Transsexuality

Female-to-Male

Female-to-male surgery: phalloplasty
Phalloplasty, penoid reconstruction as part of female-to-male (ftm) gender reassignment surgery, is arguably the most challenging and complex operation in the field of transsexual surgery.

The technique developed by Dr. Paul Daverio, in which the penoid (“artificial penis”) is formed in a microsurgical operation from skin and subcutaneous tissue including nerves and blood vessels of the forearm (so-called forearm flap), is nowadays considered the standard procedure for gender reassignment worldwide. It leads to the best optical and functional results and has been practiced at Klinik Sanssouci for over 20 years.

Surgical technique: The steps of surgical gender reassignment.
Female-to-male surgical gender reassignment is performed under general anesthesia. This procedure takes about seven to nine hours and includes:

• the removal of the breasts (mastectomy)
• removal of the uterus (hysterectomy)
• removal of the ovaries and fallopian tubes (ovarectomy, adnectomy)
• removal of the vagina (colpectomy)
• the microsurgical formation of the penoid (“artificial penis”) from a part of the forearm (so-called forearm flap) including its nerves and blood vessels. This includes the following substeps:
  • the shaping of the penoid including the new urethra (neo-urethra)
  • the plastic reconstruction of a glans (glansplasty)
  • the lengthening of the female urethra with the labia minora
  • the relocation of the penoid from the left forearm to the pubic area. The arteries (arteries) and veins (veins) of the penoid are connected to the corresponding blood vessels of the thigh. At the same time, the inguinal nerves are connected to the penoid nerves, as well as the lengthened urethra to the newly formed urethra.
  • covering the tissue defect on the forearm with skin obtained either from the groin or from the excess skin of the breast.
  • the preparation of the labia majora, where the artificial testicles will be implanted later.

Important: The clitoris (clit) remains at the base of the penoid and is not removed, only its covering epidermis. Thus, the ability to orgasm is preserved.

After the surgery

• After the surgery, intensive supervision with monitoring takes place. There will be several daily visits as well as regular dressing changes and wound inspections by our doctors.
• You may get up for the first time on the 6th day after the surgery.
• The bladder catheter is removed on the 12th day. From this moment on you can urinate standing up.
• Usually, you can leave the clinic on the 14th to 16th day.
• Further treatment after female-to-male gender reassignment can be performed by your doctors at your place of residence.
• Depending on your professional situation, you can expect to be unable to work for about 6 weeks.

Complications
Female-to-male gender reassignment surgery, especially penoid reconstruction (phalloplasty), is a complex procedure and therefore prone to complications. At Klinik Sanssouci, complications occur with about 5% of our patients.

Possible complications of phalloplasty include:

Stenosis
This is a constriction at the connection between the urethra and the newly formed urethra (neo-urethra). This complication can usually be corrected by simple bougienage (widening) by the urologist. Only in 1 to 2% of cases is a minor second surgery required, often under local anesthesia, to widen this constriction.

Fistula
This is a connection between the urethra and the skin surface through which urine can leak out. Fistulas usually close spontaneously after two to three months. If this does not occur, the fistula can be closed in a minor procedure under local anesthesia.
Serious complications such as complete penoid loss (flap loss) are very rare.

Erectile prosthesis / testicular replacement
A second procedure is necessary if an erectile prosthesis is to be installed. This surgery is possible if there is feeling in the penoid, which is usually about eight to ten months after the phalloplasty surgery.

As erectile prosthesis we use a so-called hydraulic implant from American Medical Systems (AMS) with a pump (AMS 700), which is placed in the newly formed scrotum (neoscrotum). A reservoir is surgically placed under the abdominal wall muscles. We place two inflatable silicone rods into the penoid. An erection is then possible by means of this pumping system. We also implant silicone testicles in the scrotum.

Male-to-female

Surgical technique
The surgical male-to-female sex adjustment is performed under general anesthesia and takes about 4-5 hours. If desired, we can perform augmentation at the same time (insertion of a silicone implant for breast augmentation or augmentation with autologous fat). At the same time, a thyroid cartilage reduction is also possible.

For sex adjustment, we offer two different methods (Classic penile inversion and combined method), both of which provide excellent results, but differ in several ways.

