BOTTOM SURGERY

Hysterectomy is the removal of the uterus. Bilateral Salpingo-oophorectomy (BSO) is the removal of both ovaries and fallopian tubes. Hysterectomy without BSO in cisgendered women is sometimes referred to as a 'partial hysterectomy' and is done to treat uterine disease while maintaining the female hormonal milieu until natural menopause occurs.

Some transmen desire to have a hysterectomy/BSO because of a discomfort with having internal female reproductive organs despite the fact that menses usually cease with hormonal therapy. Some undergo this as their only gender-identity confirming 'bottom surgery'.

For many transmen however, hysterectomy/BSO is done to decrease the risk of developing cervical, endometrial, and ovarian cancer[citation needed] . (Though like breast cancer, the risk does not become zero, but is drastically decreased.) It is unknown whether the risk of ovarian cancer is increased, decreased, or unchanged in transgender men compared to the general female population. The risk will probably never be known since the overall population of transgender men is very small; even within the population of transgender men on hormone therapy, many patients are at significantly decreased risk due to prior oophorectomy (removal of the ovaries). While the rates of endometrial and cervical cancer are overall higher than ovarian cancer, and these malignancies occur in younger people, it is still highly unlikely that this question will ever be definitively answered.

Decreasing cancer risk is however, particularly important as transmen often feel uncomfortable seeking gynecologic care, and many do not have access to adequate and culturally sensitive treatment. Though ideally, even after hysterectomy/BSO, transmen should see a gynecologist for a check-up at least every three years. This is particularly the case for transmen who:

• retain their vagina (whether before or after further genital reconstruction,)
• have a strong family history or cancers of the breast, ovary, or uterus (endometrium,)
• have a personal history of gynecological cancer or significant dysplasia on a Pap smear.

One important consideration is that any transman who develops vaginal bleeding after successfully ceasing menses on testosterone, must be evaluated by a gynecologist. This is equivalent to post-menopausal bleeding in a cisgendered woman and may herald the development of a gynecologic cancer.

Genital reassignment

Genital reconstructive procedures (GRT) use either the clitoris, which is enlarged by androgenic hormones (Metoidioplasty), or rely on free tissue grafts from the arm, the thigh or belly and an erectile prosthetic (Phalloplasty). The latter usually include multiple procedures, more expense and with a less satisfactory outcome, in terms of replicating nature.

In either case, the urethra can be rerouted through the phallus to allow urination through the reconstructed penis. The labia majora (see vulva) are united to form a scrotum, where prosthetic testicles can be inserted.

Metoidioplasty, sometimes referred to as a meto or meta, is an alternative to phalloplasty for Transmen [1]. With the effects of testosterone treatment, the clitoris enlarges, over time, to an average of 4-5 cm.[2] In a metoidioplasty the enlarged clitoris is released from its position and moved forward to more closely approximate the position of a normal penis. In some cases the urethra is lengthened to end at the tip of the neophallus. The clitoris and penis are developmentally homologous organs.

The labia majora (see vulva) can be united to form a scrotum, where prosthetic testicles (usually made of silicone) can be inserted.

This procedure is technically simpler than a phalloplasty, and has fewer complications. Surgery itself is also considerably shorter (1-2 hours vs. 8-10 hours) and it is much less expensive (perhaps US$15,000 instead of US$85,000). Unlike a phalloplasty, an erectile prosthesis is usually not needed to achieve erection. The clitoris contains erectile tissue which responds to sexual arousal. In most cisgender females, the clitoris is too small for the person to detect this erectile change significantly. In transmen and other female-bodied people whose clitoris is larger, this may be more visually apparent as it is in cisgender men.

If a metoidioplasty is performed without a urethral lengthening or scrotoplasty (formation of a scrotum from the labia majora), this is sometimes called a clitoral release. This is less expensive than a complete metoidioplasty but does not allow for urination (through the new penis) while standing. However this also offers surgery with less risk because the urinary system remains unaltered without a urethral extension and still affords some of the visual effects of a complete metoidioplasty.

Phalloplasty refers to the (re-)construction of a penis or, sometimes, artificial modification of the penis by surgery, often for cosmetic purposes. It is also often used to refer to penis enlargement. The first phalloplasty done for the purposes of sexual reassignment was performed on transman Michael Dillon in 1946 by Dr. Harold Gillies, which is documented in Pagan Kennedy's book The First Man-Made Man.

