At the Center for Transgender Medicine and Surgery, we perform a variety of surgical procedures in our state-of-the-art operating rooms. We will work with you to understand your goals and develop an individualized plan to meet your needs.
Our center is informed by guidelines from the World Professional Association of Transgender Health (WPATH) and the Endocrine Society. Our pre-surgery process is meant to adhere to WPATH standards, to provide necessary pre-procedure care, and to work to satisfy requirements established by your insurance company. Typical standards ask that each patient have one letter of recommendation from a mental health provider for facial surgery, one letter for chest surgery, and two letters of recommendation for genital surgery. Letters typically should come from a psychologist or psychiatrist working in the field of transgender healthcare. CTMS’ comprehensive care model means we have mental health professionals within our center who can work with you and write your letters.
As our patient, you will meet with multiple members of our team, often starting with our social worker, who will help you navigate the process. Then, you may meet with a primary care provider and often a behavioral health specialist. We try to schedule appointments to facilitate completing more than one step in a single visit. After completing the initial requirements, our team will refer you to the surgeon.
When we refer you to the surgeon, a coordinator from the surgeon’s office will reach out to you to schedule your consultation. At your consultation, you’ll meet your surgeon, discuss your goals, and agree on a plan for your surgery. Your surgeon will discuss necessary preparations, expected outcomes, risks, and recovery process and will answer any questions you may have.
You may have to make physical preparations for your surgical procedure. We will discuss this with you during your consultation. For instance, genital surgeries often require hair removal from the area where the surgery will be done. Some procedures may require the use of a tissue expander. Or in some cases, your surgeon may require you to lose weight or quit smoking to lower the risk of complications. We will schedule your surgery date with these preparations in mind.
Feminizing Surgical Procedures
CTMS surgeons perform a variety of procedures at Mount Sinai facilities. Our team will work with you to learn your goals and to develop an individualized plan to meet your needs. We currently offer:
- Facial Feminization
- Breast Augmentation
- Voice Feminization
Facial Feminization Surgery
Facial feminization includes a variety of procedures including forehead and brow bone reshaping, jaw and chin contouring, nose reshaping (rhinoplasty), hairline advancement, and tracheal shave. The CTMS plastic surgery team will work with you to determine a plan for the best possible outcome.
Facial Feminization is performed under general anesthesia and normally requires one night in the hospital after surgery. Most people recover within a few weeks.
Chest feminization surgery consists of a surgeon inserting breast implants into the chest with optional fat grafting. There is no hospital stay after surgery, and it is performed under general anesthesia.
CTMS surgeons use a variety of implants to help create an ideal chest. At the surgical consultation appointment, the surgeon will review all options to help achieve the best possible outcome.
During vaginoplasty, CTMS surgeons create a vagina, clitoris, labia majora, and labia minora using existing genital tissue. CTMS surgeons use a penile inversion technique. The surgical team will perform this procedure both on people who have and have not had orchiectomy in the past. Removal of the testes is required as a part of vaginoplasty.
Vaginoplasty is performed under general anesthesia and typically requires three full days in the hospital after surgery. Recovery from vaginoplasty can take up to 3 months, and requires intensive post-operative care. Most people spend the first 7 to 10 days after the procedure in bed, getting up only to go to the bathroom. It is important both to have someone who can help take care of you after surgery, and to have the privacy you need to take care of yourself.
It is important to have a private area after vaginoplasty in order to dilate. Dilation is the insertion of a medical dilator into the vagina to keep it from healing closed. It is also very difficult to dilate for the first few weeks after surgery because it is painful and messy. However, if you do not dilate, your vagina will heal closed and it will take more surgeries to re-create a vagina.
CTMS surgeons have pioneered an innovation with tissue known as peritoneal lining to create a self-lubricating vagina. This tissue secretes moisture all of the time. It is hairless and pink. It does not respond to sexual arousal with increased secretion. While this is a new procedure, and there are no long-term data available, it is an option CTMS offers for creating a self-lubricating vagina. It is also available for patients who are not suited to a traditional penile inversion vaginoplasty.
Orchiectomy is the removal of testes. All other tissues and parts of the genitals remain. Many people who seek elimination of testosterone production without undergoing full genital reconstruction pursue this procedure. This procedure can be done under general or local anesthesia.
Done by CTMS urologists, orchiectomy is an ambulatory procedure, meaning there is no hospital stay after surgery. Most people recover after just a few weeks.
Voice Feminization Surgery
Using a technique called the Wendler glottoplasty, CTMS surgeons can shorten the length of the vocal cords to change a voice to a higher pitch. The CTMS otolaryngology team accomplishes this by placing a webbing over a portion of the vocal cords to immobilize them. Vocal coaching with a speech and language pathologist is required prior to surgery.
