Keywords

24.1 Introduction

24.1.1 Definitions and Epidemiology

The acronym AFAB refers to those persons who have been ‘Assigned Female at Birth’. AFAB persons who, later in life, do not identify as female, are said to present a condition named ‘Gender Incongruence’ (GI). They might identify as men, or as non-binary. Persons presenting the condition of GI might experience a Gender Dysphoria (GD), which is defined as the discomfort due to the mismatch between their anatomical characteristics and the gender in which they are self-identifying. Thus, patients with GD are requesting surgical procedure (s) in order to align one’s body—mostly chest and genitals—to best match with one’s identity. The final aim is to reduce one’s dysphoria [1,2,3,4].

Epidemiological studies report a prevalence of AFAB persons with GD to range between 1:30,400 and 1:200,000 within the western population [5], and this number has increased in last decades [6]. Specifically, circa 75% of the AFAB persons with GI is identifying as male, while the rest 25% is identifying as non-binary [7, 8].

In this chapter, we present a summary of the surgical procedures as commonly requested by AFAB persons (trans men and non-binary) that are presenting GD.

24.1.2 Guidelines and Regulations

The World Professional Association for Transgender Health (WPATH) currently publishes a series of guidelines, which are named as Standards of Care (SOC), for patients presenting GI; in the SOC, eligibility criteria for surgery are presented. The last, and seventh version of the WPATH Standards of Care was published in 2011 [9, 10]. An updated version is expected anytime soon.

At the centre of the diagnostic process is the ‘real life—experience’. During the ‘real life—experience’, patients are taking and living in the desired gender role full time for at least 1 year; during this period, patients are regularly followed by a gender counsellors and/or a mental health professional.

WPATH highlights that SOC are recommendations, and these should be adapted to patients’ culture and to national laws. Finally, WPATH highlights that treatments paths should be individualized [9].

24.1.3 Aim of the Treatment

Based on a relatively wide scientific literature with low level of evidence (i.e., mostly consisting on small case series, few long-term follow-ups, and non-validated patients reported outcomes measurements [11]), the WPATH suggests to treat individuals with GD with a combined treatment, which is composed of psychotherapy, hormonal therapy, and surgery [9].

The specific aim of the surgery is to align one’s body anatomy to one’s gender identity. Thus, AFAB persons with GD might request chest-contouring mastectomy (CCM), hystero-ovariectomy, vaginectomy, penile shaft reconstruction, either with or without urethra reconstruction, scrotal reconstruction, testicle implants and, as final stage, erection implant [12]. Some patients might also ask for liposuction to flanks, hips and thighs; facial implants (to achieve a ‘stronger’—thus more masculine—face); and pectoralis implants. It is unclear to which extent this series of procedures is reducing one’s GD, or it is simply enhancing the individual self-esteem.

As said, the scientific literature is providing only limited evidence (mostly, level V of evidence: expert opinions [12, 13]) on what is the most appropriate treatment plan for each specific individual. Nevertheless, the literature is confirming that surgical treatment can help in reducing one’s dysphoria, and in improving patients’ quality of life [9]. In the author’s own experience with more than 1000 patients, regret rate is very low (less than 1%, which is consistent with peer-expert surgeons).

In this chapter, we focus on technical details for CMM and genital surgery (metoidioplasty and phalloplasty). We do omit on technical details on procedures that are widely performed for other patients’ groups as well, such as liposuction and lipofilling, and hystero-ovariectomy.

24.1.4 Standards of Care Specific Criteria for Chest-Contouring Mastectomy and Genital Surgery

As according to the seventh version if the WPATH Standards of Care [9]: surgeons are responsible for discussing with patients: the different surgical techniques available, and their advantages, disadvantages, limitations, risks, and complications; examples of successful and unsuccessful cases have to be shown. Specific criteria for CCM are as follows: one referral letter with diagnosis of GD, capacity to make a full-informed decision and to consent for the treatment, and age of majority; there is no need to be or have been on hormonal therapy for proceeding with CCM. Specific criteria for genital surgery are same as those for CCM, plus hormonal therapy is required for a minimum of 12 months as well as a 12-month period living in the identity-congruent gender role [9].

