Chest surgery during a sex change

Following hormonal treatment, the next step is usually top surgery (chest surgery). There are many different methods for performing this surgery, and is often determined by the results you want, and the size of your breasts. Your therapist will be able to put you in contact with a surgeon.

The options for chest surgery include: keyhole, drawstring, pie wedge, and double incision.

Keyhole and drawstring techniques
The keyhole and drawstring techniques are for people with very small breasts (A-cup size). When performing a keyhole procedure, the surgeon makes an incision around the areolar ring, inserts a liposuction device, and vacuums out the fatty tissue comprising the breast. With this technique, the mammary glands are usually left intact.

Drawbacks are that small deposits of fatty tissue may remain in the chest or the finished areola may be too large in comparison with the typical male chest. Advantages are little or no apparent scarring, and retention of nipple sensation.

The drawstring technique entails lifting the areolar ring away without disconnecting the nerves, and suctioning the breast and fatty tissue. Excess skin is trimmed and then pulled toward the centre of the opening, and the nipple is reattached covering the opening. Disadvantages are the same as for keyhole, and the nipple placement may be unnaturally low on the chest.

Pie wedge technique
The pie wedge technique creates a scar from the outer edge of each nipple towards the underarm, or sometimes straight down from the nipple. Usually this procedure is done with small to medium breasts. Many FTMs are dissatisfied with the appearance of the scars because they are so symmetrical and obviously breast-related.

Double incision technique
The double incision technique is the most common. Each breast is opened horizontally across the chest below the nipple. Breast and fatty tissue is cut and scraped away. The top skin panel is then brought down smooth and the skin is trimmed and sutured to the lower panel at the incision. The nipples are removed, resized to make them more masculine-looking, and grafted back onto the chest in the appropriate place. Disadvantages are loss of nipple sensation and scarring, though some nipple sensation may return over a period of months or years.

A hysterectomy is often undergone, in order to remove all high risk cells that could become cancerous due to testosterone intake.

FTM genital reconstruction

The last surgery that is undergone in female to male (FTM) reassignment treatment journey, and which is undergone by very few FTM transsexuals, is bottom surgery.

As with the case of top surgery, there are different techniques. Many FTMs don't opt for bottom surgery, as the surgical techniques are not very advanced, and there is more to being a man than the presence or absence of a penis.

Genital reconstruction is a lot more expensive and has far greater risks than top surgery.

Two options
Genital reconstruction falls into two basic types: phalloplasty and metoidioplasty.

The more contemporary phalloplasty technique is called the free tissue flap transfer (FTFT). This technique has been made possible by the advent of microsurgery, and the development of the fine art of connecting dissimilar nerves. A flap of skin and muscle tissue from the forearm, groin, or thigh, is transferred with its existing nerves and blood vessels to the groin area, and then microsurgically connecting the nerves and blood vessels to the nerves and blood vessels of the groin.

This results in a penis that may have feeling, but is not capable of achieving or sustaining an erection. Although implants are available to achieve erection, they have so far proven to be problematic due to infections, rejection by the body, and extrusion and intrusion.

The metoidioplasty technique is the other available technique for creating a penis-like structure on an FTM. This technique uses the clitoris, and transforms it into a more male-looking structure, providing there has been sufficient clitoral growth induced by testosterone. The process involves the release of the clitoris, which basically means that the ligaments that hold the clitoris in a position are severed. The result is a micro-penis. The scrotum is formed by joining the labia majora and using silicone testicular implants, sometimes preceded by tissue expanders.

This procedure allows the FTM to have a penis that is normal in appearance, with a natural glans and foreskin, as well as the appropriately sized scrotum. Sexual function is retained, and the FTM can have natural erections and orgasms.

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