Chrysalis Quarterly #9

Getting Real About FTM Surgery

© 1994 by James Green

So, you’re thinking of having a “sex change” operation. You’ve thought about it for years. You know that it’s possible and that people do it every day. You’ve been to doctors and a therapist or two, and they’ve “OK’d” you for hormones; your body’s been changing, you’ve been cross-living, and it seems like everything in your life has been leading up to the moment when you can get your surgery and be done with all this transitional stuff, get on with living your life as a man.

First of all, let’s get this straight: there’s no such thing as a sex change operation, at least not for FTMs. There’s hormone treatment, and that goes on for the rest of your life. Then there’s “top” surgery: a bilateral mastectomy and contouring of the chest. Then there’s “bottom” surgery: genital reconstruction. It takes years to go through this transition, to master the changes each step of the way. And that’s without taking money into consideration: each step costs money that can take years to accumulate.

Among candidates for FTM transition, there is considerable confusion about the physical benefits and limitations of each type of FTM surgery available today. This article is intended to clarify the advantages and disadvantages associated with these procedures so people who identify as FTMs can make educated decisions about how to alter their bodies.

Make no mistake, once you undergo one of these surgical procedures you have altered your body. The skin will experience a wound. At that site, your body will never be the same as it was before. Sure, I know that’s what you want: you want a flat, muscular chest, and you want a penis. You also probably want the perfect male body, scarless and well-hung. I hope you can achieve it, but don’t say I didn’t warn you.

Before you go in for surgery you have some homework to do. First you must understand your own body. You must know what you want it to be when the surgeon’s finished, and you must be realistic about what your body is before you enter the surgical suite. Your body may never live up to your self-image, no matter who your surgeon is or how much money you have. The surgeon works with flesh, and we have to acknowledge that the flesh we bring in is our own, and it may not present the ideal working conditions for the surgeon. Second, you must understand the surgeon’s techniques so you can discuss with him or her your desired outcome and have some idea of what to expect to see and feel when you wake up from the anesthesia. You must select your surgeon based on his or her reputation (i.e., results: talk to as many other FTMs as you can) and on your instincts: if you don’t feel comfortable with a surgeon when you’re awake, are you going to trust him or her when you’re unconscious? You should also find out directly from each surgeon how he or she approaches the various difficulties that may be encountered in each procedure. And last, but not least, get yourself into the best possible physical shape before surgery to assist your surgeon in shaping your body and to aid in your own healing. All the surgeries described in this article are invasive procedures performed under general anesthesia. Ask your doctor about the risks associated with surgery in general as well as with specific procedures. And remember that nothing in this article is intended as medical advice, just as information to equip you to discuss issues with physicians.

Let’s start at the top to review surgical techniques. After years of contact with scores of FTMs and asking questions, I’ve observed that there appear to be four primary techniques used in removal of the breast: keyhole, drawstring, pie wedge, and double incision. Your surgeon may employ one or more of these techniques. He or she will evaluate your body and recommend the surgical technique that will best remove the breast tissue and allow for proper contouring of the chest wall to maximize masculine appearance.

If you have very small breasts, that is, VERY small (‘ A ’ cup or smaller), your surgeon may recommend the keyhole or drawstring techniques. These methods leave little or no noticeable scarring, but will not yield the desired results if breasts are larger than A size or if the breast tissue extends close to the armpit. When performing a keyhole procedure, the surgeon makes an incision around the areolar ring, inserts a liposuction device, and vacuums out the fatty tissue comprising the breast. With this technique, the mammary glands are usually left intact. Drawbacks are that small deposits of fatty tissue may remain in the chest (this can be reduced by a technique called feathering), or the finished areola (after sealing the incision site) may be too large in comparison with the typical male chest. Advantages are little or no apparent scarring and retention of nipple sensation (see fig. 1). Likewise with the drawstring technique, in which the areolar ring is lifted away without disconnecting the nerves, the breast and fatty tissue is scooped or suctioned out, the excess skin is trimmed and then pulled taut toward the center of the opening like a drawstring bag, and the nipple is reattached covering the opening. Disadvantages are the same as for keyhole above, plus the nipple placement may be unnaturally low on the chest. With either of these two procedures, if the breast is too large the result will be unsatisfactory due to puckering, poor nipple placement, or overly large nipple size. If your surgeon says these procedures won’t work for you, it is not a conspiracy; he or she really means it!

