Gender Affirming Surgery

Chest reconstruction is a common top surgery among transgender and non-binary patients who were assigned female at birth (AFAB). A plastic surgeon removes your mammary and fat tissue to create a masculine chest. The nipples are repositioned and resized, if desired.

Your care team will work closely with you to understand your goals and will recommend the best surgical approach to meet your needs. We offer several different types of chest reconstruction procedures, including double incision with nipple grafts, buttonhole and peri-aeriolar incisions (keyhole), using liposuction to help with contouring and prevention of “dogears.” The team will work with you to help pick the right technique at the time of your consultation.

Chest reconstruction surgery requires general anesthesia, and is performed as an outpatient procedure, meaning there is no hospital stay after surgery. After surgery you must wear a compression vest for at least four weeks. Drains are used for peri-aeriolar incision surgery. Foam bolsters are also placed on the chest to protect nipple grafts. The bolsters and/or drains will be removed one week after surgery. Most people are able to resume regular daily activities after one month with no restrictions.

Breast Augmentation

Breast augmentation is usually for transgender women and transfeminine spectrum non-binary people. It is also often called feminizing augmentation mammoplasty. We will give your chest a female appearance by placing implants underneath your natural breast tissue or pectoral muscle. Your care team will discuss the implant type (silicone or saline), size and shape to match your body and your desires during your consultation.

A small incision will be made in the crease underneath each breast or around the nipple. A pocket is made underneath the breast or pectoral muscle to give each breast a natural teardrop shape. Often, an additional incision will need to be made around the nipple to lift the breast and nipple into a more feminine position (mastopexy).

Some patients can benefit from fat grafting from the belly, hips or thighs in conjunction with implant surgery to achieve additional fullness in specific areas of the breast. This procedure is not currently covered by insurance.

Orchiectomy

The gender health team offers this surgery as part of gender affirming care for transfeminine patients. Orchiectomy (testicle removal) requires general anesthesia and is a low-risk, outpatient procedure, meaning there is no hospital stay after surgery.

A small incision is made in the scrotum along the median raphe (line in the midline of the scrotum). This approach does not affect future bottom surgery choices. It is common to see a small amount of bruising and swelling and experience mild discomfort. Rare risks include skin infection and a large bruise (hematoma). The recovery process is brief, and most patients are able to resume work and most daily activities within a few days. In those who do not want any further bottom surgeries, the scrotum can also be removed.

Vulvoplasty

The vulva is the outside part of the vagina. A vulvoplasty is a type of surgery that uses skin and tissue from a penis to create all of the outside parts of a vagina. Vulvoplasty does not create the internal vaginal canal.

The steps of a vulvoplasty are the same as a vaginoplasty. During a vulvoplasty, your provider will:

• create a clitoris out of the glans (head) of the penis
• create a labia minor and labia majora from skin on the penis and scrotum
• create the opening of the urethra so you can urinate
• create the introitus (opening of the vagina)

The only thing that’s different between a full vaginoplasty and a vulvoplasty is the internal part of the vaginal canal. This means you will not be able to insert a penis or toys into your vagina. 

Vaginoplasty

Vaginoplasty involves creating a vagina, clitoris, labia majora, and labia minora. The procedure is effective both for people who have and those who have not had orchiectomy in the past. Removal of the testes is required as a part of vaginoplasty.

We perform vaginoplasty under general anesthesia. Most people spend six to seven full days in the hospital after surgery. Recovery from vaginoplasty can take up to three months, and requires intensive post-operative care. It is important to have both someone who can help take care of you after surgery as well as the privacy you need to take care of yourself.

You will need the privacy to dilate at least 30 minutes twice a day. Dilation involves inserting a medical dilator into the vagina. This is important because the vagina will close if people do not dilate.

The gender health team has pioneered an approach using the peritoneal lining, the tissue that lines your abdominal wall and covers most of the organs in your abdomen. The peritoneal lining is hairless and pink. While the peritoneal vaginoplasty does provide moisture, it is not self-lubricating. Patients will still need to use water-based lubricant for intercourse and dilation. This is a new procedure, and we are still gathering data about the procedure's long-term safety and efficacy.

How do I choose between vulvoplasty vs. vaginoplasty?

A vulvoplasty has a much easier recovery. It has a shorter hospital stay and does not require the lifelong maintenance of performing dilations to maintain the vagina.

Some patients know that they’re not interested in having vaginal intercourse. For these patients, a vulvoplasty may be a better choice.

After a vulvoplasty, you can still have orgasms through clitoral stimulation, just like with vaginoplasty. During a vulvoplasty, your surgeon will create a clitoris from the glans or head of the penis.

Metoidioplasty

Metoidioplasty is a procedure for patients who desire a penis. Your surgeon will remove the vagina in those that experience dysphoria from this organ, then release the clitoris from the ligament that holds it in place to lengthen it. Tissue grafting is used to create the penis. The result is a neophallus that can become erect. We are one of the only centers that offer this surgery at the same time as a hysterectomy.

We can perform this procedure with or without extending the urethra to allow urination out of the tip of the penis. The provider can also create a scrotum and insert testicular implants depending on your preference. After metoidioplasty, you will have a three to four day hospital stay. You will go home with a tube in your stomach to help drain your urine, as well as a catheter in the penis. Recovery can take six to eight weeks. Problems with urinary flow are very common, but often resolve on their own.

Phalloplasty

With phalloplasty, a surgeon will create a penis out of skin from somewhere on the body. Faculty at IU School of Medicine currently offer several different techniques. These include the radial forearm flap (RFF) phalloplasty, Anterolateral Thigh (ALT) flap, and Suprapubic.

Phalloplasty can involve several procedures in addition to the creation of a penis. We can close the front pelvic opening (vaginectomy). This often requires a hysterectomy as well.

Urethral lengthening creates a urethra that allows urination from the tip of the penis. Scrotoplasty creates a scrotum. We can perform one or both of these procedures during phalloplasty. Neither is required.

All options for phalloplasty require multiple surgical procedures. Some procedures involve a hospital stay. Some stages of phalloplasty require a hospital stay for up to a week, if not longer.

If you are interested in phalloplasty, we start with a complete consultation. IU School of Medicine providers will discuss the pros and cons of each procedure and help you decide what is right for you. Your care team will be there every step of the way to support you. It is our goal to make sure you feel comfortable and confident with your decision and satisfied with your results.

Hysterectomy and Oophorectomy

Hysterectomy is the removal of the uterus and ovaries. This surgery is part of gender affirming care for transmasculine patients. There is no hospital stay after surgery. Most people recover within two to four weeks. This can be in combination with metoidioplasty or top surgery.

You will have a complete consultation prior to scheduling surgery. At this appointment, your provider will discuss the surgery, review the role of removing the ovaries (oophorectomy) and the route of removing the uterus. For most patients a minimally invasive approach is offered via laparoscopy (making very small incisions on the abdomen).

Should I remove my ovaries?

This is a very personal decision. There is conflicting evidence on the role of the estrogen produced by the ovaries on the risk of heart disease or osteoporosis. Keeping an ovary can mean that you continue to experience cyclic hormonal symptoms, even without a uterus or menstruation.

The ovaries contain eggs for reproduction. Even without a uterus you can still use the eggs for a pregnancy. If you are interested in having children it may be beneficial to keep your ovaries. Your provider will discuss these options in your initial visit and in the surgical planning.

It is likely there is little or no benefit to keeping the ovaries for patients who are not interested in future reproduction and who intend to continue on long term testosterone therapy until at least age 50.