Classic penile inversion involves the following surgical steps:

Removal of the testicles (orchidectomy)

• plastic construction of a neovagina with an island flap plasty
• plastic construction of a sensitive neoclitoris
• plastic construction of labia from scrotum
• shortening of the urethra
• cavernous body removal
• plastic construction of pubic mound
• breast reconstruction if necessary
• if necessary, reduction of the thyroid cartilage

In the combined method, additional skin grafts and the original urethra are used to build up a neovagina. Due to the special incision in this method, a more natural vulvoplasty (plastic reconstruction of the labia) is possible.

The following surgical steps are performed:

• removal of the testicles (orchidectomy)
• plastic construction of a neovagina with a combined island flap plasty, free skin graft from the skin of the scrotum as well as pedicled urethral skin
• plastic construction of a sensitive neoclitoris
• plastic construction of labia and clitoral hood from parts of penile shaft skin
• shortening of the urethra
• cavernous body removal
• plastic construction of pubic mound
• breast reconstruction if necessary
• if necessary, reduction of the thyroid cartilage

Due to the special incision, a second surgery is mandatory for the combined method. This involves some fine plastic work that cannot technically be implemented in the first surgery. Usually, the desired breast augmentation and other optional plastic procedures are also performed during this second surgery.

In direct comparison, each method has its own strengths and weaknesses, which we will be happy to discuss with you in a personal consultation in order to select the optimal treatment strategy for you.

After surgery

• after the surgery, intensive supervision with monitoring takes place. There are several daily rounds as well as regular dressing changes and wound checks by our doctors
• you can already get up on the 1st day and also go to the toilet
• the urinary catheter is removed on day 6 to 8
• Usually you can leave the clinic on the 8th to 12th day
• further treatment after male-to-female gender reassignment surgery can be performed by your doctors at your place of residence
• depending on the professional situation, an inability to work of approx. 4 weeks is to be expected
• in the combined method, bougienage (dilatation) of the neovagina must be performed – written instructions for bougienage after discharge can be found here (PDF, 39k).

Complications
Complications occur in less than 5% of our patients.

• postoperative bleeding approx. 1 %
• narrowing (stenosis) of the urethral opening 1-2 %
• narrowing (stenosis) of the neovagina approx. 1 %
• we were not able to record any serious complications
• in about 30% of our patients, we perform corrective surgery after about 3-6 months, when the vaginal entrance is constricted by a small fold formed during invagination (invagination) of the original penile skin.

Requirements

For female-to-male or male-to-female gender reassignment, the following medical as well as legal requirements are necessary at Klinik Sanssouci:

• You should have undergone opposite-sex hormone treatment for at least six to eight months.
• We also need two expert opinions from you that confirm your transsexuality (transidentity). These can be, for example, the expert opinions that you obtained as part of your change of first name and civil status.

Of course, we will be happy to advise you in a personal preliminary consultation about the exact procedure of the operation and answer your questions. You can make an appointment with us, please use our contact form.

Costs / Cost coverage

In general, a transsexual patient has the right to a gender reassignment surgery. Usually, this is not declined by the health insurances. However, there is no obligation for the statutory health insurance companies to cover the costs of treatment in a private clinic.

The vast majority of our transsexual patients have statutory or private health insurance and have been granted reimbursement for an operation in our clinic on a case-by-case basis. Private health insurances usually reimburse partial amounts. We will be happy to assist you with the application process. In particular, you will need a cost estimate from us, which you will receive from us during your consultation appointment.

International patients who have to pay their costs in advance as self-payers should also obtain a cost estimate.

Please feel free to contact us with any questions you may have regarding the details of reimbursement and billing.

Frequently asked questions

Female-to-male

What methods of phalloplasty do you use and what are the functional results?
We perform phalloplasty with a so-called free forearm flap. The patient can urinate standing up after the operation on the 12th day. Sexual sensitivity is preserved because the clitoris (clit) is not removed in our method. All surgical steps are performed in one session.

Why do you perform all surgical steps in one session?
This procedure, the all-in-one surgery, significantly reduces the duration of the entire inpatient stay, and of course also the number of surgeries. An essential consideration is also the rapid restoration of full working capacity. It is always claimed that the risks increase due to multiple surgery, but with careful organization, good teamwork and very great experience, it is possible to perform individual surgical steps with several surgical teams at the same time without extending the total surgical time. One-stage surgery also avoids scarring adhesions in the vaginal area, which are disadvantageous in a second operation. If the breast is removed at the same time, we can use the excess skin for coverage and, if necessary, do without other skin removal sites (fewer scars). Not to be forgotten are stress factors that are eliminated when the patient has to undergo surgery only once.

