Transgender Surgery - Male To Female - UpToDate

24/6/2021 Transgender surgery: Male to female - UpToDate
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Transgender surgery: Male to female

Authors: Cecile Ferrando, MD, MPH, Tonya N Thomas, MD
Section Editor: Linda Brubaker, MD, FACOG
Deputy Editor: Kristen Eckler, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2021. | This topic last updated: Jun 01, 2021.
INTRODUCTION
Transgender women (feminine gender identity, assigned male sex at birth) may seek a variety of medical
and surgical treatments to transition physically to their self-affirmed gender. Successful transitions typically
require a scope of services, generally best provided by organizations with the capacity to provide a full
spectrum of psychological, medical, and surgical care. Medical treatment often includes hormones to expose
sex steroid-responsive target tissues to more estrogen and block androgen action. Commonly performed
surgeries include facial feminization (craniomaxillofacial procedures), chest ("top") surgery (eg, breast
augmentation), and genital ("bottom") surgery (eg, orchiectomy and vaginoplasty). Knowledge of these
commonly performed procedures and the surgical techniques used will aid medical care providers in caring
for transgender patients before, during, and after the transition process, and may help in the assessment
and management of complications related to these surgeries.
This topic will review surgeries that are commonly performed as part of male-to-female transition. Other
topics related to the care of transgender persons include:
● (See "Transgender men: Evaluation and management".)
● (See "Transgender women: Evaluation and management".)
● (See "Primary care of transgender individuals".)
TERMINOLOGY
The language and terminology used to describe gender and sexuality is presented in the table and reviewed
in detail separately ( table 1):
● (See "Primary care of transgender individuals", section on 'Terminology'.)
ISSUES IN TRANSGENDER SURGERY
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Overview of transition process — Gender dysphoria is the discomfort or distress caused by a discrepancy
between a person's natal sex (sex assigned at birth, usually according to external genitalia or chromosomes)
and that person's gender identity (innate sense of being male or female) ( table 1) [1].
Transgender individuals affected by gender dysphoria may choose to undergo a variety of treatments to
transition physically and socially to the gender role that they feel to be their true selves. Transitioning
involves learning to express and live socially in the individual's desired gender role and may include
feminizing or masculinizing hormone therapy and/or surgical procedures (known as gender affirmation or
confirmation surgery), depending on the individual's personal goals [1,2]. Mental health care and social
support play a critical role throughout the transition process, and a multidisciplinary approach to the
treatment of transgender individuals is recommended. Treatment, including hormonal therapy and/or
surgery, is medically necessary to alleviate gender dysphoria in many individuals, and with treatment, many
distressing symptoms may be alleviated [1-4]. A study of 2015 survey data reported that undergoing one of
more types of gender-affirming surgery was associated with reduced rates of past-month psychological
distress, past-year smoking, and past-year suicidal ideation [4].
Surgical options include feminizing procedures, breast ("top") surgery, and genital ("bottom") surgery. These
procedures can be performed independently or in combination. The incidence of gender-affirming genital
surgery appears to be increasing. An observational study of the United States National Inpatient Sample
reported that, for inpatients with a diagnostic code for transsexualism or gender-identity disorder
undergoing gender-affirming surgery, the incidence of genital surgery increased from 72 to 84 percent
between the time periods 2000 to 2005 and 2006 to 2011 [5]. Approximately 44 percent of patients had
insurance coverage for these procedures (private insurance, Medicare, and Medicaid), which, in part, reflects
data indicating that transgender care is both affordable and cost-effective [6]. This increase in gender-
affirming genital surgery highlights the need to prospectively assess quality metrics such as treatment
efficacy, patient satisfaction, complications, and reversal surgery as well as ensure proper clinical training of
surgeons and other health care providers.
A broad overview of the care of transgender individuals, including presentation, assessment, diagnosis, and
medical management, is covered separately. (See "Transgender women: Evaluation and management" and
"Transgender men: Evaluation and management".)
WPATH Standards of Care — The World Professional Association for Transgender Health (WPATH; formerly
known as the Harry Benjamin International Gender Dysphoria Association) is an international professional
society dedicated to promoting the highest evidence-based principles for the care of transsexual,
transgender, and gender-nonconforming people [1]. The Standards of Care are a series of flexible guidelines
for clinical practice set forth by the society based on evidence and expert consensus and may be modified to
meet the needs of an individual [1]. The guidelines provide a framework for the health care community
providing assessment; mental and physical health care; hormone therapy; and surgery for transsexual,
transgender, and gender-nonconforming people [1].
Perioperative management of estrogen therapy — The management of perioperative estrogen therapy

has been debated as data are evolving.

● Preoperative – Some experts have advocated for either reducing or discontinuing estrogen therapy two
to four weeks prior to surgery to reduce venous thromboembolic (VTE) risk [7]. However, a retrospective
review of 407 transfeminine individuals undergoing labiaplasty with (n = 212) and without (n = 190)
estrogen use reported only one episode of VTE, which occurred in a patient whose hormones had been
stopped preoperatively [8]. The authors reduce the estrogen dose to 1 mg of oral estradiol starting three
weeks prior to the surgery. (See "Transgender women: Evaluation and management", section on
'Estrogen'.)
● Intraoperative – Estrogen therapy is not dosed during the surgical procedure. The patient should
receive prophylaxis against VTE, as appropriate for the individual's risk factors and the type of
procedure. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical
patients".)
● Postoperative – There are no data to support current practice as it relates to estrogen dosing after
surgery. In our practice, we allow patients to restart their low-dose 1 mg oral estradiol one week
postoperatively for the subsequent two weeks following their surgery. Once this time period has passed,
they are allowed to resume their prescribed preoperative regimens. (See "Transgender women:
Evaluation and management", section on 'Estrogen'.)
Brief history of vaginoplasty surgery — While cases have been reported throughout history of males
feminized by means of castration, "sex-reassignment surgery" (now referred to as gender confirmation or
affirmation surgery) was not described before the 20th century. The first male-to-female genital surgeries
were performed in the 1930s in Germany. At that time, the term "transsexual" had been coined by the
sexologist Magnus Hirschfeld, who cared for and studied transgender individuals.
Lili Elbe, a Danish transgender woman, is historically regarded as one of the first to undergo gender
affirmation surgery in Dresden, Germany, in the 1930s. She underwent several surgeries and died from
complications related to her final surgery. Wide publicity and attention was brought to the United States in
the 1950s when Christine Jorgensen, a former United States Army soldier, was the first American to undergo
gender affirmation surgery in Europe.
In the late 1950s, the French plastic surgeon Dr. Georges Burou developed the modern penile inversion
vaginoplasty technique. Modifications of this technique are still commonly used today. Nearly a decade after
Dr. Burou's work, gender affirmation surgery became available at some academic centers in the United
States, including Johns Hopkins Medical Center and Stanford University. Since the late 1970s and early 1980s,
a shift in paradigm occurred, with most surgeries performed by private practicing surgeons. These
operations are again returning to academic centers in the United States and formal training programs for
this type of surgery are under development.
NONGENITAL/NONBREAST SURGERIES
Nongenital/nonbreast surgeries include a range of feminizing surgeries. While facial feminization and
thyroid cartilage reduction are discussed here, other feminizing procedures include body contouring (eg,
liposuction) and body implants (eg, buttock implants). There are no World Professional Association for
Transgender Health guidelines or criteria that need to be met by patients for these types of surgeries. As
such, no mental health care provider referral is required for these procedures as is required with chest
("top") or genital ("bottom") surgeries, but patients should be fully counseled and informed of the risks and
benefits prior to proceeding with surgery [1,9].
Facial feminization surgery — Many different components of the face, including individual features (such
as the eyes, jaw, or brow), facial configuration, and dimensional structure contribute to an individual's
desired gender ( figure 1) [10,11]. While facial surgery may be regarded by some as cosmetic, feminizing
alterations to the face may lead to reduction in gender dysphoria, high patient satisfaction, and greater
social acceptance of transgender women [1,3,9].
● Components – Facial feminization surgery aims to feminize masculine features of the face through a
wide variety of craniomaxillofacial procedures, frequently performed by specialized plastic surgeons
[9,12,13]. Facial feminization surgery may include:
• Forehead contouring and hairline advancement

