Gender Affirmation Surgery

Our team at the Erie County Medical Center offers services for gender transition. The team includes specialists in Plastic Surgery, Reconstructive Urology, Gynecology, and Psychology who all work together to provide both surgical procedures and support for our transgender patients. Our goal is a functional and aesthetically pleasing result, with the focus being on patient safety.

We strive to provide patients with the most up-to-date surgical techniques while following national guidelines for transgender surgery. Additionally, because surgery is only part of the process for patients undergoing gender transition, we also act as a portal to help our patients access mental health services and hormone therapy as needed. Patients who meet the preoperative requirements for surgery and wish to proceed can then be considered for male-to-female or female-to-male gender affirmation surgery.

Transfemale

Breast (“Top”) surgery consists of augmentation of breast tissue that has developed during the course of hormone therapy. Techniques such as placement of breast implants and fat grafting allow for improvement is size, shape, and symmetry of the breasts. These operations are done in the outpatient setting and usually do not require a hospital stay.

Genital (“Bottom”) surgery is based on the fact that male and female genitalia are homologous – meaning that they have a similar structure and origin in the developing fetus, even though they develop to have different appearance and function in adults. This common origin allows the Plastic Surgical principle of using “like to replace like” to be implemented in gender affirming vaginoplasty. In a one-stage operation, the testicles are removed (orchiectomy), the sensate scrotal skin is repurposed to form the neo-labia. The penis is dismantled with the skin inverted to create a neo- vagina (inversion vaginoplasty), the nerve and blood supply the glans or “head” of the penis is maintained and used to create a clitoris with sensation (neurovascular neo-clitoris). The urethra is shortened and moved to a female anatomic position for sitting urination, and the blood supply to the remaining urethra is maintained with the excess urethra being opened and used to line a portion of the neo-vagina. Fully utilizing the urethra in this manner provides a partial mucosal lining and some natural moisture in the neo-vagina.

The operation takes approximately 5 hours and will require a short inpatient stay. We will provide further details about this operation, typical recovery and potential complications, as well as take as much time as needed to answer your questions during an in-person consultation. Other available procedures include breast augmentation, facial feminization, and tracheal shave

Transmale

Breast (“Top”) surgery consists of removal of the patient’s breast tissue, reduction and repositioning of the nipple-areola complex, and tightening of the skin. Length and position of incisions depend on the patient’s breast size and body habitus. Transmale breast surgery is performed as an outpatient.

Genital (“Bottom”) surgery for the transmale typically refers to either phalloplasty or metoidioplasty. Hysterectomy/oophorectomy (removal of the uterus and one or both ovaries) is typically performed prior to genital surgery. Many of our patients have already undergone this procedure prior to seeing us. For those who have not, we are happy to help our patients get an appointment with one of our partners who is both experienced with transgender patients and specializes in this operation.

Phalloplasty consists of several stages in our practice. Stage 1 consists of vaginectomy with closure of the perineum along with creation of the scrotum and elongation of the urethra in preparation for creation of the phallus in the second stage operation. Several months are allowed to pass following vaginectomy before progressing to Stage 2, which is the creation of the penis (phalloplasty). We typically utilize a radial forearm free flap (RFFF) for this. The goal of phalloplasty is to provide a penis that has sexual sensation, potential for placement of an erectile device, and the ability for standing urination. Blood vessels and nerves are connected at this time, but the urethra is not connected to the phalloplasty at this time, meaning patients still need to sit to urinate until stage 3. Once the phalloplasty has completely healed, we would then progress to Stage 3, in which the urethra closure is performed which allows for standing urination via the phalloplasty once healed. This would usually be scheduled 3-4 months after Stage 2. In our opinion, staging phalloplasty reduces the severity of complications as well as decreasing or even elimination the amount of time a suprapubic catheter is needed to drain the bladder.

Metoidioplasty is a less extensive operation in which the urethra is elongated and positioned with the clitoris in a way that allows for standing urination, but not penetrative intercourse. The advantages of metoidioplasty are a single-stage operation with decreased hospital stay and complications compared to phalloplasty.

We are happy provide further details about these operations, typical recovery and potential complications, as well as take as much time as needed to answer your questions during an in-person consultation.