodation and acceptance in society and
its institutions of the full spectrum of gender diversity found among this special population.
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References
1. Coleman E, Bockting W, Botzer M, et al. with posttraumatic stress disorder symptoms
Standards of Care for the Health of Transsex- among transgender adults. J Couns Psychol
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for addressing cultural competence in health try 52:1195, 2011.
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Identity/Gender Dysphoria Questionnaire 20. Perez-Brumer A, Hatzenbuehler ML, Old-
for Adolescents and Adults. Arch Sex Behav enburg CE, et al. Individual- and structural-
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Romine RE, et al. Stigma, mental health, 21. Meyer IH. Prejudice, social stress, and men-
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10. Goldblum P, Testa RJ, Pflum S, et al. The rela- 22. Hendricks ML, Testa RJ. A conceptual frame-
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Life Th eat Behav 37:527, 2007. risk and prevention. In Proceedings of the
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24. Nuttbrock L, Bockting W, Rosenblum A, 36. Dierckx M, Motmans J, Mortelmans D, et al.

et al. Gender abuse and incident HIV/ Families in transition: a literature review. Int
STI among transgender women in New Rev Psychiatry 28:36, 2016.
York City: buffering effect of involvement 37. Emerson S, Rosenfeld C. Stages of adjust-
in a transgender community. AIDS Behav ment in family members of transgender indi-
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25. Glidden D, Bouman WP, Jones BA, et al. 38. Bockting WO, Knudson G, Goldberg JM.
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Sex Med Rev 4:3, 2016. derism 9:35, 2006.
26. Janssen A, Huang H, Duncan C. Gender 39. Vanderburgh R. Appropriate therapeutic care
variance among youth with autism spectrum for families with pre-pubescent transgender/
disorders: a retrospective chart review. Trans- gender-dissonant children. Child Adolesc
gender Health 1:63, 2016. Soc Work J 26:35, 2008.
27. Jacobs LA, Rachlin K, Erickson-Schroth L, 40. Menvielle EJ, Tuerk C. A support group for
et al. Gender dysphoria and co-occurring parents of gender-nonconforming boys. J
autism spectrum disorders: review, case ex- Am Acad Child Adolesc Psychiatry 41:1010,
amples, and treatment considerations. LGBT 2002.
Health 1:277, 2014. 41. Rachlin K. Transgender individuals’ experi-
28. Bockting W, Coleman E, Deutsch MB, et ences of psychotherapy. Int J Transgenderism
al. Adult development and quality of life of 6:1, 2002.
transgender and gender nonconforming 42. Budge SL. Psychotherapists as gatekeep-
people. Curr Opin Endocrinol Diabetes Obes ers: an evidence-based case study highlight-
23:188, 2016. ing the role and process of letter writing for
29. Bockting WO, Coleman E. Developmental transgender clients. Psychotherapy 52:287,
stages of the transgender coming out pro- 2015.
cess: toward an integrated identity. In Ettner 43. Halperin D, Guido R. Influence of antide-
R, Monstrey S, Eyler AE, eds. Principles of pressants on hemostasis. Dialogues Clin
Transgender Medicine and Surgery. New Neurosci 9:47, 2007.
York: The Haworth Press, 2007. 44. Huyse FJ, Touw DJ, van Schijndel RS, et al.
30. Gagne P, Tewksbury R, McGaughey D. Com- Psychotropic drugs and the perioperative
ing out and crossing over. Identity formation period: a proposal for a guideline in elective
and proclamation in a transgender commu- surgery. Psychosomatics 47:8, 2006.
nity. Gender & Society 11:478, 1997. 45. Smith YL, Van Goozen SH, Kuiper AJ, et al.
31. Lev AI. Transgender Emergence: Therapeutic Sex reassignment: outcomes and predictors
Guidelines for Working with Gender-Variant of treatment for adolescent and adult trans-
People and Their Families. New York: The sexuals. Psychol Med 35:89, 2005.
Haworth Clinical Practice Press, 2004. 46. Xavier JM, Simmons R. The Washington
32. Steensma TD, McGuire JK, Kreukels BP, et al. Transgender Needs Assessment Survey
Factors associated with desistence and persis- 2000. Available at http://www.glaa.org/
tence of childhood gender dysphoria: a quan- archive/2000/tgneedsassessment1112.shtml.
titative follow-up study. J Am Acad Child 47. Rehman J, Lazer S, Benet AE, et al. The re-
Adolesc Psychiatry 52:582, 2013. ported sex and surgery satisfactions of 28
33. Steensma TD, Biemond R, de Boer F, et al. postoperative male-to-female transsexual pa-
Desisting and persisting gender dysphoria tients. Arch Sex Behav 28:71, 1999.
after childhood: a qualitative follow-up 48. Rakic Z, Starcevic V, Maric J, et al. The out-
study. Clin Child Psychol Psychiatry 16:499, come of sex reassignment surgery in Bel-
2011. grade: 32 patients of both sexes. Arch Sex
34. de Vries AL, McGuire JK, Steensma TD, et al. Behav 25:515, 1996.
Young adult psychological outcome after pu- 49. Lief HI, Hubschman L. Orgasm in the post-
berty suppression and gender reassignment. operative transsexual. Arch Sex Behav 22:145,
Pediatrics 134:696, 2014. 1993.
35. Aitken M, VanderLaan DP, Wasserman L, 50. Eilenberger K, Janousek A, Poigenfürst J.
et al. Self-harm and suicidality in children [Heart arrest as a sequela of clavicular frac-
referred for gender dysphoria. J Am Acad ture] Unfallchirurgie 18:186, 1992.
Child Adolesc Psychiatry 55:513, 2016.
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51. Wierckx K, Van Caenegem E, Elaut E, et al. systematic review and meta‐analysis of qual-
Quality of life and sexual health after sex re- ity of life and psychosocial outcomes. Clin
assignment surgery in transsexual men. J Sex Endocrinol 72:214, 2010.
Med 8:3379, 2011. 56. Smith YL, Cohen L, Cohen-Kettenis PT.
52. Johansson A, Sundbom E, Hojerback T, et al. Postoperative psychological functioning of
A five-year follow-up study of Swedish adults adolescent transsexuals: a Rorschach study.
with gender identity disorder. Arch Sex Be- Arch Sex Behav 31:255, 2002.
hav 39:1429, 2010. 57. Feldman J, Brown GR, Deutsch MB, et
53. Smith YL, van Goozen SH, Cohen-Kettenis al. Priorities for transgender medical and
PT. Adolescents with gender identity disor- healthcare research. Curr Opin Endocrinol
der who were accepted or rejected for sex re- Diabetes Obes 23:180, 2016.
assignment surgery: a prospective follow-up 58. Lawrence AA. Factors associated with sat-
study. J Am Acad Child Adolesc Psychiatry isfaction or regret following male-to-female
40:472, 2001. sex reassignment surgery. Arch Sex Behav
54. Cohen-Kettenis PT, van Goozen SH. Sex 32:299, 2003.
reassignment of adolescent transsexuals: a 59. Keller AC, Althof SE, Lothstein LM. Group
follow-up study. J Am Acad Child Adolesc therapy with gender-identity patients—a
Psychiatry 36:263, 1997. four-year study. Am J Psychother 36:223,
55. Murad MH, Elamin MB, Garcia MZ, et al. 1982.
Hormonal therapy and sex reassignment: a
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CHAPTER
17
Sexual Health After Surgery
for Transgender Individuals
CHA
Marilyn K. Volker, Lydia A. Fein
Key Points
S
❖❖ Any member of the transgender individual’s ❖❖ Surgery may not alleviate all body image con-
care team, including any physician managing cerns and may even bring about new concerns
an aspect of transition that can affect sexual such as coping with keloiding/scarring.
function such as hormone therapy or gender ❖❖ Transitioning, especially gender affirmation
affirmation surgery, can evaluate sexual health. surgery, can affect a person’s current relation-
Appropriate referrals to qualified mental health ship or ability to enter into a new relationship.
or sexual health practitioners should be made Some trans individuals find that it is easier to
as necessary. begin and maintain a relationship after surgery,
❖❖ Sexual dysfunction can be categorized into four whereas others find it more challenging.
domains: desire, arousal, orgasm, and pain. ❖❖ Sex and intimacy therapy can be beneficial af-
Objective, validated questionnaires to assess ter gender affirmation surgery to cope with new
each of these categories can be beneficial for body parts as well as postsurgical developmen-
initial screening of sexual function. tal stages and exploring sexuality and intimacy
❖❖ Before gender affirmation surgery, the surgeon issues.
should counsel patients about what could be
expected sexually after the procedure.
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Sexual Health After Surgery for Transgender Individuals
Many individuals who identify on the range of gender nonconforming face a variety of criti-
cal issues both before and after gender reassignment surgeries, including gender affirmation
surgery (GAS), also known as sex reassignment surgery, bottom surgery, or lower surgery.
Frequently these issues are in relation to sexual health. For many, GAS alleviates body dys-
morphia, because the decision to pursue GAS is closely tied to the ability to function sexu-
ally as the gender with which one identifies. Accordingly, postoperative sexual satisfaction
often depends on the functional ability of the newly created genitalia. Even when sexual
function is not the driving factor for a person to undergo GAS, sexual health contributes to
overall mental health and relationship satisfaction, underscoring the importance of sexual
function throughout the transition, but particularly after GAS.1-4
With advancing techniques for GAS, preserving patients’ sexual function has become a
priority for surgeons. Still, long-term sexual and physical rehabilitation is crucial to main-
taining and improving sexual function of the new genitals,5 although optimizing the sexual
experience for transgender individuals does not simply start after surgery. Rather, it is a
long-term process that occurs throughout the transition. Lifelong transgender health care
by a team of providers, including mental health professionals, is very important. Often
transgender individuals feel they are “done” with counseling after completing marker events
such as GAS, and frequently counselors and gender specialists are seen as “gatekeepers,”
necessary only for letter writing. However, mental health professionals are an integral com-
ponent of the transgender person’s lifelong health care team, and those with expertise in
sexual health—gender specialists/sexologists/sex therapists—are crucial for the individual
to achieve optimal sexual function and satisfaction.
However, sexual health should not be left e tirely to the specialist. All members of the
health care team should evaluate and address sexual issues with transgender patients if they
manage them for other aspects of the transition. Both cross-sex hormone therapy and GAS
have signifi ant impacts on sexual function and satisfaction.1 Providers should address these
considerations before they initiate treatment or perform surgery.
Sexual Health Evaluation

Any member of the transgender individual’s care team can perform the initial evaluation
of sexual health. Appropriate referrals to qualifi d mental health or sexual health practi-
tioners should be made as necessary.
History
When facilitating sexual health concerns for transgender individuals, an initial evaluation
should include questions related to their sexuality.6 Questions that may be incorporated
into the history-taking are shown in Box 17-1. It is critical to have referral resources for any
concerns that are identifi d.
Objective Evaluations of Sexual Health

Assessing sexual health, including desire, arousal, orgasm, and sexual satisfaction, can be
evaluated objectively by any member of the transgender individual’s care team. Baseline
sexual function, particularly arousal and orgasmic capability, should be assessed before
surgical intervention that alters reproductive organs or genitalia. The goal of any surgery
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CHAPTER 17
Box 17-1 History Questions for Initial Sexual Health

Evaluation
❖❖ Many transgender individuals identify with different names/words/pronouns. Please tell

me about your preferences.
❖❖ Many people experience a variety of relationships. How do you identify in terms of your
orientation?
❖❖ Please describe your dating, sexual, romantic experiences, and relationships, including
social media—past and current, if any—and how you felt/feel about these relationships?
❖❖ Please describe your sexual activities, including masturbation and with a partner or
partners, past and current, if any. How did/do you feel about your sexual functioning by
yourself or with other(s)?
❖❖ Does your body image/function affect your dating or sexual activities? If so, in what
way(s) does it affect it?
❖❖ How do you hope gender affirmation surgery will affect your body image, masturbation,
dating, relationships, and sexual activity?
❖❖ What are some of your concerns about gender affirmation surgery regarding your sexual
desire, arousal, or sexual functioning?
❖❖ Do you have concerns about sexually transmitted infections/pregnancy or sexual abuse
issues?
to the internal or external genitalia is to preserve this functionality. If a patient lacks orgas-
mic capability or has other sexual dysfunction, the provider should refer the individual to
the appropriate practitioners, who can determine and treat the cause of the problem. Be-
cause GAS alleviates gender dysphoria,7 it may be therapeutic for sexual dysfunction if it is
caused by the distress of having gender incongruent genitalia. However, if the dysfunction
is mechanical, hormonal, or caused by other underlying psychological factors, these must
be addressed before surgery, because surgery cannot restore function. Persons who have
orgasmic capability before GAS can typically orgasm afterward. Therefore, any challenges
with orgasm must be addressed before surgery, because surgery cannot restore function
or by itself heal psychological wounds. This can also be a point of reassurance for patients,
who may be concerned about losing their ability to orgasm.
Sexual dysfunction is typically categorized into four domains: desire, arousal, orgasm, and
pain.8 Objective, validated questionnaires to assess each of these categories can be benefi-
cial for initial screening of sexual function. A multitude of inventories for evaluating sex-
ual dysfunction exist,9 and the appropriate choice should be made based on feasibility and
usefulness. Some tools such as the Female Sexual Function Index (FSFI) are designed to
briefly assess the core domains of sexual dysfunction,10 whereas others such as the Dero-
gatis Interview for Sexual Functioning (DISF) can be used to evaluate sexual cognition
and fantasy, sexual behavior and experience, and relationships, along with the standard
functional domains.11 When selecting a tool, one must remember that these have largely
been designed to assess cisgender—those whose gender identity is congruent with their
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assigned gender—sexual functioning and may contain questions that are not applicable to
transgender individuals. Therefore questions should be screened before they are used with
transgender patients.
Objective evaluations should be used only as screening tools and as a starting point for
conversation and counseling between the provider and patient. Sexual health can be dif-
fi ult for individuals to discuss, underscoring the importance of the provider to create a
comfortable environment to facilitate conversation and refer the patient to the appropriate
sexual health expert or therapist.
Transgender Sexual Health Concerns

