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# FTM Genital Reconstruction Surgery (GRS)

DISCLAIMER
The information contained herein is to be used for educational purposes only. The author is not a medical professional, and this information should not be considered medical advice. This information should NOT be used to replace consultation with or treatment by a trained medical professional. The listing of a medication herein does not imply endorsement by the author.

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Introduction

Metoidioplasty

Centurion

Phalloplasty

> Gillies technique

> Suitcase handle

> Pedicled pubic flap phalloplasty

> Pedicled groin flap phalloplasty

> Free tissue flap transfer (FTFT)

> Forearm free flap phalloplasty

> Modified forearm free flap phalloplasty

> MLD flap phalloplasty

> Scrotoplasty

> Pros, Cons, and Risks

Thoughts to consider about Genital Reconstruction Surgery

Pre-surgical advice

Resources

Introduction
Most (but not all) trans men will have at least one surgical procedure in his lifetime related to gender transition, if not several of them. However, it is important to note that many trans men do not avail themselves of the surgeries listed below due to cost considerations, health reasons, or personal reasons. Currently, most surgeries related to gender transition are not covered by insurance companies, so costs can be prohibitive for many trans men of lower or fixed incomes.

FTM surgery is generally divided into three main groups:
1. Chest reconstruction surgeries (also referred to as "top" surgery or male chest contouring);
2. Hysterectomy and oophorectomy (removal of the uterus and ovaries, respectively); and
3. Genital reconstruction surgeries (also referred to as "lower" or "bottom" surgery or GRS).
Within these three main groupings are different types of procedures and surgical methods that will be further described herein.

This section describes the main types of genital reconstruction (GRS) procedures that are currently available to trans men. Chest Surgery and hysterectomy/oophorectomy are detailed in their own separate sections.

The descriptions of the FTM surgeries listed below are generalized. It is important to note that each individual surgeon may use a different technique for any given procedure. If you are considering any of these procedures, it is important to research your options thoroughly and speak candidly with the surgeons you are considering. That way, you can choose the procedure and surgeon that best suits your body type, needs, and expectations.

Metoidioplasty
(Also sometimes spelled "metaoidioplasty," a term meaning "a surgical change toward the male")
Metoidioplasty--a surgical procedure developed in the 1970s--takes advantage of the fact that ongoing testosterone treatment in a trans man typically causes his clitoris to grow longer. The amount of clitoral growth varies with each individual, but it is not uncommon to see an increase in size to about the length of one's thumb. By cutting the ligament that holds the clitoris in place under the pubic bone, as well as cutting away some of the surrounding tissue, the surgeon is able to create a small phallus from the elongated clitoris. This is why metoidioplasty is sometimes referred to as a "clitoral free-up" or "clitoris release"-- the clitoris is freed from some of its surrounding tissue and brought forward on the body in a manner that makes it appear like a small penis. In order to further enhance the result, fat may be removed from the pubic mound and skin may be pulled upward to bring the phallus even farther forward.

Metoidioplasty may also involve the creation of a scrotum (scrotoplasty) by inserting testicular implants inside the labia majora, then joining the two labia to create a scrotal sac. This is often done in two stages, where in the first stage, tissue expanders are inserted in the labia in order to gradually stretch the skin in preparation for the insertion of permanent testicular implants at a later date. Some surgeons may insert the implants in the first procedure, and join the two labia in a later procedure.

Metoidioplasty may additionally involve a urethral lengthening procedure to allow the patient to urinate through the penis while standing. Surgeons may employ tissue from the vaginal area or from inside the mouth/cheeks to create a urethral extension. Usually, a catheter is placed inside the urethral extension for 2-3 weeks while the body heals and adapts to the new arrangement.

Depending on the surgeon and the desires/goals of the patient, the vaginal cavity may or may not be closed or removed (this is typically referred to as a "vaginectomy," "colpectomy," or "colpocleisis"). Often, a vaginectomy is performed in conjunction with scrotoplasty and/or urethral lengthening.