• Blepharoplasty (eye and lid modification)
• Cheek augmentation
• Rhinoplasty (nose reshaping)
• Lip augmentation
• Mandibular angle reduction ( figure 2)
• Genioplasty (chin width reduction) ( figure 3)
• Other facial rejuvenation procedures
● Outcomes – A 2016 systematic review of 15 retrospective case reports and series detailing the
techniques and outcomes of facial feminization surgery for over 1100 transgender patients reported
only 7 complications [9]. However, not all studies specifically reviewed surgical complications, and this
finding should be interpreted with caution. While patient satisfaction appeared high, many of the
included studies were limited by the use of nonvalidated techniques or instruments for measuring
satisfaction. In a retrospective analysis of 33 patients who underwent a total of 180 facial feminization
operations with a minimum follow-up of 24 months, all patients reported improvement in quality of life,
measured as positive responses to a survey assessing physical, emotional, and social domains [14].
When assessed objectively by independent surgeons, aesthetic improvement was noted to be "very
much improved" in nearly 88 percent and "significantly improved" in 12 percent [14]. No major
postoperative complications were observed in this study.
Thyroid cartilage reduction (chondrolaryngoplasty) — The laryngeal prominence, or Adam's apple, is

perceived as a distinctly male characteristic. Chondrolaryngoplasty, also known as thyroid cartilage reduction
or Adam's apple reduction, involves excision of the superior thyroid notch and rim, reducing the appearance
of the laryngeal prominence and altering the contour of the anterior neck to achieve a more feminine
appearance ( figure 4) [9,15,16]. In natal men, the thyroid lamina fuse in the midline at an approximate 90-
degree angle, forming a more pronounced laryngeal prominence and contributing to greater vocal cord
length and a deeper voice compared with the natal woman, in whom fusion of the thyroid lamina occurs at
approximately 120 degrees [17]. Complications of the procedure include hematoma, infection, laryngeal

cutaneous fistula, loss of voice, laryngeal edema, numbness of the larynx, or superior laryngeal nerve
neuralgia, though none of these complications were observed in a mean 10-year follow-up of 31 patients
[16]. Transient hoarseness, voice weakness, and pain with swallowing were more frequently observed
following the procedure.
Of note, chondrolaryngoplasty is a separate procedure from feminizing voice surgery and does not aim to
change an individual's vocal pitch. Feminizing voice surgery should be undertaken in conjunction with voice
and communication therapy by certified specialists in individuals who desire this treatment [1].
CHEST (TOP) SURGERY (BREAST AUGMENTATION)
Criteria for surgery — The 2011 World Professional Association for Transgender Health (WPATH) criteria for
chest ("top") surgery (ie, breast augmentation in male-to-female transgender individuals) include [1]:
● One referral letter from a qualified mental health professional.
● Persistent, well-documented gender dysphoria.
● Capacity for informed decision making and consent.
● Age of majority.
● Well-controlled medical and mental health comorbidities.
● It is also recommended that individuals undergo a minimum of 12 months of feminizing hormone

therapy to maximize breast tissue growth in order to improve aesthetic results, although hormone
therapy is not explicitly required for surgery.
These criteria have replaced older documents set forth by WPATH and the 2009 Endocrine Society clinical
practice guidelines.
Surgical technique and preoperative planning — While feminizing estrogen hormone therapy results in
breast growth within two to three months, which may continue up to two years, up to 70 percent of
transgender women reportedly seek breast augmentation due to insufficient development with hormones
alone [18-20]. Surgical technique is similar to augmentation in cisgender women, but the anatomic
differences in the chest of natal men must be considered [21]. A wider chest, greater muscle mass, and
smaller, wider-set nipple-areolar complex with shorter distance to the inframammary crease may require
adjustment in the planned location of the inframammary crease, release of the lower sternal attachments of
the pectoralis major muscle, and alterations in implant positioning. For these reasons, an inframammary
incision and subpectoral pocket with form-stable implants are commonly chosen for augmentation in
transgender women, while a periareolar incision is usually avoided due to the smaller size of the areola [7].
Additional information on the surgical technique of breast augmentation in general is discussed separately.
(See "Implant-based breast reconstruction and augmentation".)

Postoperative care — A compression bra is used for several weeks after surgery, and gentle breast
massage is recommended postoperatively [7]. Thrombophlebitis of the thoracoepigastric veins, known as
Mondor disease, may occur following approximately 1 percent of breast augmentations [22]. Patients are
also advised to limit upper body exercise to avoid displacement of the implants [7]. Following implant
surgery, transgender women with no increased risk of breast cancer are advised to follow the same
screening guidelines as for natal women, regardless of use of hormone therapy [23].
Complications of breast augmentation — Complications following augmentation mammoplasty should be

evaluated and managed by a plastic surgeon with expertise in the procedure. Short-term and immediate
postoperative complications include hematoma, seroma, and infection. Long-term complications may
include capsular contracture, malposition or asymmetry, implant displacement, implant rupture or leak,
pain, dissatisfaction with cosmetic appearance, and the need for reoperation [7]. In a 10-year retrospective
review of patients receiving implant exchange or removal, which included 24 transgender female patients,
indications for primary replacement of implants among those individuals who were transgender included
contracture only (n = 7, 29.1 percent), size only (n = 11, 45.8 percent), capsular contracture and size (n = 1, 4.1
percent), asymmetry/malposition (n = 4, 16.6 percent), and shape (n = 1, 4.1 percent) [24]. Six patients
underwent two reoperations, and two underwent greater than two reoperations, totaling eight implant
replacements (80 percent) and two hematoma evacuations (20 percent). Indications for secondary
reoperations included capsular contracture (n = 3, 30 percent), hematoma (n = 2, 20 percent), rupture (n = 2,
20 percent), and size (n = 3, 30 percent). More details on implant-related complications are discussed
separately. (See "Complications of reconstructive and aesthetic breast surgery".)
GENITAL (BOTTOM) SURGERY (VAGINOPLASTY)
The World Professional Association for Transgender Health (WPATH) criteria for genital ("bottom") surgery
(orchiectomy and vaginoplasty in male-to-female transgender individuals) include [1]:
● Two referral letters from qualified mental health professionals.
● Persistent, well-documented gender dysphoria.
● Capacity for informed decision making and consent.
● Age of majority.
● Well-controlled medical and mental health comorbidities.
● Twelve continuous months of hormone therapy, unless the individual is unwilling or unable secondary
to a medical condition (recommended for orchiectomy and vaginoplasty).
● Twelve continuous months of living in the desired gender role congruent with the individual's gender
identity (recommended for vaginoplasty).
● Regular visits with a mental health or other medical professional are also recommended but not
explicitly required for surgery.