In addition to sexual health concerns related to function and satisfaction that can arise in
any individual, unique issues may present in transgender persons. These include gender
dysphoria in a sexual relationship, changes in sexual attraction, fantasy, orientation, or pref-
erences as part of gender transition, as well as the impact of hormone therapy and surgery
on the domains of sexual function.6 Although hormone therapy and GAS are generally
associated with improved quality of life, sexual satisfaction, and sexual function, 1,7 these
outcomes may take time to achieve as the person learns to adjust to a new body.
Transgender individuals vary in their comfort and willingness to discuss their sexual health.
For some, speaking about their genitals, even with sexual partners, causes great discom-
fort.12 Th s may stem from distress caused by having gender-incongruent genitalia or be-
cause the patient has difficulty fi ding appropriate terms to describe certain body parts.6
Th s distress may arise from past sexual scripting, or surprisingly, the initial confli t be-
tween gender identity and the new experience of naming and owning newly made genitals.
It is often assumed that because transgender individuals need to undergo examinations and
surgeries that necessitate private and probing questions, they are open and comfortable with
conversations or questions about their genitals. Each provider must take the time to really
see and affirm individuals’ hearts, not parts.
The distress that a patient may associate with discussing genitalia may also be present if the
genitalia are touched, and like cisgender people, male-to-female and female-to-male indi-
viduals engage in a wide range of sexual activities. So the provider cannot make assump-
tions about the types of sexual activities in which patients’ engage.6
Despite the complexities of transgender sexual health, the entire team of providers should
invest in ensuring that it is optimized for each patient. Transgender individuals are more
likely to engage in behaviors that put them at increased risk of HIV and sexually transmitted
infections, causing higher prevalence of these infections in transgender populations.6,13,14
These high-risk behaviors and resultant infections have been linked to gender dysphoria
and the challenges associated with affirming one’s gender identity.15,16 Promoting a positive
attitude toward sexual health and enhancing sexual function are associated with greater self-
efficacy in making safer sex choices, underscoring the importance of sexual health in the
overall well-being of transgender individuals.12,17 Improving sexual health may necessitate
referral to a mental health professional with expertise in sexual counseling or to a medical
provider who can address other underlying causes of sexual dysfunction.
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Sexual Health and Gender Affirmation Surgery

Preoperative Considerations
Before GAS, the surgeon must counsel patients regarding their sexual expectations after the
procedure. Th s should include a discussion about the types of sexual activities, including
intercourse, they may have and what implications surgery may have on these. For example,
a transgender woman with a female partner may not have the same sexual goals as one
with a male partner. Any transgender patient needs to be encouraged like any cisgender
individual about the possibilities of outer/inner stimulation, which also could include any
accoutrements/aids that may enhance stimulation, arousal, and orgasm.
As part of the preoperative consultation, the surgeon should also determine how the per-
son is currently achieving sexual satisfaction, because this may provide insight into how
to appropriately counsel the patient for optimal postoperative sexual function. Familiarity
with common strategies and devices transgender individuals often use for sexual activity
can also aid in conducting this conversation more comfortably for both physician and pa-
tient. For example, transgender men often use “packers” to give the outward appearance
of a bulge through their clothing. Th s is referred to as “soft acking,” because it mimics a
flaccid penis. However, these generally cannot be used for sex. In recent years “dual-use”
packers have been developed that can be used for both daily appearance and sex but can
often be uncomfortable and unrealistic. In addition, the internal malleable rod can poten-
tially injure a sexual partner. Hard packers are dildos or similar prosthetics that are per-
manently erect for sexual penetration.18 Alternatively, transmen may not engage at all in
penetrative intercourse.
Transmen may also use “stand-to-pee” devices (STPs) to be able to urinate in the stand-
ing position, which can be of particular importance for assimilating in public bathrooms.
Some STP devices can be fashioned at home with a coffee can or other flex ble plastic disk,
a medicine spoon, or the upper portion of a plastic soda bottle. Some people choose to
purchase specially crafted STPs that they carry with them, and others wear a soft acker
with STP functionality.
Conversely, before GAS, transwomen frequently tuck their penises, which may cause their
genitalia to appear distorted on physical examination. Tucking may also not adequately
conceal their genitalia, particularly the scrotum, when wearing a bathing suit or other di-
minutive apparel. Before removal of the testes, spontaneous erections are also quite com-
mon, which may further add to distress. If GAS is not desired or is prohibited by cost or
other factors, transwomen may be counseled to have just an orchiectomy to prevent these
occurrences that may contribute to their dysphoria or interfere with sexual relationships.
Sex After Gender Affirmation Surgery

Although the conversation about sexual function should begin before GAS, it should be
revisited with frequency in the postoperative period. In general, reports of sexual function
after GAS, including the ability to orgasm, are positive.1,19,20 Having genitalia congruent with
one’s gender identity and the ability to perform sexually in that capacity contribute greatly
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to this postoperative sexual satisfaction. However, as many transgender persons point out,
attaining optimal sexual function takes time.21 The surgeon can help in this process by mak-
ing sexual counseling a component of every postoperative visit.
At their fi st postoperative appointment, which is typically 5 to 10 days after surgery, MTF

patients should receive training with vaginal dilators. The patient should be encouraged
to self-dilate in the office to ensure proper technique and overcome any apprehension that
may exist. After this initial visit, the well-healing patient should be encouraged to dilate at
home on a daily basis. Concern for wound dehiscence or tissue necrosis may necessitate
a longer waiting period before self-dilation can begin. If the patient plans to engage in re-
ceptive penetrative intercourse, she can generally start having sex 6 weeks after surgery.
She should still self-dilate for an extensive period; some surgeons recommend continuing
at least 6 months to ensure patency of the vaginal canal.22 The amount of self-dilation can
gradually be decreased as the frequency of intercourse increases over time. The transgender
woman who partners with women and/or does not engage in receptive intercourse may
require the use of vaginal dilators for a longer period to maintain a patent neovaginal ca-
nal. The risk of damaging the neovaginal construction with overly aggressive dilation also
exists,23 and thus the patient should be advised to dilate carefully.
Vaginal lubrication may be a concern for MTF patients, because the neovagina does not
have the same secretory capacity as the natal vagina, particularly when constructed from
penile and scrotal tissue. However, studies have shown that many transgender women ex-
perience fluid release with sexual stimulation,19,24 even retaining ejaculatory capacity in
some cases.24,25 It is thought that this fluid is produced in the Cowper’s glands, but these
glands can atrophy with long-term cross-sex hormone therapy. Presently the composi-
tion and origin of this fluid have not been established with certainty.1 Accordingly, most
patients will likely require lubricant use for intercourse. If this is a major concern before
surgery, the patient may be advised to consider a sigmoid colon vaginoplasty. Because of
the endogenous mucous production in this tissue, fewer patients reported complaints of
inadequate lubrication.22
For MTF patients, surgical outcomes that can affect sexual function include stenosis or
stricture of the neovaginal canal, inadequate vaginal depth, and vaginal prolapse. 22,26,27
Stenosis can occur if patency of the neovagina is not maintained with frequent dilation or
penetrative intercourse. These complications may require surgical revision, which typically
resolves any dyspareunia.22 If the patient has not undergone permanent genital hair removal
before surgery, vaginal hair growth may occur, particularly if a large scrotal graft is used.26
Th s can be sexually disruptive. If permanent depilation is cost prohibitive, the surgeon can
electrocauterize the hair follicles of the skin graft before insertion in the neovaginal canal.
FTM patients typically require longer recovery periods than MTF patients, which may ne-
cessitate a longer waiting period before initiating sexual activity, particularly if patients have
had a multistaged procedure. Depending on the type of phalloplasty, tactile and erogenous
sensation may not be immediately present in the neophallus. Patients who undergo radial
forearm phalloplasty or other free flap procedure may require up to 1 year to regain tactile
sensation to the tip of the phallus. Erogenous sensation may return sooner.28 Th s disparity
in sensation can put the patient at risk of damaging the neophallus if he wishes to engage in
sexual activity but does not yet have tactile sensation. If the patient has an osteocutaneous
flap, sexual intercourse may cause the bone to extrude inadvertently. For patients without
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osteocutaneous flaps who are awaiting implant placement, which is typically not done until
tactile sensation is regained, the barrier to intercourse may be erectile capability. Transgen-
der men have been known to wrap Coban (3M, St. Paul, MN) around the neophallus and
cover it with one or two condoms in order to achieve the rigidity required for penetration.21
For both MTF and FTM patients, familiarizing themselves with their new anatomy is im-
perative to achieving sexual gratifi ation. Although the surgeon should encourage patients
to explore new genitalia independently or with a partner, describing the location of eroge-
nous and/or erectile tissue can be helpful. Most erogenous sensation for transgender females
is derived from the neoclitoris, which is a glans penis flap with a preserved neurovascular
bundle. The patient can be encouraged to autostimulate or have a partner stimulate the
neoclitoris to achieve orgasm. MTF patients can also experience sexual arousal from the
neovagina if it has been constructed with penile or scrotal skin. The prostate is also left t
least partially intact and can be stimulated by neovaginal penetration.26
For a transgender man who has undergone phalloplasty, erogenous sensation will primar-
ily be from the clitoris that has been buried at the base of the phallus.28 He should be coun-
seled that his orgasm may depend on penetrative intercourse or stimulation that allows
pressure in that region. Additional erogenous sensation may be derived from stimulation
of the phallus itself if the dorsal nerve of the clitoris is anastomosed with one of the nerves
in the neophallus flap. Surgeons may vary in their techniques for nerve anastomoses and
positioning of the clitoris. They must also discuss these surgical plans with the patient as
part of preoperative and postoperative counseling.
Both MTF and FTM persons can experience a change in orgasmic quality after GAS. FTM
individuals report more powerful, forceful orgasms, whereas MTF patients report more
intense, smoother, and longer orgasms.19,29
Other Postoperative Considerations

After GAS sexual function and satisfaction in both MTF and FTM individuals are variable,
making the impact of surgery on sexual health a challenge to predict.1 Certainly given the
many other factors that contribute to sexual health in the transgender person, dysfunc-
tion after surgery cannot be completely attributed to the surgery alone and may only be
transient. The following concerns are commonly experienced and expressed by “the real
experts”—transgender individuals—in their unique journeys needing continued “dream
team” support after gender affirmation surgeries.
New Body Image

Even before surgery, body image can be a challenge for transgender individuals. Societal
expectations and depictions of masculinity and femininity and cultural norms related to
attractiveness may cause transgender persons to have difficulty accepting their bodies.6 Sur-
gery, whether GAS or other procedures such as chest reconstruction/breast augmentation,
may alleviate gender dysphoria but may not completely improve a transgender person’s
body image. Accordingly, many transgender individuals pursue cosmetic procedures, even
to an obsessive level, to relieve generalized discomfort with their bodies. For example, trans-
gender men can develop a preoccupation with synthol—an oil that is injected directly into
the muscle to provide bulk—to enhance their upper bodies, and transgender women can
seek multiple facial feminization procedures. Frequently these obsessions will develop as
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compensation for genital dysphoria. Providers should consider screening patients for body
dysmorphic disorder and referring them for appropriate mental health treatment if this is
a concern. Surgery may not alleviate all body image concerns and may even bring about
new ones.6 The following are some issues with which transgender individuals may be faced:
❖❖ Does my new body look and respond in the way I imagined/fantasized about?
❖❖ Will scarring/keloiding affect my total comfort around others (for example,
shirtless/in sexual situations)?
❖❖ Will I struggle with “half-body” identity in this process if I cannot afford to
continue surgeries?
It is very important that the new bodied transperson take time to shift from the initial
dysphoria through each step of “what I expected versus what I now experience/see” in the
mirror versus “what others may perceive/experience with my new body.”
Th s process impacts healthy body image versus fantasy body image.
Gender Identity and Labels

GAS for both MTF and FTM individuals results in high satisfaction and little regret.7,30
However, many transgender individuals go through a transient period of grief or loss after
GAS. Th s can be caused by feelings of sadness that accompany the realization that certain
aspects of gender are not achievable, even with surgery. Conversely, they may mourn the
loss of reproductive organs or feel temporary regret immediately after surgery that may be
provoked by postoperative pain or complications.6,30,31 Th s grief is generally self-resolving
but may require therapeutic intervention. The following are some questions that transgen-
der individuals may face after surgery:
❖❖ Does having newly constructed genitals mean I am now like a cisgender male or
female, or do I/will I identify as transman/transwoman, pangender, androgyny, boi,
demigirl/demiguy, femme, gender gifted, gender nonconforming, gender fluid, agen-
der, genderqueer, gender/sexual minorities, intersexual, intergender, neutrois (feel
ing one does not have a gender), nonbinary, postop, third gender, transfeminine/
transmasculine, two spirited, or any other of the myriad of identities that celebrate
the range of experiences?32
❖❖ Do I miss my original genitals or certain aspects of their functions?
❖❖ Even after surgery, am I still upset that I lack certain sexual/reproductive abilities?
❖❖ Will others in the cisgender or gay/bi/lesbian community affirm my identity?
❖❖ Will cisgender individuals want to date me and be intimate?
❖❖ Do I have to date only transgender individuals?
Recognizing, acknowledging, grieving, affirming, and celebrating the unique transgender

experience means that the transgender individual will never be exactly like cisgender in-
dividuals. The transgender individual, even with body parts that now align with gender
identity, contributes insights and perspective that no cisgender individual can truly under-
stand. Continued support from peers is often needed and valued through social media, local
support groups, and trans conferences. Being a role model for others on educational pan-
els is a win-win for self and other medical, mental health, religious, or education students.
Preferred Pronouns
Appropriate pronoun usage can be an important component of a person’s gender affirm-
nation. Establishing and using the person’s preferred pronoun is also a crucial aspect of
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CHAPTER 17
transgender-sensitive care. However, some individuals may fi d that they grapple with their
preferred pronoun after surgery. Some of their concerns include:
❖❖ Do I identify with he, she, him, her, hers, his, or they, ze, ey, or any other or no pro-
nouns?
❖❖ Why can’t family, friends, work peers/employers use my preferred name/pronouns,
even after surgeries and name change?
Letting family, friends, and work peers/employers know the preferred name/pronoun is
important, and those who are the closest and have had the longest history with the trans
individual usually need time and “brain rebooting.” Again, support from mental health
professionals and peers can help some individuals in this lifelong struggle.
Active Versus Stealth