The typical operating time for a metoidioplasty procedure is about 3-5 hours, and may require additional follow-up procedures and revisions at a later date. Time required may differ depending on the options chosen by the patient (i.e., if he chooses scrotal implants and/or urethral lengthening), as well as the available tissue for the procedure, and the overall health and condition of the patient. Recovery time is usually between 2 to 4 weeks of very limited activity.

Pros, Cons, and Risks
The advantages of metoidioplasty are that it results in a natural looking (albeit small), erotically sensate penis. Additionally, since the clitoris is made of erectile tissue, the patient can achieve an unassisted erection when aroused. The procedure takes advantage of existing genital tissue, and doesn't leave visible scars on other parts of the body.

The disadvantages are that the resulting penis is usually quite small, and as such often cannot be used for penetration. It also may not be a good choice for a trans man whose clitoris has not grown substantially as a result of testosterone therapy (most surgeons recommend being on testosterone therapy for at least 6 months to 2 years in order to maximize growth of the clitoris). And, as with any surgery, there are potential risks of complication, such as the extrusion of testicular implants, the formation of a stricture (an abnormal narrowing; blockage) or fistula (an abnormal connection; leakage) in the newly constructed urethral passage, and potential problems of infection and tissue death (though tissue death is less common in metoidioplasty as compared to phalloplasty). One must also consider the usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).

Metoidioplasty procedures range in cost from about $2,000 (for clitoral release only) to $20,000 (including urethral extension and testicular implants), and perhaps more if hysterectomy/oophorectomy is performed at the same time. Fees will vary among surgeons.

When considering a metoidioplasty procedure, it is important to research the surgical options carefully and discuss them with the surgeons you are considering. Each surgeon has a different approach and technique, and some may offer an array of options, such as clitoris release only, different types of scrotoplasty or urethral lengthening, etc. Also, if you are unsure if you wish to have additional genital surgery (such as phalloplasty) in the future, discuss with your surgeon which procedures will leave you with the most options for later surgery.

Centurion
The Centurion procedure is a unique variation of metoidioplasty that was first performed in 2002 by Dr. Peter Raphael. In the Centurion, the round ligaments (which run along the sides of the labia) are freed from the labia majora and brought together along the shaft of the clitoris to provide girth for the new penis. The extraction of the round ligaments from the labia majora leaves a hollowed-out area which serves as a "pocket" for solid silicone scrotal implants. The labia major are later joined to form a scrotal sac. A urethral extension to the tip of the new penis is formed by joining skin flaps around a catheter that runs along the underside of the clitoris. The catheter remains in place for about two weeks until the new urethral extension has healed.

The typical operating time for the Centurion procedure is about 2.5 hours; if it is also being performed with vaginectomy and hysterectomy/oophorectomy, the time increases to about 4-5 hours. The patient may require additional follow-up procedures and revisions at a later date. Recovery time is usually between 2 to 4 weeks of very limited activity.

Pros, Cons, and Risks
The advantages of the Centurion are that it results in a natural looking (albeit small), erotically sensate penis. Since the clitoris is made of erectile tissue, the patient can achieve an unassisted erection when aroused. The procedure takes advantage of existing genital tissue, and doesn't leave visible scars on other parts of the body.

The disadvantages are that the resulting penis is usually quite small, and as such often cannot be used for penetration. It also may not be a good choice for a trans man whose clitoris has not grown substantially as a result of testosterone therapy (most surgeons recommend being on testosterone therapy for at least 6 months to 2 years in order to maximize growth of the clitoris). And, as with any surgery, there are potential risks of complication, such as the extrusion of testicular implants, the formation of a stricture (an abnormal narrowing; blockage) or fistula (an abnormal connection; leakage) in the newly constructed urethral passage, and potential problems of infection and tissue death (though tissue death is less common in metoidioplasty/Centurion as compared to phalloplasty). One must also consider the usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).