In our experience, many transgender women seek head, neck, and breast augmentation surgery, while
relatively fewer seek genital surgery.
Preoperative planning and care — The overall approach to transgender care includes a multidisciplinary
group that incorporates input from mental health and medical health care professionals to ensure that
patients are appropriate candidates for surgery [1]. Surgical consultation prior to vaginoplasty should
involve an extensive discussion between the surgeon and patient on the individual's history and rationale for
surgery, as well as extensive counseling on the types or routes of surgeries available, the risks and benefits
related to surgery, and the limitations and expected outcome of the surgery [1].
In addition to standard surgical preparation, we address the following issues with our patients undergoing
vaginoplasty:
● Depilatory procedures (hair removal) – Long-lasting depilatory procedures (eg, electrolysis or laser
hair removal) are recommended for patients undergoing penile inversion vaginoplasty with use of local
penoscrotal grafts to optimize surgical results and to avoid hair growth in the neovagina and the
potential complications of folliculitis, hairballs, and dyspareunia [25,26]. Hair removal should be
performed on the areas of the scrotum and perineum that will be used to line the neovagina (posterior
to the penile shaft, approximately 2 cm medial to the groin creases and 4 to 5 cm anterior to the anus).
The procedures may be performed on other genital hair-bearing areas, or they may be left intact to
achieve the individual's desired hair distribution and aesthetic outcome following surgery. We do not use
split-thickness skin grafts of scrotal tissue, which would potentially allow removal of the hair follicle
layer, because the scrotal skin produces a much thinner graft and is difficult to split in such a way to
separate the hair follicles.
Laser hair removal uses a laser light source to target pigmented hair, destroying the follicle with heat
[27]. Electrolysis destroys the hair follicle through use of an electric current directed through a needle or
probe, and can be used on pigmented or unpigmented (eg, gray, red, or blonde) hair [27]. These
procedures may be uncomfortable, and lidocaine jelly or lidocaine-prilocaine cream may be prescribed
to reduce pain associated with the procedure [27]. Multiple treatments are required for optimal results,
and it is recommended that hair removal be stopped four to six weeks prior to surgery. Further details
on hair removal techniques is found elsewhere. (See "Removal of unwanted hair".)
● Thromboprophylaxis – Multiple factors may lead to the observed increased incidence of venous
thromboembolic events (VTE) observed in the male-to-female transgender population including the use
of exogenous estrogen, prolonged surgical procedures, and postoperative bed rest [28]. Prior to surgery
and in the perioperative period, the Endocrine Society clinical practice guideline recommends that
surgeons and endocrinologists collaborate to manage hormone therapy [23]. In our practice, exogenous
estrogen is lowered to a very low dose (eg, oral estradiol 1 mg daily) three to four weeks prior to surgery
and is not restarted until the patient has returned to light activity, generally two to four weeks
postoperatively. Patients should receive appropriate VTE prophylaxis in the perioperative and
postoperative periods. In our practice, patients receive prophylactic subcutaneous heparin and wear
sequential compression devices in the preoperative and immediate postoperative period. Prophylactic
subcutaneous enoxaparin is then administered for one week following hospital discharge.

● Surgical consent – In addition to routine surgical risks such as bleeding and infection, surgical consent
for vaginoplasty must address risks specific to this procedure. Our surgical consent for vaginoplasty
contains the following language:
"We discussed the risks and benefits of the surgical procedure in great detail. The goal is to achieve
good cosmesis and functioning; she understands that each body is different and results vary.
Risks include, but are not limited to, bleeding/hemorrhage, transfusion, hematoma, seroma,
infection/abscess, wound healing issues, injury to surrounding organs (bowel, rectum, bladder,
urethra) and possible development of fistula, vaginal stenosis/stricturing/shortening/narrowing,
abnormal urinary stream, urinary incontinence, inability to orgasm or change in orgasm, pain and
scarring, neuropathies, and need for additional surgery."
● Antibiotic prophylaxis – Guidelines for prophylactic antibiotic use do not exist for vaginoplasty in the
transgender population; therefore, appropriate prophylaxis should be administered for urogenital
procedures [29]. The specific antibiotic selection and length of administration is based on expert
opinion. In our practice, perioperative intravenous cefazolin is administered, followed by oral
trimethoprim-sulfamethoxazole for prevention of infection while the urinary catheter and vaginal
packing remain in place up to one week following surgery.
● Bowel preparation – The use of a mechanical bowel preparation prior to penile inversion vaginoplasty
is surgeon dependent. Many experts may choose to perform some degree of modified bowel
preparation prior to surgery to avoid fecal contamination in the rare event of a rectal injury, and to delay
the immediate return of postoperative bowel movements while a vaginal packing is in place. Modified
bowel preparation regimens may involve a combination of clear liquid diet the day prior to surgery and
mechanical bowel preparation or enemas. Rectal wash out is performed at the time of surgery with
povidone-iodine solution. For intestinal segment vaginoplasty, full mechanical bowel preparation and
oral antibiotics are recommended to reduce the risk of surgical-site infection and anastomotic leak [30].
● Intraoperative positioning – Careful attention should be paid to surgical positioning given the
potentially extended length of time required for the procedure. Patients should be positioned in dorsal
lithotomy position in adjustable padded stirrups, keeping the hip, knee, and ankle aligned, avoiding
hyperflexion or hyperextension of the knees and hips. The arms should be positioned out on arm
boards for ease of access during penile inversion vaginoplasty, or with arms tucked in neutral position at
the patient's sides for intestinal vaginoplasty, where laparoscopic abdominal access may be employed.
Sufficient padding should line the operative table, and additional adhesive padding applied to the
patient's heels and sacrum may be added for prevention of pressure sores.
Surgical techniques — The goal of vaginoplasty surgery is to achieve an aesthetic and functional vagina,
vulva, and clitoris. Patients should be counseled that each body is different and results will vary depending
on body habitus, tissue availability, and other individual medical factors such as a history of prostatic
disease. The most commonly performed technique, especially in the United States, is the penile inversion
vaginoplasty. Many modifications of this technique exist, and one of these modifications is described below.

Intestinal vaginoplasty procedures are also performed and described. Graft materials are mainly used in
revision surgeries.
Penile inversion vaginoplasty — The most common technique performed for primary male-to-female
transgender vaginoplasty is penile inversion vaginoplasty [31]. The technique has been widely researched
and described, and modifications have been made over time to improve aesthetic outcome and functional
results [32-34]. Penile inversion vaginoplasty is irreversible and generally includes orchiectomy (if not
previously performed), penile deconstruction, formation of a sensate neoclitoris from a portion of the glans
penis on its dorsal neurovascular pedicle, creation of a neourethral meatus, creation of a vaginal cavity and
lining of the neovagina with local penoscrotal skin flaps, and labiaplasty to create an aesthetic and feminine
external appearance of the genitalia. Surgery may be performed by a variety of surgical specialists in plastic
surgery, urology, gynecology, and female pelvic medicine and reconstructive surgery.
We use the following technique in performing modified penile inversion vaginoplasty, which is also
presented in the video ( movie 1):
● The scrotal flap, which will later be used to line the neovagina, is marked ( figure 5). The borders of the
graft are the base of the penile shaft anteriorly, 2 to 4 cm medial to the groin creases laterally, and 4 to 5
cm above the anus posteriorly. The flap is incised sharply, then excised from the underlying
subcutaneous tissue using electrosurgery. To prepare the graft, all excess subcutaneous tissue is
removed sharply, creating a split thickness skin graft. If hair removal is suboptimal, remaining hair
follicles can be electrosurgically coagulated. The graft is kept moist with saline-soaked sponges.
● Next, electrosurgery is used to remove excess subcutaneous tissue by skeletonizing the underlying
penile structures down to Buck fascia. If testes are present, orchiectomy is performed ( figure 6). A
circumferential incision is made around the glans of the penis, thus freeing the epithelium from the
underlying tunica albuginea ( figure 7). If excess distal penile skin is present, the distal penile skin and
prepuce may be left intact with the glans for later creation of a clitoral hood and labia minora. The penile
structures are then sharply de-epithelized leaving a penile tube. The suspensory ligament of the penis is
released. A urinary catheter is placed to drain the bladder.
● Attention is then turned to creation of the neovagina. A transverse incision is made in the perineum
below the bulbous urethra, transecting the perineal tendon and creating a cavity by separating the
levator ani muscles laterally ( figure 8). Dissection is performed, first sharply and then bluntly. Our
preference is to perform this dissection with one finger inside the rectum and the other in the
neovaginal cavity ( figure 9). Care is taken to delineate the borders of the rectum and to palpate the
urinary catheter during the dissection to avoid injury to the rectum or lower urinary tract. Dissection is
carried past the level of the prostatic urethra anterior to the rectoprostatic fascia for a total length of
approximately 15 cm ( figure 10). Once adequate caliber and depth are achieved, meticulous
hemostasis is obtained to avoid hematoma formation. A bubble test may be performed to assess for
rectal injury by filling the neovagina with irrigation solution, then insufflating the rectum using a large
syringe. If bubbles are seen in the neovaginal cavity, further investigation for rectal injury should be
performed.

