Gender-Affirming Surgery: Feminizing Options

THP - Transgender Health Program: Molly Palmer has much lower anxiety and better health after embracing her true gender
Molly Palmer has much lower anxiety and better health after embracing her true gender. She received care for her transition — as well as for multiple sclerosis — at OHSU. “I’ve felt like a woman my whole life,” she says.

OHSU surgeons are leaders in gender-diverse care. We provide specialized services tailored to the needs and goals of each patient. We offer:

  • Specialists who do hundreds of surgeries a year.
  • A urologist who is a leading expert in vaginoplasty (bottom surgery).
  • Plastic surgeons who are experts in chest feminization (top surgery) and gender-affirming face and body options.
  • Physical therapists who are international leaders in caring for vaginoplasty patients.
  • Vocal surgery with a highly trained ear, nose and throat doctor.
  • Peer volunteers who can provide support during visits.
  • Classes that help patients prepare for surgery and learn about fertility options.

Please see our patient guide to learn more about steps to surgery, WPATH standards of care, and the letter(s) of support needed for some surgeries.

Chest feminization

Estrogen therapy can produce breast development, but the chest may not have feminine proportions. Our plastic surgeons use implants and contouring to achieve these proportions. Our surgeons also use methods specific to chest-feminization surgery, which is not the same as breast augmentation for a cisgender patient.

At OHSU, our specialists do dozens of these surgeries a year. OHSU studies of outcomes have improved how we work with each patient to choose a technique.

Dr. Juliana Hansen, OHSU chief of plastic surgery, is one of our expert chest-feminization surgeons.
Dr. Juliana Hansen, OHSU chief of plastic surgery, is one of our expert chest-feminization surgeons.

You and your surgeon will decide on four key factors:

  • Type of implant (saline or silicone)
  • Shape of implant
  • Implant placement (above or below muscle)
  • Incision site

You’ll go home the same day. Patients can typically resume most normal activities after six weeks.

Chest-feminization surgery is relatively safe. Implants are subject to wear and tear, though, so it’s possible more surgery will be needed later in life.

It’s also not uncommon for a tight capsule of scar tissue to form around the implant (capsular contracture), requiring revision surgery. Your surgeon will discuss risks with you before surgery.

Dr. Daniel Dugi is a skilled urologist and surgeon who specializes in gender-affirming treatment
Dr. Daniel Dugi is a skilled urologist and surgeon who specializes in gender-affirming treatment. He completed advanced training in the U.S. and Europe.

Orchiectomy

At OHSU, expert urologists do orchiectomies (testicle removal). Patients may choose this option:

  • To remove the body’s source of testosterone
  • As part of a vaginoplasty or vulvoplasty (surgeries that create a vagina and/or vulva)
  • To relieve dysphoria (some patients choose only this surgery)

Removing the testicles usually means a patient can stop taking a testosterone blocker. Patients may also be able to lower estrogen therapy.

How orchiectomy is done

The surgeon makes an incision in the scrotum. The testicles and the spermatic cord, which supplies blood, are removed. Scrotal skin is removed only if the patient specifically requests it. The skin is used if the patient plans a vaginoplasty or vulvoplasty.

You will probably go home the same day. Patients can typically resume normal activities in a week or two.

Reducing testosterone production may increase the risk of bone loss and cardiovascular disease, so we recommend regular tests. Without prior fertility treatment, orchiectomy also ends the ability to produce children. Serious risks are uncommon but include bleeding, infection, nerve damage and scarring.

Vaginoplasty

Vaginoplasty creates a vulva and vagina. OHSU’s Dr. Daniel Dugi, a highly trained urologist and researcher, specializes in vaginoplasty and does about 100 a year. (Find links to published studies by OHSU providers in the “OHSU research” section of our For Health Care Professionals page).

A vaginoplasty can allow patients to:

  • Have a body more closely aligned with their gender
  • Urinate while sitting
  • Feel sexual sensation and have intercourse

Before your consultation

Dr. Dugi has extensive expertise in vaginoplasty, vulvoplasty and other gender-affirming procedures.
Dr. Daniel Dugi has extensive expertise in gender-affirming surgeries.

We ask that you follow some steps before your visit with Dr. Dugi. See details in our vaginoplasty handout.

Steps include:

  • Please watch our video with Dr. Daniel Dugi, in which he goes over vaginoplasty.
  • Please come to your visit with your questions written down.
  • Plan to discuss hair removal. For many patients, we recommend electrolysis.
  • We will talk with you about strict nicotine restrictions.

Pelvic floor physical therapy

Our physical therapists are international leaders in caring for vaginoplasty patients and supporting successful outcomes. Before surgery, therapists show patients exercises to stretch and relax the pelvic muscles. After surgery, they show patients relaxation exercises and positioning to ease the use of dilators (devices inserted to stretch the vagina).

How vaginoplasty is done

Tissues of the penis and scrotum are used to make the vulva (the outer genitals the labia, clitoris and urethra opening) and the vagina.

  • The surgeon removes the penis and testicles, and creates the vaginal canal between the rectum and urethra.
  • The vagina is lined with skin from the penis and scrotum, mostly with grafting and sometimes stretching the skin. If needed, the surgeon may also use skin from the hip or abdomen.
  • Scrotal skin is used to make the outer labia. The inner labia are made from skin from the penis or urethra, depending on anatomy. The clitoris is created from a small piece of the head of the penis. The urethra is shortened and repositioned.
  • The prostate is not removed. This avoids complications such as incontinence. The prostate can also provide sexual sensation.