When considering the Centurion or other metoidioplasty procedure, it is important to research the surgical options carefully and discuss them with the surgeons you are considering. Each surgeon has a different approach and technique. Also, if you are unsure if you wish to have additional genital surgery (such as phalloplasty) in the future, discuss with your surgeon which procedures will leave you with the most options for later surgery.

Phalloplasty
Phalloplasty involves the construction of a penis using donor skin from other areas of the body. Depending on the type of phalloplasty procedure, skin is typically taken from the abdomen, groin/leg, forearm, and/or side of the upper torso (latissimus dorsi area) and grafted onto the pubic area. Phalloplasty usually involves a urethral lengthening procedure so that the patient can urinate through the penis. Erections are usually achieved with either a malleable rod implanted permanently or inserted temporarily in the penis, or with an implanted pump device.

Phalloplasty techniques vary widely from surgeon to surgeon. Updated and improved surgical techniques in recent years (such as microsurgical advances) have improved phalloplasty outcomes in recent years. Be sure to research carefully the surgeons you are considering in order to get an exact account of the procedure as they perform it. Summarized below are a number of terms and procedures related to phalloplasty. Keep in mind that these descriptions are generalized and are meant as a introduction to the topic; this list is not necessarily exhaustive.

Gillies technique
This refers to one of the earliest types of phalloplasty, in which a flap of abdominal skin is rolled into a tube to create a flaccid penis. Over the years, this procedure was improved to include a urethral extension by utilizing a second section of abdominal skin wrapped "raw side out" to form a "tube within a tube," nested inside the constructed phallus. This method usually produces a penis that is not erotically sensate (i.e., does not have feeling) and is often not very realistic in appearance. Usually, a flexible rod must be inserted into the penis in order to achieve an erection. The Gillies technique is now outdated, due to advances in microsurgical phalloplasty.

Suitcase handle
In order to help prevent tissue death in the penis, the Gilles procedure was improved by the development of the "suitcase handle" technique, where the rolled flap is left attached to the abdomen at the top and bottom (like the handle of a suitcase) for a number of weeks in order to ensure a proper blood supply. In a second stage operation, the flap (handle) is detached from the top end, and that end is brought down to graft onto the genital area. It is again allowed to develop a proper blood supply over a period of time. In a third operative stage, the other end is detached from the abdomen, leaving the new penis to hang naturally from its grafted place in the genital area. Variations of the suitcase handle technique are used in the pedicled flap procedures described below. Again, this type of phalloplasty is now outdated, due to advances in microsurgical phalloplasty.

Pedicled pubic flap phalloplasty
In this procedure, the penis is constructed from an tubed pedicled flap running from the pubic area to just underneath the belly-button. (The term "pedicle" here refers to the fact that the flap of donor skin is left attached to the body, as described in the suitcase handle technique, in order to improve proper blood supply and prevent tissue death). This procedure may also utilize grafted skin from the thigh area to wrap around the outside of the pedicle, mimicking the loose outer skin of the penis. A urethral extension may by created using tissue from the labia or vaginal wall, or simply from creating an "inside-out" inner tube from the donor area. This operation is usually performed in several stages in order to ensure proper blood supply to the pedicled flap. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. This method usually produces a penis that is not erotically sensate. The aesthetic appearance of the penis is also sometimes unrealistic. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.

Because the donor skin used in this type of phalloplasty is typically hairy, some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient will have to periodically shave the skin of the penis or use depilatory cream.

Pedicled groin flap phalloplasty
This procedure is similar to the pedicled pubic procedure listed above, except that it employs a skin flap that runs sideways outward from the groin area (usually around the area where the upper thigh meets the pelvic bone). A urethral extension may by created using tissue from the labia or vaginal wall, or simply from creating an "inside-out" inner tube from the donor area. This operation is usually performed in several stages in order to ensure proper blood supply to the pedicled flap. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. This method usually produces a penis that is not erotically sensate. The aesthetic appearance of the penis is also sometimes unrealistic. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.