● Attention is returned to the penile structures. A dorsal flap containing the dorsal penile neurovascular
blood supply to the neoclitoris (created from a portion of the dorsal glans penis) and a ventral urethral
flap are created. The deep penile arteries are ligated at the inferior margins of the crura of the corpora
cavernosa. The corpora cavernosa, located between the dorsal clitoral flap and the ventral urethral flap,
are excised ( figure 11).
● The excess glans is excised, and the clitoral flap is folded on itself to position the neoclitoris at the level
of the insertion of the adductor longus tendon in the groin creases, which is where the transclitoral line
is located in the natal female. The flap is secured to the underlying fascia. Care must be taken not to kink
the blood supply or place the flap on tension, which could result in necrosis of the neoclitoris (
figure 12).
● Excess corpus spongiosum is excised from the urethral flap. The urethra is transected in the midline on
the ventral side over the catheter until the level of the pubic bone to ensure that the urethral meatus will
lie flush with the bony pelvis to avoid urinary stream spraying. The urethral flap is trimmed and secured
to the underlying fascia, leaving a mucosal bridge lining the area between the neourethral meatus and
the neoclitoris ( figure 13).
● The prepared graft is sewn onto a large vaginal stent ( figure 14). The stent is then passed through the
penile tube and the flaps are sutured together ( figure 15). The vaginal tube and stent are then placed
into the neovaginal cavity, and the stent is removed. Mattress sutures are placed to take tension off the
flap, and the vagina is tightly packed.
● An incision is made anteriorly through the penile flap, exposing the underlying clitoris, mucosal urethral
flap, and urethral meatus. Labia minora and a clitoral hood are created using the maintained distal
penile skin, or can alternatively be created by suturing the edges of the anterior penile flap ( figure 16
). Drains are placed to drain the labia majora, and the labia majora incision lines are closed in an
aesthetically appealing way. Immediate postoperative results are shown in the picture ( picture 1).
Intestinal vaginoplasty — Transgender women with penoscrotal hypoplasia or those who have failed a
primary penile inversion vaginoplasty procedure may be candidates for intestinal vaginoplasty [35,36].
Intestinal vaginoplasty involves use of a segment of small intestine (ileum) or sigmoid colon to create a
neovagina, with the advantages of self-lubrication, depth, and reduced risk of stenosis [37]. Disadvantages
of the procedure include the risks of abdominal surgery and the creation of a bowel anastomosis, excessive
discharge and/or malodor, and prolapse of the neovagina [37]. Patients with a history of cancer,
inflammatory bowel disease, or extensive intraabdominal adhesions are not candidates for this procedure
[37].
The procedure is performed through a combined abdominal and perineal approach [36,37]. The perineal
portion of the procedure includes perineal dissection of the neovaginal cavity, disassembly of the penile
structures, formation of a neoclitoris, neourethral meatus, labia minora, labia majora, and bowel-perineal
anastomosis. The neovaginal dissection, penile disassembly, and creation of vulvar structures are performed
similarly to the techniques described above for penile inversion vaginoplasty. (See 'Penile inversion
vaginoplasty' above.)

The abdominal portion may be performed via laparoscopy, laparoscopic-assisted laparotomy, or laparotomy,
depending on surgeon experience, and includes harvest of an intestinal segment (ileum or sigmoid colon)
on its vascular pedicle and bowel anastomosis [37]. Surgeons may also choose to perform a suspension
procedure to the sacral promontory to prevent prolapse of the neovagina [37].
Use of graft materials — Use of nongenital full-thickness or split-thickness skin grafts is less common
and is generally reserved for revision surgery [31,38]. Few small retrospective studies have described
surgical technique, complications, and outcomes [31]. In one study, revision vaginoplasty was performed
using abdominal full-thickness skin grafts in six patients with no reported postoperative complications [39].
All patients reported satisfaction with the results and the ability to have sexual intercourse. Vaginal depth
was reported as 12 cm at 7 months (range 3 to 18 months). Others have described the use of a penile skin
graft and a split-thickness graft (n = 12) or penile flap and inguinopudendal neurovascular island pedicle flap
(n = 109) [40]. Complications reported included vaginal stenosis (n = 5 in the first group, n = 4 in the second
group), and urethral meatus stricture (n = 7) in the second group. Other reported complications were
neovaginal hair growth and flap necrosis in the inguinopudendal flap group. Adequate vaginal depth of 8 to
10 cm was reported.
A prospective study of transgender women undergoing penile inversion vaginoplasty with penile skin length
of 7 to 12 cm added an additional full-thickness skin graft [41]. Satisfaction, sexual function, and genital self-
image were evaluated. Thirty-two patients out of 100 included in the study underwent penile-inversion
vaginoplasty with additional full-thickness skin graft augmentation. Aesthetic outcome as reported by both
patients and clinicians improved over time, and satisfaction scores did not differ significantly between
groups. Preoperative penile skin length was significantly shorter in the full-thickness skin graft group
(14.6±1.8 cm versus 11.5±2.3 cm, p <0.001), but postoperative mean neovaginal depth at one year did not
differ between groups (11.3±2.7 cm versus 11.6±2.1 cm, p = 0.65). Sexual function as assessed by the Female
Sexual Function Index was not different between groups, but scores were below levels consistent with sexual
dysfunction in cisgender women. Genital self-image as assessed by the Female Genital Self-Image Scale was
not different between groups and scores were indicative of positive self-image.
Postoperative care — Postoperatively, pain is controlled with intravenous patient-controlled analgesia and,
once diet is advanced, oral narcotic pain medication. Diet is restricted to ice chips on postoperative day 0,
then advanced to clear liquids on postoperative day 1 and later to a regular diet as tolerated. A stool
softener is administered for bowel regimen. Activity is initially restricted to bed rest in beach chair position to
avoid undue tension on the suture lines or pressure on the grafts until the dressings and drains are removed
on postoperative day 2 to 3. After drain removal, activity can be increased to light ambulation. Tight vaginal
packing and an indwelling bladder catheter remain in place until postoperative day 6 to 7, when they are
removed and vaginal dilation is taught. Vaginal dilation is performed using progressively larger rigid dilators
three times daily for 12 weeks, then once to twice daily for another 12 weeks. Six months after surgery,
patients are encouraged to dilate at least weekly if they are sexually active, or daily if they are not.
Special populations
Revision surgery — In a retrospective study of 475 transgender women who underwent penile inversion
vaginoplasty, revision vaginoplasty was performed in 14 patients (2.9 percent), all secondary to neovaginal

stenosis [42]. In comparison with primary penile inversion vaginoplasty, revision vaginoplasty carries higher
rates of complications, including intraoperative rectal injuries and postoperative complications such as
fistula formation [38]. Surgery is more difficult due to adhesions and contracture of previous grafts. Options
for revision include intestinal vaginoplasty or full-thickness skin grafts from various donor sites. Each
technique carries different and specific advantages and disadvantages. Intestinal vaginoplasty provides
depth, natural lubrication, and lower risk of stenosis but confers the risk of bowel-related complications. The
use of full-thickness skin grafts is less invasive and avoids abdominal surgery, but carries complications
related to skin grafting including donor site scarring, graft contracture, and poor graft taking.
A retrospective comparison of laparoscopic intestinal vaginoplasty versus perineal full-thickness skin graft
vaginoplasty performed in 50 transgender women and 3 cisgender women reported two rectal perforations
(10 percent) and one bladder neck injury in the intestinal group and six rectal perforations (19 percent; p =
0.46) in the full-thickness perineal skin graft group [38]. Operative time was significantly shorter for the
perineal skin graft group (130±35 minutes) than for the laparoscopic intestinal vaginoplasty group (191±45
minutes; p <0.01). Intraoperative intestinal neovaginal length was significantly greater after intestinal
vaginoplasty, but adequate intraoperative depth was able to be achieved in 31 of 32 skin graft
vaginoplasties. Both groups were hospitalized for a mean of eight days. Complications in the laparoscopic
intestinal vaginoplasty group leading to prolonged hospitalization included fecal peritonitis in a patient with
intraoperative rectal perforation, stenosis of the anastomosis, and intestinal torsion. In the perineal skin
graft group, prolonged hospitalization occurred secondary to rectal perforation in three patients and
superficial wound infection in one patient. In long-term follow-up (median 3.8 years, range 1.1 to 19.7 years),
nearly all sigmoid neovaginas (90 percent) and perineal skin graft neovaginas (80 percent; p = 0.45) were of
adequate depth for intercourse. Two sigmoid neovaginas required removal, one due to compromised
vasculature and necrosis, the other due to excessive fibrosis. Five cases of complete stenosis were observed
in the perineal skin graft group. Other complications in the intestinal group included one case of neovaginal
prolapse and two cases of introital stenosis. In the skin graft group, three patients underwent revision of the
labia majora, and two were treated for granulation tissue at the neovaginal apex.
Patients on puberty blockers — Adolescents who meet eligibility and readiness criteria may initiate
hormone therapy beginning with gonadotropin-releasing hormone (GnRH) puberty hormone suppression,
later incorporating cross-sex steroids for development of secondary sexual characteristics congruent with
the individual's gender identity [23]. A detailed discussion of hormone therapy interventions for adolescents
is discussed separately. (See "Management of transgender and gender-diverse children and adolescents".)
Young adult transgender women who have been treated with puberty suppression therapy may exhibit
penoscrotal hypoplasia, resulting in less genital skin availability for reconstructive surgery [43]. In this
setting, alternatives to penile inversion vaginoplasty including primary intestinal vaginoplasty, or the use of
grafts must be considered as described above [43]. (See 'Intestinal vaginoplasty' above and 'Use of graft
materials' above.)
When considering surgery in the young adult transgender population, the individual patient's maturity and
risk of regret must be carefully considered [43]. The WPATH recommends that candidates be of the age of
majority (18 years in most countries) and have the capacity to make an informed decision and consent for
surgery [1].
Complications of vaginoplasty
Type of complication by timing
● Intraoperative – Intraoperative complications of vaginoplasty include bleeding and injury to

