Gender Reassignment Surgery in Ankara, Turkey

Gender reassignment surgery (gender affirmation surgery) includes surgical interventions performed to eliminate the mismatch between an individual’s gender identity and biological sex. Different surgical protocols are applied for trans women and trans men, and the process is carried out with a multidisciplinary approach.

Among the surgeries performed for trans women are vagina creation using the penile inversion method (vaginoplasty), breast augmentation, and facial feminization surgeries. After surgery, structures similar to female anatomy are achieved both functionally and aesthetically.

In trans men, removal of the uterus and ovaries (hysterectomy, oophorectomy), removal of breast tissue (mastectomy), and penis reconstructions such as phalloplasty or metoidioplasty are performed. These procedures aim to create male sexual and physical characteristics.

Before gender affirmation surgeries, psychiatric evaluation, hormone therapy, and the social transition process must be completed. The recovery process after surgery is long and staged; however, with proper follow-up and support, physical, psychological, and social adaptation can be successfully achieved.

What Is Gender Reassignment Surgery?

Gender reassignment surgery refers to surgical procedures performed on individuals who have a mismatch between their gender identity and the biological sex assigned at birth. In current medical terminology, it is called “gender affirmation surgery.” This process may include breast surgeries, genital reconstruction surgeries, and other aesthetic or functional interventions deemed necessary. The aim is to align the individual’s body with their gender identity, thereby supporting psychological well-being and quality of life.

What Legal Stages Does the Gender Affirmation Process Go Through?

The first issue a plastic surgeon must be certain about before entering the operating room is the patient’s legal assurance. In Turkey, gender affirmation surgeries are clearly regulated by Article 40 of the Turkish Civil Code. These rules exist both to protect the patient and to define the legal boundaries of the physician. The process begins with the individual applying to the court before applying to the hospital.

The main conditions required for court approval are as follows:

• Being over 18 years of age
• Not being married
• Documenting that the individual has a transsexual condition
• Having a medical necessity in terms of mental health

At this point, it is necessary to mention a very important turning point. In the past, the law required that a person be “deprived of reproductive ability,” meaning sterilized, in order to grant surgical permission. This situation created a very challenging barrier in terms of human rights and medical ethics. However, with a historic decision by the Constitutional Court, this requirement was annulled. Individuals can now begin the gender affirmation process directly without being subjected to compulsory sterilization that harms their bodily integrity. This decision removed a major psychological burden from our patients and brought the process to a more humane dimension.

Simultaneously with the court process, the “Sexual Identity Councils” in hospitals come into effect. In these councils, psychiatry, endocrinology, urology, gynecology, and we plastic surgeons come together. The aim is to confirm whether the patient is mentally and physically ready for this transformation. Under Turkish conditions, undergoing surgery without a council report is not legal.

How Does Hormone Therapy Before Surgery Affect Surgical Planning?

Preparation for surgery is not limited to paperwork; the body must also biologically prepare for this change. We generally expect our patients to have undergone hormone replacement therapy (HRT) for a certain period before surgery. Hormones change the quality of the “fabric” we operate on as surgeons, meaning the tissue.

The effects of estrogen therapy used in trans women on tissues include:

• Thinning of the skin structure
• Increase in subcutaneous fat tissue
• Softening of body contours
• Glandular growth in breast tissue
• Decrease in muscle mass

Testosterone used in trans men creates the opposite effect. It thickens the skin, strengthens muscle structure, and most importantly causes enlargement (hypertrophy) of the clitoral tissue. This growth provides a valuable anatomical advantage if the patient plans to undergo metoidioplasty surgery in the future.

However, hormone therapy also has a side that threatens surgical safety. Estrogen in particular increases the blood’s tendency to clot. When patients remain immobile for long periods during major surgeries, this can lead to the risk of vascular blockage (thromboembolism). Therefore, we ask patients to stop hormone medications a few weeks before the surgery date. This is a non-negotiable precaution we take for the patient’s safety.

Why Is Facial Feminization Critical for Social Adaptation in Trans Women?

In the perception of gender within society, the first reference point is not the genital area but the face. For a trans woman, removing masculine features from the face is often an even higher priority than genital surgery. Facial Feminization Surgery (FFS) includes a series of delicate procedures that transform masculine bone structures into feminine proportions.

