Female to male sex reassignment surgery includes a variety of surgical procedures, including removal of the breasts and chest contouring (bilateral mastectomy), as well as removal of internal female genitalia (hysterectomy, adnexectomy and vaginectomy).
Mastectomy presents the removal of the breasts and the shaping of a male contoured chest. The procedure includes the removal of mammary tissue, removal of excess skin, and reduction, proper repositioning and reconstruction of the nipple and areola complex. The selection of operative procedure depends on the patients’ breast volume and the degree of ptosis. Patients with moderate to large breasts usually require a radical bilateral mastectomy with grafting and reconstruction of the nipple-areola. This will result in two horizontal scars on the lower edge of the pectoral muscle, but allows for easier resizing of the nipple and placement in a typically male position. For patients with smaller breasts, a transareolar procedure may be done where the mastectomy is performed through an incision made around the areola. This avoids the larger scars of a traditional radical mastectomy, but the nipples may be larger and may not be in a perfectly male position on the chest wall. In addition, there is less denervation (damage to the nerves supplying the skin) of the chest wall with a transareolar mastectomy and less time is required for sensation to return.
Vaginectomy is done by total removal of vaginal mucosa (colpocleisis), except the part of ventral vaginal wall close to the urethra that will be used for urethral lengthening. If persists, internal female genital organs could be removed in the same stage (hysterectomy, bilateral oophorectomy) using vaginal approach. It is very important to prevent any transabdominal approach in order to preserve anterior abdominal wall for possible abdominal phalloplasty in the future.