The pie wedge technique creates a scar from the outer edge of each nipple toward the underarm , or sometimes straight down from the nipple. Usually this procedure is done with small to medium breasts. Many FTMs are dissatisfied with the appearance of the scars because they are so symmetrical and obviously breast-related.

The most common technique for FTM breast removal is the double incision. In this procedure, each breast is opened horizontally across the chest below the nipple. The top panel of skin is peeled back to expose the chest muscle wall, and the breast and fatty tissue is cut and scraped away. The top skin panel is then brought down smooth and the skin is trimmed and sutured to the lower panel at the incision. One nipple is reserved for later use, and the other is discarded along with the extraneous skin; or, both nipples may be retained. The nipple in reserve is used to form both new nipples (or the two original nipples are trimmed), and are then grafted into place. Surgeons have varying techniques for shaping and placing nipples; be sure to look at photos of former patients (or see them in person, if possible) and discuss his or her technique with your surgeon before surgery. This procedure leaves a long horizontal scar (see fig. 2), and depending on the shape of the original breasts and the surgeon’s technique, the scar may also form a ‘W’ shape, which displeases some FTMs. Proper muscle development after healing may hide the scars beneath the pectoral fold. Disadvantages are loss of nipple sensation and scarring, though some nipple sensation may return over a period of months or years, and some FTMs are not disturbed by the scars, which may be covered by hair, or may appear as if caused by an accident or some other medical condition such as a collapsed lung. Another disadvantage may be dissatisfaction with nipple size, shape, appearance or placement. However, this method offers the most thorough removal of breast and fatty tissue because the chest wall is well-exposed.

For FTMs, bilateral mastectomy is usually performed as an outpatient procedure. This reduces costs, and also acknowledges the fact that we are usually quite happy to have this surgery, and our optimistic attitude aids in our rapid healing. The costs for “top” surgery range from $1800 to $6500, depending on your surgeon’s fees and operating room expenses associated with the technique he or she will use. The procedure usually requires two to three weeks rest, and limited pectoral and shoulder activity for a period of up to three months. Time off from work varies from two to six weeks.

The bottom line when it comes to “top” surgery is that no surgeon can give you the chest you should have been born with. Everyone’s skin and tissue type and composition is different; even using the same surgeon, no two FTMs will have identical results. Regardless of which technique is used, you may require follow-up or touch-up procedures to clean up any residual fatty tissue, puckering, or excessive scarring. And while you may have that great looking chest when you’re dressed, you may always have a sensation in your skin that there was a wound, especially if the incision was a large one. For more information on “top” surgery, see the article “Creation of a Male Chest in Female Transsexuals” by W.R. Lindsay, Annals of Plastic Surgery,1979, 3(1), 39-46.

The bottom line with “bottom” surgery is no surgeon can give you the penis you should have been born with. So what’s the reason for having genital reconstruction at all? Well, some FTMs think there is no acceptable reason to have “bottom” surgery. And some FTMs want desperately to have their bodies altered so they can have “male” sex, or get their new birth certificate, get married, or be legally male. And some are just afraid of being caught with female genitalia, with nothing in their crotch, or caught sitting in a toilet stall, unable to urinate while standing. Some are afraid of being perceived as female, or discovered to be a woman “after all” (because everybody “knows” genitals are the final arbiter of identity). There are a lot of reasons to have lower surgery, not the least of which is the desire to have one’s entire body match one’s identity. But genital reconstruction is a lot more expensive and riskier than a bilateral mastectomy. There are far fewer surgeons who are willing to perform genital reconstruction, and fewer still who are truly good at it.

Genital reconstruction falls into two basic types: phalloplasty and metoidioplasty, (also written as metadoioplasty; see end note, p. 32). The term “genitoplasty” is also, erroneously, used to refer to this type of surgery: technically, genitoplasty is any genital surgery, not necessarily limited to the creation of male genitals out of female genitals, which is, technically, metoidioplasty.

