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Use It or Lose It: The Importance of Dilation Following Vaginoplasty

Julie Vu with her set of Soul Source dilators. Source: YouTube.

Vaginoplasty is a Gender Reassignment Surgery procedure that transforms the transgender person's genitalia into female genitals, including a neo-vagina. Post-operative vaginal dilation is an integral part of the initial surgery recovery and the regular maintenance of a transgender person's neo-vagina. Typically, dilation begins a few days after surgery and is almost always required for life. Without proper dilation, the skin graft inside the vagina tends to contract which leads to narrowing, shortening or closure of the neo-vagina . This is an irreversible result—one cannot regain the original vaginal depth by simply resuming or doing more dilation. Dilation may not be pleasant but it's essential to follow your surgeon's dilation protocol in order to prevent loss of depth of your new vagina.

Dilation Explained

The purpose of dilation is to maintain the depth of the neo-vagina. Dilation helps prevent contraction of the skin graft inside vagina and also improves the elasticity of vaginal wall in order to comfortably accommodate penetrative sex.

Dilation involves inserting a lubricated dilator into the neo-vagina and keeping it in there for a specified amount of time. The size of dilator and the length of dilation time varies depending on the surgeon's protocol and patient's needs. Your surgeon will advise about the proper use and frequency of post-op dilation and it's important to follow their advice above all as it may be specific to your case.

Initially, one can expect dilation to take up to 2-2.5 hours per day, with the time and frequency decreasing after you reach 18-24 months post-op. Yes, it's a commitment!

"All I wanted to do was sleep, but I couldn't sleep since I had to wake up and dilate endlessly. It was so much dilation that I would dream about it many nights." — Autumn Asphodel

Dilation is also not as comfortable as one might hope. "[The dilators are] hard, they're plastic, they're cold, they're uncomfortable to be inside you,' said Julie Vu on YouTube .

Does Sex Count? There's some debate as to whether or not sexual intercourse can count as a dilation session. 'If [after a year post-op] you have sex once every week, you're good to go, you don't have to dilate with these instruments,' says Vu. Maddy McKenna concurs , "The only bonus it that if I have a sexual companion, 30 minutes of sex counts as 30 minutes of dilation."

"You have to dilate once a week for the rest of your life, unless you're having sex," says Nomi Ruiz , a transgender singer and host of the podcast Allegedly NYC . "So now when I'm not having sex, it's kinda sad, because you're really reminded of it. You're like, 'Oh, God, I have to dilate now because I'm not getting laid. Fuck.'" However, sexual intercourse in place of dilation may not be sufficient. This is something that you should discuss with your surgeon.

To begin, patients dilate with the largest dilator that comfortably fits inside the neo-vagina. As the weeks progress after surgery, larger dilators are introduced and the length of time with the largest dilator is gradually increased.

"So, there are four dilator sizes I have. The first one is 1?", the second one is 1¼", the third is 1?", and the largest one is 1½". I don't use the first one at all anymore. But, I have to start with the second one and then work up to the largest one. I can't just use the third or fourth one without working up to it. UHHHHH, I hate the largest one so much. It tears me up, literally. I just wanna throw it out the window. [Glass break]" — Autumn Asphodel

Dilation Isn't Fun But It's Worth It

"The only part in my vagina self-care regimen that differs from a natal vagina is that I have to dilate. When I first came out of surgery, my body naturally registered my neo vagina as a wound and, because of that, it wanted to heal and close up. No thank you!" — Maddy McKenna

When dilation isn't done according to the recommended routine, the skin graft inside the vagina can contract and close up which leads to the shortening—and even closure—of the neo-vagina. Unfortunately, once this happens it can't be fixed by simply resuming or doing more dilation. A revision surgery is usually necessary.

"Vaginal openings are similar to pierced ears in that if you don't use earrings regularly, the piercings will eventually close," says Dr. Rumer . "So we always say, 'DILATE!!! DILATE!!! DILATE!!!'"

" [Dilation is] very important. Very important. Can't say that enough. Your vagina will close up if you don't dilate. I did have a patient who didn't dilate for two weeks. She went back to the doctor, and she had closed up. And they couldn't reverse back. So, it's very important. Not to scare you, but just do it." — JD Davids

Dilation Tips

Follow your surgeon's dilation guidelines!

Find ways that help make the process go by faster.

"I dilated a lot to TV shows. They tell you to dilate for 20 minutes a day. But you're so scared that it's going to close up that you probably dilate -- well, I dilated till like an hour. I would watch the Atlanta Housewives, and I would get in my bathtub. Because at first it was the only place that I could dilate. So, I would get my pillow. I would sit in my tub. I would have my iPad, and I would watch The Real Housewives of Atlanta while I was dilating. I'd watch the whole episode. Then I was done." — Nyala Moon

Use a lot of lube. (Water-based, not silicone.)

