Masculinizing surgery#Chest reconstruction

Chest reconstruction ("top surgery") can be an important component of transition in the transmasculine population that can substantially improve gender incongruence.{{cite web |url=https://www.insider.com/what-is-top-surgery |title=What is Top Surgery? A Guide to the Reconstructive Chest Procedure for Transmasculine Individuals |date=October 14, 2020 |website=Insider |access-date=September 14, 2021}} This might be done as a step in the process of treating distress due to a difference between experienced or expressed gender and sex assigned at birth (gender dysphoria). The procedure can help transgender men transition physically to their self-affirmed gender. Surgeries for female-to-male transgender patients have similarities to gynecomastia surgeries for cisgender men,{{cite web |url=https://www.nhs.uk/common-health-questions/mens-health/what-is-gynaecomastia/ |title=What is Gynecomastia? |website=NHS |date=26 June 2018 |access-date=September 14, 2021 |archive-date=14 August 2021 |archive-url=https://web.archive.org/web/20210814121735/https://www.nhs.uk/common-health-questions/mens-health/what-is-gynaecomastia/ |url-status=live }} breast reduction surgery for gigantomastia, and the separate mastectomies done for breast cancer.{{cite journal | last1=Cuccolo | first1=Nicholas G. | last2=Kang | first2=Christine O. | last3=Boskey | first3=Elizabeth R. | last4=Ibrahim | first4=Ahmed M.S. | last5=Blankensteijn | first5=Louise L. | last6=Taghinia | first6=Amir | last7=Lee | first7=Bernard T. | last8=Lin | first8=Samuel J. | last9=Ganor | first9=Oren | title=Mastectomy in Transgender and Cisgender Patients: A Comparative Analysis of Epidemiology and Postoperative Outcomes | journal=Plastic and Reconstructive Surgery Global Open | volume=7 | issue=6 | date=2021-06-02 | pages=e2316 | pmid=31624695 | doi=10.1097/GOX.0000000000002316 | pmc=6635198 }}

Top surgery involves more than a mastectomy for the treatment of breast cancer. Special techniques are used to contour and reduce the chest wall, position the nipples and areola, and minimize scarring.

If the breast size is small, surgery that spares the skin, nipple and areola (subcutaneous nipple-sparing mastectomy) may be performed. This procedure minimizes scarring, has a faster healing time and usually preserves sensation in the nipples. During this surgery, incisions are made around the borders of the areolae and the surrounding skin. Breast tissue is removed through the incisions and some skin also might be removed. Remaining skin is reattached at the border of the areola.{{cn|date=September 2021}}

Research suggests that most transgender men are satisfied with their surgical results, with only 1% experiencing regret after the operation.{{cite journal | last1=McNichols | first1=Colton H. L. | last2=O'Brien-Coon | first2=Devin | last3=Fischer | first3=Beverly | title=Patient-reported satisfaction and quality of life after trans male gender affirming surgery | journal=International Journal of Transgender Health | publisher=Informa UK Limited | volume=21 | issue=4 | date=2020-06-17 | issn=2689-5269 | doi=10.1080/26895269.2020.1775159 | pages=410–417| pmid=34993519 | pmc=8726650 | s2cid=225704571 }}

Hysterectomy is a surgical procedure performed to remove the uterus. A total hysterectomy involves removal of the uterus and cervix, and a sub-partial hysterectomy involves removal of only the uterus. Bilateral salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes.

According to the ACOG, symptomatic uterine leiomyomas are the most common indication for hysterectomy in the US, followed by abnormal uterine bleeding, endometriosis and prolapse.{{cite web |url=https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/choosing-the-route-of-hysterectomy-for-benign-disease#:~:text=invasive%E2%80%9D%20surgical%20approaches.-,Hysterectomy%20is%20one%20of%20the%20most%20frequently%20performed%20surgical%20procedures,prolapse%20(18.2%25)%201%202. |title=Choosing the Route of Hysterectomy for Benign Disease |date=June 2017 |website=The American College of Obstetricians and Gynecologists |access-date=September 14, 2021 |language=en |archive-date=September 13, 2021 |archive-url=https://web.archive.org/web/20210913183524/https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/choosing-the-route-of-hysterectomy-for-benign-disease#:~:text=invasive%E2%80%9D%20surgical%20approaches.-,Hysterectomy%20is%20one%20of%20the%20most%20frequently%20performed%20surgical%20procedures,prolapse%20(18.2%25)%201%202. |url-status=live }} Risk-reducing hysterectomy is also performed for patients with high-risk of endometrial cancer, including patients with germ-line BRCA1/2 mutations, Lynch Syndrome and family history. Hysterectomy can also be performed for male-identifying patients with uterus in conjunction with testosterone therapy.