The first type of phalloplasty, developed in the first half of this century, was the Gillies abdominal tube, in which a flap of abdominal skin is rolled into a tube and left hanging like a flaccid organ. Early phalloplasty techniques were originally pioneered to treat men whose penises were lost by traumatic amputation in war or industrial accidents, and were first applied to FTMs (as far as we know) in 1948. Some FTMs have postulated that there is a conspiracy against us by the surgeons, that they aren’t trying hard enough to give us a good penis because they don’t care about us, but the truth is that the same problems in creating a penis apply to us as to any other penisless man.

Dr. Gillies worked later with Dr. Maltz to develop the “tube-within-a-tube” phalloplasty to provide for a urinary canal, which has proven not terribly effective due to the frequent complications of fistulae (leaks) or strictures (blockages) in the urinary passage. Maltz also developed the “suitcase handle” technique, in which the rolled tube of skin is left attached top and bottom on the abdomen for six weeks to ensure adequate blood supply to the neo-phallus, then the upper attachment is severed and the “handle” swung down over the clitoral base. This improvement resulted in better retention of the neophallus, which otherwise was prone to wither and fall off!

These early-style phalloplasties (which many surgeons still perform) require the use of a stent (silicone rod stiffener) inserted in the shaft to achieve erection. The neophallus has no feeling and usually does not have a very natural appearance. Some surgeons leave the female genitalia completely intact, and some will attempt the formation of the scrotum using a pouch of abdominal tissue beneath the neophallus, still leaving the male genitalia perched on the lower belly above the female genitalia. Still, other surgeons may be more adept using these techniques than the examples I have seen in real life.

The more contemporary phalloplasty technique is called the free tissue flap transfer (FTFT). This technique has been made possible by the advent of microsurgery, and the development of the fine art of connecting dissimilar nerves. Using a flap of skin and muscle tissue from the forearm, groin, or thigh, this flap is transferred with its existing nerves and blood vessels to the groin area, and the nerves and blood vessels are connected microsurgically to the nerves and blood vessels of the groin, e.g., the brachial nerve of the forearm is connected to the pudendal nerve (see fig. 3). Note that the head of the clitoris is removed to provide access to the pudendal nerve (the nerve providing erotic sensation). This results in a penis that may have feeling, but is not capable of achieving or sustaining an erection. Although implants are available to achieve erection, they have so far proven to be problematic due to infections, rejection by the body, and extrusion and intrusion. Without an implant, a stent is required to erect the shaft of the neophallus. This penis still may not have a natural appearance; in fact, with all phalloplasties, the sculpting of the glans leaves much to be desired, and it is usually this feature that exposes the organ as one that has been artificially constructed (see fig. 4).

The advantages of FTFT are that new microsurgical techniques can provide a phallus with erotic sensation, and one that is closer in size to that of the average genetic male penis, as well as providing for urinary extension. The risks, though, are many: damage to the remaining nerves of the donor site, damage to the pudendal nerve of the groin resulting in a numb organ, death of the graft, loss of function in the donor site, and the frequent development of fistulae or strictures in the urinary passage. And there are disadvantages, too: the inability to achieve or sustain an erection without a stent or an implant; excessive donor site scarring; the fact that these procedures usually require multiple revisions, and may be aesthetically inferior; and there is severe pain and discomfort associated with the donor sites as well as the groin area. Also, for most FTMs, FTFT is cost prohibitive, rang0ing from $50,000 to $150,000, plus months—or even years—spent in recovery and/or revisions.