You will probably spend five or six days in the hospital, followed by several weeks of reduced activity at home. We will provide detailed care and recovery instructions before you go home. You can also read details in our vaginoplasty handout.

For the first year after surgery, patients usually use a dilator often. This maintains the vagina’s desired size.

Typically, patients:

  • Use a dilator for 15 minutes, three times a day, until reaching the desired size. Or they might use it twice a day in longer sessions to better fit a work or school schedule.
  • Gradually decrease the number of sessions as dilation becomes easier. We’ll offer guidance at follow-up appointments.
  • Plan to dilate once or twice a week for life.

Serious risks from vaginoplasty are uncommon. Minor complications include temporary urine leakage, healing problems, and wound or bladder infection. Dr. Dugi will discuss possible complications with you before surgery. He will also check on how you are healing in a follow-up appointment.

A man smiling while sitting down with his legs crossed.
As a urologist, Dr. Dugi approaches surgeries with a detailed understanding of urogenital anatomy and function.

Vulvoplasty

Vulvoplasty creates a vulva the outer genitals. It is similar to a vaginoplasty but without creating a vaginal canal. The outward appearance is almost identical, with a labia, clitoris and shortened urethra. This surgery is also done by Dr. Dugi.

Patients may choose this surgery over vaginoplasty because they have no interest in having a vagina. It also requires no hair removal or dilation. A surgeon may recommend vulvoplasty for patients with certain risks, such as having had treatment for prostate or rectal cancer.

See our vaginoplasty handout to learn more about Dr. Dugi, and to understand restrictions and recommendations that also apply to vulvoplasty patients.

How vulvoplasty is done

The surgery is almost identical to vaginoplasty except for creation of a vaginal canal.

  • The outer labia are formed from part of the scrotum.
  • The inner labia are formed with skin from the penis or urethra, depending on anatomy.
  • The urethra is shortened and repositioned.
  • The clitoris is created from the head of the penis, allowing sexual sensitivity. Remaining parts of the penis and scrotum are removed.

Recovery is similar to that of vaginoplasty. You will probably spend four to six days in the hospital. It may be six to eight weeks before you return to work or resume strenuous activities.

Vulvoplasty has fewer risks than vaginoplasty. Serious complications are uncommon. More common risks include minor healing problems. Dr. Dugi will check on how you are healing after surgery.

Laryngochrondoplasty (Adam’s apple reduction)

Dr. Joshua Schindler, an ear, nose and throat doctor who does Adam’s apple and vocal surgeries, completed his training at Johns Hopkins.
Dr. Joshua Schindler, an ear, nose and throat doctor who does Adam’s apple and vocal surgeries, completed his training at Johns Hopkins University.

Laryngochrondoplasty is also known as Adam’s apple reduction or a tracheal shave (though the trachea, or windpipe, is not affected). A surgeon removes thyroid cartilage at the front of the throat to give your neck a smoother, more feminine appearance. This procedure can often be combined with facial feminization surgeries.

Thin incision: At OHSU, this procedure can be done by an ear, nose and throat doctor (otolaryngologist) with detailed knowledge of the neck’s anatomy. The surgeon uses a thin incision, tucked into a neck line or fold. It can also be done by one of our plastic surgeons, typically with other facial feminization surgeries.

In an office or an operating room: Our team can do a laryngochrondoplasty in either setting, which may limit a patient’s out-of-pocket expenses.

Vocal surgery

Many patients find that hormone therapy and speech therapy help them achieve a voice that reflects their identity. For others, vocal surgery can be added to raise the voice’s pitch.

Voice therapy: Patients have voice and communication therapy before we consider vocal surgery. Your surgeon and your speech therapist will assess your voice with tests such as videostroboscopy (allowing us to see how your vocal cords work) and acoustic voice analysis.

Effective surgery: We use a surgery called a Wendler glottoplasty. It’s done through the mouth under general anesthesia. The surgeon creates a small controlled scar between the two vocal cords, shortening them to increase tension and raise pitch. Unlike techniques that can lose effectiveness over time, this surgery offers permanent results.

Face and body feminization

Estrogen and testosterone-blocking therapy usually soften facial features. They don’t change the underlying framework or remove hair follicles, though. At OHSU, a highly trained plastic surgeon, Dr. Jens Berli, and other specialists offer the following options. Patients usually go home the same day or spend one night in a private room.

  • Forehead reduction, including Type 3 sinus setback and orbital remodeling
  • Rhinoplasty (nose job)
  • Cheek augmentation
  • Jawline contouring
  • Genioplasty (chin surgery, including reductive, implants or bone-cut options)
  • Laryngeal chondroplasty (reducing the Adam’s apple)
  • Hairline advancement (done with the forehead)
  • Browlift (done with the forehead)
  • Eyelid surgery
  • Face-lift, neck lift
  • Lipofilling (transferring fat using liposuction and filling)
  • Lip lift and/or augmentation
  • Hair removal (electrolysis with plastic surgery experts, or laser therapy with dermatologists)
  • Laser skin resurfacing or chemical peels with dermatologists

Body: Hormone treatment may not result in fat distribution consistent with your gender. We offer liposuction and fat grafting to shape these areas of the body.

For patients

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Location

Dillehunt Hall, Room 1007
3235 S.W. Pavilion Loop
Portland, OR 97239

Dillehunt Hall can be reached through Sam Jackson Hall.

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Peer volunteers

Learn about our Here4You peer volunteers. We pair patients with a peer, based on availability, for support through surgery.