There are distinct differences between male and female facial skeletons. With FFS, we eliminate these differences by smoothing, cutting, and reshaping them. For example, men often have a prominent bone protrusion above the forehead at eyebrow level. This protrusion gives the gaze a harsh expression. We shave or reposition this bone to create a smoother and more rounded forehead.

Procedures we frequently perform within facial feminization include:

• Forehead contouring (correction of frontal bossing)
• Advancement of the hairline
• Eyebrow lift
• Rhinoplasty (nose surgery)
• Cheekbone augmentation
• Jaw angle reduction
• Chin refinement
• Lip lift
• Adam’s apple reduction (tracheal shave)

Especially correcting the cartilage protrusion known as the “Adam’s apple” is very important for neck aesthetics. During this procedure, we work with millimetric precision to avoid damaging the vocal cords. The aim here is to allow the patient to see the woman they feel when they look in the mirror.

What Should Be Considered in Breast Augmentation Surgery for Trans Women?

Although some breast development occurs in trans women with hormone therapy, surgical support is usually required to achieve the desired fullness. However, the anatomy of trans women differs from biological female anatomy, and the surgeon must plan accordingly.

The male rib cage is generally wider and the pectoral muscles are more developed. Choosing a silicone implant with the correct profile suitable for this wide base is critical for the naturalness of the result. If a narrow-based implant is chosen, the breasts may appear too far apart. In addition, the inframammary fold (the groove where the breast meets the abdomen) in trans women is usually higher or not clearly defined. Creating this fold in the correct location during surgery determines the position of the breast.

The implant placement methods we prefer include:

• Submuscular placement
• Subfascial placement
• Dual-plane (partial submuscular) placement

Generally, the “dual-plane” technique is preferred because the upper part of the implant remains under the muscle, providing a softer transition. If the patient’s subcutaneous tissue is very thin, we camouflage the implant by injecting fat tissue taken from the patient’s own body around the implant (fat graft). This provides a soft tissue feeling rather than a silicone sensation when touched.

What Do Vaginoplasty Techniques Offer for Trans Women?

Vaginoplasty, which is the equivalent of genital affirmation surgery in trans women, is an operation with both aesthetic and functional goals. The aim is to create a vaginal canal with suitable depth and width for sexual intercourse, a urethra that preserves urination function, and an aesthetically pleasing vulva.

In the most commonly used “Penile Inversion” technique, the existing penile skin is turned inward like a tube to create the vaginal canal. The greatest advantage of this method is that penile skin is sensitive.

Structures created during the operation include:

• Vaginal canal (cavity)
• Neoclitoris (new clitoris)
• Labia majora (outer lips)
• Labia minora (inner lips)
• Urethral opening

The most delicate point here is the construction of the clitoris. A portion of the glans penis is reduced while preserving the vascular and nerve bundle on it and placed at the apex of the newly created vulva. In this way, the patient’s ability for sexual arousal and orgasm is preserved. The scrotum (testicular sac) skin is used to create the outer lips. In the postoperative period, regular “dilation” exercises are vital to prevent the vaginal canal from closing.

How Is the Phalloplasty Method Applied in Trans Men?

For our trans male patients, the process is somewhat more challenging and multi-staged from a surgical perspective. Expectations from an ideal phalloplasty (penis construction) include an aesthetic appearance, the ability to urinate while standing, sufficient volume for sexual intercourse, and the ability to feel sensation.

For phalloplasty, we transfer tissue from another area of the body. Today, the most commonly used and “gold standard” method is the “Free Radial Forearm Flap (RFFF)” technique using tissue taken from the forearm.

The reasons for preferring the RFFF method include:

• The thinness of the skin being suitable for shaping
• The reliability of the vascular structure
• The richness of sensory nerves
• Ease of creating a urethra

In this surgery, the skin taken from the forearm is wrapped using the “tube within a tube” method. The inner tube forms the urethra, while the outer tube forms the penile shaft. When the sensory nerves in the forearm are microsurgically connected to the genital nerves in the groin area, the patient has a very high chance of gaining tactile and erogenous sensation in the new penis.

However, not every patient may want a visible scar on their arm. In this case, tissue taken from the thigh region (ALT Flap) comes into play. Thigh tissue is thicker, which allows the creation of a fuller penis, but sensation gain may not be as high as with the forearm method. The choice of method is shaped according to the patient’s answer to the question: “Sensation, appearance, or scar concealment?”

How Is Functionality Achieved with Penile Prostheses?