An FTM’s natural advantage over a penisless man is the clitoris. Dr. Bouman in The Netherlands and Dr. Laub in the U.S. recognized this in the 1970s and independently (and virtually simultaneously) developed the metoidioplasty technique, which is the only type of genital reconstruction that actually transforms the female genitalia into male-appearing organs (see fig. 5). Providing there has been sufficient clitoral growth induced by testosterone, the closest approximation to a typically-sized adult male penis is achieved with a clitoral release (the severing of the suspensory ligaments that hold the clitoris in a position where it is tucked under the pubic bone). The clitoral release effectively gives the FTM a micropenis, a naturally occurring condition among roughly 5% of male-bodied individuals. More length can be obtained once the suspensory ligaments are cut by the surgeon proceeding beneath the pubic bone and advancing the crura (or “legs” of the clitoris—or penis) out). These “legs” can be repositioned forward with respect to the pubic bone and a flap of abdominal skin can be used to cover the newly exposed tissue on the clitpenoid shaft. This procedure is being practiced more and more often in cases of male-bodied persons born with micropenis. For FTMs, the scrotum is formed by joining the labia majora and using silicone testicular implants, sometimes preceded by tissue expanders. The primary risk with metoidioplasty is that when the surgeon advances the crura out, it is possible that the pudendal nerve may be damaged and the organ rendered numb. The advantages are that the penis, though small, is otherwise normal in appearance, with a natural glans and foreskin, and the scrotum can be sized appropriately for the patient’s body. Another advantage is that sexual function is not lost; the FTM can have natural erections and orgasm (unless the pudendal nerve is damaged). Note that intravaginal penetration is possible for some individuals with this type of penis, but this ability cannot be expected in all cases.

Urethral extension in metoidioplasty poses the same problems it always has with phalloplasties: some surgeons are more willing to attempt it than others, and 100% success is still rare. But several surgeons are working on new techniques to eliminate strictures and fistulae.

Metoidioplasty can be performed on an outpatient basis and also costs less than phalloplasty, usually running $4,000 to $10,000. If tissue expanders are used for the scrotum, expect a second procedure to remove them and replace them with the actual implants; this procedure costs approximately $2000. Each procedure requires about 10 days of absolute rest, and the initial reconstruction requires some further healing period of one to three weeks when it may be necessary to limit activity.

What else can be done for FTMs to increase penis size? Generally speaking, the extent of the possible enlargement of the adult clitoris is limited; that is, it will grow only to a certain degree because of the limited number of cells in its specific composition. Enlargement of the clitoris is a matter of the enlargement of the internal structures, also known as the spongy bodies, the corpora cavernosa and the corpora spongiosum (the tissue responsible for erections). Most of this growth is obtained during the first year of testosterone therapy. Other possibilities for clitoral enlargement are the use of testosterone propionate ointment 0.2% applied directly to the clitoris (this is still an experimental treatment), or the use of a vacuum pump to stimulate the repeated rush of blood into the area that enlarges the tissue, much as a bodybuilder increases muscle size through repeated blood engorgement. The penis is not a muscle, however, and too much pumping can actually tear the fibrous tissue of the organ.

When you are searching the medical literature for ideas about how to improve phalloplasty, don’t be misled by descriptions of penis reconstruction techniques used for loss of erectile function caused by other diseases. These methods presume the presence of an organ which is not easily mimicked by tissue from other parts of the body. Instead, look for Kallmann’s Syndrome (one of many conditions that results in micropenis) or hypospadius repair; these conditions are far more analogous to our physical situation. Also, watch out for promises made out of fat transfers: packing your penis with your own fat can make it difficult to erect and less sensate. The fat can also clump or even die!

There is one further type of surgery of which FTMs will usually avail themselves: hysterectomy, oophorectomy, and sometimes vaginectomy. These procedures may be performed through an abdominal incision, through a vaginal entry, or using laparoscopy. Some U.S. states require that oophorectomy be performed to render the FTM sterile before he may be granted legal recognition as a male. Some FTMs feel they need to be rid of these “female” organs for psychological reasons, and some need to have them removed because the testosterone therapy may aggravate existing precancerous conditions in that tissue. And some FTMs feel this is unnecessary surgery and will avoid it.

When deciding whether or not to have the uterus and ovaries removed, there are a few things to be aware of. First, because the FTM population is not well studied, we don’t know the long term impact of testosterone therapy on internal female organs. If one is in a high risk group for cancers of female organs, is prone to ovarian cysts, or has a history of problems in these organs, these are good indicators for considering removal. Also, people who live in small towns may run into problems obtaining medical treatment for “female” problems while presenting a male appearance. Sometimes big cities aren’t any easier on the physically incongruent, either.