surrounding organs including the rectum, bladder, and urethra.
• Bleeding – Excessive bleeding and hematoma formation is often a result of bleeding from the
remaining corpus spongiosum surrounding the urethra. Corpus spongiosum bleeding is typically
treated by applying pressure or hemostatic agents as suturing this delicate tissue often worsens the
bleeding. Excessive bleeding may also occur during the neovaginal dissection and result from
disruption of branches of the inferior gluteal, inferior vesical, and pudendal vascular supply to the
levator ani [44]. Surgical management with direct visualization and ligation of bleeding vessels is
preferred. Interventional radiology embolization of bleeding vessels is generally not recommended,
as this may compromise the flaps and result in flap necrosis.
• Rectal injury – In cases of intraoperative rectal injury, primary layered closure may be undertaken,
and a protective colostomy may be considered to allow for wound healing and prevention of
rectovaginal fistula formation.
• Urinary tract injury – Urethral or bladder injuries are typically managed with primary layered
closure and prolonged urinary catheter drainage. Ureteral injury is a rare complication as the
ureters are not in close proximity to the operative field. If a ureteral injury is suspected, or if a
cystotomy is encountered near the bladder trigone that raises concern for ureteral compromise,
intraoperative specialist consultation can be obtained to discuss possible imaging (eg, retrograde
pyelogram) and ureteral stenting. No specific surgical considerations are needed to address the fact
that these patients have a prostate.
● Immediate postoperative – In the immediate postoperative period, bleeding, hematoma or seroma,

wound infection or abscess, wound dehiscence, flap necrosis, or VTE may be observed. Postoperative
rectovaginal or pararectal abscess or feculent vaginal discharge should alert the surgeon to the
possibility of an undetected rectal injury, and further investigation including imaging and/or
examination under anesthesia is recommended. Neovaginal prolapse may require local excision in the
setting of a sigmoid neovagina if the prolapse is limited to mucosa only, or neovaginopexy may be
performed for complete prolapse.
● Late postoperative – Late postoperative complications include neovaginal or introital stenosis,

genitourinary or rectovaginal fistula formation, abdominal urinary stream (ie, upward or abnormal
urinary stream), urethral meatal stenosis, and sexual dysfunction. Patients with significant complications
should be referred to the original surgeon or to a surgeon with expertise in vaginoplasty techniques for
assessment and management. In cases of vaginal stenosis, revision surgery may be indicated for severe
stenosis (complete neovaginal revision) or an obvious skin bridge or scar obstructing the introits
(introitus plasty). Other cases of neovaginal or introital stenosis may be managed conservatively with
neovaginal dilation. Urethral meatal stenosis often presents as abnormal urinary stream spraying and
may be addressed by release of the stenosis or revision of an obstructing skin bridge.

Minor postoperative complications that can be managed in the office may include vaginal spotting,
vaginitis, and hair growth in the neovagina. Vaginal spotting often occurs secondary to granulation
tissue formation in the neovagina and can be managed locally with silver nitrate or excision. A trial of
vaginal estrogen may be acceptable, although there is no evidence for this intervention. Yeast vaginitis
may occur as a result of the warm, moist neovaginal environment, and postoperative skin sloughing
may also contribute to symptoms of excessive discharge and malodor [45]. Douching with a vinegar or
povidone-iodine solution, or with a mixture of baby soap and warm water may be recommended for
routine hygiene [46]. If preoperative hair removal procedures are not performed or are inadequate,
excessive hair growth within the neovagina may lead to tangling and knotting, which requires trimming
and removal in the office setting.
Incidence — The types and frequency of complications vary with the surgical techniques. In addition, it is
not known if the surgical indication impacts the risk of complication; gynecologic indications for intestinal
vaginoplasty include vaginal agenesis, cancer, and trauma.
● Penile inversion vaginoplasty – A meta-analysis of 26 studies including over 1400 patients who
underwent penile inversion vaginoplasty reported the following complications [31]:
• Wound dehiscence – 12 to 33 percent

• Stricture of the neovaginal introitus – Average 12 percent (range 4.2 to 15 percent)
• Neovaginal stricture other than the introitus – Average 7 percent (range 1 to 12 percent)
• Rectovaginal fistula – 1 to 17 percent
• Vaginal shrinkage – 2 to 10 percent
• Surgical bleeding – 3 to 10 percent
In addition, abscess, hematoma, or urethral meatal stenosis occurred in approximately 5 percent of

patients, partial necrosis of the neovagina or rectal injury occurred in 2 to 4 percent, and clitoral necrosis
or neovaginal prolapse occurred in 1 to 3 percent. A different study of 31 transgender men who
underwent vaginoplasty reported 19 percent noted some degree of urinary incontinence at three years
of follow-up [47]. In other studies including over 500 transgender women who underwent gender
confirmation surgery, postoperative genital pain occurred in 3 to 9 percent of patients [48,49].
● Intestinal vaginoplasty – In a systematic review of intestinal vaginoplasty that included nearly 900
patients (combined transgender and gynecologic indications), overall complications rates were 6.4
percent for sigmoid vaginoplasty, and 8.3 percent for ileal vaginoplasty [36]. Severe complications
occurred in 0.6 percent of sigmoid vaginoplasties and included necrosis of the sigmoid conduit,
necrotizing fasciitis, bilateral lower extremity compartment syndrome, and intraluminal abscess at the
neovaginal apex. In addition, a 0.9 percent incidence of small bowel obstruction was reported. No severe
complications were reported following ileal segment vaginoplasty; however, two cases of anastomotic
stenosis were reported. Introital stenosis was reported in 8.6 percent and 1.2 percent of sigmoid and
ileal segment vaginoplasties, respectively, with diffuse stenosis occurring in 3.5 percent and 3.0 percent.
Other sources have reported intestinal neovaginal stenosis rates up to 43 percent in the transgender
population [31]. Additional reported complications may include necrosis (one patient), rectovaginal

