Gender-Affirming Surgery: Masculinizing Options

Dr. Jens Berli is passionate about caring for gender-diverse patients. Dr. Berli is an internationally known plastic and reconstructive surgeon who focuses on gender-affirming surgery.
Dr. Jens Berli is passionate about caring for gender-diverse patients. Dr. Berli is an internationally known plastic and reconstructive surgeon who focuses on gender-affirming surgery. He is also the only Northwest surgeon providing phalloplasty.

At OHSU, our doctors and other medical professionals are international leaders in providing gender-affirming surgical options.

You’ll find:

  • Doctors who specialize in transgender surgeries, performing hundreds a year.
  • The region’s only phalloplasty surgeon.
  • Chest masculinization (top surgery) using the latest techniques.
  • Gynecologic care in a gender-neutral space.
  • 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 masculinization

OHSU’s plastic surgeons do hundreds of surgeries a year to remove breasts and reshape the chest to appear more masculine.

We offer every type of chest masculinization, including liposuction when needed. Your surgeon will work with you to choose the technique best suited to your anatomy and preferences.

Surgery is usually done in our outpatient surgery center, and you go home the same day.

You will have a compression garment for several weeks. You can expect to get back to most normal activities within six weeks.

Serious complications are uncommon. The two most common long-term problems are scarring and reduced nipple sensation. We recommend you continue routine mammograms as some breast tissue will remain.

Dr. Lishiana Shaffer is an expert gynecologic surgeon. Her specialty areas include caring for transgender and gender-nonconforming patients.
Dr. Lishiana Shaffer is an expert gynecologic surgeon. Her specialty areas include caring for transgender and gender-nonconforming patients.

Hysterectomy

At OHSU, our gynecologic surgeon, Dr. Lishiana Shaffer, specializes in hysterectomies (uterus  and cervix removal; often combined with oophorectormy, or ovary removal) for gender-diverse patients. She does more than 150 a year.

Some patients choose hysterectomy to:

  • More closely align their bodies with their gender identity.
  • With ovary removal, to remove a main source of the female hormone estrogen.
  • To end pain caused by testosterone therapy that shrinks the uterus.
  • To end the need for some gynecologic exams, such Pap smears.

Preparation: We usually recommend a year of hormone therapy first, to shrink the uterus. We don’t require a year of social transition.

Most often, we use a minimally invasive laparoscope and small incisions in the belly. We usually recommend removing fallopian tubes as well, to greatly reduce the risk of ovarian cancer.

Most patients spend one night in the hospital. Recovery typically takes about two weeks. You’re encouraged to walk during that time but to avoid heavy lifting or strenuous exercise.

Hysterectomy is usually safe, and we have a low rate of complications. Risks can include blood clots, infection and scar tissue. Because of a possible link between hysterectomy and higher risk of cardiovascular disease, your doctors may recommend regular tests.

Removing the uterus also ends the ability to carry a child. OHSU fertility experts offer options such as egg freezing before treatment, and connecting patients with a surrogacy service.

Oophorectomy

Having a gynecologic surgeon remove one or both ovaries is often done at the same time as a hysterectomy. We do nearly all these surgeries with a minimally invasive laparoscope and small incisions in the belly.

Most patients spend one night in the hospital and return to their regular routine in about two weeks.

The ovaries produce estrogen, which helps prevent bone loss and the thickening of arteries. After removal, a patient should be monitored long-term for the risk of osteoporosis and cardiovascular disease.

We encourage patients to keep at least one ovary to preserve fertility without egg freezing. This also preserves some hormone production, which can avoid early menopause.

Metoidioplasty

In a metoidioplasty, a surgeon crafts a phallus from existing tissue in the genital region. At OHSU, this is done by reconstructive urologists.

How metoidioplasty is done

A year or two of testosterone therapy typically causes the clitoris to grow, sometimes to 1 or 2 inches. The surgeon can separate the clitoris from surrounding tissue to make it longer and to position it as a phallus.

Patients may choose to have their urethra lengthened and placed in the phallus so they can urinate from their phallus while standing up.

Some patients go home the same day, and some spend one or two nights in the hospital. You may need to be off work and avoid travel for a couple of weeks.

Metoidioplasty has a lower risk of complications than phalloplasty. Risks include leaking or narrowing of the urethra, and persistent pain or sensitivity.

Results are different for everyone, but these are common:

  • Patients usually retain sexual sensitivity and can have an erection, though penetration may be difficult.
  • It’s possible to have a phalloplasty later on.
Dr. Berli, an expert phalloplasty surgeon, is dedicated to providing affirming care.
Dr. Berli, an expert phalloplasty surgeon, is dedicated to providing affirming care.

Phalloplasty

Phalloplasty creates a phallus with tissue from elsewhere on the body. At OHSU, Dr. Jens Berli, a plastic surgeon, and a team of reconstructive urologists do the various stages of this surgery.