Some people choose to live their lives as openly trans, whereas others opt to live stealth; they
prefer to pass as their identifi d gender and do not disclose that they are transgender. Some
choose to live stealth as a matter of safety or privacy, whereas others choose this option sim-
ply because it makes them happy, or it facilitates dating and intimate experiences without
disclosure. Many live in a manner that is a combination of stealth and open.33 After a patient
undergoes GAS, considerations regarding the decision to live in a certain manner can arise:
❖❖ Does surgery affect how I want to be seen . . . or not seen?
❖❖ Would my transgender peers feel I am being disloyal or politically incorrect if I
choose to be stealth (living the gender identifi d/surgery confi med life but not
“out” as trans)?
There are many ways to be supportive and educate. Some disown their past—some sit
“shiva” for their biologic birth to “rebirth” state. Some transgender individuals mark their
biologic birthday and others celebrate their surgical birthday. Each transgender individual
has a right to decide when, how, how much to disclose and hopefully not be outed by those
who do not recognize personal disclosure and privacy. A counselor or educator can help
reinforce this personal decision and help trans individuals with disclosure process.
Dating, Mating, and Relationships

Transitioning, especially GAS, can affect a person’s current relationship or the ability to en-
ter into a new relationship. Some trans individuals fi d that it is easier to begin and main-
tain a relationship after surgery, whereas others fi d it more challenging.34,35 As the transi-
tion progresses, transgender persons may fi d their sexual orientation changing, which may
complicate or confuse relationships or dating.30,36 They may also find existing relationships,
even marriages, challenging. For instance, after GAS only a small percentage of individuals
live with their spouse after surgical transition.7,30,37 Other challenges that specifi ally arise
after surgery may be regarding functionality of new genitalia and how to negotiate them in
new or preexisting sexual relationships. Concerns about the transgender person in regard
to relationships or dating include:
❖❖ If I am coupled or married, how does my partner (or partners) respond to my new
surgeries? How will it have an impact on our affection, social, emotional, intellec-
tual, physical, spiritual, aesthetic, and sexual intimacies?
❖❖ How do dating sites accept transgender individuals? When and how do I disclose?
❖❖ Would someone want to date me even with a body that now matches my gender
identity?
❖❖ How would I fi d out how my “virgin” genitals work in a safe and supportive expe-
rience?
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CHAPTER 17
Th s issue presents the most struggles, anxieties, fears, and frustrations after GAS. The trans-
gender individual must receive support in navigating through each step with a gender spe-
cialist, peer/group support, and trusted social media. Part of all dating, mating, and relating
is acceptance and rejection, which can be triggering for many trans individuals who have
experienced trauma, bullying, and rejection before gender transitioning. Sex therapy can
be helpful in understanding new body arousal and sex response and in providing strategies
for self and partner, whether transition occurs during coupleship/marriage or dating dis-
closure and intimacy. Therapy may also include the partner to address concerns and ways
in which a partner’s GAS may affect their relationship.
Sex Therapy With Transgender Individuals

Sex therapy with transgender individuals can often follow the same process as with any
person who has experienced body changes and wishes to see what is possible in body
connection/sexual arousal and functioning. Sex therapy includes assessment of any other
physical, psychological, and pharmaceutical variables that can contribute to the transgen-
der individual’s and their partner’s unique sexual desire, arousal, and functioning. The sex
therapy process often includes the following:
❖❖ Body image: Because transgender individuals often avoid looking at their breasts or
genitals before transition surgeries, encouraging visual awareness and validation of
the total body can be an important component of the therapeutic process both be-
fore and after surgery.
❖❖ Body mapping: Th s technique allows the individual to identify step-by-step feel-
ings about a variety of touches on each body part and “storyboard” how one would
like to be touched or imagines being touched. Haloing the body (close body contact
but not direct touching/sharing energy/care/concern/love) can be included for trust
building, especially if one has been physically, emotionally, or sexually abused.
❖❖ Eye gaze: Th s technique is used to invite the soul/spirit. It can also be expanded to
include body gaze.
❖❖ Holding/breath connection: Th s exercise builds trust through somatic/breath im-
printing, holding, snuggling, cuddling, breathing, and connecting.
❖❖ Sensate focus exercises: These are step-by-step touch exercises that are at fi st not
genitally focused that ultimately progress to total body connection, which includes
the genitals. These exercises can include touching that is observational, nurtur-
ing, playful, sensuous, and sexual. Evaluation after each exercise includes reviewing
what was positive and comfortable or challenging, uncomfortable, painful for each
person, and any requests or specific questions for the partner.
Th s step-by-step process allows transgender individuals safety and comfort in discover-

ing how their postoperative body responds in arousal and sexual functioning. Th s process
could include manual, oral, and intercourse experiences and is directed by a trained sex
therapist/gender specialist/sexologist who facilitates the sex therapy process by verbally
inviting the couple to practice in the privacy of their home and returning to evaluate each
step. If the transgender patient does not have a partner, a trained sexual surrogate is often
used in the same step-by-step manner supervised by the sexologist.
Although many sexologists use a three-stage or four-stage sex response model with a start-
ing (desire/arousal), middle (plateau), and ending point (orgasm/ejaculation/resolution)
(Fig. 17-1, A), Basson’s nonlinear model is often more realistic for many transgender and
cisgender individuals38 (Fig. 17-1, B).
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CHAPTER 17
A
Orgasm
Plateau
Sexual
excitement/
tension
Arousal
Resolution
Desire
Time
B Emotional
intimacy
+
+ Motivates sexually
neutral woman
Emotional
and physical
To find/
satisfaction “Spontaneous”
be responsive to
sexual drive
“hunger” Sexual
stimuli
Psychological and
Arousal and biologic factors govern
sexual desire “arousability”
Sexual
arousal
Fig. 17-1 A, Traditional sex response cycle of Masters, Johnson, and Kaplan. Masters and Johnson’s
model was four stages: arousal, plateau, orgasm, resolution. Kaplan condensed the model to three
stages: desire, arousal, orgasm. B, Blended intimacy-based and sexual drive–based cycles developed
by Dr. Rosemary Basson.
This model incorporates emotional intimacy, sexual stimuli, and relationship satisfaction
as important components of the sexual response and acknowledges that sexual function-
ing is quite complex and can be affected by psychosocial issues. One can enter the body
connection neutrally, fi ding puzzle pieces needed for arousal (specific places on/in newly
formed vagina/clitoris or penis/scrotum), emotional connections facilitating arousal, or
other visual, oral-auditory, or sensual stimulation offering the many entry and exit doors
for a variety of trans sensual/sexual experiences.
With this program, transgender individuals are honored in their total health care, includ-
ing sexual health and wellness throughout their life journey.
Conclusion
Gender affirmation, particularly the surgical aspects, can have a profound change on a
transgender person’s sexual functioning and satisfaction and in turn on their intimate re-
lationships and quality of life and overall health. Therefore the transgender person’s team
of health care providers must ensure that their patient’s sexual health is optimized through-
out transition. Th s requires open conversations with the patient before any surgery is per-
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CHAPTER 17
formed to ascertain baseline sexual function, explaining the impact of surgery on function-
ality, and carefully guided postoperative care that leads the patient toward fulfilling sexual
function and satisfaction. Frequently a sex therapist/sexologist or other gender identity
specialist may be best equipped to optimize a transgender individual’s sexual function and
satisfaction. However, every member of the transgender individual’s health care “dream
team” plays a critical part in their patient’s sexual health and well-being.
References
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26. Perovic S, Djinovic R. Genitoplasty in male- Selves: A Resource for the Transgender Com-
to-female transsexuals. Curr Op Urol 19:571, munity. New York: Oxford University Press,
2009. 2014.
27. Neto RR, Hintz F, Krege S, et al. Gender reas- 34. De Cuypere G, T’Sjoen G, Beerten R, et al.
signment surgery—a 13-year review of surgi- Sexual and physical health after sex reassign-
cal outcomes. Int Braz J Urol 38:97, 2012. ment surgery. Arch Sex Behav 34:679, 2005.
28. Selvaggi G, Monstrey S, Ceulemans P, et al. 35. Lobato MI, Koff WJ, Manenti C, et al. Follow-
Genital sensitivity after sex reassignment sur- up of sex reassignment surgery in transsexu-
gery in transsexual patients. Ann Plast Surg als: a Brazilian cohort. Arch Sex Behav 35:711,
58:427, 2007. 2006.
29. Hage JJ, Karim RB. Sensate pedicled neocli- 36. Auer MK, Fuss J, Höhne N, et al. Transgen-
toroplasty for male transsexuals: Amsterdam der transitioning and change of self-reported
experience in the fi st 60 patients. Ann Plast sexual orientation. PLoS One 9:e110016, 2014.
Surg 36:621, 1996. 37. Bodlund O, Kullgren G. Transsexualism—
30. Lawrence AA. Factors associated with sat- general outcome and prognostic factors: a
isfaction or regret following male-to-female five-year follow-up study of nineteen trans-
sex reassignment surgery. Arch Sex Behav sexuals in the process of changing sex. Arch
32:299, 2003. Sex Behav 25:303, 1996.
31. Pfäffli F. Regrets after sex reassignment sur- 38. Basson R. Female sexual response: the role of
gery. In Bockting WO, Coleman E, eds. Gen- drugs in the management of sexual dysfunc-
der Dysphoria: Interdisciplinary Approaches tion. Obstet Gynecol 98:350, 2001.
in Clinical Management. Binghamton, NY:
The Haworth Press, 1992.
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CHAPTER
18
Gender Expression and Image
CHA
Michelle Horne, Lydia A. Fein
Key Points
❖❖ Social environments and the reactions of oth- ❖❖ Transgender persons experience high levels
ers are involved in transgender identity. devel- of body image dissatisfaction, and this can put
opment. Presenting oneself as one’s true gen- them at risk for self-harming behaviors and dis-
der can be both a challenge and a liberating ordered eating, and they may experience sig-
experience. nificant social anxiety.
❖❖ Affirmation and validation of one’s gender iden- ❖❖ The main goals of image consultants are to
tity are very important. When the responses help all transgender persons honor themselves
received from others differ from expectations, through outward expression.
gender dysphoria can worsen. ❖❖ An image consultant’s job is to coach, guide,
❖❖ Dressing as one’s true gender is often the first educate, and mentor clients in the areas of ap-
external manifestation of gender identity. pearance, behavior, and communication.
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All persons live within social environments and rely to varying extents on the reactions
of those around them to develop an understanding of their own nature and persona. For
transgender individuals, this involves presenting themselves to others as their true gender,
and this public disclosure of gender identity can be at once liberating and anxiety ridden.
Concerns about the attendant social stigma associated with gender nonconformity can be
a substantial factor leading to gender dysphoria.
From Gender Binary to Gender Spectrum

Transitioning is a unique process that entails different components for each person.
Th ough changes in lifestyle and medical and surgical modifi ations, transgender persons
alter their appearance, and accordingly, how others perceive them. Just as the transition is
unique to each person, so are the goals for gender expression. Some persons seek to live a
“stealth” lifestyle whereby their goal is to present wholly as their identifi d gender and not
disclose that they are transgender. Others may opt to live openly as transgender. In more
recent years, the gender binary has gradually become a gender spectrum, and through this
evolution, persons may now increasingly identify with gender nonconformity and con-
sciously present ambiguously or at various points along the spectrum, thereby rejecting
traditional male and female presentations.
Although the gender spectrum is becoming an increasingly accepted concept, traditional

