Skip to main content

Testicular Implants — Gender-Affirming (Transmasculine Neoscrotal Augmentation)

Testicular prosthesis placement in transmasculine patients is performed as a staged, delayed component of masculinizing genital reconstruction — typically 6–12 months after scrotoplasty to allow tissue healing, neoscrotal expansion, and assessment of flap vascularity.[1][2][3] Unlike penile prostheses (which enable penetrative intercourse), testicular implants serve a cosmetic and psychological function — scrotal fullness and natural male genital contour. The largest published transmasculine series (Amsterdam, Pigot 2019, n = 206, mean follow-up 11.5 yr) reports an overall explantation rate of 20.8%, improving to 11.5% with the modern Hoebeke scrotoplasty technique.[1]

This page is the gender-affirming-specific atlas anchor. For the canonical cross-indication procedure hub (orchiectomy, congenital anorchia, torsion, pediatric, AMAB GA), see Testicular Prosthesis in the 04e genital-reconstruction section.

Indication and Context​

Testicular prostheses serve a cosmetic and psychological function in transmasculine individuals — scrotal fullness and natural male genital contour.[1][4] Both metoidioplasty and phalloplasty procedures may involve scrotoplasty with staged placement of testicular implants.[5][2] WPATH SOC and ACOG list testicular prosthesis implantation as a recognised masculinizing surgical procedure.[2] In Pletta 2025 (large transgender-adult survey), reproductive and genital surgeries were consistently rated most satisfactory across gender-identity groups (mean 4.6/5.0).[6]

Prerequisite: Scrotoplasty​

A neoscrotum must first be constructed from native tissue. The labia majora are the embryologic homologs of the scrotum and serve as the ideal donor.[7][3]

Scrotoplasty techniques​

  • Hoebeke / Ghent V-Y advancement with rotation — most frequently performed today. Superiorly based U-shaped labia-majora flaps rotated 90° medially to bring the neoscrotum anterior to the legs. Pedicled horseshoe-shaped pubic flap and clitoral-hood tissue incorporated; pedicled labia-majora fat pads relocated for bulk. Amsterdam series explantation 11.5% (6/52) — lower than historical techniques.[8][3][1]
  • Bilateral rotational advancement flaps — bilateral labia-majora elevation and rotation from posterior to anterior position. Miller 2021 n = 147: distal flap necrosis 4.1%, perineoscrotal dehiscence 4.7%, scrotal hematoma 1.4%.[7]
  • Tissue expanders — placed at initial scrotoplasty to gradually stretch neoscrotal skin before definitive implant placement; increasingly used as the field has trended toward delayed implantation.[1][9]

Timing of Implant Placement​

ACOG recommends placement ~6 months after scrotoplasty.[2] The field has shifted from immediate placement at scrotal reconstruction to delayed implantation, which allows:[1]

  • Complete flap healing and maturation.
  • Assessment of tissue adequacy and vascularity.
  • Use of smaller initial implants with potential upsizing later.
  • Reduced risk of infection and extrusion.

In staged phalloplasty, testicular implants are typically placed during the second or third stage — often concurrent with or prior to penile-prosthesis insertion (see Penile Implant After Phalloplasty).[5]

Prosthesis Types​

The devices are the same as those used in cisgender men after orchiectomy — no purpose-designed transmasculine implant exists. See the 04e canonical hub for full materials history and device specifications.

TypeExamplesNotes
Silicone gel-filledNagor, Sebbin, Polytech, Eurosilicone, PromedonMost common worldwide; multiple sizes; natural feel[1][2]
Saline-filledRigicon Testi10, Coloplast Torosa / MentorFDA-approved in the US; adjustable volume at implantation; Testi10 99.8% survival at 54 mo (cisgender data)[10][11]
Silastic (custom)Silicone elastomerElliptical shapes; some Asian centres[12]

Amsterdam transmasculine series (n = 206) brands used: Nagor (n = 205), Promedon (n = 105), Sebbin (n = 44), Dow Corning (n = 22), Prometel (n = 22), Polytech (n = 10), Eurosilicone (n = 2).[1]

Size trend — earlier practice was to place large implants immediately at scrotoplasty; current trend is toward smaller, lighter prostheses with delayed implantation.[1] Patient concerns (cisgender and transmasculine alike) most commonly involve positioning, size, and weight.[13]

Surgical Technique​

Differs from cisgender placement due to absence of native scrotal sac, dartos fascia, and tunica vaginalis:[1][13][7]

  1. Incision — typically scrotal or inguinal; small incision in neoscrotal skin.
  2. Pocket creation — blunt subcutaneous pocket sized to accommodate implant. Too large → migration; too small → pressure necrosis and extrusion.
  3. Implant placement — prosthesis inserted; bilateral implants placed through separate pockets.
  4. Closure — layered closure of neoscrotal tissue over implant.
  5. Fixation — some surgeons use suture fixation to prevent migration (no native gubernacular attachment exists in the neoscrotum).