Because the donor skin used in this type of phalloplasty can be hairy, some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient will have to periodically shave the skin of the penis or use depilatory cream.

Free tissue flap transfer (FTFT)
The FTFT procedure is a more recent and improved approach to phalloplasty which uses a flap of skin and tissue from the groin, thigh, forearm, or upper torso area. In FTFT, a skin flap is removed completely from the donor area and transferred, with its existing nerves and blood vessels intact, to the groin area. There the flap's nerves and blood vessels are connected microsurgically to the nerves and blood vessels of the groin. This is done with the aim of the new penis becoming erotically sensate, while also helping to ensure proper blood supply to the penis.

Forearm free flap phalloplasty
This procedure is considered by many to produce a more realistic-looking, more erotically sensate phallus than older phalloplasty procedures. This is due to the nature of the skin of the forearm (areas on the underside of the forearm are of good consistency and often are fairly hairless) as well as the nerves and blood vessels that are able to be harvested with that skin. The main drawback to the procedure is that it leaves a very large scarred area on the forearm, and there is some risk of damage to the overall function and feeling of the arm. The donor area on the arm is usually covered with skin from the thigh or groin, leaving a secondary scar in that area as well.

The forearm skin is shaped into the new penis and grafted into place on the groin, where the nerves and blood vessels are microsurgically connected. Some surgeons will connect the brachial nerve of the forearm to the pudendal nerve of the clitoris (with the goal being erotic sensation in the penis). A urethra is typically created using tissue from the labia, the inside of the mouth/cheeks, the vaginal wall, or with a section of relatively hairless skin from the forearm donor site, shaped into an inverted tube. The clitoris is usually left intact near the base of the penis; the exact placement of the base of the penis with regard to the clitoris should be discussed with the surgeon. Usually, a flexible rod must be inserted into the penis or an implanted pump device used in order to achieve an erection.

Because the donor skin on the forearm can be hairy (depending on the patient and the area from which the skin is taken), some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. Indeed, some surgeons require electrolysis of the donor areas before they will proceed with the procedure. If electrolysis is not chosen, the patient may have to periodically shave the skin of the penis or use depilatory cream.

Modified forearm free flap phalloplasty
In order to address the issue of major scarring on the forearm, some surgeons have combined the benefits of forearm free tissue flap transfer with other methods such as the pedicled groin flap. A surgeon may choose to create the main shaft of the phallus from a non-sensate source such as a pedicled groin flap, but in a later surgical stage, use sensate tissue from the forearm to create the head of the penis. In another approach to minimize scarring, tissue expanders may be inserted into the forearm and used over a period of months so that when the tissue is harvested from the forearm, the donor area can be closed without an additional skin graft. Such options should be carefully researched and discussed with the surgeons you are considering.

MLD flap phalloplasty
A recent advance in phalloplasty technique developed by Dr. S.V. Perovic uses an area of donor skin taken from the side of the upper torso, under the arm. This is called a "musculocutaneous latissimus dorsi flap," or "MLD flap." One advantage of taking donor tissue from this area is that there is a less conspicuous scar than in the forearm flap procedure. Also, because the MLD flap donor area is a bit larger, this can allow for larger penis size if desired.

The MLD flap procedure is considered by many to produce a more realistic-looking, more erotically sensate phallus than older phalloplasty procedures. This is due to the nature of the skin of the MLD flap (the donor area is often relatively hairless) as well as the nerves and blood vessels that are able to be harvested with that skin. Pre-surgical massage in the donor area is strongly recommended in order to increase skin elasticity and enable the surgeon to close the donor site directly. Patients who are obese may not have a successful or aesthetically pleasing outcome-- weight loss and/or lip suction may be required by a surgeon prior to performing this procedure.