representations of male and female gender are by and large those of societal norms, and
for many transgender persons, assimilating into society as their true gender is a priority.
To achieve this goal, an image consultant may be a beneficial member of a transgender
person’s care team.
Gender Expression
Appearance is a key aspect of self-identity. Therefore it is important for transgender per-
sons to present themselves in such a way that they appear to others as their true gender.1
Outward appearance, including one’s manner of dress, hairstyle, speech, posture, walk, and
body language is what drives perception and assignment of gender in society. Devor2 uses
two key themes to characterize the process of transgender identity formation, witnessing
and mirroring. Witnessing is the need to be seen by others for who one is, and mirroring is
the need to see oneself refl cted in others’ eyes as how one sees oneself. These are affirma-
tions of an individual’s identity and provide validation. When the messages received from
others differ from expectations, gender dysphoria can worsen.
Gender expression has a profound impact on many aspects of transgender persons’ lives
and is integrally involved in the formation of gender identity. Dressing in the manner tra-
ditionally attributed to one’s identifi d gender is often the fi st outward manifestation of
gender variance for many transgender persons.3 Frequently, dressing as one’s true gender is
clandestine but serves as a way transgender persons can express their true identity, even if
it is only in private. Eventually, most transgender persons will reach a point at which they
begin to transition publicly. Again, this often starts with changes in clothing and outward
appearance. Bockting and Coleman4 identifi d stages of transgender identity development.
The third stage, exploration, is characterized by experimentation with stereotyped notions
of femininity and masculinity, addressing personal attractiveness and sexual competence,
and transforming shame into pride. Thus outward appearance can be crucial to the process
of gender identity formation.
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It is important to understand that gender expression for some trans persons may in fact be
to appear easily identifiable as transgender. Trying to completely assimilate as a cisgender
person may carry its own set of stressors and has been associated with higher levels of de-
pression and increased stigma in transgender individuals.5,6 Openly identifying as trans-
gender may bring a broader network of social support and subsequently greater comfort
and confide ce in one’s appearance. Still, presenting oneself in a manner that most organi-
cally represents the true self is crucial, whether it be to assimilate completely with cisgen-
der persons or to live openly as transgender. In either scenario, guidance from an image
professional may be benefic al.
Body Image
The social construct of gender largely depends on the presence or absence of certain char-
acteristics that are typically associated with males or females, such as facial hair or breasts.
For transgender individuals, dysphoria can arise from the incongruence of outward appear-
ance and identity. They may also experience dissatisfaction with their body image, which
is a complex psychological experience of thoughts, beliefs, feelings, and behaviors related
to one’s physical appearance.7 Transgender persons experience the highest levels of body
image dissatisfaction with regard to secondary sex characteristics.8
Dissatisfaction with body image puts persons at risk for self-harming behaviors and disor-
dered eating and may cause signifi ant social anxiety.9,10 Because of dissatisfaction with the
secondary sex characteristics of the wrong gender, cross-sex hormone therapy and surgery
have been shown to improve body satisfaction and image in transgender persons.11 Still,
there are certain unchangeable aspects of appearance, such as stature and bone structure,
that may cause persistent distress.
Clothing and other nonmedical lifestyle modifi ations may be benefic al in alleviating some
of the distress associated with these less malleable aspects of appearance; for instance,
learning how to dress for one’s body type or fi ding flattering hairstyles and makeup. In a
study conducted by physicians at the University of Miami, lifestyle modifi ations such as
changing one’s style of dress, changing one’s hairstyle, and wearing makeup were consid-
ered very important to transgender persons for passing as and feeling comfortable as one’s
identifi d gender.12
Image Consulting
Clothing and appearance have been shown to have an impact on the formation of impres-
sions of a person. Complex judgments about others can be made in a matter of seconds.13,14
Even subtle differences in one’s style of clothing can generate a different impression among
observers.15 Individuals can make calculated changes to their appearance to project state-
ments about their identity or to shape others’ impressions of them.16 For transgender per-
sons, this can be crucial to their transition as they strive to outwardly express their true
gender. An image consultant can help transgender individuals achieve the outward appear-
ance that is congruent with their identifi d gender, which allows them to be perceived by
others in the manner they desire.
For image consultants, working with the transgender community has some specific hal-
lenges, because they are dealing primarily with how the world sees these individuals and,
to a greater extent, how they see themselves. One of the main goals for an image consul-
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tant is to help transgender clients honor themselves and bring these images into harmony.
It can be both humbling and gratifying to be invited on such a personal journey that en-
gages all aspects of personal change, and along the way to share and contribute to making
someone’s life a little better.
Image consulting is typically offered in a private practice format. Their clientele may be
derived from referrals by health care providers, advertisements, or word-of-mouth within
the transgender community. Private client work involves a broad spectrum of services that
are customized for each client. The process is thorough, intense, and ultimately transfor-
mative. Clients may consult with an image specialist at one particular time during their
transition, such as when they fi st start presenting as their true gender, or they may con-
tinue to work with the consultant on a long-term basis. New clients typically complete a
confide tial intake form, which offers them an opportunity to share their “image story”
and in turn helps to create a roadmap that determines the most appropriate services to
achieve optimal results. The client’s image story helps to ensure fid lity to the client’s goals
and acts as an accountability document. The image consulting program may include color
analysis, style and body type analysis, clothing personality assessment, and behavior and
communication coaching.
Color analysis helps transgender clients understand their best colors, also referred to as
“wow” colors. The process involves using drapes of fabric in shades of color representing
the four seasons to determine which color scheme suits the client best. Many variables are
needed when determining the season, such as skin undertone, hair, and eye color. After the
color analysis, clients are empowered to make better selections when shopping for them-
selves using a palette of 36 colors that correspond to their season. By building a wardrobe
with their “best colors,” they are in essence creating harmony and balance, two important
life qualities. Coloring is a characteristic we are born with. It is not makeup or clothing or
even the color we dye our hair. It is not external. Creating the most powerful connection
to who we are on the inside occurs through color. It creates a beautiful congruency. For
transgender individuals, the color analysis allows them to align their external appearance
with their inner self. Th s translates into wardrobe, hair, and makeup alterations, which are
then done with the help of the image consultant. Many transgender clients who seek image
consulting often wear black or gray or colors that are not within their best palette. They may
also have hair or a beard that is too dark, which makes the face appear darker or shadowed.
Similarly, their makeup color choices can be too dark or heavy, and the result is harsh and
overdone, or too light, causing the face and neck to appear too pale.
Clothes that fit well can be a particular challenge, especially for male-to-female persons.
When dressing male-to-female clients, two primary solutions for getting a perfect fit exist:
shop in a store for full-figu e customers to fi d the added length in the sleeves and pant legs
as well as added width in the shoulders, or have clothing custom made. With either method,
having a tailor available is essential. Clothing can always be made smaller by taking fabric
away but adding it is much more challenging. Educating clients on fit is extremely impor-
tant and will make all the difference to their overall image. Custom clothing is always the
most recommended to ensure the best fit, quality and construction. Transgender women
also often need help when shopping for a proper-fitting bra. If clients have not yet under-
gone breast augmentation, cup size can be variable based on the amount of padding used.
To achieve properly fitting clothes, the person must decide which cup size will be worn
with which outfit to ensure proper fit.
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In addition, transgender individuals can benefit from coaching on the characteristics of

femininity or masculinity, including voice, posture, walk, gestures, and attitude. In today’s
media culture of pervasive images of stunning celebrities, models, and rock stars, trans-
gender individuals see representations of femininity or masculinity that are not necessar-
ily attainable by the average person. But because there is no one single way to present as
feminine or masculine, the image consultant can guide individuals to emphasize their own
best attributes to become their most authentic self rather an imitation of the style and man-
nerisms of someone prominent in the media.
Other areas in which many clients struggle are those involving body type, body image, and
weight. Computer-based tools exist that use body measurements to assess body proportion.
From this information, clients can receive a beautifully illustrated and descriptive shop-
ping guide that is personalized to show which styles will have the best fit. It can be very
empowering to have a personalized portfolio that visually demonstrates styles with the best
fit, which is benefic al for selecting off- he-rack garments as well as custom clothing pieces.
It is important to explore clients’ individual likes and dislikes as well their personality, life-
style, profession, and individual goals to determine their personal style and how they speak
to the world through style. For transgender clients, how the world sees them and how they
see themselves are not necessarily congruent. The clothing personality assessment is very
personal and transformative. It enables image consultants to assess various factors about
the client’s style. It is important to determine whether the client is confide t in his or her
style as a transgender individual and whether the client knows what his or her style is and
how to communicate it to the world.
Many transgender individuals explore different clothing and appearance personalities be-
fore settling on the one that feels most comfortable. It becomes a trial of sorts between dif-
ferent personas, hairstyles, wig colors, makeup, and accessories. By exploring the deeper
questions of their persona and helping them confi m their unique style, the image con-
sultant can guide and coach clients to feel confide t and authentic about their image. It is
critical that transgender clients feel as though their inner image of themselves matches their
external image—that what they see in themselves, others will also see. These images must
align, so that the client will feel “normal.” Transgender clients often ask their consultant if
it is acceptable to go out and be seen with the consultant to assess whether they look nor-
mal and whether they blend in with others. Transgender clients typically have known who
they are for a very long time. The challenge is garnering the courage to connect their outer
image with their inner one. Th s can be accomplished with a supportive transition team.
In the following case scenarios, written by an image professional who specializes in trans-
gender image consulting, all clients’ names have been changed.
Case Scenario
“Donna” had invited me to get together at her apartment for color analysis, style and body
type assessment, and wardrobe review. After an initial chat and review of our planned
agenda, I unpacked my color bag, set up lighting, took out all the fabric drapes, then asked
the elegant Donna to remove her makeup to prepare for our color session. She refused; I
was taken aback. She explained that by removing her makeup, she would transform back
into a man, and that was a very painful place for her. She also didn’t want me to meet her as
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a man. I felt stunned and completely understood and empathized. I also felt confli ted, be-
cause I wanted to honor her in her wishes as well as to preserve the integrity of my services.
This had not happened before. I had encountered clients who had a hard time looking at
themselves in the mirror—they literally had a hard time maintaining eye contact with them-
selves. But Donna’s reaction was unexpected. To her, makeup represented the initial step of
her transition—it was the fi st thing she had done to transform from “Donny” to “Donna.”
I was humbled by her vulnerability and trust, as well as how comparatively easy it was for
me as a woman to get ready every day. After some discussion, we established a compromise
with which she was comfortable, and we moved forward together.
Th s encounter provided so much perspective and remains with me today, 15 years later.
The impact of that experience also provided a coachable moment, a lesson to pay attention
and connect with what is really going on with the individual. How transgender male-to-
female clients feel about their “transformation time” is a very personal, sacred place where
transgender individuals take the time to transition from male to female. Th s is who they
already know themselves to be on the inside.
Case Scenario
“Julie,” a transgender woman, did not seem happy that I was the appointed consultant to
assist her with her wardrobe selection for a very important interview and contract renewal
meeting. It was the day before New Year’s. That old saying about things getting worse before
they get better came immediately to mind. “See that closet?” she asked, pointing to a door.
“Well, there you go—fi d something in there for me to wear to this meeting, because that is
what I have!” Julie is a very intelligent entrepreneur, and extremely analytical. Her expertise
and skills had set her apart in a small niche market within her industry—as a man. Many
image consultants have shared that it is ideal to work with a client who is open and ready,
who has decided that you are going to be the one to help them, and they have chosen you
themselves. These are warm indications that the business relationship and boundaries are
off to a good start. Th s was not happening for me and Julie.
There were red flags everywhere. Julie had not hired me directly; I had been contracted by
a colleague of hers who was acting in an advocacy role for her formal transition. My task
was to fi d an appropriate business outfit for Julie to wear to her meeting with the president
of the company. Th s was the same company with which she had already been employed
as a consultant—but as a man. Julie had already begun the formal gender transition pro-
cess, and now there was no turning back. The reason for this meeting was for a contract
renegotiation, since she had chosen to legally change her name. I was strongly advised to
dress her to “look the part,” blend in, and not give the president a reason to say no to her.
The timelines were tight, with the meeting scheduled for the fi st week of January, so we
had just under a week to put it all together. I went into her closet, desperately looking for
something that would work for her interview. I mentally reviewed our objectives and goals,
then stopped what I was doing and pulled my head out of the closet. I looked right at Julie
and asked her to explain in her own words what this meeting meant to her, why this was
so important, and what outcome she desired. Her answers to this question helped to align
us to the same outcome: success for Julie.
I then advised her that her existing wardrobe would not help her achieve that successful
outcome. Her existing wardrobe wasn’t professional material and wasn’t going to help her
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secure the big contract she wanted and needed. Success was something she was very used to
attaining as a man. At fi st she protested, “It shouldn’t matter what I look like; my clothing
shouldn’t matter this much.” However, regardless of whether we think it or feel it, clothing
and image do matter. First impressions are powerful statements of branding and expecta-
tion. When people meet candidates for the fi st time, their fi st impression has a signifi ant
impact on how they respond to the individual if it is in any way incongruent with what
they expect. In addition to the visual impact, voice and body language share a very high
percentage of the overall fi st impression.
By coaching Julie on where we needed to focus our energies, she quickly shifted to a stance
of openness and receptivity. When she was able to visualize her success, her acknowledg-
ment of the possibilities made our time together transformative for her. She had to make
the decision to move from fear to acceptance, and this happened when we were creating
very specific wardrobe combinations using color and style to communicate that she was as
a strong, powerful, and influential business leader.
For Julie, clothing hadn’t previously been about style, but about function. The physical fit of
Julie’s wardrobe was a little more challenging, as it is for most transgender male-to-female
clients I have helped with wardrobe. Her actual off- he-rack size was 12, which is consid-
ered an average size, but stature and structure can be a confounding factor in fitting male-
to-female trans individuals. As stated previously, two solutions for achieving a perfect fit
include shopping in a full-figu e store because of the more generous cuts of material and
width of the shoulders, or having clothing custom made. In either case, having a tailor on
hand is essential to assist with customizing clothing for a perfect fit. I always remind clients
that you can take away length or fabric, but you cannot add it. One of the most expensive
areas to tailor is the shoulders in a blazer or jacket, so ensuring that this area is really well
proportioned can result in more ease of tailoring in the chest and waist. Educating clients
on fit is extremely important and will make a signifi ant difference to their overall image.
Custom clothing is always highly recommended, if it can be afforded, to ensure the best
quality, construction, and fit. Having a bra fitting with an expert is essential. Before under-
going reconstructive surgery for breast augmentation, Julie had the option of selecting a
large or small cup size. This decision affects the overall fit of garments, so Julie had to de-
cide which outfits would be what size.
The result of our shopping expedition was a significant success. We created two different
wardrobe capsules in module form. The most important module for her meeting gave her
a very professional, appropriate, powerful image, and her second capsule was made up of
items that could be broken into modules for business casual and leisure wear. Because she
had so much fun, we spent quite a bit of extra time as I coached her on some casual cloth-
ing. Before, clothing and style hadn’t been a priority; now she decided it was time to honor
herself as a woman and live out her personal style.
As a result of our work together, Julie met with the president, who commented that if he
didn’t know she was transgender and a male before now, he wouldn’t have believed she was
anything other than a woman. Julie was offered a contract as a woman, a renewal, and a
raise in her per diem rate. I was thrilled at this complete success for her. She had put every
other consideration aside and focused on the outcome she wanted. In the end, she not only
gained a new contract but also found peace and confide ce in her personal style.
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Case Scenario
“Do you remember me?” Caroline wrote in an email to me recently. We had worked to-
gether about 10 years earlier (when she was a man), and now she was asking whether I
would be interested in helping her with her transition. She said that she had not revealed
to me previously that she was trans. My willingness to work with trans people was the pri-
mary reason she had wanted to work with me back then, and of course, the reason for her
reconnecting with me. She was in the middle of transitioning to living and working full-
time as a woman. She had recently had facial feminization surgery and was going back to
work within 2 weeks. She said, “I need to look good.” Her psychologist had recommended
that a photo be sent out as part of her communications package. It was vital that the suc-
cess of her visual communication be absolutely perfect.
Caroline had very few demands in terms of items she needed in her wardrobe. She stated
that she really hadn’t cared much about how she looked before, but as a woman, she took
a lot of pride in her appearance. From her perspective, her wardrobe for certain seasons
was acceptable; however, she felt she should pay attention to what she would need going
into the next season. She had questions and required coaching regarding appropriate cloth-
ing and styles for the offic and the board room. She also asked for guidance in the area in
which all clients have issues and questions regarding body type, body image, and weight.
Caroline needed new professional photos to introduce herself as a woman professionally,