Stretch before and after dilating.

"All that dilating made my hip get out of place because it's an uncomfortable position to be in multiple times a day. So, it's always best to stretch before and after." — Autumn Asphodel

You will need several towels or waterproof pads to place under you while dilating. Chux pads or puppy training pads are a good solution if you don't have laundry facilities.

You can take a painkiller after dilating, but not before because it would increase the chance of hurting yourself.

Try urinating or having a bowel movement before your dilation session as it can make it more comfortable.

More dilation tips at Transgender Map »

WATCH: Dr. Gabriel Del Corral's Dilation Instructional Video (sign-in required)

"The average canal can be anywhere between four and six and a half, seven inches. Certainly with good discipline using the dilators, you'd be able to accommodate a regular sized penis. It just takes work after a Vaginoplasty. It takes a lot of discipline. And it takes a lot of time to be able to dilate three times a day for the first couple months post-surgery." — Dr. Gabriel Del Corral

WATCH: Dr. Heidi Wittenberg on Basic Equipment & Positioning to Optimize Dilation

Where to Buy Dilators

You should receive everything you need to dilate before you leave the hospital or recovery facility, from your surgeon. You will use several dilators of different lengths and widths during your recovery and beyond.

Dr. Rumer provides a Dilator Kit for patients, which includes dilators made specifically for trans women by Soul Source . $40-55 each.

Note on materials: Some believe that dilators shouldn't be made out of silicone or other soft materials. Dilators should be rigid and hard enough to provide the rigidity necessary to stretch forming scar tissue.

This section contains affiliate links.

BioMoi's Silicone Vaginal Trainers with BioCote Protection (Full Set) The "best quality" vaginal dilators on the market, made of US Platinum silicone. $129.99.

VuVa Smooth Set of 5 dilators made of medical grade polycarbonate plastic, with Instructions and pouch. Made in the USA.

VWell Set of 5 dilators made of silky smooth medical grade silicone, BPA and paraben-free.

Amielle Care Set of Vaginal Dilators Set of 4 graduated dilators with a universal handle to make insertion and removal easier, lubricant and a discreet bag.

Vaginal Trainer Set These dilators are smooth and comfortable, easy to control, light-weight, latex-free, washable and safe. 6 gradual sizes plus an ergonomic solid-lock handle. HopeandHer.com

Expandable Dilators

Milli - Gradual expansion from from 15mm to 40mm, with 25mm total achievable expansion. Optional vibration, charging case. $395.

ZSI 200 NS Expander - In?atable cylinder made of biocompatible silicone. Lengths available: 90 mm & 120mm. Diameter: 40mm. No retail sales, must be purchased by a surgeon.

Last updated: 02/04/21

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Procedure: Male to Female Gender Reassignment Surgery (MTF GRS)

Male-to-female gender reassignment surgery (MTF GRS) is a complex and irreversible genital surgery for male transsexual who is diagnosed with gender identity disorder and has a strong desire to live as female. The procedure is to remove all male genital organs including the penis and testes with the construction of female genitalia composed of labia major/minor, clitoris and neovagina simultaneously.   

The patient who is fit for this surgery must strictly follow the standard of care set by the World Professional Association of Transgender Healthcare (WPATH) or equivalent criteria; Express desire or live in another gender role (Male gender) long enough, under hormonal replacement therapy, evaluated and approved by a psychiatrist or other qualified professional gender therapist.  

Apart from genital surgery, the patient would seek other procedures to allow them to live as female smoothly such as breast aesthetic surgery, facial feminization surgery, body contouring, hair removal, voice change surgery, etc.

Interested in having this procedure?

Useful Information

Ensure you consider all aspects of a procedure. You can speak to your surgeon about these areas of the surgery in more detail during a consultation.

The surgery is quite complicated and only a handful of surgeons are able to perform this procedure. It can be completed in one stage or more stages depending on techniques and surgeons. The average surgical time ranges between 5-8 hours. There are several options of neovaginal construction depending on the type of tissue, single or in combination, such as penile skin, scrotal skin, large intestine, small intestine, or peritoneum.   

The procedure is done under general anesthesia and might be combined with spinal anesthesia for faster recovery by reducing the usage of anesthetic gas.  

Inpatient/Outpatient

The patient will be hospitalized as an in-patient for between 5-14 days depending on the technique and surgeon. The patient will have a urinary catheter at all times in the hospital.  

