Genital Reconstructive Services / Bottom Surgery

Genital Reconstructive Surgery

The mission of the UCLA Gender Health Program is to provide healthcare for the transgender or gender-diverse community that is sensitive to everyone’s individual needs. At UCLA, we understand that gender affirmation surgery is an important step in a person’s transitioning process, but not the only step. Which is why at UCLA we not only assemble an expert team of specialists in plastic surgery, urology and gynecology to work together to perform procedures for surgical gender transition, but also provide access to providers in behavioral health, hormone therapy and primary care.

For patients seeking Genital Reconstructive Services / Bottom Surgery, these services include:

For Transfeminine patients:

• Orchiectomy: Bilateral orchiectomy is a minor outpatient procedure performed by a UCLA urologist that involves surgical removal of the testicles through a small scrotal incision. This procedure is done with a particular technique that allows for vaginoplasty later, if desired. Afterward, patients may adjust their dose of estrogens downward and no longer require spironolactone or any other androgen blockade. Recovery takes approximately 2 weeks. Individuals seeking orchiectomy as part of their transition may wish to consider semen banking and discussing with their provider about possible fertility preserving options before surgery.
• Vaginoplasty and Vulvoplasty: In addition to an orchiectomy, a person seeking feminizing gender affirming surgery may elect to undergo a vaginoplasty, a surgical procedure that involves reconstructing the genitals to create external female genitalia with or without a vaginal cavity, based on the patient's preference. There are multiple techniques for reconstruction with the most common using modified penile skin inversion technique to create a functional and aesthetic vagina. At our program we offer both the modified penile skin inversion technique and the robotic assisted vaginoplasty with use of a peritoneal tissue.
  Webinar: Considerations Before and After Vaginoplasty - UCLA gender health expert, Gladys Y. Ng, MD, MPH, provides an overview of the gender-affirming vaginoplasty surgery. View Webinar on YouTube >

For Transmasculine patients:

• Phalloplasty: This gender affirming surgery involves a multi-staged procedure for masculinizing genitoperineal reconstruction with creation of a penis, urethra or urinary channel (to be able to urinate), scrotum, and the obliteration of the vaginal cavity with closure. This surgery is performed by both Plastic Surgery and Urology. The removal of the female genital organs such as the uterus and ovaries and fallopian tubes are required and usually performed separately and prior to the phalloplasty surgery if a vaginectomy is desired. The creation of the penis is performed with use of tissue from other parts of the body, which could include, more commonly the radial forearm free flap, or anterolateral thigh flap, and latissimus dorsi (MLD) flap. Prosthetics such as silicone or saline testicles can be placed as well as inflatable penile prosthetics in the later stages.
  Webinar: Phalloplasty and Associated Procedures - UCLA gender health experts Gladys Y. Ng, MD, MPH and J. Brian Boyd, MD provide an overview of the gender-affirming phalloplasty surgery. View Webinar on YouTube >
• Metoidioplasty: This masculinizing genital affirming procedure builds upon the existing growth of the clitoris after prior testosterone hormone therapy. In this procedure, the surrounding tissue of the enlarged clitoris is released and removed to achieve maximal length and a more natural-looking male aesthetic. A urethra can also be reconstructed using either local skin tissue or a graft from the mouth depending on the amount of tissue present and is usually combined with a vaginectomy. The result is an aesthetic, small penis with ability to void from the tip. Construction of a scrotum with testicular prosthetics can also be performed at the same time. Should it be desired, removal of the uterus, vagina and/or ovaries can be performed at the same time. 
  Webinar: Masculinizing Surgery with Metoidioplasty - UCLA gender health expert Gladys Y. Ng, MD, MPH, provides an overview of the gender-affirming metoidioplasty surgery. Watch Age Restricted Video on YouTube > 

• Vaginectomy:  Transmasculine patients may desire removal and obliteration of the vaginal canal and opening. These procedures involve removal or ablation of vaginal mucosa, and closure of the vaginal canal. This is performed at the time of genital gender affirming surgery and is usually performed in association with urethral lengthening procedures. 

  The details of each of these procedures, including recovery time, expected outcomes, and possible complications, will be discussed during a consultation with your UCLA specialist. Regardless of where your genital reconstruction has been done, our specialists can evaluate any concerns following surgery. 

• Hysterectomy: At UCLA Gynecology, we offer a total hysterectomy, or removal of the uterus and cervix, via both laparoscopic and vaginal techniques. The hysterectomy is considered a therapeutic procedure by WPATH for transmasculine patients as part of the gender affirmation process.
• Salpingo-oophorectomy: The removal of the Fallopian tubes and ovaries can be accomplished via minimally invasive techniques. If a patient desires a vaginal hysterectomy, the tubes and ovaries can be removed at the time of this procedure. A patient who does not desire removal of the uterus may have a laparoscopic removal of the tubes and ovaries alone. 

For more detailed information regarding these surgeries available at UCLA, please visit our Gynecological Care program.