so we formulated a set of goals and scheduled a shopping trip. However, off- he-rack shop-
ping for her was challenging. She was between a size 16 and 18 and found it hard to fi d
garments to fit her properly. Ultimately I brought in a local custom clothing designer who
did an amazing job creating beautiful but budget-conscious custom clothing for Caroline
that fit her body perfectly. We carefully selected fabrics that honored her clothing person-
ality, silhouettes that complimented her body type, and fabrics in flattering colors that had
just the right amount of drape and texture. The result for Caroline was stunning, and she
was thrilled. We then carefully selected the most appropriate color and style combinations
in eyewear, wigs, accessories, and makeup in preparation for her photo shoot. Caroline’s
process of transition had been a long time in coming (she was just over 50 years of age),
and I asked her permission to share her journey with you. I know it has the power to help
someone else in transition, because of her insight, preparation, and determination. Th s is
her story.
Transition can seem quite daunting. Many informed sources suggest that
a transition plan will make this frightening process more manageable. As a
consultant working in strategic planning and change management, this bit of
logic seemed natural to me, and so that is what I did. I created a detailed step-by-
step plan that had dozens of sequenced and prioritized tasks. I also created an
advisory group of four people, all consultants, who reviewed the plan with me and
helped me to refine it in the places where my emotions and fear had gotten the
better of me. They helped me keep the plan as simple as possible without omitting
any important steps.
In addition, from time to time, I reviewed the key areas of the plan with my
psychologist, who once again pointed out any areas that could be improved. One
outcome of this iterative planning process was that my transition letter underwent
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27 revisions before there was a version ready for each type of person who would
eventually receive it.
It was during these weeks of planning that one of my advisors, who had a sibling
who had gone through transition 2 years earlier, said, “You know, Caroline,
transition is not so much about your planning your personal journey as it is
managing the impact of your transition on those around you.” That was a real “slap
my forehead” moment. How could I have missed something so obvious? With this
important addition in focus, a new intended outcome of my transition plan became
facilitating and easing the impact my transition would have on those around me.
This involved different groups, including family (divided into close family and
extended family), friends, colleagues, and clients. I decided what I needed from all
of these groups was:
❖❖ To use my new name and the appropriate pronouns in our future conversa-
tions
❖❖ To continue our relationship as it has always been
That was all. I did not ask for anything else in my transition letter or any of the
other communications I sent. With that clarified, I checked with my psychologist,
who said to include a photo as soon as possible in my communications. She had
found that some people imagined the worst when thinking what an individual
would look like after transition, and the sooner that misconception could be put to
rest, the better.
With that I engaged an image consultant, Michelle, to assist me with clarifying the
image I needed to project as a business professional and to streamline procuring
a wardrobe and the necessary accessories that would sustain that image through
the first few weeks and months after transition. Together we identified the right
photographer to capture the new look and prepare a professional portrait for
online use. Michelle took an immense amount of pressure off my shoulders, as
she was able to identify and introduce a small team of resources (wardrobe,
makeup, jewelry, optician, and glasses) so that I no longer had to worry about
these aspects. She also kept this entire effort by all these people focused on the
one goal of achieving the new look we had agreed to. That left me more time to do
all the things that I had to do myself.
Following my original plan, I began by sending my transition letter first to
immediate family, then friends, colleagues, extended family, and finally, clients.
There was a pause between the communications to each specific group to allow
them to absorb the information and give them a bit of time to reach out with any
questions they might wish to ask. For example, my colleagues had to be on board
before our clients were informed. This sequencing ensured that everyone could
feel they had been informed appropriately and with due consideration.
Now it was time to take the next step and introduce myself visually. Minutes before
I sent the final transition letters to everyone in my networks who not yet been
informed, I updated my online profiles with my new portrait and then pressed
send on the distribution list that reached out to hundreds of people from all four
groups. Everyone could now see the real me which I was so pleased with, thanks
to my image consultant, Michelle Horne. Then I panicked. But it did not last long.
Within 10 minutes the notes of support began to arrive and continued for over 3
weeks. Within a month, even people who were not on the original distribution list
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had been informed by others and began to write to me saying wonderful things.
There has not been a single objection from anyone, although two people did wait
quite a long time before asking to meet me in person. Both of these meetings went
exceptionally well. Both people had simply not known what “transgender” was, and
they had needed some time to process this before we met.
While the communication part of the transition plan was going on, I remained at
home. All in all, it took about 3 weeks to complete. Then it was time to go back
to work and meet people. Although my fear was intense, I was confident in my
new look, and I had all I needed to sustain it. This too went well. In time, I hope to
offer the best ideas of this approach to transition to anyone for whom it may make
things easier. I think that the critical success factors were these:
❖❖ Accepting the responsibility to help others manage the impact my transition
had on them.
❖❖ Simplifying my need from others to only the essentials. This made it easier
for them to say, “Sure, let’s continue the way it has always been.”
❖❖ Working with an image consultant and a professional photographer to allay
the fears of others about my new image.
❖❖ Letting people respond in their own time. Some took 10 minutes, most a day
or two, others took 3 months.
In the end, it is the words of my oldest son that stay with me: “I have always been
proud of you—and I will always be proud of you.” What he expressed is what most
everyone else expressed in their own words. My heart bursts with gratitude. Given
the chance, and a bit of kindness, people rise to what you expect of them.
Conclusion
Transgender persons can face great challenges as they transition to their true genders, par-
ticularly when it comes to the outward expression of gender identity. Th s can be a crucial
component of identity formation and can carry great signifi ance for the transgender indi-
vidual, especially as the person navigates social relationships and professional settings. In-
corporating the expertise of an image consultant as a member of a transgender individual’s
transition team can be integral to alleviating the stress that can arise from these challenges.
References
1. Gagne P, Tewksbury R, McGaughey D. Com- Transgender Medicine and Surgery. New
ing out and crossing over: identity formation York: The Haworth Press, 2007.
and proclamation in a transgender commu- 5. Rotondi NK, Bauer GR, Travers R, et al. De-
nity. Gender Soc 11:478, 1997. pression in male-to-female transgender On-
2. Devor A. Witnessing and mirroring: a four- tarians: results from the trans pulse project.
teen-stage model of transsexual identity for- Can J Comm Mental Health 30:113,2011.
mation. J Gay Lesb Psychother 8:41, 2004. 6. Bockting WO, Miner MH, Romine RE, et al.
3. Morgan SW, Stevens PE. Transgender iden- Stigma, mental health, and resilience in an
tity development as represented by a group online sample of the US transgender popula-
of transgendered adults. Issues Ment Health tion. Am J Public Health 103:943, 2013.
Nurs 33:301, 2012. 7. Jones BA, Haycraft E, Murjan S, et al. Body
4. Bockting W, Coleman E. Developmental dissatisfaction and disordered eating in trans
stages of the transgender coming out pro- people: a systematic review of the literature.
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8. van de Grift TC, Cohen-Kettenis PT, aspects of the transitioning process for trans-
Steensma TD, et al. Body satisfaction and gender persons. Presented at the National
physical appearance in gender dysphoria. Transgender Health Summit, Oakland, CA,
Arch Sex Behav 45:575, 2016. Apr 2015.
9. McGuire JK, Doty JL, Catalpa JM, et al. Body 13. Todorov A, Pakrashi M, Oosterhof NN. Eval-
image in transgender young people: fi dings uating faces on trustworthiness after minimal
from a qualitative, community based study. time exposure. Social Cognit 27:813, 2009.
Body Image 18:96, 2016. 14. Willis J, Todorov A. First impressions: mak-
10. Witcomb GL, Bouman WP, Brewin N, et al. ing up your mind after a 100-ms exposure to
Body image dissatisfaction and eating- a face. Pysch Sci 17:592, 2006.
related psychopathology in trans individuals: 15. Howlett N, Pine K, Orakçıoǧlu I, et al.
a matched control study. Eur Eat Disorders The influence of clothing on fi st impres-
Rev 23:287, 2015. sions: rapid and positive responses to mi-
11. van de Grift TC, Cohen-Kettenis PT, Elaut E, nor changes in male attire. J Fashion Market
et al. A network analysis of body satisfaction Manage 17:38, 2013.
of people with gender dysphoria. Body Image 16. Naumann LP, Vazire S, Rentfrow PJ, et al.
17:184, 2016. Personality judgments based on physical
12. Fein LA, Salgado CJ, Estes CM. Transitioning appearance. Pers Soc Psychol Bull 35:1661,
transgender: an investigation of important 2009.
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Credits
Chapter 1 Lee PA, Houk CP, Ahmed SF, Hughes IA; Interna-
Fig. 1-10 From Capitán L, Simon D, Kaye K, tional Consensus Conference on Intersex organized
Tenório T. Facial feminization surgery: the fore- by the Lawson Wilkins Pediatric Endocrine Society
head. Surgical techniques and analysis of results. and the European Society for Paediatric Enocrinol-
Plast Reconstr Surg 134:609, 2014. ogy. Consensus statement on management of inter-
sex disorders. International Consensus Conference
on Intersex. Pediatrics 118:e488, 2006.
Chapter 2
Tables 15-2 and 15-5 Data from Hembree WC,
Fig. 2-1 From Mohan S, Judd O, Young K. A Cohen-Kettenis P, Delemarre-van de Waal HA, et
Practical Guide to Laryngeal Framework Surgery. al. Endocrine treatment of transsexual persons: an
Devon, UK: Compton Publishing, 2017. Endocrine Society clinical practice guideline. J Clin
Endocrinol Metab 94:3132, 2009; and Spack NP.
Management of transgenderism. JAMA 309:478,
Chapter 3 2013.
Figs. 3-3 through 3-9 From Monstrey S, Selvaggi Table 15-3 Data from Hembree WC, Cohen-
G, Ceulemans P, et al. Chest-wall contouring sur- Kettenis P, Delemarre-van de Waal HA, et al. En-
gery in female-to-male transsexuals: a new algo- docrine treatment of transsexual persons: an En-
rithm. Plast Reconstr Surg 121:849, 2008. docrine Society clinical practice guideline. J Clin
Endocrinol Metab 94:3132, 2009; and Nakamura
A, Watanabe M, Sugimoto M, et al. Dose-response
Chapter 4 analysis of testosterone replacement therapy in pa-
tients with female to male gender identity disorder.
Box 4-1 Data from Coleman E, Bockting W, Endocr J 60:275, 2013.
Botzer M, et al. Standards of care for the health of
transsexual, transgender, and gender-nonconform- Table 15-6 Data from Hembree WC, Cohen-
ing people, version 7. Intl J Transgenderism 13:165, Kettenis P, Delemarre-van de Waal HA, et al. En-
2011. docrine treatment of transsexual persons: an En-
docrine Society clinical practice guideline. J Clin
Fig. 4-2 From Monstrey S, Selvaggi G, Ceulemans Endocrinol Metab 94:3132, 2009; and Wierckx K,
P, et al. Chest-wall contouring surgery in female-to- Gooren L, T’Sjoen G. Clinical review: breast devel-
male transsexuals: a new algorithm. Plast Reconstr opment in trans women receiving cross-sex hor-
Surg 121:849, 2008. mones. J Sex Med 11:1240, 2014.
Chapter 15 Chapter 17
Tables 15-1, 15-4, and 15-7 Data from Houk CP, Fig. 17-1 From Basson R. Female sexual response:
Levitsky L. Evaluation of the infant with am- the role of drugs in the management of sexual dys-
biguous genitalia, www. uptodate.com, 2013; and function. Obstet Gynecol 98:350, 2001.
285
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Index
A
Adam’s apple with previous inadequate phalloplasty, 145
feminization of, 28 superfic al circumflex liac artery perforator flap for,
gender of, 6 145-148
Adolescents tissue expansion for, 143
case examples of, 218-220 tube-within-a-tube technique for, 143
combined total laparoscopic hysterectomy with bilat- vascular insuffici cy after, 198-199
eral salpingo-oophorectomy in, 69 Antiandrogen therapy
cross-sex hormones for, 216-218 bone health with, 236
desistance in, 211, 249 cancer screening with, 237
diagnosis of gender dysphoria in, 210 cardiovascular risk of, 236
key points, 209 routine follow-up for, 235-236
mental health care for, 249-250 timing of physical changes from, 234-235
normal puberty of, 213-214 treatment protocols for, 232-234
overview of medical management of, 214 Appearance, 274-282
pubertal suppression in, 214-216, 218-220, 250 Arterial interposition graft or short pedicle, 193-194
surgical considerations in, 218 Arterial thrombosis after phalloplasty, 194-195
transgender child and, 210-212 Arterial transposition for short pedicle, 192-193
Adrenal hyperplasia, congenital, 226, 227 Arteriovenous shunts after phalloplasty, 195
Aging patients, 238 ASIS (Anterior superior iliac spine) in anterolateral thigh
Alopecia, androgenic, 7, 19 flap phalloplasty, 139, 140, 141, 145
17 alpha-ethinyl-3-desoxy-19-nortestosterone (Lynestre- Assisted reproductive technologies, 69
nol), for breakthrough uterine bleeding, 229 ATP phalloplasty; see Anterolateral thigh flap phallo-
Ambiguous genitalia, 246 plasty
Androgen insensitivity, 227 Atrophy after phalloplasty, 204
Androgen synthesis, abnormal, 227 Augmentation mammaplasty, 52-56
Androgen therapy, 228-232 Autism spectrum disorder, 247
Anterior commissure advancement, 35, 39 Autologous flap surgery for breast augmentation, 55
Anterior partial laryngectomy, 35, 40-48
Anterior superior iliac spine (ASIS) in anterolateral thigh B
flap phalloplasty, 139, 140, 141, 145 Belgrade metoidioplasty, 114-116
Anterolateral thigh flap (ATP) phalloplasty Bilateral salpingo-oophorectomy (BSO)
anatomy of, 138-139 combined with chest reconstruction
circumference of phallus with, 151-152 in adolescents, 69
expert commentary on, 151-154 advantages of, 68-69
fi al considerations and future perspectives on, 148 guidelines for, 68-69
hair removal for, 152 indications and contraindications for, 69
key points, 135 key points, 67
overview of, 136-138 patient evaluation for, 70
patient preparation for, 140 preoperative management for, 70
preoperative markings for, 140-141 problems, complications and considerations with,
preoperative planning for, 139 76-78
versus radial forearm flap, 132, 136, 137 results and outcomes of, 75-76
with short pedicle, 191-194 surgical technique for, 70-72
surgical technique for, 141-142 and latissimus dorsi flap phalloplasty, 157, 158
urethral reconstruction in, 143-148 BMD (bone mineral density)
flap prelamination for, 144 with estradiol, 236
narrow free radial forearm flap for, 144-145, 152 testosterone therapy and, 231
peritoneal flap for, 144 Body dysmorphic disorder, 266
287
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INDEX
Body image with estrogen and antiandrogen therapy, 237

