Gender Affirming Surgery

There are three critical aspects of gender-affirming surgery: facial gender-affirming surgery, “top” surgery, and “bottom” surgery. You can read about facial surgery on our dedicated procedure page. For the other two, let’s look at what treatment entails.

Feminizing “top” surgery involves altering the torso to achieve a more typically feminine appearance. This usually involves receiving breast implants to augment the breasts.

Feminizing “bottom” surgery usually involves a “penile inversion vaginoplasty” procedure, in which the male genitalia are dissected and their tissues repurposed to form anatomy that approximates a clitoris, labia, and vaginal canal. Other less common techniques include the use of a piece of your intestine to create the vaginal canal.

Masculinizing “top” surgery usually involves removing breast tissue to give you a more masculine chest appearance. Your surgeon will make an incision around the nipple or along the crease that is under the breast before removing breast tissue and performing liposuction. The nipples may also be modified and repositioned.

Masculinizing “bottom” surgery usually involves either a “metoidioplasty” or a “phalloplasty.” A metoidioplasty involves the dissection and repurposing of the female genitalia (after their enlargement through testosterone therapy) to create male-appearing genitalia. The result is a small penis with sensation, but you will lack the ability to perform penetrative sex. A phalloplasty uses tissue, typically from your forearm or thigh, to attempt to create a penis. The nerves can be hooked up to provide sensation and orgasms may be achievable, but you would need a penile prosthesis to be able to perform penetrative sex. This surgery carries higher risks of complications.

Masculinizing bottom surgery usually involves multiple surgical stages. Prioritizing what is most important for you (for example, genital appearance, sensation, and orgasm, peeing while standing, or penetrative intercourse) will help determine the best approach.

It is very important to discuss your personal goals with your board-certified plastic surgeon and fully understand your surgical options and their advantages and disadvantages.

Gender-affirming surgery is highly complex, involving multiple procedures tailored to an individual’s unique anatomical and psychological needs. It often requires a multidisciplinary team approach, encompassing meticulous planning, extensive surgical expertise, and comprehensive postoperative care to ensure both functional and aesthetic outcomes that align with the patient’s gender identity.

Above, in What to Know, “bottom” surgery was discussed in detail. Here, let’s take a closer look at aspects of “top” surgery that can vary from person to person.

For feminizing top surgery, one key consideration is the type of implant. There are several types and shapes, including those filled with saline (sterile salt water) or silicone gel designed to feel like breast tissue. Some are “structured,” meaning they contain internal supports that make the augmented breast feel more natural. Each has different qualities and risks, which should be discussed with your surgeon.

For masculinizing top surgery, your surgeon’s approach will depend in part on what size the breasts are at the outset. If your breasts are small to start with, the surgery will typically involve removing the breast tissue through a small incision around the nipple, in addition to performing liposuction. If the breasts are very large, a larger incision will be needed to remove all the breast tissue before the nipple is modified and repositioned. The incision is usually placed along the crease under the breast to minimize its appearance and mimic the natural lower edge of the chest (pectoralis) muscles. When the nipple is modified and before it is repositioned, it is often made smaller and replaced as a skin graft in a more typically masculine location.

It is important to have a thorough consultation with a board-certified plastic surgeon to determine which approach may be best for you, given your unique anatomy and goals.

Before you go

During a consultation for gender-affirming surgery, a multidisciplinary team of physicians, including surgeons, endocrinologists, and mental health professionals, will assess your medical history and current health status. Preoperative testing typically involves blood tests, imaging studies, and psychological evaluations to ensure you are a suitable candidate. The team will review your hormone therapy regimen and its effects on your body.

Key topics to discuss include your primary surgeon’s experience, detailed risks and benefits of the procedure, recovery time, potential complications, and expected outcomes. Discuss any alternative surgical options and their implications. You should review before-and-after photos to ensure the proposed results match your expectations. Before surgery, follow all preoperative instructions, such as medication adjustments and lifestyle changes.

During the procedure

Gender-affirming surgery may be staged over multiple procedures to optimize outcomes and reduce risks, such as performing top surgery separately from bottom surgery or spacing out complex procedures like phalloplasty and subsequent penile prosthesis implantation. This approach allows for better healing, reduces the risk of complications, and ensures each stage can be carefully monitored and adjusted as needed.

On the day of your gender-affirming surgery, you will check in at the hospital or surgical center and complete the necessary paperwork. You will meet with your surgeon and anesthesiologist to review the procedure, address any last-minute questions, and discuss anesthesia options. After being prepped, you will be taken to the operating room, where general anesthesia will be administered so you do not experience any pain.

The length of the surgery varies: feminizing surgeries like vaginoplasty typically last four to six hours, while masculinizing surgeries like phalloplasty can take eight to ten hours. Post-surgery, you’ll be moved to a recovery room where medical staff will monitor your vital signs and manage your pain levels with prescribed medications. Initial pain and discomfort are common but controlled effectively. You will receive detailed postoperative care instructions before being discharged, and follow-up appointments will be scheduled to monitor your healing and progress.

Gender-Affirming Surgery Aftercare 

You will be seen after surgery at predetermined intervals to make sure you are healing as expected and without any wound complications. Restrictions will gradually be lifted over a period of a few weeks so that you can return to your usual activities of daily living, hobbies, and sexual activity. This period may differ depending on the procedure or procedures you are getting and your personal recovery process.

You are generally advised to wait at least eight to twelve weeks before engaging in sexual intercourse to ensure proper healing and minimize complications. Voiding patterns may initially be affected, especially after bottom surgery, with the potential for temporary use of catheters and a gradual return to normal urination.

Final results from gender-affirming surgery typically become apparent after six to twelve months, as swelling subsides and tissues fully heal, allowing for the complete appreciation of the surgical outcomes and any necessary adjustments. Regular follow-up appointments with your surgical team will ensure optimal results and address any concerns during recovery.