The details of each of these procedures, including recovery time, expected outcomes, and possible complications, will be discussed during a consultation with your UCLA specialist. Regardless of where your genital reconstruction has been done, our specialists can evaluate any concerns following surgery.

Pelvic Health Physical Therapy

Pelvic floor physical therapists play a unique and important role in the care of our UCLA Gender Health Program patients.

Pelvic floor physical therapy can address musculoskeletal dysfunction associated with gender-transition practices such as chest binding as well as genital packing and tucking. Specifically, soft tissue restrictions, muscular pain, postural deficits, altered sensation and scarring can potentially be reduced.  

In addition, pelvic floor physical therapy is recommended prior to and following genital reconstructive surgery. Surgeries can possibly lead to formation of scar tissue that can contribute to painful movement patterns, soft tissue restriction and reduced range of motion. Dilation of the neovagina is an important part of recovery to prevent stenosis, normalize sensation and maximize the circumference and length of the neovagina. Consistency of a dilation program can optimize the healing and maintenance of the vaginal canal. Pelvic floor dysfunction can result in increased muscle tension in the abdomen, back, pelvis, hips and legs leading to bladder, bowel and sexual issues. By managing bothersome symptoms, patients can optimize functional outcomes with a home program tailored by a pelvic health physical therapist. Physical therapy is often recommended for many types of surgeries to facilitate a patient’s recovery and return to function, therefore genital reconstructive surgery should be no different and patients can expect to benefit from rehab management.

For more information about our pelvic floor physical therapy services, please refer to the UCLA Rehabilitation Brochure .

Our Pelvic Floor Physical Therapists

Cindy Graham, PT, MPT
Education:
 Master of Physical Therapy, Northwestern University
Bachelor of Science, Biological Sciences, University of Notre Dame
Professional Memberships:
 American Physical Therapy Association (APTA)
APTA Academy of Pelvic Health
California Physical Therapy Association
Languages Spoken:
 English 

Valerie Lapeña, PT, DPT
Education:
 Doctor of Physical Therapy, Western University of Health Sciences
Master of Physical Therapy, Western University of Health Sciences
Bachelor of Science, Physiological Sciences and Psychology, UCLA
Certifications:
 Board Certified Clinical Specialist in Women's Health Physical Therapy
Herman and Wallace Pelvic Rehabilitation Practitioner Certification
Board Certified Clinical Specialist in Geriatric Physical Therapy
Professional Memberships:
 American Physical Therapy Association (APTA)
APTA Academy of Pelvic Health
APTA Academy of Geriatrics
California Physical Therapy Association
Languages Spoken:
English 

Termeh Toufanian, PT, DPT
Education:
 Doctor of Physical Therapy, University of Southern California
Bachelor of Science, Loyola Marymount University
Professional Memberships:
 American Physical Therapy Association (APTA)
APTA Academy of Pelvic Health
California Physical Therapy Association
Languages Spoken:
 English, Spanish, Farsi

Emily Whalen, PT, DPT
Education:
 Doctorate, Physical Therapy, Mount St. Mary’s University
Bachelor of Science, Kinesiology, California Polytechnic University
Professional Memberships:
 American Physical Therapy Association (APTA)
APTA Academy of Pelvic Health
California Physical Therapy Association
Languages Spoken:
 English

The World Professional Association of Transgender Health (WPATH): a non-profit, interdisciplinary professional and educational organization devoted to transgender health care, that has published Standards of Care for the health and care of transsexual, transgender and gender diverse people. The UCLA Gender Health Program follows the WPATH Standards of Care Guidelines for our surgeries. The most recent version of WPATH’s Standards of Care can be found here. It is available in 18 different languages.

Photographs: Due to privacy considerations, we do not publish photos of our patients on our website. Surgery photos - both preoperative and postoperative - are available to be seen during your initial consult.

Health Records: To ensure that our surgeons are providing the best and most informed care when discussing surgical techniques, expectations and outcomes, we REQUIRE that all patients submit their most recent progress notes/health records. If a patient does not have recent progress notes/health records they will be required to establish primary care within the UCLA Gender Health Program or with an outside primary care provider if their insurance is not contracted with UCLA Health.

Surgery Letters: To help streamline your surgery timeline the Gender Health Program (GHP) recommends that folks come to their consult with both surgery letters. These surgery letters are part of the WPATH requirements and the majority health insurances that provide bottom surgery coverage require these letters for surgery authorization and scheduling. Our surgery clinical teams cannot move forward with a surgery date until these letters are obtained and submitted to insurance. Health insurance policies and requirements can vary, please check with your individual insurance plan/policy about additional requirements for bottom surgery (if any). If you need help obtaining these letters, please let the GHP team know during intake and consults.

Care Coordination: At the UCLA Gender Health Program, we understand the unique challenges that gender expansive patients face when accessing health care. That's why our dedicated Care Coordination Team serves as your first point of contact. We offer a variety of services to support you. For more information >