and gender expression, 275 after subcutaneous mastectomy, 65, 78
and image consulting, 275-282 with testosterone therapy, 232
in sex therapy, 268 of intestinal neovagina, 107
and sexual health, 265-266 Cancer risk, with total laparoscopic sigmoid vaginoplasty,
Body mapping, 268 107
Body proportion, 277 Cancer screening
Bone health with estrogen and antiandrogen therapy, 237
with estrogen and antiandrogen therapy, 236 with testosterone therapy, 231-232
with testosterone therapy, 231 Cardiovascular risk
Bone mineral density (BMD) of estrogen and antiandrogen therapy, 236
with estradiol, 236 of testosterone therapy, 230
testosterone therapy and, 231 Cervical cancer, testosterone therapy and, 232
Bone sculpture, 3, 24 Cheek area, gender of, 5
Bottom surgery Cheek augmentation, 20-21
in adolescents, 218 Chest reconstruction
metoidioplasty as, 109-117 breast cancer after, 78
phalloplasty as combined with hysterectomy and oophorectomy
anterolateral thigh flap, 135-154 in adolescents, 69
latissimus dorsi flap, 155-170 advantages of, 68-69
management of unfavorable urologic sequelae follow- guidelines for, 68-69
ing, 177-187 indications and contraindications for, 69
radial forearm flap, 119-134 key points, 67
testicular and erectile implants after, 171-175 patient evaluation for, 70
unfavorable results of, 189-207 preoperative management for, 70
referral for, 252 problems, complications and considerations with, 78
vaginoplasty as results and outcomes of, 75-76
skin-flap, 83-93 surgical technique for, 72-75
total laparoscopic sigmoid, 95-107 Children
Breakthrough uterine bleeding, 229 case examples of, 218-220
Breast augmentation, 52 mental health care for, 249-250
complications of, 55-56 normal puberty of, 213-214
surgical techniques for, 53-55 overview of medical management of, 214
autologous flap surgery as, 55 pubertal suppression in, 214-216, 218-220, 250
breast implant as, 53-54 transgender, 210-212
fat grafting as, 54-55 Chin feminization, 22-26
“Breast binding,” 57, 72 Chin, gender of, 6
Breast buds, 214 Clitoral lengthening and repositioning in latissimus dorsi
Breast cancer flap phalloplasty, 157-158
after breast augmentation, 55-56 Clitoris
after chest reconstruction, 78 anatomy of, 157
with estrogen and antiandrogen therapy, 237 in metoidioplasty, 112
after subcutaneous mastectomy, 65, 78 Clitoroplasty, with vaginoplasty
with testosterone therapy, 232 skin-flap, 85, 86
Breast development, 53 total laparoscopic sigmoid, 99-100
with hormone therapy, 234-235 Clothing, 274-282
Breast implant, 53-54 Clothing personality assessment, 277
Breast “reconstruction”; see Breast augmentation Colonic conduit necrosis, 105
Breast surgery; see Top surgery Color analysis, 276
BSO; see Bilateral salpingo-oophorectomy Colpocleisis
Buccal mucosal graft in etoidioplasty, 114-115 with latissimus dorsi flap phalloplasty, 157, 158
Bulbar urethra, creation of, 114 with metoidioplasty, 114
Combined hysterectomy, oophorectomy, and chest recon-
C struction
Cancer in adolescents, 69
breast advantages of, 68-69
after breast augmentation, 55-56 guidelines for, 68-69
after chest reconstruction, 78 indications and contraindications for, 69
288
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INDEX
key points, 67 Estrogen

patient evaluation for, 70 in fetal life, 210-211
preoperative management for, 70 in normal puberty, 213
problems, complications and considerations with, 76-78 Estrogen therapy
results and outcomes of, 75-76 for adolescents, 216-217, 218
surgical technique for, 70-75 bone health with, 236
Coming out stage, 248 cancer screening with, 237
Compartment syndrome after phalloplasty, 195-196, 199 cardiovascular risk of, 236
Compression neuropathy after phalloplasty, 205 routine follow-up for, 235-236
Concentric circular technique for subcutaneous mastec- timing of physical changes from, 234-235
tomy, 61-62, 74 treatment protocols for, 232-234
extended, 62-63, 74 Ethinyl estradiol, cardiovascular risk with, 236
Congenital adrenal hyperplasia, 226, 227 Excision and primary anastomosis (EPA) for urethral
Coronaplasty in phalloplasty stricture, 182
anterolateral thigh flap, 142 Exploration stage of transgender identity development,
radial forearm flap, 129 248
Cosmetic procedures, 265-266 Extended concentric circular technique for subcutaneous
Craniofacial skeleton, gender of, 4-7 mastectomy, 62-63, 74
Cricothyroid approximation (CTA), 33-34, 36 Eye gaze in sex therapy, 268
Cross-sex hormones; see Hormone therapy
Cultural competence, 244 F
Cyproterone acetate, 232, 233 Facial fat, distribution and volume of, 7
Facial feminization surgery (FFS)
D versus cosmetic surgery, 4
Dating, 267-268 defi ed, 4
Deep inferior epigastric artery (DIEA)/descending branch evaluation and diagnosis for, 3, 9-12
of lateral circumflex emoral artery interposition goal of, 3, 4
graft or short pedicle, 193-194 importance of, 4
Deep inferior epigastric artery (DIEA) transposition for key points, 3
short pedicle, 192-193 postoperative management in, 28-29
Dentition, gender of, 6 for primary aspects, 4-7
Depot medroxyprogesterone for breakthrough uterine procedures for, 13-28
bleeding, 229 of lower third (lower jaw and chin), 22-27
Derogatis Interview for Sexual Functioning (DISF), 261 of middle third (cheeks, nose, and upper lip), 20-21
Descending branch of the lateral circumflex femoral artery of neck (thyroid cartilage), 28
(DBLCFA) perforator flap, 138 of upper third (forehead and hairline), 14-20
Desistance in adolescents, 211, 249 for secondary aspects, 8
Dihydrotestosterone in normal puberty, 213 virtual, 12-13
Dilators, 264 Facial hair, 7
Direct visualization internal urethrotomy (DVIU) for ure- Falsetto, 33
thral strictures, 181 Family therapy, 250
Discrimination, 246-247 Fat grafting for breast augmentation, 54-55
Diversion neovaginitis, 106 Fat transfer for cheek augmentation, 20-21
Donor-site scar, unaesthetic, 205 Female Sexual Function Index (FSFI), 261
Dorsal inlay approach for urethral strictures, 182-183 Female-to-male (FTM) patients; see Transmen
Dressing, 274-282 Fertility preservation
Dyspareunia after phalloplasty, 204 with combined hysterectomy, oophorectomy, and chest
reconstruction, 69
E in transmen, 239
Elderly patients, 238 in transwomen, 238-239
EPA (excision and primary anastomosis) for urethral Finasteride, 233
stricture, 182 Fistulas
Erectile implants; see Penile prostheses neovaginal, 106
Erogenous sensation, 265 urinary; see Urinary fistula management
Estradiol Flap prelamination for urethral reconstruction, 144
for adolescents, 216-217, 218 Follicle-stimulating hormone (FSH) in normal puberty,
bone health with, 236 213
cardiovascular risk with, 236
for transwomen, 233, 235
289
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INDEX
Forehead reconstruction, 3, 14-16 Gonadotropin-releasing hormone (GnRH) in normal pu-

with hairline lowering surgery, 17, 18 berty, 213
with immediate hair transplant technique, 19-20 Goserelin for breakthrough uterine bleeding, 229
46,XY pure gonadal dysgenesis, 227 Grief, 266
Free nipple graft echnique for subcutaneous mastectomy,
63-64, 74-75 H
Frontonasal-orbital complex, gender of, 5 Hair, gender of, 7
FTM patients; see Transmen Hair growth, vaginal, 264
Full-thickness grafts or revision of failed vaginoplasty, 103 Hair transplantation, hairline redefin tion with, 18-20
Full-thickness skin graft (F SG) for urethral reconstruc- Hairline, gender of, 7
tion, 144 Hairline-lowering surgery, 17-18
Fundamental frequency, 49 Hairline redefin tion, 18-20
Hairline treatment, 16-20
G Hard packers, 263
Galactorrhea, 55 Heineke-Mikulicz repair of urethral stricture, 182
Gender affirmation surgery (GAS), 2 Hilotherapy after facial feminization surgery, 28
facial feminization surgery as, 3 Histrelin acetate
preparation and referral for, 252-253 for pubertal suppression, 215-216, 218, 220
sexual satisfaction after, 263-265 for transwomen, 232-233
Gender attribution, 211 HIV infection, 262
Gender binary, 274 Holding/breath connection in sex therapy, 268
Gender confi mation surgery (GCS); see Gender affirma- Hormone therapy
tion surgery for adolescents, 211, 214-218
Gender dysphoria counseling before, 225
assessment of, 245-246 criteria for, 224-225, 252
in children and adolescents, 249-250 illegal sources of, 225
defi ed, 121, 210, 245 key points, 223
diagnosis of, 245 objectives of, 225
differential diagnosis of, 224 in older patients, 238
Gender expression overview of, 224
and appearance, 274-275 patient evaluation for, 225
assessment of, 246 preparation and referral for, 251-252
and body image, 275 recommendations on, 225-228
facilitation of change in, 250-251 and reproduction, 238-239
and image consulting, 275-282 after sex reassignment surgery, 238
key points, 273 before sex reassignment surgery, 237-238
Gender identity and syndromes affecting sexual development, 224,
assessment of, 246 226-227
defi ed, 210 for transmen
and sexual health, 266 bone health with, 231
Gender identity disorder, 210 cancer screening with, 231-232
Gender labels and sexual health, 266 cardiovascular risk of, 230-231
Gender reassignment surgery (GRS); see Gender affirma- goal of, 228
tion surgery options for, 228-229
Gender role, facilitation of change in, 250-251 protocols for, 228-229
Gender role nonconformity, 246 routine follow-up for, 229-230
Gender spectrum, 274 timing of physical changes from, 229
Genderqueer, 219, 249 for transwomen
Genital sexual reassignment; see Gender affirmation sur- bone health with, 236
gery cancer screening with, 237
Genital surgery; see Bottom surgery cardiovascular risk of, 236
Genitalia, ambiguous, 246 routine follow-up for, 235-236
Genitofemoral nerve in radial forearm flap phalloplasty, timing of physical changes from, 234-235
128 treatment protocols for, 232-234
Gestational hyperandrogenism, 226 Hyperandrogenism, gestational, 226
Gonadal dysgenesis, 46,XY pure, 227 Hypothalamic-pituitary-gonadal axis in normal puberty,
Gonadotropin-releasing hormone (GnRH) agonist 213-214
for breakthrough uterine bleeding, 229
for pubertal suppression, 214-216, 218, 220
290
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INDEX
Hysterectomy staged neophallic urethral reconstruction in, 164-165,

