Considering Gender-Affirming Surgery? Here’s What To Know

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For those who identify as transgender, the journey of transitioning is deeply personal—and varied. Transitioning could mean coming out to your friends and family. It could mean legally changing your gender identity. It could mean transitioning socially, or dressing in a way that society views as masculine or feminine. It could also mean transitioning medically, or using hormones and gender-affirming surgery to help you feel more confident in your skin. 

Whatever you decide, there is no right or wrong way to transition—and your path may or may not involve surgery, depending upon what you feel comfortable with. For most people who get gender-affirming surgery, it is usually the last step in their transition.

Here, common questions people ask before deciding upon surgery.

1. How should you prepare for gender-affirming surgery?

 It’s generally recommended to be on hormone therapy for at least a year before getting surgery. This allows you to see what features can be changed with hormones alone.

“If you’re transitioning from male to female, for example, estrogen replacement therapy could give you feminine soft-tissue features,” says Laura Garcia-Rodriguez, M.D., a facial plastic surgeon who specializes in facial feminization surgery at Henry Ford Health. “Your cheeks could get fuller, your skin texture can change, you can have less body hair. Sometimes male pattern baldness can improve as well.”

Some insurance companies cover gender-affirming surgery, but they also require you be on hormones for a year beforehand, says Dr. Garcia-Rodriguez. They also require a diagnosis of gender dysphoria, or an intense feeling that your biological sex and gender identity are mismatched. A behavioral health specialist can give you this diagnosis.

It’s also important to note that most surgeons require you to be at least 18 years old to undergo surgery. When you’re younger than that, your body is still growing and your features may change. 

2. Could hormone therapy negate the need for gender-affirming surgery altogether?

The younger you start hormone therapy, the greater impact it can have. “If you’re a young transgender person and you’re on hormones, some of those secondary male or female characteristics won’t develop,” says Dr. Garcia-Rodriguez. “Some males take up to their early 20s to complete facial growth—their jawline and forehead get bigger, for example—but if you’re on hormones before that age, you likely won’t complete that transition.

“If you look up Jazz Jennings—she is a trans woman who started puberty blockers very early in life—you can see that she really has no male features whatsoever. There are few lucky people who have transitioned just socially and with hormone management. That said, if you start hormone therapy as an adult, you may decide you also want surgery.”

3. What types of gender-affirming operations are there?

Gender-affirming surgeries can be split into a few overarching categories: top surgeries and bottom surgeries, feminization and masculinization.

If you are transitioning from male to female, surgeries include:

  • Facial feminization surgery, such as forehead and browbone reduction, jaw and neck feminization, rhinoplasty and Adam’s apple reduction. “About 75% of my patients come to me with a plan. Most commonly they want their forehead, nose, jaw and Adam’s apple done,” says Dr. Garcia-Rodriguez. “Biological males have foreheads, browbones and jawlines that are more pronounced, and their noses tend to droop more than women. So lifting the nose a little and having these surgeries can really give you a more feminine appearance.”
  • Breast augmentation. “There are a variety of approaches we can take so that transgender females can have the shape and volume they desire, with realistic expectations,” says Donna Tepper, M.D., a plastic surgeon who specializes in gender-affirming top surgery at Henry Ford Health. “If someone has fat stores, sometimes I can use fat instead of implants, so you don’t have the risks that come with implants—such as worrying about longevity.”
  • Vaginoplasty, a procedure that creates a vagina and vaginal canal from existing genital tissue. Alternatively, you could get a vulvoplasty, which creates a vagina but not a vaginal canal. “Before getting either of these procedures, it’s important to talk to your doctor about fertility preservation, since the testicles will be removed,” says Dr. Tepper. “You’ll also have physical therapy before surgery—pelvic floor exercises that will guide you to a successful outcome.”

If you are transitioning from female to male, surgeries include:  

  • Facial masculinization surgeries, such as forehead lengthening, chin and jaw contouring, Adam’s apple surgery and rhinoplasty.
  • Mastectomy, which removes breast tissue. “We can create an incision that follows the contour of someone’s chest muscles so that as they work out or grow hair, those incisions can be more camouflaged,” says Dr. Tepper. “The mastectomies we perform for transgender men are not the same as the mastectomies we perform for people who have breast cancer. A transgender man who has received a mastectomy still requires breast cancer surveillance. This can be a discussion before surgery, so if you are at high risk for breast cancer, the surgery can be geared toward cancer prevention.”
  • Metoidioplasty, a lower-body surgery where surgeons create a penis from genital tissue. Doctors usually recommend being on testosterone for at least two years before getting a metoidioplasty, as testosterone can improve clitoris growth and aid in the creation of a neophallus, or new penis.

4. How should you prepare for surgery?

Your doctor will give you specific instructions, but Dr. Tepper says hair removal is necessary prior to bottom surgeries, which can take up to a year to fully complete.  

It’s also important not to vape or smoke at least a month before surgery, as it impairs wound healing and alters pain management after surgery, she adds. You should also stay away from second-hand smoke and refrain from smoking for at least six weeks until after you’re fully recovered. (Although that’s a good time to give up smoking altogether.) 

5. What is the recovery time for gender-affirming surgeries?

Recovery is highly dependent upon the surgery. “For Adam’s apple surgery, it takes about 40 minutes to an hour. If it's your only surgery, you can be out and about in a day and a half,” says Dr. Garcia-Rodriguez. “For forehead surgery, it can be about three or four weeks of recovery; you may have eyelid swelling for a week after surgery. For jaw surgery, I compare it to getting six wisdom teeth removed—you can get really puffy and it may take six to 12 weeks for the swelling to go completely down.”

For mastectomies, patients typically wear a foam binder for about seven to 10 days, says Dr. Tepper. You can be back to work in about two or three weeks. With a breast augmentation, you can go back to work within a week.

Bottom surgeries like vaginoplasties are more involved—they require about five days in the hospital and typically six weeks off work, says Dr. Tepper.   

6. In your experience, how do people feel after receiving gender-affirming surgery?

“I have so many patients ghost me after surgery because they’re so happy. I saw a patient a few months ago for suture and staple removal, and she’s been so happy that I haven’t gotten her in for post-op pictures,” says Dr. Garcia-Rodriguez. “It’s amazing to see how they feel afterward. The inside now matches the outside.”

Adds Dr. Tepper: “The majority of people who come to me for a surgery consultation know they want this. And afterward, they express to me how pleased they are that they moved forward with it. Whatever we can do to help someone feel more comfortable in their skin—that’s the goal.”

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Laura Garcia-Rodriguez, M.D., is a facial plastic surgeon who specializes in facial feminization surgery at Henry Ford Health. She sees patients at Henry Ford Medical Center—Fairlane and Henry Ford West Bloomfield Hospital.

Donna Tepper, M.D., is a plastic surgeon who specializes in gender-affirming top surgery at Henry Ford Health. She sees patients at Henry Ford Hospital, Henry Ford Medical Center—Cottage, Henry Ford Medical Center—Fairlane and Henry Ford Wyandotte Hospital. 

Categories: FeelWell