Recovery from this procedure involves not speaking for one week after surgery, and gradually increasing the amount of talking that is possible over the course of a month. Glottoplasty is an ambulatory procedure, meaning there is no hospital stay after surgery.
During chest masculinization, a CTMS plastic surgeon will remove mammary and fat tissue to create a masculine chest.
A CTMS surgeon will work closely with you to understand your goals, and will recommend the best surgical approach to meet your needs. The CTMS plastic surgery team offers several different types of chest masculinization procedures, including double incision and peri-aeriolar incisions. The team will work with you to help pick the right technique at the time of your consultation.
Chest masculinization requires general anesthesia, and is performed as an ambulatory procedure, meaning there is no hospital stay after surgery. After surgery, you will have a compression vest and surgical drains. The drains will be removed several weeks after surgery, but you must wear the compression vest for at least four weeks post-operatively. It can take six months to one year to regain the full use of your arms after surgery, but there is gradual improvement during this time. Most people are able to resume regular daily activities after three months.
During metoidioplasty, a CTMS plastic and urological surgeon collaborate to create a phallus from the clitoris by releasing it from the ligament that holds it in place, and wrapping skin around it to create a phallus. The result is a phallus that can become erect. Hysterectomy and vaginectomy (removal of the frontal pelvic opening) can be done at the same time.
Metoidioplasty can be done with or without extending the urethra to allow urination out of the tip of the phallus. CTMS surgeons can also create a scrotum and insert testicular implants depending on your preference. After metoidioplasty, there is a three day hospital stay, and you will go home with a tube in your stomach that will help drain your urine. Recovery can take six to eight weeks, and problems with urinary flow are very common, but often resolve on their own.
With phalloplasty, a surgeon will create a penis out of skin from somewhere on the body. There are many different techniques for phalloplasty. CTMS currently offers several different phalloplasty techniques including the radial forearm flap (RFF) phalloplasty and ALT flap. Other innovative phalloplasty techniques not utilizing forearm skin or anterior thigh skin are in the development phase and show great promise.
Phalloplasty can involve several procedures in addition to the creation of a penis. Vaginectomy (closure of the front pelvic opening) can be done; it requires hysterectomy as well. The procedure can be done as a part of a phalloplasty, but is not required in order to undergo phalloplasty.
Urethral lengthening will create a urethra that allows urination from the tip of the phallus. Scrotoplasty, or creation of a scrotum, can also be done during one of the phalloplasty procedures. Neither is required in order to get phalloplasty.
All options for phalloplasty require multiple surgical procedures that may or may not include a hospital stay. Some stages of phalloplasty require a hospital stay for three to seven days, and some do not.
CTMS providers can help discuss the pros and cons of each procedure and help make a decision about what is right for you.
Hysterectomy is the removal of the uterus and ovaries, completed by our OB/GYN team. Hysterectomy is as an ambulatory procedure, meaning there is no hospital stay after surgery. Most people recover within two to four weeks after surgery.
When seeking surgery at CTMS, everyone is first seen by medical, social work, and mental health providers to plan for post-operative recovery and to make sure there are no problems that would make surgery unsafe. Our providers follow the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 7 and can provide required letters before surgery. Visits to our pre-operative team, as well as the surgical consultation, must be completed in person.
CTMS providers will also review letters from other providers to make sure they meet the WPATH standards and will be accepted for insurance approval. They may ask for updated letters, or for different information to be included. CTMS medical providers are able to answer all questions about surgery at this initial appointment and help prioritize what to ask when speaking directly with the surgeon.
After these initial visits, the surgeon’s office will call to schedule surgical consultation, when patients can discuss their preferences with the surgeon prior to surgery. This consultation visit can be scheduled within the same week as the initial medical, mental health, and social work appointments. However, such scheduling will require sending medical records to CTMS in advance of assigning appointment dates.
In order to ensure the best possible post-surgery results, CTMS targets a body-mass index of 33 or lower for phalloplasty, metoidioplasty, and vaginoplasty procedures. The program also requires that everyone be nicotine-free prior to surgery. For people with diabetes, hemoglobin A1C levels must be at 8.0 or lower.
CTMS also offers hair removal prior to vaginoplasty and phalloplasty procedures. This is highly recommended and will improve the post-operative outcome.
CTMS and the Mount Sinai Hospital System require pre-surgical testing, including a blood draw and a physical exam, within two weeks of your surgery date. This requirement is to make sure there are no immediate problems that will interfere with surgery.
Your Surgery Day
At each site, Mount Sinai nursing staff will help you prepare for surgery. Preparing for surgery includes seeing the surgeon, anesthesiologist, and several nurses who will ask questions to verify everything is in order. As well, they will answer any new questions. Patients are then brought to the operating room, and the anesthesiologist puts them to sleep.
After surgery, all patients go to the post-anesthesia care unit. If the procedure requires an overnight stay in the hospital, patients are then taken to their hospital rooms.