24.2 Chest-Contouring- Mastectomy

Nearly all trans men and many non-binary AFAB individuals might seek for CCM surgery; usually, the aim is to reduce GD and/or (isolated) breast dysphoria. The surgery mostly consists in (partial) removal of the breast glandular tissue and, often, reduction of the Nipple-Areola-Complex (NAC); liposuction can also be used to complete the chest contouring [14].

24.2.1 Surgical Planning

Several authors have described approaches to select the most appropriate surgical technique for CCM [14,15,16,17,18]. These approaches take into account patient readiness for surgery (confirmed by the mental health professional, usually at the times of the diagnosis); assessment of the breast anatomical characteristics (volume of breast tissues, ptosis, skin excess, and elasticity [15]); family history for breast disease, which is especially important in patients with genetic risks for breast cancer; and patient’s wishes [14].

Specifically, if there is a family history for breast cancer (including BRCA genes), a specialist breast oncologist should be consulted for a prophylactic mastectomy.

The importance of one’s wishes has been previously highlighted [14]: in dubious cases, as when the patient is presenting an average breast size without significant ptosis, the patient should decide whether to go for a concentric circular technique (in order to avoid horizontal scarring, but undergo multiple staged surgeries if necessary), or a free nipple graft technique (in order to avoid multiple surgeries, but accepting the long horizontal scarring). To date, no algorithm has been validated by an evidence-based science [14].

24.2.2 Surgical Techniques

Common surgical techniques for CCM are hereby presented; mostly, these techniques were originally described for cis men presenting with gynecomastia.

Semicircular Technique: This is used for small volume breast, and it leaves inconspicuous scar, which is located at the inferior border of the areola [19].

Concentric Circular: This is used for average size breast (variable, according to the authors, and anyway less than 300 cc). Two circles are drawn: the first outside the areola, and the second within the same areola; the skin between the circles is de-epithelialized, a dermo-glandular pedicle is harvested, and the breast is removed. Although with this technique long scars are avoided, there is an higher risk of bleeding if compared to the amputation with free nipple graft technique, and scar revisions are not uncommon [14, 20]. Pre-op and post-op result of this technique is shown in Figs. 24.1 and 24.2.

Fig. 24.1
figure 1

Breast in trans man patient, with indication to concentric circular mastectomy

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Fig. 24.2
figure 2

Post-operative outcome following concentric circular mastectomy in patient from Fig. 24.1

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Amputation with Free Nipple Graft: This is used for ptotic, or large breasts.

The incision is positioned onto the inframammary fold, and the NAC is harvested as a graft and transplanted to a new position. This is a reliable technique, although the (low) risk of bad scarring and NAC necrosis, and the permanent presence of a long scar all over the chest wall [14, 21,22,23]. Pre-op and post-op result of this technique is shown is Figs. 24.3 and 24.4.

Fig. 24.3
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Breast in trans man patient, with indication to amputation with free NAC graft mastectomy

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Fig. 24.4
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Post-operative outcome following amputation with free NAC graft mastectomy in patient from Fig. 24.3

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Technique Variations and Revisions Surgeries: Other less common techniques consist in breast reduction techniques with pedicled NAC flap (which are usually leaving extended scars) [14, 17, 19]; extended concentric circular techniques (scars are positioned horizontally, medially, and laterally to the circular peri-areolar scar; this technique is used today quite exclusively for secondary cases) [14,15,16]; liposuction (which is rarely used alone, but mostly in combination with other techniques or for revision surgery) [14,15,16,17]; lipofilling for revision surgeries [14,15,16,17]. In fact, following the primary surgery, patients might still seek for reducing residual skin or breast tissue; better contouring the chest wall with fat grafting; revising scars; and reshaping or resizing the NAC. Usually, the revision rate is up to 25% [14].