and phalloplasty 167
latissimus dorsi flap, 157, 158 subsequent procedures for, 162-166
radial forearm flap, 123-124 urethral lengthening in, 158-159, 167
total abdominal, 77 Leuprolide acetate
total laparoscopic; see Total laparoscopic hysterectomy for breakthrough uterine bleeding, 229
combined with chest reconstruction for pubertal suppression, 215-216, 219
vaginal, 71, 77 for transwomen, 232, 233
Lifestyle modifi ations, 275
I Lip lift, 2
Ilioinguinal nerve in radial forearm flap phalloplasty, 128 Lipofilling for breast augmentation, 54-55
Image consulting, 274-282 Lower jaw feminization, 22-26
Immediate hair transplant (IHT) technique, 19-20 Lubrication, 264
Implant Luteinizing hormone (LH) in normal puberty, 213
breast, 53-54 Lymphatic drainage after facial feminization surgery, 28-29
penile; see Penile prostheses Lynestrenol (17 alpha-ethinyl-3-desoxy-19-nortestoster-
Incontinence, 186 one), for breakthrough uterine bleeding, 229
Inferior epigastric artery in radial forearm flap phallo-
plasty, 126 M
Integration stage of transgender identity development, Makeup, 277-278
248-249 Malar region, gender of, 5
Intimacy stage of transgender identity development, 248 Male-to-female (MTF) patients; see Transwomen
Intracorporeal anastomosis, 104 Mammaplasty, 52-56
Inverted penile skin-flap technique; see Skin-flap vagino- Mammogenesis, 53
plasty Mandibular angle area, gender of, 6
Mandibular body, gender of, 6
J Manual lymphatic drainage after facial feminization sur-
Jaw, gender of, 6 gery, 28-29
Jaw feminization, 22-26 Marriage, 267-268
Jawline modifi ation, 22-26 Mastectomy, subcutaneous; see Subcutaneous mastectomy
Mating, 267-268
L Medroxyprogesterone acetate
Labia majora, creation of, 88, 89 in adolescents, 216
Labia minora, creation of, 88, 89 for breakthrough uterine bleeding, 229
Laryngectomy, anterior partial, 35, 40-48 Menstrual suppression
Laser vocal cord reduction, 34-35, 36-38 in adolescents, 216, 219
Lateral circumflex emoral artery interposition graft or with testosterone therapy, 229
short pedicle, 193-194 Mental health care
Latissimus dorsi flap phalloplasty for assessment of gender dysphoria, 245-246
clitoral anatomy and, 157 for children and adolescents, 249-250
clitoral lengthening and repositioning in, 157-158 clinical competence in, 244
complications of, 168-169 cultural competence in, 244
dissection of blood vessels at recipient site in, 161 epidemiology and need for, 246-247
donor-site closure in, 162 to facilitate changes in gender role and expression, 250-
flap design and marking for, 159-161 251
indications and contraindications for, 156 key points, 243
key points, 155 postoperative, 253-254
main procedure for, 157-162 in preparation and referral for hormone therapy, 251-
patient evaluation after, 167-168 252
penile prosthesis with, 162-164, 167 in preparation and referral for surgery, 252-253
postoperative care after, 166 role of, 244
preoperative assessment for, 157 and transgender identity development, 247-249
reconstruction of perineum and creation of scrotum in, Metoidioplasty
159 Belgrade, 114-116
removal of female reproductive organs with, 157, 158 clinical evaluation for, 111-112
results of, 166-167 goals of, 109
size of neophallus in, 167 indications and contraindications for, 110-111
291
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INDEX
Metoidioplasty—cont’d and phalloplasty

key points, 109 latissimus dorsi flap, 157, 158
patient evaluation for, 110 radial forearm flap, 123-124
ring, 113-114 Orchiectomy, 263
selection criteria for, 111 bilateral, 98, 99
simple, 112-113 Orgasms, 265
surgical techniques for, 112-116 Osteocutaneous flap
Minority stress model, 246-247 for radial forearm flap phalloplasty, 122, 127, 129
Monsplasty, 110 sexual intercourse with, 264-265
Mourning, 266 Osteoporosis
MTF patients; see Transwomen with estrogen and antiandrogen therapy, 236
Müllerian duct, persistent, 227 with testosterone therapy, 231
Ovarian cancer, testosterone therapy and, 231-232
N Ovotesticular disorder of sex development, 226
Nafarelin
for breakthrough uterine bleeding, 229 P
for transwomen, 232-233 Packers, 263
Name change, 266-267 Pedicle, short, 191-194
Natesto (testosterone nasal), 228 Penile disassembly technique, 83, 85-87
Neck, feminization of, 28 Penile inversion vaginoplasty; see Skin-flap vaginoplasty
Necrosis, partial, after phalloplasty, 199-202 Penile prostheses, 172-175
Neoclitoris, 85, 86 complications of, 169
Neophallus exposure as, 205
metoidioplasty for, 109-117 with phalloplasty
phalloplasty for latissimus dorsi flap, 162-164, 167
anterolateral thigh flap, 135-154 radial forearm flap, 131-132
latissimus dorsi flap, 155-170 tissue-engineered cartilage rods versus, 132
management of unfavorable urologic sequelae follow- Penile skin–flap technique; see Skin-flap vaginoplasty
ing, 177-187 Penile transplantations, 132-133
metoidioplasty as alternative to, 109-117 Penoscrotal skin flap, 84
radial forearm flap, 119-134 Perforator flaps for phalloplasty, 132
testicular and erectile implants after, 171-175 Perineal phase of total laparoscopic sigmoid vaginoplasty,
unfavorable results of, 189-207 98-100
Neourethra Perineal reconstruction in latissimus dorsi flap phallo-
with metoidioplasty, 114-115 plasty, 159
with radial forearm flap phalloplasty, 123, 124-126 Perineal urethrostomy for urethral strictures, 184, 186
Neovagina; see Vaginoplasty Peritoneal flap for urethral reconstruction, 144
Neovaginal fistulas, 106 Persistent Müllerian duct syndrome, 227
Neovaginal prolapse, 106 Phalloplasty
Neovaginal stenosis, 105-106 anterolateral thigh flap
Neovaginal tunnel, passing sigmoid through, 101-103 anatomy of, 138-139
Neovaginitis, diversion, 106 circumference of phallus with, 151-152
Neovaginopexy, 103 expert commentary on, 151-154
Neuropathy, compression, after phalloplasty, 205 fi al considerations and future perspectives on, 148
Nipple graft, ree, for subcutaneous mastectomy, 63-64, hair removal for, 152
74-75 key points, 135
Norethindrone in adolescents, 216, 219 overview of, 136-138
Nose, gender of, 5 patient preparation for, 140
Nose-refini g surgery, 21 preoperative markings for, 140-141
preoperative planning for, 139
O versus radial forearm flap, 132, 136, 137
Older patients, 238 with short pedicle, 191-194
Oocyte harvesting and cryopreservation surgical technique for, 141-142
with combined hysterectomy, oophorectomy, and chest urethral reconstruction in, 143-148
reconstruction, 69 vascular insuffici cy after, 198
with radial forearm flap phalloplasty, 124 goals of, 190
Oophorectomy latissimus dorsi flap
bilateral salpingo-oophorectomy, 69 clitoral anatomy and, 157
clitoral lengthening and repositioning in, 157-158
292
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INDEX
complications of, 168-169 testicular and erectile implants after, 171-175

dissection of blood vessels at recipient site in, 161 tissue-engineered cartilage rods versus penile implants
donor-site closure in, 162 with, 132
flap design and marking for, 159-161 unfavorable results of
indications and contraindications for, 156 arterial thrombosis as, 194-195
key points, 155 arteriovenous shunts as, 195
main procedure for, 157-162 atrophy as, 204
patient evaluation after, 167-168 compression neuropathy as, 205
penile prosthesis with, 162-164, 167 defi ed, 190
postoperative care after, 166 delayed, 203
preoperative assessment for, 157 dyspareunia as, 204
reconstruction of perineum and creation of scrotum early complications as, 196-202
in, 159 erectile implant exposure as, 205
removal of female reproductive organs with, 157, 158 fistulas as, 202
results of, 166-167 immediate or perioperative, 191-196
size of neophallus in, 167 insuffici t venous outfl w as, 196-197
staged neophallic urethral reconstruction in, 164-165, key points, 189
167 late, 204-205
subsequent procedures for, 162-166 partial necrosis as, 199-202
urethral lengthening in, 158-159, 167 redos for, 190, 206
management of unfavorable urologic sequelae following short pedicle as, 191-194
indications and contraindications for, 178-179 stricture as, 203
key points, 177 tight closure as, 195-196
patient evaluation for, 179-180 unaesthetic donor-site scar as, 205
preoperative planning and preparation for, 180 vascular insuffici cy as, 197-199
problems and complications with, 186 Polyethylene implants for cheek augmentation, 20
results of, 184-186 Postoperative mental health care, 253-254
surgical technique for, 180-184 Pre-coming out stage, 248
metoidioplasty as alternative to, 109-117 Pregnancy in posttransition males, 110, 239
perforator flaps for, 132 Prelamination technique for radial forearm flap phallo-
radial forearm flap plasty, 124-126
versus anterolateral thigh flap, 132, 136, 137 Progestational agents
arteriovenous shunts after, 195 in adolescents, 216, 217
atrophy after, 204 for transwomen, 232-233
contraindications to, 122-123 Progesterone for transwomen, 233
dyspareunia after, 204 Prolactin level in transwomen, 236
flap transfer procedure for, 126-131 Prolapse, neovaginal, 106
insuffici t venous outfl w in, 196-197 Pronouns, preferred, 266-267
justifi ation for, 121 Prostate cancer with estrogen and antiandrogen therapy,
key points, 119 237
osteocutaneous versus fasciocutaneous option for, Prostheses
122, 127, 129 breast, 53-54
overview of, 120-121 penile; see Penile prostheses
patient evaluation for, 121-123 Psychiatric consultation, 247
penile implant with, 131-132 Psychological assessment
postoperative sequelae/complications of, 131 of gender dysphoria, 245-246
potential drawbacks of, 131-132 of mental health, 246-247
prelamination technique for, 124-126 of psychosocial adjustment, 250-251
preoperative preparation for, 123-124 role of, 244
with short pedicle, 191-194 Psychological counseling, 244
unaesthetic donor-site scar after, 205 Psychosocial adjustment, 244, 247, 250-251
urethral reconstruction with, 144-145, 152 Psychotherapy, 244
vascular insuffici cy after, 198 postoperative, 254
recent advances in, 132-133 Pubertal suppression, 214-216, 218-220, 250
redo, 190, 206 Puberty
sexual function after, 264-265 mental health care during, 249-250
shriveled or incomplete, 206 normal, 213-214
tensor fasciae latae, 137-138
293
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INDEX
Q Self-dilation, 264
Quality of life, 254 Semicircular technique for subcutaneous mastectomy,
59, 72
R Sensate focus exercises in sex therapy, 268
Radial artery–based free flap urethroplasty, 205 Sex hormones, 210-211
Radial forearm free flap (RFFF) phalloplasty Sex response model, 268-269
versus anterolateral thigh flap, 132, 136, 137 Sex therapy, 268-269
arteriovenous shunts after, 195 Sexual activity
atrophy after, 204 after gender affirmation surgery, 263-265
contraindications to, 122-123 with metoidioplasty, 111
dyspareunia after, 204 after radial forearm flap phalloplasty, 131-132
flap transfer procedure for, 126-131 after vaginoplasty
insuffici t venous outfl w in, 196-197 skin-flap, 90
justifi ation for, 121 total laparoscopic sigmoid, 105
key points, 119 Sexual development, syndromes affecting, 224, 226-227
osteocutaneous versus fasciocutaneous option for, 122, Sexual dysfunction, 261-262
127, 129 Sexual health
overview of, 120-121 active versus stealth life in, 267
patient evaluation for, 121-123 dating, mating, and relationships in, 267-268
penile implant with, 131-132 evaluation of, 260-262
postoperative sequelae/complications of, 131 gender identity and labels in, 266
potential drawbacks of, 131-132 key points, 259
prelamination technique for, 124-126 new body image in, 265-266
preoperative preparation for, 123-124 overview of, 260
with short pedicle, 191-194 postoperative considerations for, 263-268
unaesthetic donor-site scar after, 205 preferred pronouns in, 266-267
urethral reconstruction with, 144-145, 152 preoperative considerations for, 263
vascular insuffici cy after, 198 sex therapy for, 268-269
Receptor activator of nuclear factor kappa B ligand sexual function after surgery in, 263-265
(RANKL), testosterone therapy and, 231 transgender-specific c ncerns about, 262
Rectus sheath hematoma after phalloplasty, 198 Sexual orientation, 267
Redo phalloplasty, 190, 206 versus gender identity, 246
Referral Sexual satisfaction
for hormone therapy, 251-252 after gender affirmation surgery, 263-265
for surgery, 252-253 with metoidioplasty, 111
Relationships, 267-268 after vaginoplasty
Reproduction, 238-239 skin-flap, 90-91
Resonant frequency, 49 total laparoscopic sigmoid, 105
RFFF phalloplasty; see Radial forearm free flap phallo- Sexually transmitted infections, 262
plasty Short pedicle, 191-194
Rhinoplasty, 21 Sigmoid segment
Ring metoidioplasty (RM), 113-114 mobilization of, 100-101
passing through neovaginal tunnel of, 101-103
S Sigmoid vaginoplasty, total laparoscopic
Sacrospinous ligament fix tion, transvaginal, 88 cancer risk with, 107
Salpingo-oophorectomy, bilateral; see Bilateral salpingo- follow-up protocol for, 107
oophorectomy indications and contraindications for, 96
Scar, unaesthetic donor-site, 205 intraoperative measures and positioning for, 97-98
SCIAP (superfic al circumflex liac artery perforator) flap key points, 95
in anterolateral thigh flap phalloplasty, 140, 141, laparoscopic isolation and transposition of sigmoid seg-
145-148 ment in, 100-103
SCM; see Subcutaneous mastectomy patient evaluation for, 97
Scrotoplasty perineal phase and vulvoplasty in, 98-100
with metoidioplasty, 113-114 preoperative planning and preparation for, 97
in phalloplasty problems and complications with, 105-107
latissimus dorsi flap, 159 results and outcomes of, 104-105
radial forearm flap, 126 in secondary/tertiary revision cases, 103
294
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INDEX
surgical technique for, 98-103 key points, 67