The MLD flap phalloplasty is typically a three-stage procedure; 3-6 months recovery time is typically required between each stage. In the first surgical stage, skin from the donor area is shaped into the new penis and grafted into place on the groin, where the nerves and blood vessels are microsurgically connected. The foundation for the new urethra is also created during this stage using tissue from inside the mouth/cheeks. The second surgical stage finalizes the new urethra and connects it surgically with the native urethra. The third surgical stage involves implanting a flexible rod or a pump device that is used in order to achieve an erection.

Because the donor skin on the MLD flap can be hairy (depending on the patient), some patients may choose to undergo electrolysis in the donor areas for a period of months to help minimize hair growth on the new penis. If electrolysis is not chosen, the patient may have to periodically shave the skin of the penis or use depilatory cream.

Scrotoplasty
In general, the creation of the scrotum is usually accomplished by hollowing out the labia majora, inserting solid silicone implants, and eventually joining the labia to create a single scrotal sac (similar to the procedure used in metoidioplasty). However, other techniques are sometimes employed to create a scrotum, such as the creation of a scrotal sac from donor tissue from the abdomen or thigh. Sometimes fat is harvested from the pubic mound and transplanted into the constructed sac rather than using implants, though often this does not produce adequate size and symmetry.

Pros, Cons, and Risks
It is important to note that most phalloplasty procedures require multiple surgical visits as well as some revisions. The procedures can involve pain and discomfort, require significant recovery time, and often leave large areas of visible scarring. Because of the nature of using skin grafts, there is always a risk of tissue death and loss of part or all of the penis. Other potential complications include the extrusion of testicular or penile implants, the formation of a stricture (an abnormal narrowing; blockage) or fistula (an abnormal connection; leakage) in the newly constructed urethral passage, and infection. There may also be damage to the nerves of the donor area, resulting in numbness or loss of function. Erotic sensation may be changed or diminished. And the results may not be as aesthetically pleasing as one might like them to be. Also, one must consider the usual risks of any surgery, including bleeding, infection, problems from anesthesia, blood clots, or death (rare).

Phalloplasty procedures also tend to be very expensive (between $50,000 to $150,000) and are often not covered by insurance.

However, if one desires an average-sized penis that looks acceptable in the locker room, through which he can urinate, and with which he can engage in penetrative sex, a phalloplasty is a way to achieve that end. Additionally, many trans men do not feel complete without a penis, and so may pursue a phalloplasty with that in mind. It is often reported by trans men that the forearm free flap phalloplasty and the MLD flap phalloplasty provide the most realistic-looking penis of the options currently available, if you are willing to accept the surgical risks.

Thoughts to consider about genital reconstruction surgery
If you are considering GRS, it is wise to research the available methods and surgeons as much as possible, and keep an open mind about the things that are important to you (sexual sensation, ability to urinate standing up, scarring, aesthetics, size of penis, placement of penis, costs, etc.). Keep in mind that not all surgeons can perform all kinds of genital surgery, and often specific surgeons will specialize in their own surgical method. You may need to travel to another country to find a surgeon who specializes in the procedure you desire (though sometimes this can offer cost savings, depending on where your surgeon does the procedure).

If you have other genital or abdominal procedures done before your GRS (such as hysterectomy/oophorectomy or vaginectomy), be sure to ask how the removal of any tissues or resultant scarring might effect later GRS options. For example, if you are having a metoidioplasty now but want to reserve the option of a future phalloplasty, you may wish to inquire about whether vaginal/labial tissues should be preserved for future use.

Whenever possible, ask to see photographic samples of surgeons' work, as well as statistical records. How many times have they performed a certain procedure? What have been the outcomes regarding post-surgical complications, patient satisfaction, and so on? If you can see an example of their work that shows a patient with a similar body type to yours, so much the better. There is a web site (www.transbucket.com) that serves as a repository for FTM surgery photos and information. The site can be searched by procedure type and by surgeon. Another good resource for FTM surgical information and advice can be found on the FTM Surgery Info Group on Yahoo (groups.yahoo.com/group/ftmsurgeryinfo) and the FTM Phalloplasty Info Group on Yahoo (groups.yahoo.com/group/ftmphalloplastyinfo). These can be invaluable resources when considering which surgeons and procedures may be right for you. See also the resources list below for further options.