In addition to the surgical techniques presented above, patients might also ask to reduce the nipple itself: techniques are various and none is standard.

24.2.3 Post-Operative Rehabilitation and Cancer Prevention

Post-operative care is easy: patients can return to full physical activities usually in 6 weeks following the surgery.

Complications are variable from 0% to 14% and consist in bleeding/hematoma, seroma, infection, wound dehiscence, hypertrophic/keloid scarring; asymmetrical shape of chest contour (i.e., asymmetrical distribution of the residual skin or breast tissue), asymmetrical size and/or position of the NAC; loss of tactile and erogenous sensitivity of NAC and breast skin; and NAC malposition and/or necrosis [14].

Regardless of the operative technique used, some small amount of breast tissue might be left in place voluntarily. In fact, small amount of breast tissue can be used to resemble the pectoralis muscle, or simply to create a larger chest size in people with higher BMI, thus helping for achieving a contour more proportionated to the rest of the upper body.

Finally, it is unclear to what extent CCM is reducing the risk of breast cancer; it is also unclear whether the testosterone therapy is preventing or, in selected cases, triggering the occurrence of breast cancer; thus, research is needed to draw evidence-based guidelines to recommend which patients should be followed up for prevention of breast cancer, and which radiological examination should be used.

24.3 Penis Reconstruction

Penis reconstruction has different goals, as according to patients’ wishes.

Ideally, it could allow patient for urination while standing, to allow for sexual penetration, and it could create a penis which can be cosmetically acceptable and let the patient to pass in social situations; the ultimate goal is always to reduce one’s GD.

The first surgery for penis reconstruction was performed by Bogoras in 1939 with bipedicled abdominal tubed flaps [24], and named peniplastica totalis; later, it was Sir Harold Gillies [25] who performed the first (multi-staged) phalloplasty to a trans man person, Dr. Gillon, in the UK in the 30’s. Techniques for phalloplasty have evolved from local flaps (such as suprapubic and groin flaps), to microsurgical flaps (such as free radial forearm flap, fibula free flap, and latissimus dorsi flap). More recently, the anterolateral flap has been more commonly performed; combined flaps (e.g., anterolateral flap for penis reconstruction combined with radial forearm flap for urethra reconstruction) have been described, both for primary as well as for secondary cases.

As an alternative to phalloplasty, a metoidioplasty can be performed to elongate a clitoris to construct a penis of small size [26,27,28].

To date, not every trans man is keen to go through all the surgical steps leading to a full functioning penis. In fact, a non-surgical alternative is possible: many patients are seeking for an external prothesis shaped as a penis (Fig. 24.5), which is usually custom made of medical silicone by a specialized anaplastologist.

Fig. 24.5
figure 5

Penile prosthesis, usually used by trans men as packer

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24.3.1 Surgical Planning

As to a previous publication from our group from Sahlgrenska University Hospital [8], patients’ wishes are different, and one’s identity is indicative for one’s choice: non-binary AFAB persons are likely not to be interested in the ability for active penetrative sexual intercourses with a reconstructed penis, and they are likely to keep the vagina; on the other hand, binary trans men are likely to seek for a full-functioning penis (i.e., ability for urinating while standing, and for penetration) and for removal of the vagina; trans men are also requesting for the ejaculation function which—to date—has not been developed yet by surgeons. Common to all patients is to keep the original erogenous sensation (triggered from the clitoris), and possibly to have it triggered also from the reconstructed penis.