fistula (two patients), prolapse of the sigmoid vaginal segment (mean 7.7 percent; 6.5 percent mucosal
prolapse only), and excessive discharge (0.7 percent) or malodor [31,36].
Outcomes
Surgery — As there are no standardized outcome measures for transgender surgery and the sample sizes of
available studies are small, direct comparison of the surgical techniques by outcome is limited [31]. Both
approaches appear to result in functional sexual anatomy and satisfied patients.
● Penile inversion vaginoplasty – In a meta-analysis of five studies of 223 transgender women who
underwent penile inversion vaginoplasty, a mean of 75 percent reported the ability to have vaginal
intercourse (range 33 to 87 percent), 70 to 84 percent reported the ability to orgasm, 76 to 100 percent
reported satisfaction with vaginal length, and 2 to 6 percent reported dyspareunia [31]. Eighty-four to
100 percent were satisfied with the aesthetic appearance of their genital reconstruction. A different
study of 232 transgender women reported that patients rated their happiness with sexual function as an
average of 7.8 on a 10-point scale [48]. Patients rated their overall satisfaction with the surgery as 8.7
(10-point scale) while 6 percent of patients had some degree of regret.
● Intestinal vaginoplasty – Two studies of intestinal vaginoplasty (n = 89, 81 of 89 patients underwent

gender confirmation surgery) reported that 63 to 79 percent were sexually active one year after surgery
[50,51]. Based on scores from the Female Sexual Function Index, a different study reported that 78
percent of intestinal vaginoplasty patients had satisfactory sexual function (n = 86, 27 transgender) [52].
In the subset of 28 transgender patients from a combined study, 89 percent reported a "good aesthetic
appearance" while 11 percent felt their appearance was "fair" [51]. While data on overall satisfaction are
limited, one study evaluated patients with the Beck Depression Inventory questionnaire and reported
that 30 percent of transgender patients had scores consistent with depression, but preoperative scores
were not available for comparison [52].
Regret — While the studies are limited, the rate of regret after gender-affirming surgery appears to be low.
Overall regret rates of 0 to 3.8 percent have been reported [53-56], with the largest study reporting regret
rates of 0.3 percent (transmen) and 0.6 percent (transwomen) in patients who underwent gonadectomy [57].
In addition, a cross-sectional survey study of nearly 700 transgender individuals reported that patients who
underwent definitive bottom surgery had lower rates of depression and anxiety, and higher levels of body-
gender congruence and body image satisfaction, compared with patients who received less treatment or no
treatment [58].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the
world are provided separately. (See "Society guideline links: Transgender health".)
SUMMARY AND RECOMMENDATIONS

● The language and terminology used to describe gender and sexuality is presented in the table (
table 1). (See 'Terminology' above.)
● Transgender individuals affected by gender dysphoria may choose to undergo a variety of treatments to
transition physically and socially to the gender role in which they feel to be their true selves.
Transitioning involves learning to express and live socially in the individual's desired gender role and
may include feminizing or masculinizing hormone therapy and/or surgical procedures. (See 'Overview of
transition process' above.)
● The World Professional Association for Transgender Health (WPATH) is an international professional
society dedicated to promoting the highest evidence-based principles for the care of transsexual,
transgender, and gender-nonconforming people [1]. The Standards of Care are a series of flexible
guidelines for clinical practice set forth by the society based on evidence and expert consensus. (See
'WPATH Standards of Care' above.)
● For patients who use estrogen therapy undergoing major surgery, we suggest lowering the dose of
estrogen therapy rather than continuation of the full dose or complete cessation (Grade 2C). We reduce
the estrogen dose to 1 mg of oral estradiol starting three weeks prior to the surgery. This approach is
based on limited data and our clinical experience. (See 'Perioperative management of estrogen therapy'
above.)
● Common nongenital/nonbreast surgeries include a combination of procedures for facial feminization

and thyroid cartilage reduction (chondrolaryngoplasty). (See 'Nongenital/nonbreast surgeries' above.)
● Chest, or top, surgery typically consists of breast augmentation with implants after a period of
feminizing hormone therapy. WPATH has created criteria for chest surgery (ie, breast augmentation in
male-to-female transgender individuals). (See 'Chest (top) surgery (breast augmentation)' above.)
● Genital, or bottom, gender confirmation surgery consists of vaginoplasty and orchiectomy, if not already
performed. WPATH provides criteria to help assess candidate appropriateness. (See 'Preoperative
planning and care' above.)
• The goal of vaginoplasty surgery is to achieve an aesthetic and functional vagina, vulva, and clitoris.
The most commonly performed technique, especially in the United States, is the penile inversion
vaginoplasty. Intestinal vaginoplasty procedures are also performed and described. Graft materials
are mainly limited to revision surgeries or patients taking puberty blockers with resultant
penoscrotal hypoplasia. (See 'Surgical techniques' above.)
• Patients who require revision surgery or who have been treated with puberty-blocking drugs have
unique considerations for their care. (See 'Special populations' above.)
• Intraoperative complications of vaginoplasty include bleeding and injury of the surrounding organs.
Common immediate postoperative period complications include bleeding, hematoma or seroma,
wound infection or abscess, wound dehiscence, flap necrosis, or venous thromboembolic events.
Late postoperative complications include neovaginal or introital stenosis, genitourinary or

rectovaginal fistula formation, urethral meatal stenosis, and sexual dysfunction. (See 'Type of
complication by timing' above.)
• There are no standardized outcome measures for transgender surgery, and the sample sizes of
available studies are small, which limits direct comparison of the surgical techniques. Vaginoplasty
procedures appear to result in functional sexual anatomy and satisfied patients in the majority of
cases. (See 'Outcomes' above.)
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REFERENCES
1. The World Professional Association for Transgender Health. Standards of Care for the Health of Transse
xual, Transgender, and Gender Nonconforming People. www.wpath.org/site_page.cfm?pk_association_
webpage_menu=1351&pk_association_webpage=3926 (Accessed on January 30, 2017).
2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-
Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017;
102:3869.
3. Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review
and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf) 2010; 72:214.
4. Almazan AN, Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health
Outcomes. JAMA Surg 2021.
5. Canner JK, Harfouch O, Kodadek LM, et al. Temporal Trends in Gender-Affirming Surgery Among
Transgender Patients in the United States. JAMA Surg 2018; 153:609.
6. Padula WV, Heru S, Campbell JD. Societal Implications of Health Insurance Coverage for Medically
Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis. J Gen Intern Med
2016; 31:394.
7. Schechter L, Schechter R. Breast and Chest Surgery for Transgender Patients. Unpublished book chapte
r.
8. Kozato A, Fox GWC, Yong PC, et al. No Venous Thromboembolism Increase Among Transgender Female
Patients Remaining on Estrogen for Gender-Affirming Surgery. J Clin Endocrinol Metab 2021; 106:e1586.
9. Morrison SD, Vyas KS, Motakef S, et al. Facial Feminization: Systematic Review of the Literature. Plast
Reconstr Surg 2016; 137:1759.
10. Brown E, Perrett DI. What gives a face its gender? Perception 1993; 22:829.
11. Bruce V, Burton AM, Hanna E, et al. Sex discrimination: how do we tell the difference between male and
female faces? Perception 1993; 22:131.
12. Altman K. Facial feminization surgery: current state of the art. Int J Oral Maxillofac Surg 2012; 41:885.
13. Garcia-Rodriguez L, Thain LM, Spiegel JH. Scalp advancement for transgender women: Closing the gap.
Laryngoscope 2020; 130:1431.

