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Gender-affirming surgery, the long road to it, and the account I went looking for and couldn't find.

Gender-affirming surgery, a first-hand and respectful account.

MtF Gender-Affirming Surgery: Feminising Procedures Explained

Key takeaways

  • MtF (feminising) gender-affirming surgery describes procedures for a trans woman or transfeminine person, ranging from genital to chest to facial surgery.
  • Vaginoplasty is the main genital feminising surgery; it creates a vulva and vaginal canal, most commonly by penile inversion, and requires lifelong dilation.
  • Breast augmentation is usually considered after about 12 months on oestrogen if hormone-driven growth is insufficient.
  • Facial feminisation surgery (FFS) is a group of procedures across the forehead, hairline, nose, jaw and chin, tailored to the individual.
  • Surgery is one option among many; the right combination is personal and chosen with a clinical team.

By Jessica Tran  |  Medically reviewed by Mr Tobias Lindgren, FRCS(Plast)

Published · Last revised · Last reviewed · 3 min read

MtF (feminising) gender-affirming surgery describes procedures for a trans woman or transfeminine person, ranging from genital to chest to facial surgery. The main genital procedure is vaginoplasty, which creates a vulva and vaginal canal, most commonly by penile inversion, and requires lifelong dilation. Other options include breast augmentation, facial feminisation surgery, tracheal shave and voice surgery. Surgery is one option among many, and the right combination is personal, chosen with a clinical team1.

When I started looking into feminising surgery, what I wanted was the whole menu in one place, explained respectfully and without sensationalism. So here it is, checked by a consultant gender-affirmation surgeon. Each procedure has its own guide, and the wider context is in our pillar, gender-affirming surgery.

What is MtF gender-affirming surgery?

MtF gender-affirming surgery is the group of feminising procedures a trans woman or transfeminine person may choose, and it is best thought of as a set of options rather than one operation. Some people choose one procedure, some several over years, and many choose none.

The procedures fall into three broad areas: genital, chest, and facial or voice. The right combination is individual, and it is decided through assessment, following the principles of informed consent and individualised assessment set out in WPATH SOC-81.

Vaginoplasty: the main genital surgery

Vaginoplasty is the main genital feminising surgery, and it creates a vulva and vaginal canal, most commonly by penile inversion. Its defining piece of aftercare is lifelong dilation, which keeps the vaginal canal at depth and width because the neovagina does not self-maintain like natal tissue.

There is a minimal-depth alternative, vulvoplasty, which creates an external vulva without a full vaginal canal and needs little or no dilation; it is chosen when dilation is not wanted or not advised. The full detail of the main procedure, including dilation, is in our guide to vaginoplasty.

Breast augmentation

Breast augmentation is implant-based chest feminisation, usually considered after about 12 months on oestrogen if hormone-driven growth is insufficient. The waiting period lets the body’s response to hormones be assessed before deciding on implants.

Recovery is generally about 1 week off work, with heavy lifting avoided for about 4 to 6 weeks. It is a relatively contained procedure compared with genital surgery, though, as with any surgery, it carries its own risks to weigh.

Facial feminisation surgery

Facial feminisation surgery (FFS) is a group of procedures tailored to the individual, across the forehead and brow, hairline, nose, jaw and chin. It is not a single operation but a plan built around a person’s face and what they want to change.

Recovery is patient work: major swelling settles over weeks, and full settling can take up to 6 to 12 months. The slow reveal is part of the process, and it helps to expect it rather than to read too much into the early weeks.

Tracheal shave and voice surgery

Two further feminising options address the throat and voice. Tracheal shave (chondrolaryngoplasty) reduces the prominence of the thyroid cartilage, sometimes called the Adam’s apple. Voice surgery, such as glottoplasty to raise pitch, is usually considered after voice therapy, which is first-line.

For me, voice was the change I had most underestimated. Starting with therapy rather than reaching straight for surgery turned out to be the right order, and it is the order clinicians generally recommend.

Choosing what is right for you

There is no standard set of feminising procedures, and that is the point: the combination is personal. The reassuring backdrop is that outcomes are generally good. A 2021 systematic review and meta-analysis found pooled regret of about 1 in 100, with the large majority reporting improved wellbeing2.

Eligibility and timing follow the same pathway as all gender-affirming surgery, set out in am I eligible for gender-affirming surgery, and the NHS route is in gender-affirming surgery on the NHS. Nothing here is personal medical advice; the right plan for you is one your clinical team builds with you.

Frequently asked questions

What is MtF gender-affirming surgery?

MtF (feminising) gender-affirming surgery describes procedures for a trans woman or transfeminine person. It ranges from genital surgery such as vaginoplasty, to chest surgery such as breast augmentation, to facial feminisation surgery, tracheal shave and voice surgery. It is one option among many, and the right combination is personal and chosen with a clinical team.

What is the main feminising genital surgery?

Vaginoplasty is the main genital feminising surgery. It creates a vulva and vaginal canal, most commonly by penile inversion, and requires lifelong dilation. Vulvoplasty is a minimal-depth alternative that creates an external vulva without a full vaginal canal and needs little or no dilation.

When can a trans woman have breast augmentation?

Breast augmentation is implant-based chest feminisation, usually considered after about 12 months on oestrogen if hormone-driven growth is insufficient. The 12-month period lets the body's response to hormones be assessed before deciding on implants. Recovery is generally about 1 week off work, avoiding heavy lifting for about 4 to 6 weeks.

What is facial feminisation surgery?

Facial feminisation surgery (FFS) is a group of procedures across the forehead and brow, hairline, nose, jaw and chin, tailored to the individual. Major swelling settles over weeks, and full settling can take up to 6 to 12 months. Which procedures suit a person is decided individually with the surgeon.

Does feminising surgery require hormones first?

Where hormones are not contraindicated, about 12 months of continuous hormone therapy before genital surgery is usual under WPATH SOC-8. Breast augmentation is usually considered after about 12 months on oestrogen. Some procedures may not require this; your clinical team confirms what applies.

How common is regret after feminising surgery?

Regret is low. A 2021 systematic review and meta-analysis of about 7,900 patients found pooled regret of about 1 in 100, and the large majority report improved wellbeing. It is low but not zero, and figures vary by procedure and how they are measured.

References

  1. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, World Professional Association for Transgender Health (WPATH). ↩
  2. Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence, Plastic and Reconstructive Surgery, Global Open (Bustos et al., 2021). ↩
  3. Gender dysphoria: Treatment, NHS.

Written by Jessica Tran. Medically reviewed by Mr Tobias Lindgren, FRCS(Plast).

Our guides are written from personal experience and reviewed by a qualified clinician for accuracy. Read our editorial policy.

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