Gender Surgery

Vaginal Reconstruction

A vaginoplasty is a surgical procedure where a vagina and vulva (external female genitalia) is created.  The surgery is most often done in one stage, although sometimes a multi-staged approach is needed to achieve optimal form and function.  Surgical approach can vary depending on a patient’s past medical history and surgical goals, and options are best discussed between the patient and the surgical team.

Vaginoplasty involves rearranging the current tissue in the genital area to create the vaginal canal and external genitalia, the labia minora and labia majora. To create the vaginal canal, the surgeon uses a combination of the skin surrounding the existing penis in addition to the scrotal skin. Sometimes, an additional skin graft from the abdomen or thigh is needed to achieve an adequately deep vaginal canal. In specific, less common cases, our team may employ the Da Vinci surgical robot through an abdominal approach to create a lining for the deeper parts of the vagina from peritoneal tissue.

The skin of the penis is separated from the structures underneath to form a tube. The dorsal penile nerves and blood vessels on the penis remain attached to the glans tissue.  A skin graft is taken from the scrotum and attached to the end of the penile skin tube. The bladder and prostate are surgically separated from the rectum through Denonvillier’s fascia to make the space for the vaginal canal. The skin tube is inserted into the canal to provide vaginal lining. The end portion of the urethra is opened and used to create the ‘pink’ appearance of the middle of the female vulva, and the urethra is re-directed to allow urination while sitting from the new reconstructed genital area.

He performs several techniques for vaginoplasty depending on patient goals, including penile inversion vaginoplasty and vulvar creation without a canal (“short-depth vaginoplasty”). He also has experience with vaginoplasty revision cases and has developed more unique procedures for difficult cases (e.g. “Sensate total clitoris reconstruction via microneurovascular dorsal foot web space flap with pudendal nerve coaptation“).

Metoidioplasty

A metoidioplasty is the surgical creation of a penis by rearranging local tissue and elongating the clitoris in the genital area. The surgical plan for metoidioplasty is dependent on patient surgical goals and desired outcomes.  Metiodioplasty differs from phalloplasty in that there is no  new tissue harvested from another part of the body; only the native tissue is involved.  Because of this metoidioplasty is largely dependent on the successful enlargement of genital tissue from testosterone. Both “full” (UL/ring) and “simple” (non-UL) metoidioplasty are performed. The surgical plan is variable and may include multiple stages and is largely dependent on the patient’s surgical goals. For example, it is possible to stand to urinate following the completion of full metoidioplasty, but is not likely the patient will be able to use the phallus for penetration.

Chest Masculinization

Bilateral mastectomy, or chest masculinization, is the removal of breast tissue to achieve a more masculine appearing chest.  This is one of the most common gender affirming surgeries performed, typically sought out by transmasculine and non-binary patients.

There are numerous different surgical approaches to be considered and discussed with your surgeon, but the most common is the “double incision” surgical approach.  In the double incision approach, two incisions are made (one on each side), that once healed will resemble a pectoral muscle shadow.  The breast tissue is removed and the nipple areola complex is reduced and repositioned to a lower and more lateral position on the chest, again similar to an aesthetic male chest. 

Another surgical technique is the “keyhole” technique.  This technique is best suited for patients with minimal chest tissue starting out.  In this approach, an incision is made around the nipple complex, and the breast tissue is removed. Excess tissue from the nipple areola complex is removed, and then the incisions are closed.  These surgeries may require revisions due to skin “puckering” or pleating. 

Dr. Coon offers all standard forms of top surgery, which also includes non-binary incision patterns. Which technique is appropriate is decided upon based on patient preferences during the consultation discussion and depends on anatomy, body shape and patient priorities. Depending on goals, ancillary procedures like liposuction or fat transfer for shoulder/pec enhancement may be considered.

Transfeminine Breast Augmentation

Breast augmentation is the enhancement of natural breast tissue through the use of breast implants.  Most commonly, smooth silicone implants are used.  One of the most common surgical approaches in gender affirming surgery, patients typically report a very high patient satisfaction rate following surgery. 

The goal of breast augmentation is to ensure following surgery the breasts and areolae are appropriate in size, shape, and location on the chest.  To optimize results, existing breast tissue is dissected, and often the inframammary fold (the crease where the breast and chest meet) is lowered to accommodate more appropriate placement.  The patient’s natural anatomy and goals as discussed in the consultation will dictate whether the implant is placed under the pectoralis muscle, or over the muscle and under existing breast tissue. The surgical considerations for transfeminine breast augmentation are not identical to cosmetic breast augmentation and warrant certain differences in technique to obtain optimal results, which we have developed and published on (reference: “Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results“).