14. Raffaini M, Magri AS, Agostini T. Full Facial Feminization Surgery: Patient Satisfaction Assessment Based
on 180 Procedures Involving 33 Consecutive Patients. Plast Reconstr Surg 2016; 137:438.
15. Wolfort FG, Parry RG. Laryngeal chondroplasty for appearance. Plast Reconstr Surg 1975; 56:371.
16. Wolfort FG, Dejerine ES, Ramos DJ, Parry RG. Chondrolaryngoplasty for appearance. Plast Reconstr Surg
1990; 86:464.
17. Standring S. Larynx. In: Gray's Anatomy: The Anatomical Basis of Clinical Practice, 41st, Standring S (Ed),
Elsevier, 2016. p.586.
18. Wierckx K, Gooren L, T'Sjoen G. Clinical review: Breast development in trans women receiving cross-sex
hormones. J Sex Med 2014; 11:1240.
19. Gooren L. Hormone treatment of the adult transsexual patient. Horm Res 2005; 64 Suppl 2:31.
20. de Blok CJM, Staphorsius AS, Wiepjes CM, et al. Frequency, Determinants, and Satisfaction of Breast
Augmentation in Trans Women Receiving Hormone Treatment. J Sex Med 2020; 17:342.
21. Kanhai RC, Hage JJ, Asscheman H, Mulder JW. Augmentation mammaplasty in male-to-female
transsexuals. Plast Reconstr Surg 1999; 104:542.
22. Khan UD. Incidence of mondor disease in breast augmentation: a retrospective study of 2052 breasts
using inframammary incision. Plast Reconstr Surg 2008; 122:88e.
23. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual
persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132.
24. Forster NA, Künzi W, Giovanoli P. The reoperation cascade after breast augmentation with implants:
what the patient needs to know. J Plast Reconstr Aesthet Surg 2013; 66:313.
25. Carter EE, Saade DS, Vashi NA. Presurgical Laser Hair Removal: Protocoling a Safe and Effective
Procedure for Transgender Patients. Transgend Health 2020.
26. Gao Y, Maurer T, Mirmirani P. Understanding and Addressing Hair Disorders in Transgender Individuals.
Am J Clin Dermatol 2018; 19:517.
27. Wanitphakdeedecha R, Alster TS. Physical means of treating unwanted hair. Dermatol Ther 2008;
21:392.
28. Elamin MB, Garcia MZ, Murad MH, et al. Effect of sex steroid use on cardiovascular risk in transsexual
individuals: a systematic review and meta-analyses. Clin Endocrinol (Oxf) 2010; 72:1.
29. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in
surgery. Am J Health Syst Pharm 2013; 70:195.
30. Scarborough JE, Mantyh CR, Sun Z, Migaly J. Combined Mechanical and Oral Antibiotic Bowel
Preparation Reduces Incisional Surgical Site Infection and Anastomotic Leak Rates After Elective
Colorectal Resection: An Analysis of Colectomy-Targeted ACS NSQIP. Ann Surg 2015; 262:331.
31. Horbach SE, Bouman MB, Smit JM, et al. Outcome of Vaginoplasty in Male-to-Female Transgenders: A
Systematic Review of Surgical Techniques. J Sex Med 2015; 12:1499.
32. Wangjiraniran B, Selvaggi G, Chokrungvaranont P, et al. Male-to-female vaginoplasty: Preecha's surgical
technique. J Plast Surg Hand Surg 2015; 49:153.

33. Selvaggi G, Ceulemans P, De Cuypere G, et al. Gender identity disorder: general overview and surgical
treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg 2005; 116:135e.
34. Perovic SV, Stanojevic DS, Djordjevic ML. Vaginoplasty in male transsexuals using penile skin and a
urethral flap. BJU Int 2000; 86:843.
35. Bouman MB, van der Sluis WB, Buncamper ME, et al. Primary Total Laparoscopic Sigmoid Vaginoplasty
in Transgender Women with Penoscrotal Hypoplasia: A Prospective Cohort Study of Surgical Outcomes
and Follow-Up of 42 Patients. Plast Reconstr Surg 2016; 138:614e.
36. Bouman MB, van Zeijl MC, Buncamper ME, et al. Intestinal vaginoplasty revisited: a review of surgical
techniques, complications, and sexual function. J Sex Med 2014; 11:1835.
37. Bouman MB, Buncamper ME, van der Sluis WB, Meijerink WJ. Total laparoscopic sigmoid vaginoplasty.
Fertil Steril 2016; 106:e22.
38. Van der Sluis WB, Bouman MB, Buncamper ME, et al. Revision Vaginoplasty: A Comparison of Surgical
Outcomes of Laparoscopic Intestinal versus Perineal Full-Thickness Skin Graft Vaginoplasty. Plast
Reconstr Surg 2016; 138:793.
39. Hage JJ, Karim RB. Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female
transsexuals. Plast Reconstr Surg 1998; 101:1512.
40. Huang TT. Twenty years of experience in managing gender dysphoric patients: I. Surgical management
of male transsexuals. Plast Reconstr Surg 1995; 96:921.
41. Buncamper ME, van der Sluis WB, de Vries M, et al. Penile Inversion Vaginoplasty with or without
Additional Full-Thickness Skin Graft: To Graft or Not to Graft? Plast Reconstr Surg 2017; 139:649e.
42. Buncamper ME, van der Sluis WB, van der Pas RSD, et al. Surgical Outcome after Penile Inversion
Vaginoplasty: A Retrospective Study of 475 Transgender Women. Plast Reconstr Surg 2016; 138:999.
43. Unger CA. Gynecologic care for transgender youth. Curr Opin Obstet Gynecol 2014; 26:347.
44. Standring S. True pelvis, pelvic floor, and perineum. In: Gray's Anatomy: The Anatomical Basis of Clinical
Practice, 41st, Standring S (Ed), Elsevier, 2016. p.1221.
45. de Haseth KB, Buncamper ME, Özer M, et al. Symptomatic Neovaginal Candidiasis in Transgender
Women After Penile Inversion Vaginoplasty: A Clinical Case Series of Five Consecutive Patients.
Transgend Health 2018; 3:105.
46. Center of Excellence for Transgender Health. Guidelines for the Primary and Gender-Affirming Care of Tr
ansgender and Gender Nonbinary People. http://transhealth.ucsf.edu/pdf/Transgender-PGACG-6-17-16.
pdf (Accessed on February 08, 2017).
47. Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract
function. Eur Urol 2005; 47:398.
48. Lawrence AA. Patient-reported complications and functional outcomes of male-to-female sex
reassignment surgery. Arch Sex Behav 2006; 35:717.
49. Rossi Neto R, Hintz F, Krege S, et al. Gender reassignment surgery--a 13 year review of surgical
outcomes. Int Braz J Urol 2012; 38:97.

50. Wedler V, Meuli-Simmen C, Guggenheim M, et al. Laparoscopic technique for secondary vaginoplasty in
male to female transsexuals using a modified vascularized pedicled sigmoid. Gynecol Obstet Invest
2004; 57:181.
51. Kwun Kim S, Hoon Park J, Cheol Lee K, et al. Long-term results in patients after rectosigmoid
vaginoplasty. Plast Reconstr Surg 2003; 112:143.
52. Djordjevic ML, Stanojevic DS, Bizic MR. Rectosigmoid vaginoplasty: clinical experience and outcomes in
86 cases. J Sex Med 2011; 8:3487.
53. Ruppin U, Pfäfflin F. Long-Term Follow-Up of Adults with Gender Identity Disorder. Arch Sex Behav 2015;
44:1321.
54. Gooren LJ. Clinical practice. Care of transsexual persons. N Engl J Med 2011; 364:1251.
55. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment
surgery. Arch Sex Behav 2003; 32:299.
56. Landén M, Wålinder J, Hambert G, Lundström B. Factors predictive of regret in sex reassignment. Acta
Psychiatr Scand 1998; 97:284.
57. Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972-
2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med 2018; 15:582.
58. Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and
Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender
Individuals. J Sex Med 2018; 15:591.
Topic 114517 Version 21.0

GRAPHICS
Terms used to describe various aspects of gender and sexuality*
Gender identity An individual's innate sense of feeling male, female, neither, or some combination of both.
Natal or birth-assigned/birth- Typically assigned/designated according to external genitalia or chromosomes.

