Author: Georgia Miliotou, Cyprus, Foundation Programme in UK
Gender dysphoria1 is stated as the conflict between a person’s assigned gender and their gender identity, which causes significant distress, and it is associated with high rates of suicide. A combined treatment of hormonal, surgical and psychotherapeutic approach is suggested by the SOC of WPATH2. Limited data is available on the prevalence of transgender people since only after the completion of transition, a certificate is legally awarded.
Before any surgical approach, communication between the surgeon and mental health provider is essential to confirm the diagnosis and cater to each patient’s specific needs2,3,4.
Transfemale genitalia surgery
A natural-appearing vagina and mons pubis are accomplished by the removal of male scrotum, the construction of a sensate neoclitoris and the creation of labia majora and minora, and adequate vaginal depth. Breast augmentation, thyroid chondroplasty and facial feminization may follow.
There are three neovaginal construction techniques: penile inversion vaginoplasty, intestinal transplantation or nongenital flaps. In the first one, the vaginal cavity is formed by the pedicled penile skin flap, a posterior scrotal-perineal flap (fig1) and supplementary skin graft. To avoid any hair growth in the introitus, a period of 3-6 months of laser hair removal precedes the surgery4. Intestinal transposition is the procedure of choice, in which a vascularized 12-15 cm vagina with a moist lining is created, allowing opting out of vaginal dilation procedure and lubrication during intercourse. However, an intra-abdominal operation with a bowel anastomosis is required, and a malodorous vaginal discharge could get noticed. In all techniques, the lateral periscrotal skin is used in the formation of labia majora, and the penile base skin and urethral flap for the labia minora, whereas the neoclitoris is formed from the penile dorsal glans. The neoclitoris perfusion comes from the dorsal penile artery and sensation from the dorsal penile nerve. Additionally, the male urethra is shortened, spatulated and everted. Beside standard surgical complications, vaginal stenosis, rectovaginal fistula, hematoma, and loss of sensation are expected, although they rarely occur4.
Labiaplasty is performed under local anaesthesia at a subsequent time. Additional contouring of the area and clitoral hooding are provided4.
Transmen genitalia surgery
The goal in this occasion is an aesthetically pleasing phallus with sufficient length for vaginal penetration, sensate and capable of voiding in standing position. Phalloplasty is the final stage of a series of complex procedures. As to chest surgery, due to minimal influence of hormonal treatment in breast size, bilateral subcutaneous mastectomy and contouring are essential. Repositioning and resizing of the nipple-areola complex follows when necessary. Hematoma, nipple necrosis and abscess formation are the main complications. Rarely, breast cancer is reported after mastectomy due to incomplete glandular resection4.
Metoidioplasty is the preferable method for lengthening the hypertrophied clitoris, by degloving the suspensory ligament from the pubic bone, releasing the ventral clitoral curvature and lengthening the female urethra with the aid of labia minora and occasionally the use of vaginal musculomucosal flaps. Removal of the female genitalia (vaginectomy) is often involved, while hysterectomy and oophorectomy were performed in advance.
There are two techniques used in phalloplasty; pedicled flaps which transfer tissue from thigh, groin or lower abdomen, and free flaps which involve a flap from the radial forearm. Overall, the radial forearm-free flap is preferred, due to blood vessels and nerves transfer, allowing a single-stage reconstruction of a sensate phallus and glans penis. A technique called “tube-in-a-tube” is performed, where the flat is tubed around a Foley catheter while still attached to the forearm, creating the neourethra4. Testicular implants and an erectile device can be placed after the complete healing of the neophallus4. Phallic loss, infection, hematoma and urinary stricture or fistulae are among the most common complications.
One of the most delicate issues is post-operatively fertility. Infertility is caused by orchiectomy in trans-women and by hysterectomy and oophorectomy in trans-men. Hormonal therapy causes significant reversible fertility impairment. Cryopreservation of gametes or embryos is recommended in case of post-operatively desire of offspring. A uterus transplantation may be a crucial development for the fertility of transwomen, in the future3.
Neoclitoral sensitivity, in traswomen, contributed to more intense orgasms than before, as well as an enjoyment with the neovaginal canal5.
Respectively the use of radial forearm flap in phalloplasty has great sensitivity, and since the denuded clitoris is placed below the phallic shaft, it enables a sexual satisfaction in trasmen.
Gender surgery is a rapidly evolving domain, offering a better quality of life for transgenders. A long-term postoperative care and follow-up must be set2.
 American Psychiatric Association. Gender Dysphoria. Diagnostic and Statistical Manual of Mental Disorders, 5th edition. 2013. doi:10.1176/appi.books.9780890425596.dsm14 (checked January 2021)
 World Professional Association for Transgender Health, Standards of Care. 2011;V7 (checked January 2021)
 Bizic, M.R., et al. Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed Res Int. 2018;ID: 9652305
 Schecter, L.S., et al. Gender Confirmation Surgery. Tran Hea. 2016;10.1089/trgh.2015.0006
 Hess, J., Sexuality after Male-to-Female Gender Affirmation Surgery. BioMed Res Inte. 2018;ID: 9037979
Figure 1: Mukai, Y., et al. Vaginoplasty with a Pudendal-groin Flap in Male-to-female Transsexuals. 2017. Acta Med. Okayama. Vol. 71, No. 5, pp. 399-405
Figure 2: Vukadinovic, V., et al. The Role of Clitoral Anatomy in Female to Male Sex Reassignment Surgery. Hind Publ Corp. 2014. http://dx.org/10.1155/2014/437378