Outcomes — Amsterdam Largest Series (Pigot 2019, n = 206, 11.5-yr mean follow-up)[1]​

OutcomeRate
Overall explantation20.8% (43/206)
Explantation — modern Hoebeke technique11.5% (6/52)
Trend over timeExplantation rates dropped over the last decade with improved techniques and prosthesis selection

Complications​

ComplicationNotes
InfectionMajor contributor to explantation; smoking a significant risk factor on multivariate analysis
ExtrusionMore common with larger / heavier implants and immediate placement
DiscomfortSize mismatch or malposition
Prosthesis leakagePrimarily saline-filled
Urethral problemsRelated to neourethra proximity to implant pocket

Risk factors​

  • Smoking — significant on both univariate and multivariate analysis.[1]
  • Larger prosthesis size — historical large-immediate-implant practice carried higher complications.[1]
  • Immediate vs delayed placement — delayed implantation associated with improved outcomes.[1]

Comparison vs Cisgender Testicular-Prosthesis Outcomes​

Complication rates in transmasculine patients are higher than cisgender men receiving prostheses after orchiectomy, reflecting the challenges of implanting into reconstructed tissue rather than a native scrotal sac:

PopulationAdverse-event / explantation rateAnchor
Cisgender saline (Torosa / Mentor, n = 149)19% adverse events (discomfort 3%, infection 1.3%, extrusion 2.6%, deflation 0.7%)Turek 2004[11]
Cisgender Rigicon Testi10 (n = 427)99.8% Kaplan-Meier survival at 54 moAtwater 2025[10]
Cisgender satisfaction (general)96.1% implant satisfaction; 89.8% appearance; 59.3% feel ("too firm" 25.5%)Araújo 2024[14]; Nichols 2019[15]
Transmasculine (Amsterdam n = 206)20.8% overall explantation; 11.5% modern techniquePigot 2019[1]

Psychological Impact​

Testicular prostheses contribute meaningfully to overall genital appearance and body-image satisfaction in transmasculine individuals. In cisgender data, placement significantly improves subjective testicular-appearance assessment (p < 0.05); receiving a testicular prosthesis is a positive predictor of overall genital satisfaction (OR 3.29).[11][15]

Pletta 2025 (transmasculine): reproductive and genital surgeries were rated most satisfactory across all gender-identity groups (mean 4.6/5.0), though this encompasses all genital procedures.[6] Qualitative data suggest that achieving a complete male genital appearance — including scrotal fullness — contributes meaningfully to reduced gender dysphoria and improved self-image.[4]

Special Considerations in the Gender-Affirming Context​

What makes transmasculine placement unique vs cisgender:[1][7]

  1. Reconstructed tissue bed — neoscrotum from labia-majora flaps has different tissue characteristics (thinner, less redundant) than native scrotal skin.
  2. Absence of native anatomy — no dartos muscle, tunica vaginalis, or gubernacular attachment → increased migration and extrusion risk.
  3. Concurrent procedures — implants may be placed alongside or near a penile prosthesis, requiring spatial planning within the neoscrotum.
  4. Urethral proximity — in patients who underwent urethral lengthening, the neourethra passes through or near the neoscrotum; urethral complications can necessitate implant removal.[1]
  5. Bilateral placement — transmasculine patients require two implants (vs most cisgender patients needing one after unilateral orchiectomy), doubling potential complications.
  6. ZSI 475 FtM penile prosthesis overlap — the purpose-designed FtM erectile prosthesis features a testicle-shaped pump placed in the neoscrotum, which may partially serve the cosmetic function of one testicular implant, potentially reducing the need for a separate prosthesis on that side.[16] Cross-link to Penile Implant After Phalloplasty.

Staging Within Masculinizing Reconstruction​

Typical staging:[5]

  1. Stage 1 — chest reconstruction, hysterectomy ± BSO.
  2. Stage 2 — vaginectomy, scrotoplasty (± tissue expanders), metoidioplasty or phalloplasty, urethroplasty.
  3. Stage 3 (~6 mo later) — testicular implant placement.
  4. Stage 4 (9–12 mo after phalloplasty) — penile prosthesis insertion if phalloplasty performed.