Hysterectomy can be performed through three methods: abdominal, laparoscopic, vaginal.{{cite journal |title=Hysterectomy |journal=Best Practice & Research Clinical Obstetrics & Gynaecology |date=1 February 2006 |volume=20 |issue=1 |pages=73–87 |doi=10.1016/j.bpobgyn.2005.09.007 |url=https://www.sciencedirect.com/science/article/pii/S1521693405001203 |language=en |issn=1521-6934|last1=Clayton |first1=R.D. |pmid=16275095 }} Abdominal hysterectomy is performed with incision into the abdominal wall, whereas laparoscopic and vaginal hysterectomies are minimally invasive procedures.{{Cite journal |last1=Pickett |first1=Charlotte M. |last2=Seeratan |first2=Dachel D. |last3=Mol |first3=Ben Willem J. |last4=Nieboer |first4=Theodoor E. |last5=Johnson |first5=Neil |last6=Bonestroo |first6=Tijmen |last7=Aarts |first7=Johanna Wm |date=2023-08-29 |title=Surgical approach to hysterectomy for benign gynaecological disease |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=8 |pages=CD003677 |doi=10.1002/14651858.CD003677.pub6 |issn=1469-493X |pmc=10464658 |pmid=37642285 }} Current ACOG guidelines recommend minimally invasive procedures, specifically vaginal hysterectomy, over surgical hysterectomy due to faster recovery time, shorter procedural time, shorter hospital stays and better quality of life.{{cite web|url=https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/choosing-the-route-of-hysterectomy-for-benign-disease#:~:text=invasive%E2%80%9D%20surgical%20approaches.-,Hysterectomy%20is%20one%20of%20the%20most%20frequently%20performed%20surgical%20procedures,prolapse%20(18.2%25)%201%202.|title=Choosing the Route of Hysterectomy for Benign Disease|access-date=2021-09-13|archive-date=2021-09-13|archive-url=https://web.archive.org/web/20210913183518/https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/choosing-the-route-of-hysterectomy-for-benign-disease#:~:text=invasive%E2%80%9D%20surgical%20approaches.-,Hysterectomy%20is%20one%20of%20the%20most%20frequently%20performed%20surgical%20procedures,prolapse%20(18.2%25)%201%202.|url-status=live}}{{cite journal |last1=Garry |first1=Ray |title=The future of hysterectomy |journal=BJOG: An International Journal of Obstetrics and Gynaecology |date=February 2005 |volume=112 |issue=2 |pages=133–139 |doi=10.1111/j.1471-0528.2004.00431.x |pmid=15663575 |s2cid=36424081 |issn=1470-0328 |doi-access=free }} Discharge from minimally invasive hysterectomy can occur as fast as one day post-operation, in contrast to five days post-operation for abdominal hysterectomies. Following discharge, patients often experience gastrointestinal symptoms such as constipation or urinary tract infections, as well as vaginal bleeding or discharge. These symptoms should be temporary and resolve within six weeks.{{cite web |url=https://www.nhs.uk/conditions/hysterectomy/recovery/ |title=Recovery - Hysterectomy |website=NHS |date=14 May 2018 |access-date=September 14, 2021 |archive-date=13 September 2021 |archive-url=https://web.archive.org/web/20210913183523/https://www.nhs.uk/conditions/hysterectomy/recovery/ |url-status=live }} Follow-up visits with a gynecologist is recommended six-weeks following hysterectomy.

