Chest reconstruction surgery (Top Surgery)
Chest reconstruction surgery
Chest surgery is the most common surgical procedure sought by trans men. The goal of chest surgery is to create a contoured, male-looking chest. There are two basic procedures that are typically performed to accomplish this goal:
1. Double incision/Bilateral mastectomy
2. Keyhole/Peri-areolar incision
There are a few other surgical variations used for chest reconstruction, including the "inverted T" incision, the "pie wedge" method, and other combinations of incisions that a surgeon may see as the best approach for the patient. These methods are not covered in great detail here, as they are not nearly as common as the above two approaches, and because they are similar to the other approaches except for the resultant scarring. For example, the inverted T approach is quite similar to the double incision method except that the incisions run vertically down from the nipple to the bottom of the pectoral area, and the resulting scar ends up looking like an anchor or an upside-down letter "T." The pie wedge method is also similar to the double incision, but uses a curved incision from the bottom of the nipple toward the underarm.
The surgical method chosen will depend on the body type of the patient and the skills/preferences of the surgeon. In general, guys with larger chests (cup size C or larger) will benefit most from the double incision method, while guys with smaller chests (preferably A, sometimes B) can opt for the keyhole/peri-areolar procedure. The inverted T or pie wedge procedures can be used on guys with medium sized chests (B or C); however, these procedures tend to be used less frequently than the other two approaches because the scarring is not always preferred (as compared to the double incision method).
It is best to discuss the options with the surgeon(s) you are considering. Whenever possible, ask to see photographic samples of the surgeon's work. 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. These can be invaluable resources when considering which surgeons and procedures may be right for you.
Costs for chest reconstruction
In the United States, one can expect to pay between $1,500 and $8,500 for chest surgery, depending on the surgeon's fee, cost of the surgical facility, the cost of the anesthesiologist, and other miscellaneous expenses (tissue pathology tests, aftercare visits, travel and hotel stay, etc.). As mentioned in the introduction, gender reconstruction related surgeries are specifically not covered by insurance companies in the U.S., so these costs are typically paid out of pocket by the patient.
Scarring is a risk with any surgery. The degree of scarring will vary depending on the type of procedure and techniques of the surgeon, the amount of tension on the incisions as they heal, and the genetic makeup of the patient.
The body makes scar tissue in the natural process of healing itself from a wound. During the first several weeks after surgery, collagen accumulates at the scar site. This process tends to create temporarily raised and sometimes darkened scars. After this initial healing period, the scars begin to mature and become less prominent over time, usually flattening and fading in color over a period of months and years.
Sometimes, scars remain thickened and quite red. This is called hypertrophic scarring, and it occurs in some patients. It may simply be due to heredity, or from incisions that have been unduly stretched during the healing process (if, for example, a patient reaches frequently above his head during the healing process, this may pull at the scar tissue). Speak directly with your surgeon about ways to minimize scarring.
If hypertrophic scarring occurs, there are post-operative scar treatments available to address the problem. These products include topical Vitamin E oils or lotions, topical products such as Mederma, Scar Fade, and ScarEase, silicone gel creams, or re-usable silicone sheeting. These scar remedies may work for some patients and not others.
Keep in mind that scars will look their worst at about six weeks post-operative, and will fade and become less noticeable in the upcoming months and years. If you have an area of particularly bad scarring, you may wish to consult with your surgeon about possible revisions.
Why have a hysterectomy/oophorectomy?
Some physicians recommend hysterectomy and oophorectomy within the first 5 years of starting testosterone therapy. There are two reasons for this. First, there is some concern that long-term testosterone treatment may cause the ovaries to develop similar symptoms as those seen in polycystic ovarian syndrome (PCOS). PCOS has been linked to increased risk of endometrial hyperplasia (a condition that occurs when the lining of the uterus (endometrium) grows too much) and thus endometrial cancer, as well as ovarian cancer.