Phalloplasty can be done many ways. At OHSU, we have adopted and modified a method developed by surgeons at St. Peter’s Andrology Centre in London.

Our surgeons have extensive experience, doing almost two dozen a year. They maintain a database of phalloplasty surgeries to aid research and improve outcomes. They have also published and lectured on phalloplasty nationally and internationally. (Find links to published studies by OHSU providers in the “OHSU research” section of our For Health Care Professionals page).

Phalloplasty, in ideal circumstances, enables patients to:

  • Have a body that more closely aligns with their gender
  • Have a natural-looking phallus with sensation
  • Have intercourse with an external or internal device
  • Urinate while standing

A phalloplasty may include some or all of these procedures:

  • Creation of a shaft
  • Creation of a urethra within the shaft (shaft urethra)
  • Creation of a segment of urethra, called a perineal urethra, to connect the existing urethra to the shaft urethra
  • Scrotoplasty (creation of a scrotum)
  • Vaginectomy (removal of the vagina)
  • Burial of clitoral tissue
  • Glansplasty (creation of a circumcised-appearing tip)
  • Erectile device implant (inflatable or semi-rigid)
  • Testicular implants

We offer these types at OHSU:

  • Tube-within-a-tube phalloplasty: We use one piece of tissue to form two tubes. One has skin on the outside for a shaft, and one has skin on the inside for the urethra. The tissue usually comes from the forearm. In very thin patients, it can come from the thigh.
  • Shaft phalloplasty: Only an outer tube is created, and the patient continues to urinate from their existing urethra. Patients can still choose to have the vaginal lining removed; creation of a scrotum; and burial of the clitoris. Or they can have a scrotum created while keeping the vaginal canal. All donor sites (where tissue is taken from) are options.
  • Composite phalloplasty: This is an option for patients who aren’t good candidates for a tube-within-a-tube phalloplasty. The surgeon uses two pieces of tissue, usually from the thigh and forearm, to create the shaft and urethra separately.
  • Revision surgery: Patients who had an unsatisfactory phalloplasty done elsewhere can come to us to have it corrected.

Common donor sites:

  • Radial forearm free flap: This is the most common. We take skin, blood vessels and nerves from the forearm. This provides sensitivity and a natural appearance.
  • Anterior lateral thigh flap: Tissue including skin, blood vessels and nerves comes from the side of the thighs. Whenever possible, the blood supply is left attached (pedicled flap), and only the nerves are cut and reconnected.
  • Abdominal flap: Lower abdominal skin is used for a shaft-only phalloplasty. This technique does not involve nerves, and patients do not have the ability to urinate standing.

Phalloplasty typically requires multiple steps, though there are many variations. Your surgeon will discuss options with you. Steps may include:

First surgery: The plastic surgeon grafts tissue, and forms and attaches the new phallus.

Second surgery, about five months later: Depending on choices, the plastic surgeon and/or urologist:

  • Removes the vagina (this is always done by our urologic team)
  • Connects the urethra
  • Creates a scrotum
  • Forms a circumcised appearance (glansplasty)
  • Places two temporary catheters (thin tubes), one through the phallus and one through the abdomen

Third surgery, about six months later (if a patient chooses these options):

  • Testicular implants are placed.
  • An erectile device is implanted.

You will probably be in the hospital for a week after your first surgery. You should limit walking and strenuous activity for up to six weeks. Your second surgery comes with a two-night hospital stay. The implants are offered as an overnight-stay surgery.

Out-of-town patients: Because these surgeries are not widely offered, many patients travel from outside the area. We typically require patients to stay in the Portland area for four weeks after the first surgery and two weeks after the second. Patients also need to return four weeks after the second surgery to have their catheter removed. In addition, we ask patients to be prepared for an extended stay in case complications arise or healing is delayed.

Rehabilitation: OHSU occupational therapy specialists offer arm splints to help manage pain from forearm surgery.

Phalloplasty is complex, increasing the risk of complications. Risks include a narrowed urethra or urine leaks, infection, scarring, lack of sensation and the death of transferred tissue.

It’s also important to have realistic expectations. Appearance can vary depending on your anatomy and tissue.

Facial and body masculinization

Hormone therapy can bring out masculine traits but can’t change the underlying structure of your face or neck. Our expert plastic surgeons offer options including:

  • Forehead lengthening
  • Cheek augmentation
  • Nose, jaw and chin reshaping
  • Adam’s apple enhancement

Body:  Even with hormone treatment, fat distribution may remain unaligned with a patient’s gender. We offer liposuction and fat grafting to shape these areas of the body.

Contact us

Location

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

Dillehunt Hall can be reached through Sam Jackson Hall.

Refer a patient

Please download our referral form and fax with relevant medical records to 503-346-1501. Learn more on our For Health Care Professionals page.

Peer volunteers

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