Gender reassignment surgery (GRS; also known as sex reassignment surgery, SRS) is a means of transitioning to a different gender through surgical alteration of the body. Men who are transitioning to female are known as male to female, or MTF, and women who are transitioning to male are known as female to male, or FTM.

FTM (Female to Male) Surgery

• Elective bilateral mastectomy (FTM), the removal or reduction of the breasts (also called reduction mammoplasty, or "top surgery"), involves making a small incision near the nipple and removing most of the tissue and fat from under the skin. This results in a chest shape that appears more masculine. Some people also choose to have skin grafted from the existing nipple to create a new male-like nipple. The procedure has relatively few complications. The length of the hospital stay is dependent on the patient. Reduction mammoplasty is often all a FTM needs to comfortably assume a new gender role and pass in society.

• Metoidioplasty (FTM) is the creation of a penis by extending the clitoris that has been significantly enlarged by testosterone hormone use. The skin around the clitoris is removed so that the clitoris can extend from the pubic region and appear as a penis. The resulting penis is smaller than the average size of an adult male penis and its use in sexual intercourse is limited. Some people also have the urethra lengthened, which makes it possible to urinate while standing. This requires removal of the vagina. The fat of the pubic area is typically removed and the skin pulled tighter around the area, creating a more male-like appearance. The vaginal opening is closed and the skin of the vaginal labia (lips) is used to create a scrotum. Inflatable expanders are placed in the scrotum either during or after surgery in order to expand the skin of the newly created scrotum. Once expanded, the scrotum can accommodate testicle implants.

• Phalloplasty involves constructing a penis from the inner forearm skin (nondominant side) and vaginal tissue and attaching it to the vaginal area. This is also known as a free flap phalloplasty. The forearm skin is grafted along with its nerves, arteries, and veins and formed around a plastic catheter tube, which will serve as the urethra and allow for urination once connected to the female urethra. The forearm skin is used to create the shaft, glans (head), and urethra. The nerves of the clitoris are attached to the grafted nerves and will grow into the penis after surgery. The skin and tissue of the vaginal labia is used to create a scrotum. The procedure may take 3 hours or more. After 6 to 9 months of healthy recovery, cosmetic testicle implants can be inserted in the scrotum. Erectile implants, those used in men with impotence (erectile dysfunction), can be added to achieve erection in the new penis.

  Hardening of the urinary tract and tissue death in the new penis are complications of phalloplasty.

• Elective bilateral orchiectomy (MTF), the removal of both testicles, is done through an incision in the scrotum. After each testicle is pulled from the scrotum, its spermatic cord is clamped, double sutured to control bleeding, and cut, releasing the testicle. The end of the cord is then placed back in the body. The procedure is done on an outpatient basis under local or general anesthetic, depending on the patient.

  Transitioning MTFs undergo orchiectomy because it significantly reduces testosterone production. The reduction of testosterone may allow a person with a male body to transition to a woman and to take less estrogen.

• Tracheal shave involves surgically reducing the tracheal cartilage (the Adam's apple). A small incision is made at the front of the throat and the cartilage is carved until it is flat. This results in a throat contour that is flatter and more feminine in appearance. The procedure is done on an outpatient basis with local anesthetic.

  Although uncommon, there is a risk of shaving too much cartilage and affecting the vocal chords that lie just behind the trachea. This may permanently affect the voice.

• Vaginoplasty, the surgical construction of a vagina through skin inversion, involves removing the organs and erectile tissue of the penis. The skin and tissue is used to create a vaginal opening, clitoris, clitoral hood, and labia (lips). The urethra is kept for urination and the skin and nerves of the glans (head) of the penis can be salvaged for sensitivity. The procedure takes several hours and is done under general anesthesia. After surgery, the patient must progressively stretch the vaginal opening. This is done with plastic dilation molds, which are supplied by a medical care team.

  There is a risk for the rectum or urethra to join with the newly created vaginal canal. Although rare, these complications can result in gas, feces, and urine in the vagina. Other complications include hardening of the urethra and death of the vaginal tissue.

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