No matter how aesthetic the new penis created with phalloplasty appears, it does not have the ability to become erect (erection) on its own like a biological penis. This is because it does not contain the spongy tissues that fill with blood and provide rigidity. Therefore, to provide sexual intercourse function, we need external support, namely penile prostheses.

Prosthesis surgery is not performed immediately after phalloplasty. First, the tissue must fully heal, swelling must subside, and sensory return must begin. This period is usually around 9–12 months after the initial surgery.

Types of prostheses used include:

• Malleable prostheses
• Two-piece inflatable prostheses
• Three-piece inflatable prostheses

Malleable prostheses provide constant rigidity thanks to the wire mechanism placed inside them. The patient manually positions the penis straight before intercourse and bends it afterward to conceal it. They are very easy to use and have a low risk of malfunction, but being constantly rigid may cause discomfort for some patients in social environments.

Inflatable prostheses offer a more complex but more natural result. By squeezing a pump placed in the scrotum, fluid from the reservoir fills the cylinders and the penis becomes rigid. When finished, the deflation button is pressed and the penis softens. This mechanism provides the most satisfactory natural appearance but has a slightly higher risk of mechanical failure compared to malleable prostheses.

Why Are Microsurgical Techniques Vital?

It would not be an exaggeration to say that gender affirmation surgery, especially the phalloplasty stage, requires the highest level of skills in plastic surgery. The procedure performed here is not simply transferring tissue; it is a microsurgical battle to maintain vitality.

When we transfer tissue taken from one part of the body (for example the arm) to the groin region, we must connect its vessels to the vessels in the new location (anastomosis) so that the tissue can be nourished. These vessels may sometimes be only 1–2 millimeters in diameter. In these sutures we perform under a microscope with threads thinner than a hair strand, there is no margin for error.

Critical points of microsurgery include:

• Artery repair
• Vein repair
• Nerve coaptation (connection)

If even the slightest clot or blockage occurs in the vascular connection, the transferred tissue cannot receive blood and necrosis (tissue death) develops. This means the surgery has failed. Nerve repair is the functional aspect of the procedure. Correctly aligning the nerve ends is essential for the patient to start feeling sensation months later. Nerve healing requires patience; it progresses at approximately 1 mm per day. Therefore, the patient feeling a touch with the tip of their finger will be a miracle that occurs months after surgery.

What Awaits the Patient in the Postoperative Period?

When the surgery is finished, only half of the process has actually been completed. The recovery period is the time when the patient and physician must cooperate most closely. These surgeries fall into the “major” surgical category, meaning the body undergoes significant trauma and needs time to recover.

The hospital stay varies between 5 and 10 days depending on the procedure performed. Especially after phalloplasty, the patient’s position in the first days is very important for the blood circulation of the flap (transferred tissue). Every hour, our nurses and we check the color, temperature, and fullness of the tissue.

For vaginoplasty patients, the most important homework is “vaginal dilation.” The body perceives the newly created cavity as a wound and reflexively tries to close it. To prevent this, the patient must regularly use the special devices (dilators) provided.

Possible complications during the recovery process include:

• Urethral fistula (urine leakage)
• Urethral stricture (difficulty urinating)
• Vaginal stenosis
• Infection
• Wound healing problems
• Hematoma (blood accumulation)

Urinary leaks (fistulas) especially in trans men can be frustrating. Most of the time we keep the urinary catheter slightly longer and wait for these holes to close spontaneously. In cases that do not close, minor corrective surgeries may be required. During this period, maintaining high morale, paying attention to nutrition, and strictly avoiding smoking are the most important factors that accelerate recovery.

What Innovations Exist in the Future of Gender Affirmation Surgery?

The medical world does not stand still; new techniques and technologies enter our practice every day. Gender affirmation surgery also benefits from these developments. Although current methods are quite successful, we are working on techniques that leave fewer scars and provide more functional results.

Promising developments include:

• Urethra construction with tissue engineering
• Production of mucosa in laboratory environments
• Use of robotic surgery
• Pre-fabricated flap techniques

Tissue engineering is particularly exciting. If urethral tubes or vaginal mucosa can be produced in the laboratory from the patient’s own cells, it will no longer be necessary to take tissue from another part of the body. This means scars on the arm or leg will become a thing of the past. In addition, robotic surgery provides great convenience when using intra-abdominal tissues (peritoneum or intestine) in vaginoplasty procedures. Thanks to the precision of robotic arms, less bleeding and faster recovery become possible.