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 phalloplastiess (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.
—©Jamison Green, 1994
Reprinted here with permission.