Follow-up care for male-identifying patients with uterus should still see a gynecologist for a check-up at least every three years. This is particularly the case for patients who:

• retain their vagina (whether before or after further genital reconstruction,)
• have a strong family history of cancers of the breast, ovary, or uterus (endometrium,)
• have a personal history of gynecological cancer or significant dysplasia on a Pap smear.
• develop vaginal bleeding post-operation and hormone therapy

Complications of hysterectomy involve infection, venous thromboembolic events, genitourinary and gastrointestinal tract injury and nerve injury. The most common of these complications is infection, which occurs at a rate of 10.5% of abdominal hysterectomy, 13% of vaginal hysterectomy and 9% of laparoscopic hysterectomy.{{cite journal |last1=Clarke-Pearson |first1=Daniel L. |last2=Geller |first2=Elizabeth J. |title=Complications of hysterectomy |journal=Obstetrics and Gynecology |date=March 2013 |volume=121 |issue=3 |pages=654–673 |doi=10.1097/AOG.0b013e3182841594 |pmid=23635631 |s2cid=25380233 |url=https://pubmed.ncbi.nlm.nih.gov/23635631/ |issn=1873-233X |access-date=2021-09-13 |archive-date=2021-09-13 |archive-url=https://web.archive.org/web/20210913183518/https://pubmed.ncbi.nlm.nih.gov/23635631/ |url-status=live }} There is also a low risk of long-term complications, which can include chronic pain, sexual dysfunction and bowel dysfunction.

Also known as genital reconstructive procedures (GRT).{{Cite journal |last1=Frey |first1=Jordan D. |last2=Poudrier |first2=Grace |last3=Chiodo |first3=Michael V. |last4=Hazen |first4=Alexes |date=March 2017 |title=An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature |journal=Plastic and Reconstructive Surgery |volume=139 |issue=3 |pages=728–737 |doi=10.1097/PRS.0000000000003062 |issn=1529-4242 |pmid=28234856}}

{{Further|Phalloplasty|}}

File:Phalloplasty-Artificial male genitals on grey background.jpg

Phalloplasty is the process of constructing a penis using a flap (graft) from the patient's arm, thigh, abdomen, or back.{{cite journal|last1=Kang|first1=Audry|last2=Aizen|first2=Joshua M.|last3=Cohen|first3=Andrew J.|last4=Bales|first4=Gregory T.|last5=Pariser|first5=Joseph J.|date=June 2019|title=Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male|journal=Translational Andrology and Urology|volume=8|issue=3|pages=273–282|doi=10.21037/tau.2019.06.02|pmid=31380234|pmc=6626310|doi-access=free}} Compared to metoidioplasty, phalloplasty provides a larger penis which may more closely resemble a natal penis.{{medical citation needed|date=July 2023}} A neophallus created through phalloplasty relies on penile implants to achieve erection. Sexual sensation varies in location and intensity, but is usually preserved at least at base of the penis, where the original clitoris was.{{medical citation needed|date=February 2024}}

{{Further|Metoidioplasty|}}

File:Metoidioplasty 2 yr post-op.jpg, two years post-operation.{{cite journal | vauthors = Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML | title = Metoidioplasty: Surgical Options and Outcomes in 813 Cases | journal = Frontiers in Endocrinology | volume = 12 | pages = 760284 | date = 2021-10-13 | pmid = 34721306 | pmc = 8548780 | doi = 10.3389/fendo.2021.760284 | doi-access = free }}]]

Metoidioplasty is done after enlarging the clitoris using hormone replacement therapy, where a neophallus is constructed from the enlarged clitoris, with or without extending the urethra to allow urination while standing up. The labia majora are united to form a scrotum, where prosthetic testicles can be inserted. The new neophallus ranges in size from 4–10 cm (with an average of 5.7 cm) and has the approximate girth of a human adult thumb.Metoidioplasty as a Single Stage Sex Reassignment Surgery in Female Transsexuals: Belgrade Experience Djordjevic, Miroslav L. et al., Journal of Sexual Medicine, Volume 6, Issue 5, 1306 - 1313 Sexual sensation and erectile function are usually completely preserved. Specialized metoidioplasty penile implants may be an option in those who cannot achieve penetration during sex.{{Cite journal|last1=Littara|first1=Alessandro|last2=Melone|first2=Roberto|last3=Morales-Medina|first3=Julio Cesar|last4=Iannitti|first4=Tommaso|last5=Palmieri|first5=Beniamino|date=2019-04-19|title=Cosmetic penile enhancement surgery: a 3-year single-centre retrospective clinical evaluation of 355 cases|journal=Scientific Reports|language=en|volume=9|issue=1|pages=6323|doi=10.1038/s41598-019-41652-w|issn=2045-2322|pmc=6474863|pmid=31004096|bibcode=2019NatSR...9.6323L}}

