In this article, we’re not going to go in-depth on gender affirming surgeries for gettin’ square. We will provide short descriptions of several of the most common procedures for top and bottom surgeries (including metoidioplasty and phalloplasty) and point you towards resources to learn more about your options.
Content advisory: medical and anatomical language, discussion of surgical procedures. We use “penis” and “phallus” when describing new bottom genitals.
More and more surgeons are offering highly customizable gender affirming surgery options. We’re thrilled!
You probably know by now that we think there is no one way to transition. We also believe there is no one right surgery. Your square doesn’t have to look like anyone else’s square.
Top Surgery
Resources:
Dr. Mosser’s Gender Confirmation Center has a ton of information on top surgery, including a guide on what to expect, a discussion of different techniques, and a whole section on non-binary top surgery options if you’re looking for a less traditionally squared-up chest. Genderconfirmation.com also has an excellent section on body contouring.
Top Surgery for Getting Square is when breast tissue is removed to flatten the chest. Areolas and nipples may be resized and moved or removed altogether. The type of top surgery suitable for you depends on your goals, your pre-surgery shape and size, and your skin elasticity.
Read our blogs on exercising before top surgery, returning to exercise after top surgery, and scar care!
Top Surgery Types
Periareolar Incision (Keyhole)
- Suitable for individuals with very little tissue to remove and very good skin elasticity.
- A half-circle incision is made at the bottom edge of the areola.
- No skin is removed.
- Nipples are not moved.
- Can preserve sensation.
Periareolar incision (Donut)
- Suitable for individuals with little tissue to remove and very good skin elasticity.
- A circular incision is made in the areola, which allows access to the tissue to be removed. A second circular incision is made further out, and the skin in between is removed. The skin edge is then drawn towards the areola and sutured.
- Minimal skin removal.
- Nipples are not moved.
- Can preserve sensation.
Lollipop
- Suitable for patients who have more skin to remove
- A circular incision around the areola, then a vertical incision down to the bottom of the chest tissue.
- Nipples are not moved.
- Can preserve sensation.
Double Incision
- Best suited for individuals with a moderate amount of tissue and skin to remove.
- Two incisions are made along the lower edge of the chest tissue.
- These incisions may be curved along the line of the pectoralis muscle (the pecs.)
- Areolas and nipples are removed, resized, and repositioned as a skin graft.
- May lose nipple sensation.
Nipple-Sparing Double Incision
- Incisions are made in a curved wedge shape on the outer edges of the chest.
- Nipples are moved outwards and down due to the skin edge being moved towards the abdomen and side and sutured. Can preserve nipple sensation.
Buttonhole
- Incisions are similar to double incision surgery, but areolas and nipples are resized rather than removed and repositioned.
- Can preserve sensation.
Inverted T (Anchor)
- Buttonhole with an extra vertical incision underneath each nipple
- Suited for individuals with a greater amount of tissue and skin to remove.
- Three incisions: a circular incision around the areola, a curved horizontal one at the bottom edge of the chest tissue, and a vertical connecting incision.
- Can preserve sensation – tissue is removed around the nipple “pedicle,” then the skin is pulled towards the nipple and vertical incision.
Fishmouth
- Incisions are horizontal at the level of the nipple from the outside edge to the areola, around the areola, and then horizontally to the center of the chest.
- Suited for individuals who want a very flat look and don’t mind an untraditional scar.
- Can preserve sensation.
Bottom Surgeries
Metoidioplasty (Meta)
In a metoidioplasty, erectile tissue (usually after bottom growth from T) is moved forward and potentially higher on the pubic bone by separating the connective tissues that hold the clitoris in place.
This lengthening of the new penis may be combined with tissue taken from the labia minora (the inner labia) to increase the girth of the penis. A vaginectomy is not required.
Sensitivity is usually not changed.
Metoidioplasty with Urethral Lengthening
In addition to a meta, the tissues of the labia minora (and perhaps other tissues) are used to lengthen the urethra so that the opening where urine leaves the body is at the tip of the new penis. A vaginectomy may be required. Sensitivity is likely to remain.
Meta Resources:
Dr. Santucci of the Crane Center’s Ask Me Anything on Metoidioplasty (note, binary language)
OHSU’s Metoidioplasty Guide
Phalloplasty (Phallo)
In a phalloplasty, skin from another part of the body is used to create the shaft of the penis. Phalloplasty often requires several procedures in a row. This is called staging.