team and infrastructure for, 96-97 patient evaluation for, 70
Simple metoidioplasty (SM), 112-113 preoperative management for, 70
Skin slough after phalloplasty, 199-202 problems, complications and considerations with, 78
Skin texture of face, 7 results and outcomes of, 75-76
Skin-flap vaginoplasty, 83-93 surgical technique for, 72-75
clinical evaluation for, 84 complications of, 64-65
complications of, 91-92 and radial forearm flap phalloplasty, 124
indications and contraindications for, 84-85 recommendations on, 65
key points, 83 surgical techniques for
preoperative planning and preparation for, 85 algorithm for choice of, 58
results of, 89-91 concentric circular, 61-62, 74
revision of failed, 103 extended concentric circular, 62-63, 74
surgical techniques for, 85-89 free nipple graft, 63-64, 74-7
SM (simple metoidioplasty), 112-113 semicircular, 59, 72
Soft acking, 263 transareolar, 60, 73
Speech modifi ation two-stage procedure for, 65
discussion of, 48-49 Superfic al circumflex liac artery perforator (SCIAP) flap
indications and contraindications to, 32 in anterolateral thigh flap phalloplasty, 140, 141,
key points, 31 145-148
patient evaluation for, 32-33 Support groups, 250
preoperative planning and preparation for, 33 Swyer syndrome, 227
surgical procedures for, 36-48 Synthol, 265
for anterior commissure advancement, 39
for anterior partial laryngectomy, 40-48 T
for cricothyroid approximation, 36 TAH (total abdominal hysterectomy), 77
for laser vocal cord reduction, 36-38 Tensor fasciae latae (TFL) flap phalloplasty, 137-138
for thyrohyoid elevation, 48 Testes, vanishing, 227
for vocal cord webbing, 38-39 Testicular enlargement in puberty, 214
surgical techniques for, 33-35 Testicular implants, 172
anterior commissure advancement as, 35 complications of, 169
anterior partial laryngectomy as, 35 Testicular regression syndrome, 227
cricothyroid approximation as, 33-34 Testicular tissue, preservation of, 239
laser vocal cord reduction as, 34-35 Testosterone
thyrohyoid elevation as, 35 in fetal life, 210-211
vocal cord webbing as, 35 in normal puberty, 213
Sperm, cryopreservation of, 238-239 Testosterone cypionate, 228
Spironolactone Testosterone enanthate, 228
in adolescents, 216 Testosterone gel 1%, 228
for transwomen, 233, 235-236 Testosterone levels in transwomen, 235
Split-thickness skin graft ( TSG) for urethral reconstruc- Testosterone nasal (Natesto), 228
tion, 144 Testosterone patch, 228
Staged neophallic urethral construction, 164-165, 167 Testosterone therapy
“Stand-to-pee” devices (STPs), 263 for adolescents, 216, 217, 219
Stealth living, 267 bone health with, 231
Stenosis, vaginal, 264 cancer screening with, 231-232
Stigma, 246-247 cardiovascular risk of, 230-231
Stricture, urethral; see Urethral stricture management goal of, 228
Subcutaneous mastectomy (SCM), 56-65 options for, 228
anatomic considerations in, 56 protocols for, 228-229
breast cancer after, 65, 78 routine follow-up for, 229-230
challenges of, 56-57 timing of physical changes from, 229
combined with hysterectomy and oophorectomy for transmen, 228-232
in adolescents, 69 Testosterone undecanoate, 228
advantages of, 68-69 Thyrohyoid elevation, 35, 48
guidelines for, 68-69 Thyroid cartilage
indications and contraindications for, 69 feminization of, 28
gender of, 6
295
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INDEX
Tight closure after phalloplasty, 195-196 Transgender child, 210-212

Tissue expansion for urethral reconstruction, 143 Transgender identity development, 250-251
Tissue-engineered cartilage rods for phalloplasty, 132 Transgender men; see Transmen
TLH combined with chest reconstruction; see Total lapa- Transgender person, 210
roscopic hysterectomy combined with chest recon- Transgender women; see Transwomen
struction Transmen
Top surgery, 51-66 combined hysterectomy, oophorectomy, and chest re-
breast augmentation in transwomen as, 52-56 construction in, 67-81
combined with hysterectomy and oophorectomy hormone therapy for
in adolescents, 69 bone health with, 231
advantages of, 68-69 cancer screening with, 231-232
guidelines for, 68-69 cardiovascular risk of, 230-231
indications and contraindications for, 69 goal of, 228
key points, 67 options for, 228-229
patient evaluation for, 70 protocols for, 228-229
preoperative management for, 70 routine follow-up for, 229-230
problems, complications, and considerations with, 78 timing of physical changes from, 229
results and outcomes of, 75-76 metoidioplasty for, 109-117
surgical technique for, 72-75 phalloplasty for
criteria for, 252-253 anterolateral thigh flap, 135-154
indications and contraindication for, 52 latissimus dorsi flap, 155-170
key points, 51 management of unfavorable urologic sequelae follow-
referral for, 252 ing, 177-187
subcutaneous mastectomy in transmen as, 56-65 metoidioplasty as alternative to, 109-117
Total abdominal hysterectomy (TAH), 77 radial forearm flap, 119-134
Total laparoscopic hysterectomy (TLH) combined with recent advances in, 132-133
chest reconstruction testicular and erectile implants after, 171-175
in adolescents, 69 unfavorable results of, 189-207
advantages of, 68-69 subcutaneous mastectomy in, 56-65
guidelines for, 68-69 top surgery for, 56-65
indications and contraindications for, 69 Transvaginal sacrospinous ligament fix tion, 88
key points, 67 Transwomen
patient evaluation for, 70 breast augmentation in, 52-56
preoperative management for, 70 hormone therapy for
problems, complications, and considerations with, bone health with, 236
76-78 cancer screening with, 237
results and outcomes of, 75-76 cardiovascular risk of, 236
surgical technique for, 70-72 routine follow-up for, 235-236
Total laparoscopic sigmoid vaginoplasty timing of physical changes from, 234-235
cancer risk with, 107 treatment protocols for, 232-234
follow-up protocol for, 107 top surgery in, 52-56
indications and contraindications for, 96 vaginoplasty in
intraoperative measures and positioning for, 97-98 laparoscopic sigmoid, 95-107
key points, 95 skin-flap, 83-93
laparoscopic isolation and transposition of sigmoid seg- Tube-within-a-tube technique for urethral reconstruction,
ment in, 100-103 143
patient evaluation for, 97 Tucking, 263
perineal phase and vulvoplasty in, 98-100
preoperative planning and preparation for, 97 U
problems and complications with, 105-107 Upper lip modifi ation, 21
results and outcomes of, 104-105 Urethra after phalloplasty, 178
in secondary/tertiary revision cases, 103 Urethral diverticulum, 185
surgical technique for, 98-103 Urethral fistula; see Urinary fistula management
team and infrastructure for, 96-97 Urethral flap, vascularized, 83, 87
Transareolar technique for subcutaneous mastectomy, Urethral lengthening in phalloplasty
60, 73 latissimus dorsi flap, 158-159, 167
radial forearm flap, 124-126
296
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INDEX
Urethral reconstruction V
in anterolateral thigh flap phalloplasty Vaginal dilators, 264
flap prelamination for, 144 Vaginal hair growth, 264
narrow free radial forearm flap for, 144-145, 152 Vaginal hysterectomy, 71
peritoneal flap for, 144 Vaginal lubrication, 264
with previous inadequate phalloplasty, 145 Vaginal stenosis, 264
superfic al circumflex liac artery perforator flap for, Vaginectomy
145-148 with metoidioplasty, 110-111, 114
tissue expansion for, 143 in radial forearm flap phalloplasty, 124
tube-within-a-tube technique for, 143 Vaginoplasty
staged neophallic, 164-165, 167 skin-flap
Urethral stricture surgery clinical evaluation for, 84
indications and contraindications for, 178-179 complications of, 91-92
key points, 177 indications and contraindications for, 84-85
management of, 203 key points, 83
patient evaluation for, 179-180 preoperative planning and preparation for, 85
preoperative planning and preparation for, 180 results of, 89-91
problems and complications with, 186 revision of failed, 103
results of, 184-186 surgical techniques for, 85-89
surgical technique for, 180-184 total laparoscopic sigmoid
Urethrocutaneous fistula; see Urinary fistula management cancer risk with, 107
Urethroplasty follow-up protocol for, 107
radial artery–based free flap, 205 indications and contraindications for, 96
for urethral strictures, 181-182, 185 intraoperative measures and positioning for, 97-98
Urethrostomy, perineal, for urethral strictures, 184, 186 key points, 95
Urethrotomy, direct visualization internal, for urethral laparoscopic isolation and transposition of sigmoid
strictures, 181 segment in, 100-103
Urinary fi tula patient evaluation for, 97
indications and contraindications for, 178-179 perineal phase and vulvoplasty in, 98-100
key points, 177 preoperative planning and preparation for, 97
management of, 202 problems and complications with, 105-107
patient evaluation for, 179-180 results and outcomes of, 104-105
preoperative planning and preparation for, 180 in secondary/tertiary revision cases, 103
problems and complications with, 186 surgical technique for, 98-103
results of, 184 team and infrastructure for, 96-97
technique for, 180-181 Vanishing testes syndrome, 227
Urinary incontinence, 186 Vascular insuffici cy after phalloplasty, 197-199
Urologic sequelae following phalloplasty, management of Vascularized urethral flap, 83, 87
unfavorable Venous outfl w insuffici cy in free radial forearm flap,
indications and contraindications for, 178-179 196-197
key points, 177 Virtual facial feminization surgery (VFFS), 12-13
patient evaluation for, 179-180 Vocal cord webbing, 35, 38-39
preoperative planning and preparation for, 180 Vulvoplasty
problems and complications with, 186 in skin-flap vaginoplasty, 88, 89
results of, 184-186 in total laparoscopic sigmoid vaginoplasty, 99-100
surgical technique for, 180-184
Z
Zygomaticomalar region, gender of, 5
297
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33734

K24940_C000_FM_r5_cl.indd 1 8/26/2016 3:48:01 PM

Stan J. Monstrey, MD, PhD

Miroslav L. Djordjevic, MD, PhD

With Illustrations by Renée Cannon, MA

K24940_C000_FM_r5_cl.indd 3 8/26/2016 3:48:02 PM

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-4987-0848-7 (Pack - Book and Ebook)

K24940_C000_FM_r5_cl.indd 4 8/26/2016 3:48:02 PM

Remembering my mother’s teachings will further motivate me to advance our current

K24940_C000_FM_r5_cl.indd 5 8/26/2016 3:48:02 PM

K24940_C000_FM_r5_cl.indd 6 8/26/2016 3:48:02 PM

Clara Alvarez-Villalba, MD Melany Castillo, MD

Mark-Bram Bouman, MD, FESSM Salvatore D’Arpa, MD, PhD

Luis Capitán, MD, PhD Lydia A. Fein, MD, MPH

K24940_C000_FM_r5_cl.indd 7 8/26/2016 3:48:02 PM

Renee Gasgarth, MD Daniel Simon, DDS

Jamie P. Levine, MD Dusan Stanojevic, MD

Wilhelmus J.H.J. Meijerink, PhD, MD Amir Adam Tarsha, MD

Stan J. Monstrey, MD, PhD James P. Th mas, MD

K24940_C000_FM_r5_cl.indd 8 8/26/2016 3:48:03 PM

Roy E. Weiss, MD, PhD, FACP, FACE, FAAP Lee C. Zhao, MD

K24940_C000_FM_r5_cl.indd 9 8/26/2016 3:48:03 PM

K24940_C000_FM_r5_cl.indd 11 8/26/2016 3:48:03 PM

The psychological impact of the initial stages of an individual’s transition is addressed in a

K24940_C000_FM_r5_cl.indd 12 8/26/2016 3:48:03 PM

1 Facial Feminization Surgery: A Global Approach 3

2 Speech Modifi ation 31

4  ombined Hysterectomy, Oophorectomy, and Chest Reconstruction

5 Male-to-Female Gender Affirmation Skin-Flap Vaginoplasty 83

6  ale-to-Female Gender Affirmation Colon Vaginoplasty: Total

7 Female-to-Male Gender Affirmation Metoidioplasty 109

8  emale-to-Male Gender Affirmation Phalloplasty: Radial

9 Anterolateral Thi h Flap Phalloplasty 135

Expert Commentary 151

K24940_C000_FM_r5_cl.indd 13 8/26/2016 3:48:03 PM

10 Female-to-Male Gender Affirmation Phalloplasty: Latissimus

11 Testicular and Erectile Implants in Transmen After Phalloplasty 171

12 Management of Unfavorable Urologic Sequelae After Phalloplasty

13 Unfavorable Results and Complications in Phalloplasty Surgery 189

14 Medical Treatment of Adolescent Transgender Patients 209

15 Adult Hormone Therapy in Transgender Patients 223

16 Mental Health Care for Transgender and Gender Nonconforming

17 Sexual Health After Surgery for Transgender Individuals 259

18 Gender Expression and Image 273

K24940_C000_FM_r5_cl.indd 14 8/26/2016 3:48:03 PM

1-1 Facial Feminization Surgery: Forehead Reconstruction

1-2 Burring of the Lateral Brow

1-3 Facial Feminization Surgery: Hairline Lowering Surgery

1-4 Facial Feminization Surgery: Adam’s Apple Reduction

2-1 Feminization Laryngoplasty

5-1 Male-to-Female Penile Skin Inversion

6-1 Colon Vaginoplasty Result

8-1 Insertion of Foley Catheter in the Bladder

8-2 Transgender Male Urinating in Standing Position

K24940_C000_FM_r5_cl.indd 15 8/26/2016 3:48:03 PM

K24940_C000_FM_r5_cl.indd 17 8/26/2016 3:48:03 PM

Christopher J. Salgado, Lydia A. Fein

K24940_Book.indb 1 8/22/2016 7:15:03 AM

K24940_Book.indb 2 8/22/2016 7:15:03 AM

Luis Capitán, Daniel Simon

K24940_Book.indb 3 8/22/2016 7:15:04 AM

4 ombined Hysterectomy, Oophorectomy, and Chest Reconstruction

6 ale-to-Female Gender Affirmation Colon Vaginoplasty: Total

8 emale-to-Male Gender Affirmation Phalloplasty: Radial

10 Female-to-Male Gender Affirmation Phalloplasty: Latissimus

12 Management of Unfavorable Urologic Sequelae After Phalloplasty

16 Mental Health Care for Transgender and Gender Nonconforming