Surgery

Hair removal

If you are having any of the phalloplasties it is likely you will need to have electrolysis or laser hair removal on the part of your body used for the skin graft used in your phalloplasty. This is likely to come from your arm, thigh or abdomen and you will need to permanently remove the hair. It’s important that you discuss with your surgeon which area of hair needs to be removed - discuss this well in advance of your surgery date, as it can take many months for the hair to be permanently removed.

Electrolysis

When you have electrolysis, a fine needle is inserted into the hair follicle and a tiny electrical current is passed through to damage the lower part of it. This means no more hairs will be able to grow from that follicle in the future. Electrolysis is the only permanent method of hair removal.

It will take more than one session to remove the hair from a particular part of the body, and how many depends on how much hair you have, so you will need to do this in advance of your surgery. Most surgery teams do not offer electrolysis as part of the service - you will need to find your own practitioner privately and pay for it yourself. Your surgeon may be able to recommend a good practitioner to carry out your electrolysis.

Laser hair removal

Laser treatment can be used to temporarily remove hair, although it can grow back. Laser treatment works quickly and is less likely to cause pain than electrolysis.

Intense pulsed light therapy (IPL) hair removal

Intense pulsed light therapy is a form of temporary hair reduction which works in a similar way to laser treatment. Hair follicles are targeted with light pulses which cause the hair to fall out and stop any more hairs growing from that follicle. This treatment tends to be more successful on people who have dark hair and is not effective for people with light hair.

Chest or ‘top’ surgery involves re-sculpting the breasts to create a flatter, ‘male’ chest appearance. In the UK you need to have been taking testosterone for at least a year before you can be put forward for chest surgery on the NHS. The waiting time can sometimes be reduced - for instance if you are very large-chested. If you decide to have private surgery you will probably still need a referral from a gender identity disorder (GID) psychiatrist.

There are different techniques used for top surgery, which result in different levels of scarring. Which type you opt for will depend upon the size of your chest, your preference and also which surgeon you choose. Whether you go privately or on the NHS, you can choose which surgeon you prefer. The different techniques are:

Double incision

This technique creates two curved or flat scars (depending on the surgeon) that follow the line of the crease under the chest muscles. It is suitable for all chest sizes and is therefore the most common type of chest surgery for transmen in the UK. During surgery the nipples will be completely removed, possibly re-sized and then re-attached. There is a good chance of nipple sensation being reduced, or lost because of this. It is quite common to go back for surgical revisions.

T-anchor

This technique is similar to double incision but it leaves the nipple attached, so sensation is preserved. In many ways, a T-anchor is much more like a severe breast reduction. It leaves vertical and horizontal scars.

Keyhole and peri-areolar incision

This technique has the advantage of leaving virtually no scarring, but it is usually only suitable for guys with small chests - generally an A-cup or smaller. Both of these techniques involve making an incision on the edge of the areole (the dark skin around the nipple) and removing the breast tissue without completely detaching the nipple itself. The advantages are both the lack of scarring and the fact that the nipple sensation is left intact. Peri-areolar surgery will leave scars around the areolar but because of the change in skin colour they are often invisible. For larger men, having peri-areolar surgery may mean several revisions to take away extra skin.

The results for any chest surgery will depend on your original chest size because the larger your chest is, the more scarring there will be. It will also depend on how your body generally scars as some people naturally heal better than others. Other factors influencing the outcome of surgery are whether you are overweight, how fit and healthy you are in general and how you take care of yourself after surgery.

The best steps you can take to improve the results of your chest surgery and to reduce the healing time are to stop smoking and, if you are overweight, get down to a healthy weight. Building the chest muscles with exercises such as push ups and weight training for the pectoral muscles will help the surgeon to create a scar line in a place where your body would naturally create a line along the curve of the muscle.

Care after chest surgery

Chest scars take time to fade. How quickly they fade and their final appearance will depend on how well you heal naturally, your general health and to some extent the size of your chest. Your doctor or nurse will advise you when you can remove your dressings or take a shower after the surgery, but there are some things you can do to help your scars heal well:

• Using your arms will increase the stretching of these scars. Some scarring can’t be helped but the less you do, the better scars will heal.
• Don’t exercise too soon. Give yourself at least four weeks before returning to exercise.
• Once the scars have healed, rubbing moisturiser or scar treatment oils/creams into them can help break down any lumps and will help to reduce redness.
• Avoid the sun while the scars are healing as it will cause the scars to darken.
  