Thus, due to the many possible surgical approaches, the informative sessions and the decision-making process are key to the final success of the operation. Firstly, patients should be screened by a mental health professional for not presenting unrealistic expectations or a wishful thinking [29]; in fact, the psychologist takes account of patients’ wishes and fears, and understands how meeting (or not) one’s own goals shall impact one’s GD. Secondly, patients are meeting the surgeon (s) and expressing specific priorities in merit to what they want to achieve with the surgery; at this time, the surgeon can examine the anatomy (size of clitoris, presence of adequate fat tissue at the arm and thighs, presence of hair, etc.) and discuss outcomes and risks of the various procedure; also, the surgeon clearly explain the limits of a specific procedure in relation to patient’s own goal. Usually, after the first meeting with the surgeon, patients have to think over, rediscuss and, at a later time, decide which approach and surgical technique to take [9]. Table 24.1 shows questions and significant information necessary for the decision-making process.

Table 24.1 Questions and possible decisions when discussing surgical options with the surgeon
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Due to the multiple and specific goals of each person, there is no surgical technique that can be considered as the gold standard for penis reconstruction. In fact, many AFAB patients simply go for CCM, and they avoid any type of surgery to their genitals, while others might opt for a simple elongation of the clitoris to create a micropenis (metoidioplasty), or for a phalloplasty (with local or distant flaps). None of these surgical approaches and techniques has to be considered substandard, and no technique could be considered the ultimate one for penis reconstruction, regardless the complexity of some of these, and regardless the multiple functional outcomes achievable.

24.3.2 Surgical Techniques

General information on specific surgical techniques is hereby presented.

Either metoidioplasty or phalloplasty can be differently combined with urethra reconstruction, vaginoplasty, scrotoplasty, insertion of testicle, and erection implants. Table 24.2 is listing limits and benefits for the most common used and described techniques [26]. It must be stressed that, to date, scientific literature is not presenting high level of evidence manuscripts reporting on patient reported outcome measurements at long-term follow-up.

Table 24.2 Techniques for penis reconstruction in trans men
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24.3.2.1 Metoidioplasty

This surgical technique [26,27,28] is based on the procedures for correction of microphallus, have later described as metoidioplasty by Lebovic and Laub [30, 31], or clitoris-penoid by Eicher [32]. Urethral lengthening and surgical refinements were described by Hage [33] and Perovic [34].

Usually, this surgery is possible only in case of an hypertrophied clitoris following the hormonal (testosterone) therapy. Some patients are also using vacuum devices pre- and post-operatively; however, its effectiveness in enlarging the clitoris or the reconstructed penis has not been validated.

Nowadays, metoidioplasty can be performed with or without urethra reconstruction for urinary function, and with or without removal of the vaginal mucosa and closure of the cavity (vaginectomy).

For urethra reconstruction, surgeons might use vaginal flap, vaginal mucosa graft, local labia minora, or buccal mucosa graft; all combinations are possible. Whenever a urinary tract reconstruction is attempted, urinary complications such as fistulas, strictures, post-operative urinary infections, and urinary leakage (sometimes simple dribbling) are possible and not uncommon [12].

Patients might opt for testicle implants at the time of the primary operation, or later on. Patients might also opt to have a scrotal pouch reconstruction (using labia majora as according to the Hoebeke technique [35]) or to insert the implants directly into the labia majora (Fig. 24.6).

Fig. 24.6
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Metoidioplasty with urethra reconstruction, vaginectomy, and testicle implant inserted directly into the labia majora

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Compared to other techniques for phalloplasty, metoidioplasty has a shorter hospital stay, there is no additional donor site morbidity from other parts of the body, and it should keep erogenous sensitivity; also, half of the patients able to void whilst standing [33, 34, 36]. Downside is that the phallus created is short (with a mean of 5.7 cm—range 4–10 cm) [33]; finally, few patients are claiming to be able for penetrative sexual intercourse [28].

24.3.2.2 Phalloplasty

The penile shaft can be constructed with local flaps such as the supra-pubic flap or groin flap; free radial forearm flap (Fig. 24.7); pedicled antero-lateral thigh flap (rarely performed as a free flap) (Fig. 24.8); free latissimus dorsi flap. Although performed in the past, there are no recent reports of free fibula flap in the literature [26,27,28].