{{Further|Penile implant}}

Penile implants are usually used in phalloplasty surgery due to the inability of the neophallus to achieve proper erection. The penile implants are used in cisgender men to treat erectile dysfunction, and in transgender men during female-to-male sex reassignment surgery. Although the same penile implant has been used for both cisgender and transgender men, specialized penile implants for transgender men were recently developed by Zephyr Surgical Implants (Switzerland), in both inflatable and malleable models.{{Cite journal|last1=Pigot|first1=Garry L. S.|last2=Sigurjónsson|first2=Hannes|last3=Ronkes|first3=Brechje|last4=Al-Tamimi|first4=Muhammed|last5=van der Sluis|first5=Wouter B.|date=January 2020|title=Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty|journal=The Journal of Sexual Medicine|volume=17|issue=1|pages=152–158|doi=10.1016/j.jsxm.2019.09.019|issn=1743-6109|pmid=31680006|s2cid=207890601}} During phalloplasty, the tissue flap used to build the neophallus is wrapped around the implant either in the same surgery, or in separate surgeries. Penile implants are less commonly used in metoidioplasty due to how the process is done.

Facial masculinization also alters anatomical features to achieve an appearance that aligns more closely with gender identity. This can be achieved surgically, which might entail reconstruction of the forehead, nose, upper lip, or chin.{{Citation|last=Deschamps-Braly|first=Jordan|title=Facial Gender Affirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery|date=2020|url=https://doi.org/10.1007/978-3-030-29093-1_12|work=Gender Confirmation Surgery: Principles and Techniques for an Emerging Field|pages=99–113|editor-last=Schechter|editor-first=Loren S.|place=Cham|publisher=Springer International Publishing|language=en|doi=10.1007/978-3-030-29093-1_12|isbn=978-3-030-29093-1|s2cid=241880496|access-date=2021-09-11}} Non-surgical options include injections to alter the jawline and chin.{{Cite journal|last1=Ascha|first1=Mona|last2=Swanson|first2=Marco A|last3=Massie|first3=Jonathan P|last4=Evans|first4=Morgan W|last5=Chambers|first5=Christopher|last6=Ginsberg|first6=Brian A|last7=Gatherwright|first7=James|last8=Satterwhite|first8=Thomas|last9=Morrison|first9=Shane D|last10=Gougoutas|first10=Alexander J|date=2018-10-31|title=Nonsurgical Management of Facial Masculinization and Feminization|journal=Aesthetic Surgery Journal|volume=39|issue=5|pages=NP123–NP137|doi=10.1093/asj/sjy253|pmid=30383180|issn=1090-820X|doi-access=free}} Non-surgical methods can be combined with surgery or used alone when subtle changes are desired. In addition to alteration of facial structure, hair transplantation can be used to achieve more permanent masculine hair growth patterns such as sideburns, mustaches, or beards.

• Facial masculinization
• List of transgender-related topics
• Penile implant
• Sex reassignment surgery (male-to-female)

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{{reflist|2}}

• [https://www.academia.edu/238605/Factors_Which_Influence_Individuals_Decisions_When_Considering_Female-To-Male_Genital_Reconstructive_Surgery Factors Which Influence Individual's Decisions When Considering Female-To-Male Genital Reconstructive Surgery] by Katherine Rachlin from the [http://www.tandfonline.com/toc/wijt20/current#.U_bwlahdWEc International Journal of Transgenderism]. [http://thaimedicalvacation.com/male-to-female-sex-reassignment-surgery Female-To-Male Genital Reconstructive Surgery. Factors, Benefits and Risks by Preecha Tiewtranon] This article also discusses some general issues of female-to-male GRT.

• [http://www.gendercentre.org.au/resources/polare-archive/archived-articles/everything-you-wanted-to-know-about.htm Everything you wanted to know about ... Total Abdominal Hysterectomy with Bilateral Salpingo Oophorectomy] {{Webarchive|url=https://web.archive.org/web/20141116082027/http://www.gendercentre.org.au/resources/polare-archive/archived-articles/everything-you-wanted-to-know-about.htm |date=2014-11-16 }}

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