It should be noted that it is difficult to prove whether the risk for such cancers is increased by testosterone therapy in trans men. Female-to-male transsexuals are a small population to begin with, and many undergo hysterectomy/oophorectomy early on in their hormonal treatment, thus making the study of long-term effects of testosterone on the uterus and ovaries difficult. Also, some trans men may have suffered from PCOS before beginning testosterone treatment.
Because the relationship between long-term androgen use and gynecological health is not yet fully understood, and because many trans men experience embarrassment and/or access issues over obtaining ongoing gynecological care, some may feel it is appropriate to pursue such surgeries as a preventative measure. For more information on PCOS, endometrial cancer, and ovarian cancer see the resources section at the end of this page.
The second reason why it may be considered beneficial to undergo a hysto/oopho is that after the removal of the ovaries, testosterone doses can often be decreased because the ovaries are no longer producing estrogen.
If a trans man chooses not to have a hysto/oopho procedure, he should continue to have regular Pap smears (to screen for cervical cancer) and should seek out the care of a doctor if he experiences any irregular vaginal bleeding (including spotting), cramping, or pain. It is not uncommon for trans men who are pre-hysterectomy to experience a buildup of endometrial tissue, especially during the first few years of testosterone therapy. Endometrial tissue is normally shed during menstruation, but since this process is usually stopped a few months into testosterone therapy, additional tissue may continue to build up and may eventually begin to shed in the form of spotting. Because irregular bleeding can be a sign of cancer (though this is often not the case), trans men who experience any bleeding/spotting should see a doctor who will perform tests to determine the cause of the spotting. These tests may include an endometrial biopsy and/or an ultrasound. The doctor may advise a short course of progesterone to cause the uterus to shed the excess endometrial tissue-- this is much like inducing a period. While this may be unpleasant, it should be understood as a preventative measure, since the unusual buildup of endometrial tissue has been linked to endometrial cancer.
Types of hysterectomy and Oophorectomy procedures
There are three main ways in which the uterus can be removed from the body: either through an incision in the abdomen, vaginally through an incision in the top of the vagina (sometimes assisted laparoscopically through small incisions in the abdomen), or through a combination of tissue removal through small incisions in the abdomen as well as through the vagina. The type of surgery chosen will depend on the patient's physical limitations as well as the surgeon's expertise.
Some surgeons who perform genital reconstruction surgery (GRS) may wish to do a hysterectomy/oophorectomy at the same time as GRS. If you are considering GRS, you may wish to fully research such options.
Total abdominal hysterectomy (TAH)
This is the removal of the uterus and the cervix via an incision in the abdomen. During the procedure, the surgeon will make an incision, either horizontally or vertically, in the abdominal wall. The abdominal muscles will be spread apart with retractors. The uterus and cervix are cut away from the surrounding ligaments and blood vessels, and then removed by cutting them off at the top of the vagina. The vagina is sewn closed at the top.
The surgical procedure lasts about 1 to 3 hours, and usually involves a hospital stay of 3 to 5 days. Recovery is usually a 6 to 8 week period of restricted activity. The procedure leaves a 4 to 6 inch scar on the abdomen, usually just above the pubic hair line.
Because of the advances in laparoscopic surgical procedures, surgeons will often recommend less invasive procedures such as LAVH or TLH, listed below, if the patient is a good candidate. Laparoscopic procedures generally involve smaller incisions, less scarring, shorter recovery time, and shorter hospital stays than abdominal hysterectomy.
Total Vaginal Hysterectomy (TVH)
This is the removal of the uterus and the cervix via an incision in the vagina; all operating procedures are performed through the vagina. The uterus and cervix are cut away from the surrounding ligaments and blood vessels, and then removed by cutting them off at the top of the vagina. The vagina is sewn closed at the top.
Because there are no incisions made in the abdomen during TVH, the surgeon cannot easily access the abdominal cavity. She/he cannot examine for and remove endometriosis, she/he cannot perform the procedure if adhesions are present, and certain complications may arise if also attempting to remove the ovaries. Additionally, because TVH is performed entirely through the vagina, it is best performed on individuals who have vaginal laxity (i.e. a wide enough and flexible enough vaginal canal, as often seen after childbirth).