Do you work with microsurgery?
Yes. In phalloplasty, the penoid is formed from skin and subcutaneous tissue, including nerves and blood vessels of the forearm (called the forearm flap) in a microsurgical surgery.

How many surgeries are necessary until a final result?
At Klinik Sanssouci Potsdam, two surgeries are necessary for complete female-to-male gender reassignment: The first surgery includes removal of the uterus (hysterectomy), removal of the ovaries and fallopian tubes (ovarectomy, adnectomy), removal of the breast (mastectomy), removal of the vagina (colpectomy), and penoid reconstruction (phalloplasty). In a second surgery (about eight to ten months after the first surgery), an erectile prosthesis and a silicone testicle are implanted into the newly formed scrotum.

How long does a patient have to stay in the clinic?
For the first surgery, during which the penoid reconstruction (phalloplasty) takes place, you will need to plan for about 14 to 16 days of hospitalization.

What is the sensitivity of the penoid (neophallus)?
The sensitivity, i.e. the sensation of the penoid, corresponds to normal skin sensitivity, comparable to the sensitivity of the skin on the forearm. Sensitivity is achieved by the ingrowth of nerves about eight to ten months after the initial surgery. Some erotic sensitivity, starting from nerves of the clitoris, is also possible.

What happens to the clitoris? Will it be removed or how will this important organ be preserved?
During the phalloplasty surgery we preserve the clitoris completely and with it the sensitivity and sexual experience. We achieve this by only removing (deepithelializing) the clitoris from its epidermis, placing it at the base of the penoid and only covering it with skin so that arousal is possible as before the procedure. We do not consider the removal of the clitoris to be useful.

Have serious problems occurred at the forearm collection site?
No. In the first days and weeks after the phalloplasty surgery, the hand may swell a little and become thicker. Then you should keep it elevated. We also recommend regular exercise of the hand. Serious, for example motor (movement) problems have not occurred – even fine motor movements of the hand are not affected.

Where are scars found on the penoid and are they visible?
The only scar that will be visible on the penis is on the back of the penoid, so it will not be visible from the front.

Is there an acorn buildup? And when does it take place?
Yes, glans reconstruction (glansplasty) is performed as standard together with phalloplasty in the first procedure.

Male-to-female

Will a sensitive clitoris be created and how is it done?
Microsurgically, while preserving the blood vessels, a clitoris is constructed from a portion of the glans (penis) in such a way that it is sexually aroused and placed in a typical location.

Are additional surgeries performed at the same time and what are they often?
If desired, we perform breast reconstruction, i.e. implantation of a silicone prosthesis, in the same session. If desired, a thyroid cartilage reduction is also possible. These procedures extend the total operation time only insignificantly.

Will follow-up procedures be necessary and how often?
Due to invagination of the original penile skin for the construction of the neovagina, there is often a fold at the posterior vaginal entrance, which we leave intraoperatively in order not to endanger blood circulation and thus good healing of the penile skin in the pelvis. Therefore, in about 30% of our patients we perform a widening of the vaginal entrance about 3-6 months after the initial procedure. During this procedure, small labia are formed at the same time and, if desired, the clitoris is reduced in size. As a rule, the clitoris is created during the initial operation in such a way that the safety of blood circulation and sensitivity are ensured, so that for many patients the clitoris primarily appears to be somewhat large. This is corrected during the follow-up surgery.

Are other procedures performed in your clinic for optical adaptation to the female gender?
Reduction of the larynx can be performed. Likewise, nose correction and other procedures from the repertoire of aesthetic plastic surgery are possible.

When is sexual intercourse possible after surgery?
There is no set rule, but medically it is possible to have normal sexual intercourse about 6 weeks after surgery.

Where are visible scars found?
There are scars only on the labia majora, which are formed by reduction of the scrotum.

At what point is vaginal dilatation possible and do you use a so-called stent?
After surgery, a loose tamponade is inserted into the neovagina, which is replaced on the 5th to 6th day. Careful stretching with a small dildo is possible about 10 to 14 days after surgery. It is not necessary to use a stent.

Can there be problems with sexual intercourse after surgery?
Every transsexual patient should keep in mind that the pelvis of a man is much smaller and narrower than usually the pelvis of a so-called biological woman. In addition, the pelvic floor muscles are usually more strongly developed and not as soft and stretchy as in bio-women. For these reasons, it is not uncommon for muscular constriction to occur, which can persist over a longer period of time and can also lead to difficulties during sexual intercourse. Consistent stretching and relaxation is helpful in this case.