Individual timing varies by patient goals, comorbidities, and surgical history.

Evidence Limitations​

  • Pigot 2019 (n = 206) is the largest transmasculine-specific series — Amsterdam single-centre with 26 years of practice evolution; explantation-rate trend (20.8% → 11.5%) reflects within-centre technique refinement rather than a controlled comparison.[1]
  • No comparative trials between prosthesis types or brands in the transmasculine context.
  • No purpose-designed transmasculine testicular implant exists — all devices are adapted from cisgender use.
  • Validated PROMs specific to transmasculine testicular-implant outcomes are lacking; existing satisfaction data come from broader gender-affirming-surgery surveys.[6]
  • Emerging hormone-eluting and tissue-engineered devices (poly-HEMA, double-layer silastic, tissue-engineered cartilage) — covered on the 04e canonical hub — have not been studied in the transmasculine context.

References​

1. Pigot GLS, Al-Tamimi M, Ronkes B, et al. Surgical outcomes of neoscrotal augmentation with testicular prostheses in transgender men. J Sex Med. 2019;16(10):1664–1671. doi:10.1016/j.jsxm.2019.07.020

2. Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75–e88. doi:10.1097/AOG.0000000000004294

3. Selvaggi G, Hoebeke P, Ceulemans P, et al. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast Reconstr Surg. 2009;123(6):1710–1718. doi:10.1097/PRS.0b013e3181a659fe

4. van de Grift TC. Masculinizing and defeminizing gender-affirming surgery. Best Pract Res Clin Obstet Gynaecol. 2023;88:102323. doi:10.1016/j.bpobgyn.2023.102323

5. Berli JU, Knudson G, Fraser L, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review. JAMA Surg. 2017;152(4):394–400. doi:10.1001/jamasurg.2016.5549

6. Pletta DR, Quint M, Radix AE, et al. Gender-affirming surgical history, satisfaction, and unmet needs among transgender adults. JAMA Netw Open. 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494

7. Miller TJ, Lin WC, Safa B, Watt AJ, Chen ML. Transgender scrotoplasty and perineal reconstruction with labia-majora flaps: technique and outcomes from 147 consecutive cases. Ann Plast Surg. 2021;87(3):324–330. doi:10.1097/SAP.0000000000002602

8. Pigot GL, Al-Tamimi M, van der Sluis WB, et al. Scrotal reconstruction in transgender men undergoing genital gender-affirming surgery without urethral lengthening: a stepwise approach. Urology. 2020;146:303. doi:10.1016/j.urology.2020.09.017

9. Stojanovic B, Djordjevic ML. Updates on metoidioplasty. Neurourol Urodyn. 2023;42(5):956–962. doi:10.1002/nau.25102

10. Atwater BL, Kirkik D, Wilson SK, et al. Short-term revision rate of Rigicon Testi10 testicular prosthesis in adolescents and adults: a retrospective chart review. Int J Impot Res. 2025;37(4):303–309. doi:10.1038/s41443-024-00893-8

11. Turek PJ, Master VA, Testicular Prosthesis Study Group. Safety and effectiveness of a new saline-filled testicular prosthesis. J Urol. 2004;172(4 Pt 1):1427–1430. doi:10.1097/01.ju.0000139718.09510.a4

12. Ning Y, Cai Z, Chen H, et al. Development and clinical application of a new testicular prosthesis. Asian J Androl. 2011;13(6):903–904. doi:10.1038/aja.2011.87

13. Hayon S, Michael J, Coward RM. The modern testicular prosthesis: patient selection and counseling, surgical technique, and outcomes. Asian J Androl. 2020;22(1):64–69. doi:10.4103/aja.aja_93_19

14. Araújo AS, Anacleto S, Rodrigues R, et al. Testicular prostheses — impact on quality of life and sexual function. Asian J Androl. 2024;26(2):160–164. doi:10.4103/aja202325

15. Nichols PE, Harris KT, Brant A, et al. Patient decision-making and predictors of genital satisfaction associated with testicular prostheses after radical orchiectomy: a questionnaire-based study of men with germ-cell tumors of the testicle. Urology. 2019;124:276–281. doi:10.1016/j.urology.2018.09.021

16. Neuville P, Morel-Journel N, Cabelguenne D, et al. First outcomes of the ZSI 475 FtM, a specific prosthesis designed for phalloplasty. J Sex Med. 2019;16(2):316–322. doi:10.1016/j.jsxm.2018.11.013