Surgery for Trans Men and Non-binary People Assigned Female at Birth
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Surgery for Trans Men and Non-binary People Assigned Female at Birth

There are many surgical options available. It is important to remember that each individual will have different needs, desires, and ability to undergo these procedures. An individualised care plan should be developed for each trans person; this care plan may change over time. Procedures can happen in many different orders and configurations.

In Malta, there is no linkage between accessing legal gender recognition procedures and a history of surgical interventions; it is illegal to require surgeries or proof of treatment in the process of legal gender recognition.

Breast removal/chest reconstruction
In a mammectomy, a male chest is constructed by removing the mammary gland tissue. If necessary, the nipple and areola are also reduced, in combination with a correction of the excess skin. Different techniques are used for this operation, depending on the volume of the breasts, the excess skin, the elasticity of the skin, the nipples and the areola (Monstrey et al. 2008).

After this operation, possible complications include haemorrhages and infections. Nipples can heal unevenly, and scars can remain visible. The less elastic the skin, the more chance of complications and scarring. It is therefore strongly advised against binding the breasts with, for example, bandages, since pushing the breasts flat stretches the skin. It should be noted that nowadays the quality of these surgeries is often high and many trans people are satisfied with the results. They are usually safe and reliable.

Hysterectomy
In a hysterectomy and oophorectomy, the uterus, cervix, ovaries and fallopian tubes are removed. This procedure is usually done via a laparoscopic route via three small incisions in the abdominal wall, though other methods are also possible, including via abdominal incision. The laparoscopic method results in minimal scarring afterwards and limited postoperative pain . However, there is always a chance that during the procedure, complications might arise and it is decided to open the abdomen via a classic 'bikini cut'.

This intervention is available on the NHS through the Gender Wellbeing Clinic.

Metoidioplasty
In metoidioplasty, the clitoris is used to make a small penis. The clitoris is moved into a higher position and the urethra can be extended to the tip of the clitoris. The final functionality is determined by the length of the clitoris, which can vary greatly and will be influenced by age of onset of the testosterone hormonal therapy. For some, the clitoris grows sharply, so that standing peeing becomes possible during reconstruction. However, this is not the case with the majority.

For the construction of the scrotum, tissue from the outer labia is used, which is transferred forward and rotated to get the testicular sac in the right place. Subcutaneous adipose tissue from the venous mound can be used to fill the scrotum. Over time this tissue usually shrinks, so that testicle prostheses can be placed a few months later.

Phalloplasty
Phalloplasty is the construction of the penis with a graft from the forearm, leg, or stomach. It is recommended to epilate the graft donor site a number of times to deaden the hair follicles. It is also very important to stop smoking to prevent the graft from dying.

The main types of phalloplasty are radial forearm free-flap phalloplasty; anterior lateral thigh pedicled flap phalloplasty; abdominal phalloplasty; and musculocutaneous latissimus dorsi flap phalloplasty (see here). Detailed pre- and post-operative care should be discussed with the surgeon and an endocrinologist. Trans people may also need or desire counselling before and/or after genital surgeries.

Almost all people who have this surgery can reach an orgasm after phalloplasty. In order to penetrate, an erection prosthesis is needed, which can be placed from 12 months after phalloplasty.

Testicular implants
The scrotum formed from the labia in the first procedure can be filled with testicular prostheses or implants at a later time. A minimum waiting period of 6 months after the first intervention is recommended. The testicular prosthesis are filled with silicone gel and come in various sizes. As with all implants, there is a risk of infection: in that case, it must be removed, and a waiting period of 6 months is required again before a new implant can be performed.

Erection prosthesis
An internal erection prosthesis​ is only possible after a phalloplasty. A condition for implantation of an erection prosthesis is that the sensitivity has returned to the top of the phallus, usually after 12 months. If there is no feeling, the risk of traumatic perforation of the prosthesis is higher. It is best to consider a waiting period of 12 to 18 months after the first operation.