Fig. 24.7
figure 7

Phalloplasty with free RFF, vaginectomy and scrotoplasty (according to the Hoebeke’s technique). The urethra has been reconstructed rolling the fee RFF as a tube-within-a-tube. The patient also got testicle and erection implants (post-op result 1 week following testicle and erection implants)

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Fig. 24.8
figure 8

This patient originally underwent metoidioplasty with urethra reconstruction; later, he has decided to go for phalloplasty. This figure is showing the phalloplasty with combined ALT flap for shaft reconstruction, free RFF for urethra reconstruction, vaginectomy, and scrotoplasty (according to the Hoebeke’s technique). The patient is planned for glans reconstruction with the Norfolk’s technique, testicle and erection implants, at a later stage

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Phalloplasty can be performed: with or without urethra reconstruction for urinary function, and with or without removal of the vaginal mucosa and closure of the cavity (vaginectomy).

When a urethra reconstruction is attempted, the pars fixa of the urethra (from the original meatus to the base of the penis) is reconstructed as done for the metoidioplasty (i.e., by displacing the clitoris upward and using the labia minora, and eventually a small vaginal flap).

More options are possible for the reconstruction of the pars pendulans (penile urethra).

For penis reconstruction with local flap such as suprapubic and groin, vaginal epithelium graft and tubularized skin can be used; however, this technique is seldom able to reach the tip of the phallus [12, 37].

In case of a radial forearm free flap phalloplasty, the pars pendula is reconstructed rolling the flap as a tube-within-a-tube, with the ulnar part being the urethra; with an antero-lateral thigh flap, the urethra can be reconstructed by rolling the same flap as a tube-within-a-tube, but this is possible only if the flap is very thin; differently, the urethra has to be reconstructed with a free radial forearm flap, or with a superficial circumflex iliac artery perforator (SCIAP) flap. Pre-fabricating the urethra within the same flap has also been described when free RFF and ALT have been used for penile shaft construction.

As for metoidioplasty, whenever a urinary tract reconstruction is attempted, urinary complications (fistulas, strictures, post-operative urinary infections and urinary leakage or dribbling) are common. Thus, patients must be really motivated to undergo urethra reconstruction. Indeed, an unsuccessful attempt for urethra reconstruction can always be converted in a permanent urethral perineostomy, thus returning to a similar situation as to pre-operatively [12].

In order to provide the penis with erogenous sensation, the clitoris can be displaced at the base of the new phallus. Also, cutaneous nerves from flaps such as RFF and ALT can be connected to the dorsal nerves of the clitoris, and to the ilioinguinal nerve [12].

Finally, to shape the tip of the penis as glans and providing a coronal sulcus, the ‘Norfolk’ technique can be used [38], regardless the type of flap chosen for phalloplasty. The glans can later be tattooed.

Reconstructions of specific complications using flaps are partial and total necrosis; the risk for total necrosis for free flap reconstruction is up to 2%.

24.3.2.3 Vaginectomy

A submucosa vaginectomy can be performed, usually at the time of the metoidioplasty or phalloplasty. This consists in removing the mucosa of the vagina only. In order not to leave residual mucosa in place, gynaecologists usually recommend to remove the uterus prior to performing the vaginectomy.

Indeed, there are patients that want to preserve the vagina for keeping the ability for penetrative intercourse; also, there are patients that are not bothered by having the vagina, since it might not affect negatively once GD, thus they prefer not undergoing surgeries with lower priority.

24.3.2.4 Scrotoplasty and Testicle Implants

When reconstructing the scrotum, surgeons must plan for both reconstructing of the scrotal envelope and providing volume and internal shape which, in a cis man, is obtained by the presence of two testicles.