  

Transmen choose to have hysterectomies for different reasons. A common reason is to end the need for regular smear tests. Smear tests are necessary for anyone who has a cervix to check for cervical cancer or early cancerous changes. A complete hysterectomy will remove the uterus and cervix. A second reason for having a hysterectomy is because you are planning on having a metadioplasty or phalloplasty. Alternatively, some men will just want it gone!

Hysterectomy is a relatively simple procedure. Often it is done via the keyhole method which leaves only two small scars on either side of the bikini line. Alternatively the surgeon can go in through the abdomen but this can leave a scar across the lower belly on skin that would be used for the abdominal phalloplasty, if the person wished to have that, so for transmen the keyhole option is often preferred as it leaves your options open.

Some transmen choose to have an Oophorectomy, which is the removal of the ovaries, or a Salpingo-Oophorectomy which is the removal of the fallopian tubes and the ovaries, and these can be performed usually at the same time as the hysterectomy. Transmen may choose to have the ovaries removed because even while taking T, the ovaries may still produce oestrogen. The theory is that after they are removed, sometimes the testosterone can be reduced or be more effective , however, there is no evidence that is actually the case. These surgeries can be for health reasons or for personal reasons, and it is best to speak to your endocrinologist or gynaecologist to decide what is best for you.

There are several different types of genital or ‘lower surgery’ for transmen and each has advantages, disadvantages and risks to consider. It is a good idea to speak to people who have had surgery.

You may find it helpful to join sites such as Transbucket or the Yahoo ‘ftm-uk’ forum. These have photographs of surgery results and may help you to consider what you want from the surgery before going ahead.

Lower surgery is available on the NHS, or privately where it costs around £50,000. The advantages of this surgery are that it creates an adult-sized penis that, with erectile devices, can get hard and which can allow standing urination.

In the UK, you will not usually be put forward as a candidate for lower surgery unless you have been on hormones for at least two years and have had top surgery. Referral for lower surgery on the NHS is through a Gender Identity Clinic. If you are a private patient, either in the UK or abroad, you will need to speak to your surgeon to find out their particular criteria. It is likely that you will need a referral from two consultants (NHS or private) and to have been on hormones for at least a year (more often two).

Many surgeons will not consider you for lower surgery (on the NHS or privately) if you are a smoker or are overweight to an extent that the surgery would be dangerous.

Different procedures

Metoidioplasty

This surgery releases the clitoris from its ligaments and lets it hang further out and forward from the body creating a small penis. The clitoris will have grown if you have been taking testosterone and when released from the hood can resemble a small penis of about one to two inches in length. Testicles can be fashioned from the skin of the labia with implants placed inside. If you choose, you can have your urethra (the tube you pee through) extended so you can pee from the end of your new penis. The advantages of this surgery are that you have full sensation in your penis and a lack of scarring elsewhere on the body. The disadvantage is that the penis will be relatively small.

Phalloplasty

This surgery involves taking a graft of flesh from another part of the body to create the length and shape of the penis. Different surgeons use different graft sites - usually the abdomen and forearm but some surgeons will consider using the thigh if the forearm is not suitable. The clitoris can be tucked inside the graft with a nerve extended into the length of the penis giving some erotic sensation throughout - although sensation will be reduced. Alternatively the clitoris can be left outside, and will be positioned under the base of the penis with no change to sensation. If you want to have penetrative sex, an erectile device can be inserted into the penis. This will be either a pump or a bendable rod.

The advantage of the phalloplasty is a more realistic-sized and -shaped penis, which can be used for penetrative sex. The disadvantages are that scars are larger and if you have the urethra extended, scars are more visible as the urethra is usually created from skin on the arm whether the main graft is taken from there or not. Another disadvantage is the risk of reduced sensation if you tuck the clitoris into the penis. The phalloplasty is a much longer process, involving around two to five surgeries (depending on the surgery team) with at least a year in between for recovery before moving onto the next stage. The phalloplasty can give transmen a realistic-looking penis. It was first developed for cis gendered men who had lost their penis from injury or illness. However, it will never look or feel entirely like a biological penis. It is important that you know what to expect from this surgery to avoid disappointment.

It is important to note that it is not essential to have the urethra extended whichever type of surgery you have. This has a risk of infection and complication.

Advice about surgery

If you want more advice about surgery, the Gender Identity Research and Education Society (GIRES) is a good starting point.

They have also produced a detailed guide to lower surgery.