Staging
Staging varies according to what procedures are planned and the surgeon’s style of practice. In general, the order of surgeries is:
- Creation of the new phallus by a tissue graft
- May include the creation of a new urethra
- Creation of glans and scrotum
- May include connecting the new urethra to the bladder
- Implants for erections and testicles
Deciding what kind of phalloplasty to get is highly personal and includes such considerations as:
- how much sensation is desired
- how much length is desired
- how much scarring is acceptable
- where that scarring is
- whether erections and penetrative ability are desired
- cost and time
- whether to keep or remove the vagina
Resources for Phallo
OHSU’s Phalloplasty Guide is a comprehensive look at making these decisions for three types of phalloplasty (radial forearm free flap, anterior lateral thigh flap, and abdominal flap.) It provides extensive information about what to expect during surgery preparation and recovery.
Phallo.net is a detailed website dedicated to all things phallo and has a great guide to the different techniques. It can be pretty technical but does discuss each surgery option in-depth. Pictures and links to surgeons performing each type of surgery are available. Often surgeons will have photos on their individual web pages or their clinic’s web pages. Phallo.net also provides a guide to hair removal for phalloplasty and a link page to phalloplasty blogs for first-person accounts of phalloplasties.
Types of Phalloplasties
Phalloplasties are generally divided into two different types:
- free skin flap, where a section of skin is completely removed from a donor site on the body and used to create the shaft of the new penis, and
- pedicle surgery, where a section of skin is moved but maintains blood supply from the original site.
Some techniques combine the two styles – a pedicled flap for the penis and a free flap for the urethra lengthening. The clitoris and clitoral nerves may be incorporated into the new penis to maintain erotic sensation.
Additional procedures that may be done in conjunction with phalloplasty include:
- Urethral lengthening to allow the person to pee standing up. Urethral lengthening requires hair removal.
- Erectile devices may be implanted.
- Glansplasty – creates a glans/head of the penis
- Glans implants – shapes a glans/head of the penis
- Plastic surgery to create a corona – the ridge between the glans and shaft
- Scrotoplasty – creates a scrotum. Scrotal implants may be added.
- Vaginectomy may be done: some phalloplasty procedures require vaginectomy, and some don’t.
Free Skin Flap Phallo
Common sites for the skin flap:
- Forearm – may provide better sensitivity and aesthetics (radial forearm free flap)
- Thigh – may allow for greater length. It may be easier to cover scars (anterior lateral thigh flap)
- Back – may mean less scarring and less need for an erectile device (MLD, or Musculocutaneous Latissiums Dorsi Flap)
- Abdominal or Pubic area flap – may have less sensitivity, but better erectile and penetrative function
Free flap surgeries may need multiple areas of donor skin: one to create the penis shaft and smaller ones used for urethral lengthening or to fill in the larger donor site.
Free skin flap phalloplasty procedures involve microsurgery to connect nerves and blood vessels and may allow for more erogenous sensation along the shaft of the penis.
Pedicle Phallo
Skin donor sites are close to the groin, and one end of the flap is left connected to the body, where blood flow is maintained. Microsurgery to connect nerves may not be done, so sensation may be more limited than a free flap phallo. However, there may be less scarring overall, and scars may be easier to hide.
Tips You Didn’t Expect:
If considering a donor site and using injectable medicines, don’t inject in that site – especially if you’re doing IM (intramuscular) injections on your thigh and are considering a thigh flap phallo! Injections can cause scar tissue and decrease elasticity of skin, both of which can affect your surgical outcomes.
Skin with tattoos can be used for grafts. The tattoo won’t go away, but may be distorted or only appear partially, depending on how it is positioned in surgery.
You can get tattoos after surgery, too. Some people get medical tattooing on the glans for coloring, but anything goes!
You said the what about what? Quick definitions of other surgeries:
Vaginectomy: The tissues of the vagina are removed, and the opening is closed. A hysterectomy is required.
Hysterectomy: Removal of the uterus. A total hysterectomy removes the cervix as well as the uterus.
Oophorectomy: Removal of the ovaries. You can have one or both removed.
Salpingectomy: Removal of one or both of the fallopian tubes.
Scrotoplasty: Labia majora tissue is used to create a scrotum. Tissue expanders may be used to prepare the scrotum for testicular implants to be added later.
Monsplasty: Post-phalloplasty, or after meta with scrotoplasty, a monsplasty can lift the genitals forward and up and reshape the base of the genitals.
Some Resources Worth Reading:
Our Gender Affirming Surgery page.
Johns Hopkins Center for Transgender Health has a detailed Phalloplasty FAQ.
OHSU’s phalloplasty nerve rehab guide is pretty phenomenal.
Penile Implant Options, a surgeon’s opinion.
