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Vulvoplasty (also called “zero-depth vaginoplasty” or "minimal depth vaginoplasty") is surgery to create an external vulva including labia majora, labia minora, and clitoris without creating a vaginal canal. The vulva is created using skin from the penis and scrotum. Because there is no vaginal canal created, patients do not need to perform vaginal dilation.

Metoidioplasty is surgery to create a penis using only tissue from the genital region. The clitoris is released from its surrounding attachments and allowed to hang further away from the body creating a penile shaft. Metoidioplasty is often combined with vaginectomy and scrotoplasty. In this case, the labia minora is used to elongate the urethra and the labia majora and perineal skin is used to create the scrotum. Metoidioplasty recovery is typically much easier than phalloplasty. However, metoidioplasty frequently does not provide enough penile length toperform penetrative intercourse.

Phalloplasty is surgery to create a penis using tissue from somewhere other than the genital region. Radial forearm phalloplasty uses skin and fat from the forearm. This tissue is shaped into a penis and transferred to the pubic area where the blood vessels and nerves from the new penis are connected to the blood vessels and nerves in the pelvic region using the operating microscope. The skin that is removed from the forearm is replaced with a skin graft taken from the thigh.

When combined with urethral lengthening (“UL”), radial forearm phalloplasty allows for standing to pee. In this approach, the forearm tissue is wrapped into an inner tube which forms the urethra and an outer tube which forms the penis shaft. This is called a “tube-in-tube” design.

When combined with erectile device, radial forearm phalloplasty allows for penetrative sexual intercourse.

Phalloplasty can be combined with vaginectomy and scrotoplasty in a single surgery or can be performed separately.

Phalloplasty is surgery to create a penis using tissue from somewhere other than the genital region. Anterolateral thigh phalloplasty uses skin and fat from the thigh. This tissue is shaped into a penis and transferred to the pubic area where the nerves from the new penis are connected to the nerves in the pelvic region using the operating microscope. The thigh tissue is close enough to the pubic area that the blood vessels often can be repositioned without being cut, although this can vary based on anatomy. The skin that is removed from the thigh is replaced with a skin graft taken from the other thigh.

When combined with urethral lengthening (“UL”), anterolateral thigh phalloplasty allows for standing to pee. The technique used to create a urethra depends on patient anatomy and thigh thickness. In a very small subset of patients the thigh skin is thin enough to be wrapped around itself in a “tube-in-tube” design where the thigh skin creates both the urethra and the penis shaft. In the vast majority of patients the thigh skin is too thick for a tube-in-tube design. For these patients we prefer a 3-stage approach. In stage 1 the thigh tissue is used to create the penis shaft. In stage 2 the penis is split and a skin graft is applied to the underside of the penis. In stage 3 the penis is retubularized and the healed skin graft becomes the urethra.

When combined with an erectile device, anterolateral thigh phalloplasty allows for penetrative sexual intercourse.

Phalloplasty can be combined with vaginectomy and scrotoplasty in a single surgery or can be performed separately.

Vaginectomy is surgery to remove the vaginal canal. This procedure is frequently combined with scrotoplasty and metoidioplasty or phalloplasty. In order to have vaginectomy, patients need to have had their uterus removed (hysterectomy).

Scrotoplasty is surgery to create a scrotum using tissue from the labia majora and perineum. This procedure is frequently combined with scrotoplasty and metoidioplasty or phalloplasty. Once the scrotum is healed, testicular implants can be inserted in a second surgery to provide more volume.

Urethral lengthening is surgery to elongate the urethra. This procedure can be included as a part of phalloplasty for patients who want to stand to pee. The technique for creating the urethra depends on the type of phalloplasty performed. With a radial forearm (RFFF) phalloplasty, a tube-in-tube design is used where the urethra is made with part of the forearm skin in a single surgery. With an anterolateral thigh (ALT) phalloplasty, skin graft taken from the thigh is used for the urethra. This process occurs over 3 different surgeries.

To perform urethral lengthening safely, vaginectomy is required either before or at the time of urethral lengthening.

Glansplasty is surgery to create a penile glans after phalloplasty. This procedure involves rearranging skin at the tip of the penis to form the coronal ridge and taking a small skin graft from the hip to line the area next to the coronal ridge. Glansplasty is performed after the phalloplasty has healed and is often combined with testicular implant insertion.

Testicular implants are implants can be placed following scrotoplasty. The maximum implant size is determined by the patient’s anatomy.

Erectile devices are implants that are inserted into a penis after phalloplasty to allow the patient to achieve erections for penetrative sexual intercourse. Erectile device options include inflatable penile prostheses (IPP) and malleable penile prostheses (MPP).

An inflatable penile prosthesis can be inflated and deflated using a pump located in the scrotum which allows the penis to be transitioned from flaccid to erect at the patient’s discretion. A malleable penile prosthesis is a penile implant that does not change size and maintains the penis in a semi-erect state at all times. Unlike inflatable prostheses, malleable prostheses do not require cycling or pump maintenance.

Item descriptionLymphatic reconstruction is surgery to address chronic fluid build-up related to damaged lymphatic structures (lymphedema). Lymphedema can occur in the hand or forearm following radial forearm phalloplasty when the lymphatic channels in the hand are cut. Lymphatic reconstruction involves using the operating microscope to identify the cut ends of the lymphatic channels and redirect those channels into adjacent veins.

Mastectomy is surgery to remove the breasts to create a flat chest. The incision pattern used depends on patient anatomy and preference. The most common incision patterns are straight line incisions that sit in the pectoralis shadow combined with nipple grafts (“double incision”) and curved incisions that sit in the border of the areola (“periareolar”). A smaller group of patients are candidates for the “inferior ellipse” technique which involves a straight line incision in the pectoralis shadow without removing and replacing the nipples.

With double incision mastectomy, patients can choose whether or not to keep their nipples. For patients who want to preserve their nipples, the nipple is removed and replaced onto the chest as a skin graft. For periareolar and inferior ellipse mastectomy, the nipples are not removed.

Standard mastectomy techniques involve cutting the nerves that bring sensation to the chest and nipple skin. Sensation-recovering mastectomy involves reconstructing these cut nerves to restore some of the sensation that is lost when the nerves are cut.

Breast reduction is surgery to reduce the size of the breast without creating a completely flat chest. This involves an anchor incision pattern with scars around the nipple, a straight line incision from the nipple to the bottom of the breast, and a curved horizontal incision in the breast fold.

Facial feminization is a group of surgeries that emphasize the feminine appearance of the face. The specific components involved depend on the patient’s anatomy and specific goals. Common components of facial feminization include frontal bone contouring, brow lift, rhinoplasty, cheek implants, mandible contouring, genioplasty, tracheal shave, and fat grafting to the lips.

Facial masculinization is a group of surgeries that emphasize the masculine appearance of the face. The specific components involved depend on the patient’s anatomy and specific goals. Common components of facial masculinization include frontal bone augmentation, mandible augmentation, genioplasty, and rhinoplasty.