MALE TO FEMALE GENDER REASSIGNMENT
My goals in GCS (Gender Confirmation Surgery) are to create as normal a vagina and introitus as possible, provide maximal clitoral and vaginal sensation, furnish a deep vagina allowing satisfactory sexual intercourse, and minimize disfiguring scars. To accomplish these goals, many small steps are necessary that require time, patience, and expertise. This operation is both cosmetic and reconstructive, so maximum attention to detail is necessary to achieve the best result.
PENILE SKIN INVERSION TECHNIQUE:
A portion of the glans (head of the penis) with its nerve supply is converted into the clitoris. This sensitive clitoris maintains normal erogenous sexual sensation and allows my patients to have orgasms. (FIGURE 1) Other techniques amputate the glans or invert it into the vagina, usually without maintaining normal sexual sensation; these procedures usually use spongy tissue surrounding the urethra to create a clitoris. During the clitoris creation, I use a small amount of penile skin just below the glans to create a clitoral hood. The testicles are removed. (FIGURE 2)
The skin of the penis is inverted to create a vagina. The depth of the vagina is important to most patients, especially those desiring sexual intercourse. Traditionally, the depth of the vagina is determined by the amount of shaft skin. Since many patients with a smaller penis did not have adequate depth for satisfactory intercourse, they were often disappointed. Skin grafts from the lower flanks or sides were often used, but the graft donor site can cause unsightly scars. Therefore, I routinely use a skin graft from extra scrotal skin and attach it to the deepest part of the penile skin to make the vagina deeper. The skin must be hairless in order to prevent hair growth inside the vagina, so the hair is removed first by multiple electrolysis treatments. (FIGURES 1C & 1D)Occasionally, a patient may not have sufficient penile shaft skin or scrotal skin for a deep vagina, so flank skin is then also used. Usually this results in a linear scar.
The remaining scrotum is tailored to make the labia majora or outer lips, and various other techniques are used to create labia minora or inner lips. I also spend considerable time performing intricate maneuvers that give the genitalia a more normal appearance and minimize scars. I rarely perform secondary surgery to enhance the appearance, since most of my patients are very happy with their single stage operation.
The electrolysis treatments should be performed on the entire scrotum except for a small area on each side. This allows the use of the maximum amount of scrotal skin for the graft. Even if a scrotal skin graft is not needed, electrolysis should be performed on the area just below the scrotum on the midline. This skin is used as a flap to widen the vagina, so hair growth at this location can be uncomfortable or unsightly. A numbing cream can be used to lessen the discomfort from electrolysis. Laser hair removal is not considered permanent at this time, so it is not recommended. Later hair growth in the vagina can cause problems.
(FIGURE 3, 4, & 5)
We now perform electrolysis in my accredited operating rooms under sedation. An electrologist performs complete scrotal and penile removal in three extended sessions, which last approximately five hours each. An anesthesiologist performs sedation and local blocks, so the procedure is comfortable and convenient. You can contact me at my office or see the web site of the electrologist at www.laylaselectrolysis.com.
VAGINOPLASTY USING RECTOSIGMOID COLON:
The procedure is performed in the same manner as using full thickness skin grafts, except the vagina is constructed from rectosigmoid colon instead of skin grafts. The advantage is that the vagina is lubricated and deep, whereas as major disadvantage is that it is a more invasive operation requiring entry into the abdominal cavity with bowel surgery.
SECONDARY GENITAL RECONSTRUCTION:
Many patients from other surgeons seek improvement in the appearance of their genitalia. Each patient is different, because GCS techniques vary amongst surgeons. Examples of desired procedures are remodeling of the labia majora, creation of labia minora, creation of a clitoral hood, elimination of a concavity of depression in the pubic area, removal of spongy tissue around the urethra that enlarges with sexual stimulation, and set-back of the urethra. Each reconstruction is challenging but can be very rewarding for the patient. It is usually performed in the surgical center as an outpatient.
Some patients may have had narrowing or shortening of the vagina, which prevents sexual intercourse. Colon surgery to deepen and to widen the vagina is very invasive and requires removal of the previous graft or vagina. The procedure is difficult. I rarely perform colon surgery, because I have been very successful by adding full thickness skin grafts to make the vagina deeper. Incisions are made inside the vagina from the 3 to 9 o’clock location, the space is made deeper, and the skin graft is placed. The skin must be hairless, so it is usually taken from the lower abdomen. I do not use split thickness skin grafts, because they tend to contract and are more difficult to stretch. The surgery takes about 5 hours and requires 6 days in the hospital.
If you have any questions about transsexual surgery – male to female, please feel free to contact Board Certified Plastic Surgeon, Board Certified Urologist Dr. Gary Alter at his Manhattan, New York or Beverly Hills, California office.