A complete construction or reconstruction of a penis is done on both cisgendered men who have lost their penis through either illness or accidents, and on trans men, that is, female-to-male transgendered or transsexual people.

The basic procedures have similarities (except in extreme cases of micro/macropenis), although surgery on cisgendered men can be simpler, since the urethra still ends in the front of the genital area, whereas the urethras of trans men end near the vaginal opening and have to be lengthened considerably. The lengthening of the urethra is a difficult part of total phalloplasty, and also the one where complications often occur.

With all types of phalloplasty in trans men, the labia (see vulva) are united to form a scrotum, where prosthetic testicles can be inserted.

An erectile prosthesis can be inserted into the neophallus to replace the erectile tissue and enable sexual penetration. This is usually done in separate surgery for healing reasons. There are several types of erectile prostheses, ranging from malleable rod-like medical devices so the neo-penis can either stand up or hang down, to elaborate pumping systems. Penile implants require a neophallus of appropriate length and volume in order to be a safe option. The long term success rates of implants in a reconstructed penis have been poor. Good sensation of the reconstruction can help reduce the risk for the implant eventually eroding through the skin. It is for this reason that living bone was first used inside the reconstruction. Long-term follow-up studies from Germany and Turkey of more than 10 years now prove that these reconstructions maintain their stiffness without late complications.

There are three different techniques for phalloplasty:

This technique involves using a free graft of tissue that is removed from its original place, rolled up, with a part of it forming the new urethra, and grafted to its new place between the thighs. In the past, the donor site was usually the inner side of the forearm but sometimes the upper arm, leg or abdomen. The arm flap operation is easier to perform but requires an implant and has a cosmetically undesirable scar on the exposed area of the arm. The lower leg operation takes along with the skin a piece of the small bone of the leg. Like the appendix, humans can live fine without it. The scar in the leg is easily covered with a sock and hidden from view. These are the two operations which are used most commonly today in the world. They have normal skin on them and can have good cosmetic results. Skin grafted muscle flaps have fallen from popularity. The grafts have a less natural appearance and are less likely to maintain an implant long term.

Good references for these issues may be found in the Journal of Plastic and Reconstructive Surgery by the authors, Papadapoulos and Biemer, Sengezer, Sadove and McRoberts, and Hage.

Belgrade University School of Medicine admits in the British Journal of Urology, Volume 100, Issue 4, that the four stages of this total phalloplasty method of penile reconstruction over a period of 9–18 months is one of the most demanding tasks in genital reconstructive surgery but the benefits for patients are great.

It satisfies the 12 major aesthetic and functional goals of modern penile reconstruction — a penis that:
1) is large, with substantial volume;
2) enables safe insertion of a prosthesis;
3) is hairless;
4) has satisfactory aesthetic appearance;
5) has normally colored skin;
6) has both penile tactile and erogenous sensation;
7) has a competent neo-urethra with a meatus at the top of the glans;
8) can have sexual intercourse;
9) leaves no conspicuous, disfiguring scars at the donor site;
10) has very low occurrence of disease or other complication;
11) achieves patient satisfaction; and
12) improves quality of life.

Not a major medical goal, but important to many patients, total phalloplasty using the MLD flap[clarification needed] enables the person to urinate standing up. This is true of all modern operations.

Suitable candidates for this surgery which creates a penis up to 7 inches (18 cm) long with a circumference up to 5.9 inches (15 cm) include: 1) patients with congenital anomalies such as micropenis, epispadias, and hypospadias; 2) FtM (Female-to-Male) transsexual patients; and 3) victims of minor to serious iatrogenic, accidental or intentional penile trauma injuries (or total emasculation) caused by motor vehicle accidents, child abuse, animal bites, angry girlfriend, agricultural disasters, gun shots, burns, electrocution or self-mutilation.

For trans men getting a procedure not using the MLD flap, the urethra up to this point is formed by many doctors from the inner labia. Often, this is done in a separate procedure; sometimes a full-scale metoidioplasty is done a few months before the actual phalloplasty to prevent complications or make intervention easier when they occur.

Sensation is retained through the clitoris which is at the base of the neo-phallus; also, often a large nerve in the graft is connected to nerves either from the clitoris or other nearby nerves. In addition, nerves from the graft and the tissue it has been attached to usually connect after a while, thereby allowing additional sensation.

The forearm and leg flaps are the most common surgical techniques for total phalloplasty today. They remain the state of the day for both function and aesthetics. Muscle Flap procedures need long term publications of their function and aesthetics before making extreme claims of their popularity and superiority.