Considering the three different approaches, the advantages and disadvantages are these: The abdominal approach is the least desirable because it induces more trauma, leaves a noticeable scar, and may interfere with a later phalloplasty via abdominal tube; however, in cases where the organs are difficult to remove or there are large fibroids or other growths, this method may be necessary. The laparoscopic approach can only remove the ovaries and fallopian tubes; it is more expensive than the abdominal method, and not all gynecologists are skilled in the technique; it leaves some scarring. The vaginal approach leaves no external scar, causes less trauma, allows for more rapid healing, and is convenient if the surgeon is also performing a vaginectomy and/or anterior vaginal flap urethroplasty (the most effective technique to date for urethral extensions); one prerequisite is that the vaginal opening must be large enough to accommodate the surgical instruments.

Some doctors recommend removing the vagina (like the other unnecessary female organs) to avoid infections and cancer. But FTMs might consider retaining the vagina when no urethroplasty is being done because it reserves this important tissue in the event a urethroplasty is elected in the future. And some people who are accustomed to vaginal response during orgasm may want to retain the tissue to avoid loss of that sexual response.

Getting real about FTM surgery means accepting the fact that we are altering our bodies; we will never have the bodies we should have been born with. Getting real means accepting the limitations that our bodies have before we get on the operating table, and accepting that we will not come out of this scarless, without wounds, without compromises. That’s not to say that we can’t keep working and hoping for improvements; we can and we do. But we have to live in our bodies one way or another: where do we get the ideas of perfection that we try to live up to? How much imperfection can you handle? Identifying as transsexual means you have signed up to consider these questions. Not to do so is to invite disaster—which may occur anyway under the knife. I’ve had a bilateral mastectomy via double incision, hysterectomy and oopohrectomy via abdominal incision, and metoidioplasty without urethral extension. My last procedure was in 1991, and I’ve been really pleased with the results. I’ve made some compromises in order to live legally as a man, and I feel I’ve been fortunate in both my decisions and in their consequences. Things could have easily turned out otherwise. For me, getting real means taking responsibility for my decisions about my body and living with myself every day.

End Note

1. The original term was metaoidioplasty, as coined by Dr. Donald Laub. The word combines Greek expressions which mean “changing form.” In its application to an exclusively FTM procedure, the term may be construed to mean “a surgical change toward the male form.” Recently, Dr. Laub has contracted the spelling to metoidioplasty (this is etymologically analogous to the contraction of encyclopaedia to the more familiar encyclopedia.) Since it is Dr. Laub’s term, I have conformed to his spelling for the sake of respectful consistency.

Illustrations

(We were unable to duplicate these images, presented in Chrysalis Quarterly #9, on the site at current, but hope to bring them to you in the near future)

Figure 1. A successful keyhole procedure by unknown surgeon 1993. Photo ©1993 by Loren Cameron, from his project “Our Vision, Our Voices: Transsexual Portraits and Nudes” exhibited San Francisco, May 1994.

Figure 2. Scars left by a successful double incision method of breast reduction performed in 1989 by D.R. Laub. Photo ©1993 by Loren Cameron, from his project “Our Vision, Our Voices: Transsexual Portraits and Nudes.”

Figure 3. Diagram showing nerve and vascular connections in FTFT phalloplasty (from “Transsexual Surgery in the Genetic Female,” D.A. Gilbert, et al., Clinics in Plastic Surgery, 15(3), July 1985, figure 4J, page 481).

Figure 4. A phalloplasty. Photo ©1995 by Loren Cameron. The little lump on the top near the base is the clitoris, placed there to enable erotic sensation. Note the scar demarking the glans. Surgeon and date procedure was performed unknown at time of this publication.

Figure 5. A successful metoidioplasty performed by D.R. Laub in 1990 (photo © 1993 by Loren Cameron, from his project “Our Vision, Our Voices: Transsexual Portraits and Nudes,” exhibited San Francisco, May, 1994.