designated sex
Gender expression How gender is presented to the outside world (eg, feminine, masculine, androgynous); gender expression
does not necessarily correlate with birth-designated sex or gender identity.
Gender diversity Variation from the cultural norm in gender identity, expression, or gender role behavior (eg, in choices of
toys, playmates); "gender diversity" acknowledges the spectrum of gender identities and replaces "gender
nonconformity," which has negative and exclusionary connotations.
"Transgender" ("trans" as an Umbrella term that is used to describe individuals with gender diversity; it includes individuals whose
abbreviation) gender identity is different from their birth-designated sex and/or whose gender expression does not fall
within stereotypical definitions of masculinity and femininity; "transgender" is used as an adjective
("transgender people"), not a noun ("transgenders").
Gender dysphoria or incongruence Distress or discomfort that may occur when gender identity and birth-designated sex are not completely
congruent.
Transsexual Older, clinical term that has fallen out of favor; historically, it was used to refer to transgender people who
sought medical or surgical interventions for gender affirmation.
Sexual orientation An individual's pattern of physical and emotional arousal (including fantasies, activities, and behaviors) and
the gender(s) of persons to whom an individual is physically or sexually attracted (gay/lesbian, straight,
bisexual); sexual orientation is an entirely different construct than gender identity, but is often confused
with it; the sexual orientation of transgender people is based upon their identified gender (eg, a
transgender man who is attracted to other men might identify as a gay man; a transgender woman who is
attracted to other women might identify as a lesbian).
Sexual behaviors Specific behaviors involving sexual activities that are useful for screening and risk assessment; many youth
reject traditional labeling (homosexual, heterosexual, bisexual) but still have same-sex partners.
Transgender Person with a masculine gender identity who was designated a female sex at birth.
man/transman/transmasculine
person
Transgender Person with a feminine gender identity who was designated a male sex at birth.
woman/transwoman/transfeminine
person
Nonbinary gender identity Person of any birth-designated sex who has a gender identity that is neither masculine nor feminine, is
some combination of the two, or is fluid. Other terms that may be used for nonbinary gender identity
include genderqueer, gender creative, gender independent, bigender, noncisgender, agender, two-spirit,
third sex, and gender blender.
* These are cultural and descriptive terms, not diagnostic terms, which are specific to medical and pathology-based paradigms.
References:
1. Perrin EC. Sexual Orientation in Child and Adolescent Health Care, Springer, New York 2002.
2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society* Clinical
Practice Guideline. J Clin Endocrinol Metab 2017.
3. Adelson SL, American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual
sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry 2012; 51:957.
4. Frankowski BL, American Academy of Pediatrics Committee on Adolescence. Sexual orientation and adolescents. Pediatrics 2004; 113:1827.
5. Edwards-Leeper L, Spack NP. Psychological evaluation and medical treatment of transgender youth in an interdisciplinary "Gender Management Service"
(GeMS) in a major pediatric center. J Homosex 2012; 59:321.
6. Rafferty J, Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender
Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics 2018;
142:e20182162.
Graphic 86993 Version 12.0

Comparison of angles of male and female faces
Line illustrations demonstrating the differences between male (A) and female (B) faces. The male face is square and angulated with sharp lines
and a strong jaw, while the female face is curved, round, oval, and heart-shaped with smooth lines and smaller overall.
Reproduced from: Altman K. Facial feminization surgery: Current state of the art. Int J Oral Maxillofac Surg 2012; 41:885. Illustration used with the permission of
Elsevier Inc. All rights reserved.

Mandibular angle reduction for male-to-female transgender surgery
Mandibular angle shave by reducing the lipping at the mandibular angle (A) and subsequent result (B). Shading indicates area to be contoured.

Chin width reduction in male-to-female transgender surgery
Chin width reduction (A) and fixation (B).

Thyroid cartilage reduction (chondrolaryngoplasty) for male-to-female transgender surgery
Thyroid cartilage, demonstrating the areas of resection in thyroid shave (shading).

MtF gender confirmation surgery: Scrotal flap markings
Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2017. All Rights Reserved.

MtF gender confirmation surgery: Orchiectomy

MtF gender confirmation surgery: Removal of penile epithelium to tunica albuginea

MtF gender confirmation surgery: Transection of perineal tendon for creation of neovagina
A transverse incision is made in the perineum below the bulbous urethra, transecting the perineal tendon and creating a cavity by
separating the levator ani muscles laterally.

MtF gender confirmation surgery: Dissection of neovagina cavity
Creation of neovagina cavity.

MtF gender confirmation surgery: Full-length neovagina cavity
Dissection of the neovagina cavity is carried past the level of the prostatic urethra anterior to the
rectoprostatic fascia for a total length of approximately 15 cm.

MtF gender confirmation surgery: Ligation of deep penile arteries

MtF gender confirmation surgery: Creation of neoclitoris
The excess glans is excised, and the clitoral flap is folded on itself to position the neoclitoris approximately 5 cm above the intended
location of the neourethral meatus.
Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2017-2019. All Rights Reserved.

MtF gender confirmation surgery: Creation of urethral meatus
The urethra is transected in the midline on the ventral side over the catheter until the level of the pubic bone. The urethral flap is
trimmed and secured to the underlying fascia, leaving a mucosal bridge lining the area between the neourethral meatus and the
neoclitoris.

MtF gender confirmation surgery: Vaginal graft sewn over vaginal stent
The prepared graft is sewn onto a large vaginal stent.

MtF gender confirmation surgery: Completion of neovagina graft
The stent is passed through the penile tube, and the flaps are sutured together to create the full neovagina graft.

MtF gender confirmation surgery: Creation of labia minora and clitoral hood
Labia minora and a clitoral hood are created using the maintained distal penile skin.

MtF gender confirmation surgery: Photo of completed

vaginoplasty
Courtesy of Cecile Unger, MD, MPH.

Contributor Disclosures
Cecile Ferrando, MD, MPH Nothing to disclose Tonya N Thomas, MD Nothing to disclose Linda Brubaker, MD,
FACOG Grant/Research/Clinical Trial Support: National Institutes of Health [Prevention of lower urinary symptoms].
Other Financial Interest: Journal of the American Medical Association [Women's health]; Female Pelvic Medicine and
Reconstructive Surgery [Female pelvic medicine and reconstructive surgery]. Kristen Eckler, MD, FACOG Nothing to
disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
evidence.
Conflict of interest policy

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24/6/2021 Transgender surgery: Male to female - UpToDate

Official reprint from UpToDate®

Transgender surgery: Male to female

● (See "Transgender men: Evaluation and management".)

● (See "Transgender women: Evaluation and management".)

● (See "Primary care of transgender individuals".)

● (See "Primary care of transgender individuals", section on 'Terminology'.)

ISSUES IN TRANSGENDER SURGERY

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Perioperative management of estrogen therapy — The management of perioperative estrogen therapy

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• Forehead contouring and hairline advancement

Thyroid cartilage reduction (chondrolaryngoplasty) — The laryngeal prominence, or Adam's apple, is

https://www.uptodate.com/contents/transgender-surgery-male-to-female/print?search=disforia de genero&source=search_result&selectedTitle=6~15… 4/39

CHEST (TOP) SURGERY (BREAST AUGMENTATION)

● One referral letter from a qualified mental health professional.

● Persistent, well-documented gender dysphoria.

● Capacity for informed decision making and consent.

● Well-controlled medical and mental health comorbidities.

● It is also recommended that individuals undergo a minimum of 12 months of feminizing hormone

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Complications of breast augmentation — Complications following augmentation mammoplasty should be

GENITAL (BOTTOM) SURGERY (VAGINOPLASTY)

● Two referral letters from qualified mental health professionals.

● Persistent, well-documented gender dysphoria.

● Capacity for informed decision making and consent.

● Well-controlled medical and mental health comorbidities.

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Type of complication by timing

● Intraoperative – Intraoperative complications of vaginoplasty include bleeding and injury to

● Immediate postoperative – In the immediate postoperative period, bleeding, hematoma or seroma,

● Late postoperative – Late postoperative complications include neovaginal or introital stenosis,

https://www.uptodate.com/contents/transgender-surgery-male-to-female/print?search=disforia de genero&source=search_result&selectedTitle=6~1… 13/39

• Wound dehiscence – 12 to 33 percent

In addition, abscess, hematoma, or urethral meatal stenosis occurred in approximately 5 percent of

https://www.uptodate.com/contents/transgender-surgery-male-to-female/print?search=disforia de genero&source=search_result&selectedTitle=6~1… 14/39

● Intestinal vaginoplasty – Two studies of intestinal vaginoplasty (n = 89, 81 of 89 patients underwent

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

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● Common nongenital/nonbreast surgeries include a combination of procedures for facial feminization

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Use of UpToDate is subject to the Subscription and License Agreement.

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Terms used to describe various aspects of gender and sexuality*

Natal or birth-assigned/birth- Typically assigned/designated according to external genitalia or chromosomes.

Graphic 86993 Version 12.0

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Comparison of angles of male and female faces

Graphic 115589 Version 1.0

MtF gender confirmation surgery: Removal of penile epithelium to tunica albuginea