The surgical procedure lasts about 1 to 3 hours, and usually involves a hospital stay of 1 to 3 days. Recovery is usually a 6 to 8 week period of restricted activity. This surgery is not recommended if your vaginal canal is restricted, as the surgeon will need space for instruments and for the removal of the organs. For a restricted vaginal canal, your surgeon may recommend TLH as an alternative option.
Laparoscopically Assisted Vaginal Hysterectomy (LAVH)
This is similar to TVH above, but performed with the aid of laparoscopy. During the procedure, the surgeon makes several small cuts in the abdominal wall to provide access for a laparoscope (a tiny telescopic camera) and other small surgical instruments. The laparoscope is used by the surgeon to see inside the abdomen during the procedure. The surgeon may perform some of the cutting procedures by working through the abdominal incisions, but other surgical procedures will still be performed through the vagina. The uterus and cervix will be mainly removed through a cut at the top of the vagina, and then the vagina is sewn closed.
The surgical procedure lasts about 1 to 3 hours, and usually involves a hospital stay of 1 to 2 days. Recovery is usually a 4 to 6 week period of restricted activity. This surgery is not recommended if your vaginal canal is very restricted, as the surgeon will need space for instruments and for the removal of the organs. For a restricted vaginal canal, your surgeon may recommend TLH as an alternative option.
Total Laparoscopic Hysterectomy (TLH)
Is the removal of the uterus and the cervix by operating through several small cuts in the abdominal wall that provide access for a laparoscope (a tiny telescopic camera) and other small surgical instruments. The uterus is removed by passing the tissue out through the vagina or through one of the small abdominal incisions. Because there is no operating performed through the vagina (though small pieces of tissue can be passed down through it), there is no requirement for a wide vaginal passage, and there are fewer problems with increased urinary incontinence at a later date.
The surgical procedure lasts about 1 to 3 hours, and usually involves a hospital stay of 1 to 2 days. Recovery is usually a 2 to 4 week period of restricted activity. Because there is no requirement for a wide vaginal passage and because this procedure involves less blood loss, lowered risk of urinary incontinence, shorter hospital stay, and shorter recovery time for most patients, TLH can be an excellent choice if it is available. Because TLH is a relatively new procedure, not all surgeons are necessarily skilled in its practice. Be sure to inquire as to your surgeon's direct experience with TLH, or with any type of surgical procedure you are considering.
Bilateral Salpingo Oophorectomy (BSO)
This involves the removal of both ovaries and of both fallopian tubes (bilateral=both sides, salpingo=fallopian tubes, oophor=ovaries, ectomy=removal). For trans men, this procedure will usually be performed at the same time as your hysterectomy. Because the risk of ovarian cancer remains if the fallopian tubes are left behind, both the ovaries and fallopian tubes are usually removed during this procedure.
Risks & Cost
As with any surgical procedure, there are some risks that may occur. These include bleeding, infection, problems from anesthesia, blood clots, or death (rare). Some other problems that have been reported after hysterectomy include irritable bowel syndrome, incontinence, damage to the urethra or bowel, prolapse of the vagina, back pain, or loss of sexual feeling or function. Depending on the type of procedure you undergo, these risks may be more or less common-- speak directly with your surgeon about the risks of the specific procedures you are considering.
The cost of hysterectomy/oophorectomy will vary, but in general will run between $7,000 and $20,000 in the United States (including surgery fees and related hospital/staff fees). Because there is usually a hospital stay after the procedure, and since hospitals charge by the day, this will effect the overall price depending on the duration of the stay.
Hysterectomy is one of the few surgeries that trans men may be able to have covered by insurance, if the procedure is shown to be health-related. If you are experiencing pain or irregular bleeding, or if you have a history of abnormal Pap smears, fibroids, or polyps, you may wish speak with your doctor about the possibility of hysterectomy as a necessary procedure for insurance purposes.
Genital Reconstruction Surgery (GRS or Bottom Surgery)
(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.
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.
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.
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.
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.