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vaginoplasty, metoidioplasty, and phalloplasty, these procedures can be performed by plastic surgeons, urologists, gynecologists, and, in some cases, colorectal (or general) surgeons. In fact, it is recommended that these procedures be performed by a team of surgeons, often representing more than one specialty. From a global perspective, it is important to appreciate and recognize regional differences in training and scope of practice. Most gender surgeons agree that surgeons performing such surgeries, J Sex Med 2017;14:852e856 854 Schechter et al regardless of their particular specialty, require additional education and training after completion of their chosen discipline. There are multiple mechanisms by which training and competency can be assessed. Historically, institutions have required documentation of an arbitrary number of particular procedures to grant a surgeon privileges. More recently, evidence of competency has been evaluated not only by the number of procedures performed but also by evidence of ongoing education and outcome measures. The optimal method to determine a surgeon’s competency in gender confirming procedures requires further study. As an international organization representing the spectrum of medical specialties and advocacy groups caring for transgender individuals, the WPATH is currently the best equipped organization to assess compliance with the aforementioned guiding principles. Not all institutions or providers will necessarily seek comprehensive certification. Levels of certification can be provided, ranging from non-surgical programs to complete multidisciplinary programs with associated surgical training fellowships. OVERVIEW OF SURGICAL PROCEDURES A brief summary of surgical procedures is described below. This list is not inclusive, but it provides a starting point for the development of a curriculum on which knowledge and practical experience can be based. Surgical Procedures for Transwomen Vaginoplasty A successful surgical result involves the creation of a naturalappearing vagina and mons pubis7 that are sensate and functional. This includes removal of the stigmatizing scrotum, creation of feminine-appearing labia majora and minora, construction of a sensate neoclitoris (including clitoral hood), and development of adequate vaginal depth and introital width for intercourse. Additional desirable qualities include a smooth, graded, and contiguous appearance to the labia majora, a moist appearance to the labia minora simulating the vestibular lining in natal women, clitoral hooding, and lubrication for intercourse. The most common procedure involves the penile disassembly and inversion vaginoplasty. However, alternative techniques, such as with skin grafts or an intestinal vaginoplasty, also are performed. Recommended metrics are (i) delayed wound healing, (ii) venous thromboembolism (VTE), (iii) blood transfusion, (iv) surgical site infection, (v) hospital-acquired urinary tract infection (UTI), (vi) rectovaginal fistula, (vii) unplanned return to the operating room (OR), and (viii) revision rate. Recommended case volume is 25 procedures in a 2-year period. Ancillary Procedures Aside from genital reconstruction, breast augmentation, thyroid chondroplasty (“tracheal shave”), facial feminization, and body contouring offer additional procedures designed to feminize one’s appearance. Surgical Procedures for Transmen Chest Surgery This procedure, commonly performed before genital surgery, involves bilateral subcutaneous mastectomies, liposuction of the chest, and repositioning and resizing of the nipple-areola complex, when necessary. Several different techniques are used, and the choice of technique depends on the volume of breast parenchyma, degree of breast ptosis, position and size of the nipple-areola complex, and degree of skin elasticity. Recommended metrics are (i) delayed healing (including nipple-areolar loss), (ii) VTE, (iii) surgical site infection, (iv) unplanned return to the OR, and (v) revision rate. Recommended case volume is 25 procedures in a 2-year period. Metoidioplasty The procedure entails lengthening the hormonally hypertrophied clitoris by release of the suspensory ligament and resection of the ventral chordee and lengthening of the female urethra with the aid of labia minora and/or vaginal musculomucosal flaps.8 Recommended metrics are (i) delayed wound healing, (ii) VTE, (iii) urethral stricture or fistula, (iv) blood transfusion, (v) surgical site infection, (vi) hospital-acquired UTI, (vii) unplanned return to the OR, and (viii) revision rate. Phalloplasty As outlined by Monstrey et al,9 an ideal phallic reconstruction should result in an esthetic phallus with tactile and erogenous sensation, the ability to void while standing, minimal morbidity of the surgical intervention and donor site, an esthetic scrotum, and the ability to experience sexual satisfaction postoperatively. Phalloplasty techniques can be divided into pedicled flaps and free flaps. Pedicle flaps transfer tissue, typically of the thigh (anterolateral thigh flap), groin (superficial circumflex iliac perforator flap), or lower abdomen (deep inferior epigastric artery perforator flap or superficial inferior epigastric flap), to reconstruct the penis, whereas free flaps involve the microsurgical transfer of tissue from a remote location (radial forearm free flap). Although phalloplasty
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