Pre-surgical advice
One of the main keys to an optimal surgical outcome is the overall health and fitness of the patient going into surgery. Two factors that are often considered important before a GRS procedure (besides overall good health) are smoking and excess body weight.

Smoking slows the ability of the body to heal itself after surgery; thus, it is usually recommended that patients who smoke avoid smoking for at least two weeks prior to surgery, if at all possible. It is not necessary, but highly recommended.

As for the issue of excess body weight: while there is no reason why an individual who is overweight cannot undergo surgery if he is otherwise healthy, for certain procedures the aesthetic results may be more pleasing if an individual is near their optimal body weight. However, if a patient cannot foresee losing weight before the procedure, or simply chooses not to lose weight, he should be able to proceed if he is in otherwise good health. Some surgeons are more willing to work with patients with excess body weight than others. Speak to the surgeons you are considering if you have weight concerns.

Other, specific pre-surgical advice will be provided to you by your surgeon. Typically, you will be asked to discontinue use of aspirin, ibuprofen, and other blood-thinning medications during the 10 days prior and up to the surgical date. You may also be asked to discontinue use of other medications; be sure to discuss any medications you are taking-- including supplements-- with your surgeon.

There are certain vitamins and supplements that are said to help benefit in the healing process. You may wish to research this topic and outline a nutritional regimen for both before and after surgery to aid your body's natural healing process. However, taking supplements or vitamins is not necessary for a positive surgical outcome.

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Resources

Transbucket
www.transbucket.com
Transbucket is a repository for images of FTM gender reassignment surgery results. FTM transsexuals can upload pictures of their own surgical results, as well as search and sort through images other trans men have submitted.

FTM Surgery Info Group on Yahoo
groups.yahoo.com/group/ftmsurgeryinfo
An extensive resource for information, photos, links, and research materials pertaining to surgery options for Female-to-Male transgender persons. You must apply for membership to access this group. Includes information about the following FTM-related procedures: metaoidoioplasty (metoidioplasty), phalloplasty, Centurion, hysterectomy, vaginectomy, salpingo-oophectomy, scrotoplasty, urethroplasty, testicular prostheses, and chest surgeries including double incision, liposuction, periareolar, keyhole, non-surgical enhancement alternatives such as pumping, stretching, piercing, and more. Interested persons are required to answer a short questionnaire before membership is granted.

FTM Phalloplasty Info Group on Yahoo
groups.yahoo.com/group/ftmphalloplastyinfo
This group is intended to complement the all-inclusive ftmsurgeryinfo Yahoo group (above). This is a smaller group dedicated to the serious discussions needed as one moves forward with plans for a phalloplasty. All FTMs who are seriously considering phalloplasty surgery as well as those who have completed a phalloplasty are welcome. Interested persons are required to answer a short questionnaire before membership is granted.

Trans Care Project of Vancouver, British Colombia
transhealth.vch.ca/resources/library/index.html
Completed in January of 2006, the Trans Care Project created a series of training materials and practice guidelines for clinicians treating trans patients, as well as consumer information about trans health for trans people-- FTM and MTF. Their materials are downloadable in PDF, and cover numerous topics of concern to trans people and their care providers. Scroll down the page to the "Consumer Information" section to see the pamphlet "Surgery: A Guide for FTMs."

Man Tool
www.lorencameron.com/mantool
An online photo-book of FTM genital surgeries. A $19.95 fee gives you viewing access for one year.

The Transitional Male
www.thetransitionalmale.com
Check out both the Surgery Information Index and the Surgical Photo Galleries on this site.

Back to Hudson's FTM Resource Guide main page

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