Thus, the easiest technique is to insert oval-shaped silicone implants (named ‘testicle implants’ by the manufacturers) directly into the labia majora. However, the result of this approach results in two separate pouches, which indeed can be joined together, usually in a second stage. However, this approach does not locate the testicle in the natural position, which is obtained only when the scrotum is presenting some degree of ptosis. Thus, Hoebeke [35] developed a technique consisting in harvesting and rotating (medially) two superiorly-based labia majora flaps. This technique achieves confer the scrotum ptosis and an anterior position. In a following stage, testicle implants can be inserted.

24.3.2.5 Erection Implants

When requested by the patient, an erection implant can be inserted. In order to prevent decubitus and extrusion of the implant, best is to insert it when the penile shaft has gained full tactile (or erogenous) sensation, which is usually happening around 1 year following the phalloplasty with nerve anastomosis.

Few literature is reporting on the use of erectile implants following penis reconstruction in trans men. Specifically, there are several complications associated with implant placement in the reconstructed penis, such as hematoma, infection, urinary fistulas and strictures, partial or total penis necrosis, as well as implant deformity [39,40,41,42].

Different implants have been used during the years, and these were originally manufactured for cis men with impotence, thus, these were planned for a different anatomy (corpora cavernosa vs. operated tissue) and to be, usually, in an older population group. Both malleable (Draphase, Spectra, Coloplast) and inflatable implants (Dynaflex, AMS, Coloplast) have been tested. Finally, erection implants specific for trans men post phalloplasty have been manufactured by ZSI. Generally, up to 50% of the implants need to be explanted at 5 years follow-up, usually because of infection, extrusion, or pubic pain [39, 42].

24.3.3 Pre-Operative Preparations

Patients are requested to stop smoking completely 6 weeks prior to surgery, and their BMI should be less than 30.

Electrolysis epilation is fundamental for nearly every patient that have been planned for urethroplasty with any hair-bearing tissue, e.g., a radial forearm flap.

The epilation regimen might take 6–12 months, depending on the amount and type of hair follicles. Normally, patients undergo one epilation session every 3–4 weeks. Last epilation session should not be closer than 3 weeks to the surgery. Besides epilation to the tissue going to be urethra, the tissue to become penile shaft (such as the dorsal and radial part of the forearm in a full RFF penile reconstruction, or the thigh for an ALT flap) also needs to be epilated; still, this could be done successively to the surgery.

Patients are suspending the hormonal therapy 3–4 weeks prior to surgery, in order to reduce the risk for DVT. Seven to ten days before surgery, it is advised not to use any medication or food supplements affecting the coagulation system.

Patients start Clexane (5000 UI) the night before the surgery; this therapy is maintained until discharge. In the morning prior to surgery, patients receive one tablet of Bactrim forte as prophylaxis antibiotic.

24.3.3.1 Post-Operative Rehabilitation

Post-operative care is easier when urethra has not been reconstructed; although patients without urinary complications might return to full physical activities usually in 6 weeks following the surgery, the majority needs post-op urinary controls for dribbling/leakage of urine, and for possible urinary infections and stenosis in the future.

Since the surgery for penis reconstruction is usually multi-staged, the entire peri-operative period (from pre-op examinations to the completion of the last stage), can take up to 2 years or more.

Additionally, those who have undergone erectile implant placement might need to follow up, and eventually replace, the same erection implant.

24.3.3.2 Ongoing Researches

Recently, researches have been performed to bone-anchor the external prosthesis (named ‘epithesis’) by titanium screws, which can osteointegration into the pubic bones. Although first clinical cases have been described, this is still experimental: silicone penile epithesis prototypes need further development, and then, these prototypes need to be tested on a large scale of patients [43].

Also, after the first four successful cases of penis transplantation to cis man, research programs for penis transplantation to trans men have started and first manuscripts on surgical anatomy have been published [44,45,46].

Finally, many preclinical researches have been conducted on engineered urethra reconstruction: no applications in humans have been reported [47].