Additional Information

What is the recovery process.

During hospitalization, the patient must be restricted in bed continuously or intermittently for several days between 3-5 days. After release from the hospital, the patient can return to their normal lives but not have to do physical exercise during the first 2 months after surgery. The patient has to do vaginal dilation continuously for 6 months to maintain the neovagina canal until completely healed and is ready for sexual intimacy.  

What are the results?

With the good surgical technique, the result is very satisfying with an improved quality of life. The patient is able to live in a female role completely and happily either on their own or with their male or female partners.  

What are the risks?

The most frequent complication of MTF GRS is bleeding, wound infection, skin flap or graft necrosis, urinary stenosis, neovaginal contracture, unsightly scar or deformed genitalia,  vaginal fistula, etc. The revision procedures to improve external appearance are composed of secondary labiaplasty/ urethroplasty/ perineoplasty/ and vulvaplasty. The other revision procedure is secondary vaginoplasty to help the patient able to have sexual intimacy with the partner.  

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IU School of Medicine surgeons perform a variety of gender affirming surgeries at our clinical affiliates for patients over 18 years of age. Our team will work with you to learn your goals and to develop an individualized plan to meet your needs. We currently offer:

chest reconstruction

breast augmentation

orchiectomy

vulvoplasty

vaginoplasty

voice surgery

facial feminization surgery

metoidioplasty

phalloplasty

hysterectomy and oophorectomy

Surgeons work together with other specialists to provide a coordinated, safe approach to medical and surgical care. All of our providers follow the World Professional Association for Transgender Health (WPATH) Standards of Care.

WPATH Standards of Care

Chest Reconstruction

Chest reconstruction is a common top surgery among transgender and non-binary patients who were assigned female at birth (AFAB). A plastic surgeon removes your mammary and fat tissue to create a masculine chest. The nipples are repositioned and resized, if desired.

Your care team will work closely with you to understand your goals and will recommend the best surgical approach to meet your needs. We offer several different types of chest reconstruction procedures, including double incision with nipple grafts, buttonhole and peri-aeriolar incisions (keyhole), using liposuction to help with contouring and prevention of “dogears.” The team will work with you to help pick the right technique at the time of your consultation.

Chest reconstruction surgery requires general anesthesia, and is performed as an outpatient procedure, meaning there is no hospital stay after surgery. After surgery you must wear a compression vest for at least four weeks. Drains are used for peri-aeriolar incision surgery. Foam bolsters are also placed on the chest to protect nipple grafts. The bolsters and/or drains will be removed one week after surgery. Most people are able to resume regular daily activities after one month with no restrictions.

Breast Augmentation

Breast augmentation is usually for transgender women and transfeminine spectrum non-binary people. It is also often called feminizing augmentation mammoplasty. We will give your chest a female appearance by placing implants underneath your natural breast tissue or pectoral muscle. Your care team will discuss the implant type (silicone or saline), size and shape to match your body and your desires during your consultation.

A small incision will be made in the crease underneath each breast or around the nipple. A pocket is made underneath the breast or pectoral muscle to give each breast a natural teardrop shape. Often, an additional incision will need to be made around the nipple to lift the breast and nipple into a more feminine position (mastopexy).

Some patients can benefit from fat grafting from the belly, hips or thighs in conjunction with implant surgery to achieve additional fullness in specific areas of the breast. This procedure is not currently covered by insurance.

Orchiectomy

The gender health team offers this surgery as part of gender affirming care for transfeminine patients. Orchiectomy (testicle removal) requires general anesthesia and is a low-risk, outpatient procedure, meaning there is no hospital stay after surgery.

A small incision is made in the scrotum along the median raphe (line in the midline of the scrotum). This approach does not affect future bottom surgery choices. It is common to see a small amount of bruising and swelling and experience mild discomfort. Rare risks include skin infection and a large bruise (hematoma). The recovery process is brief, and most patients are able to resume work and most daily activities within a few days. In those who do not want any further bottom surgeries, the scrotum can also be removed.

Vulvoplasty

The vulva is the outside part of the vagina. A vulvoplasty is a type of surgery that uses skin and tissue from a penis to create all of the outside parts of a vagina. Vulvoplasty does not create the internal vaginal canal.

The steps of a vulvoplasty are the same as a vaginoplasty. During a vulvoplasty, your provider will:

• create a clitoris out of the glans (head) of the penis
• create a labia minor and labia majora from skin on the penis and scrotum
• create the opening of the urethra so you can urinate
• create the introitus (opening of the vagina)

The only thing that’s different between a full vaginoplasty and a vulvoplasty is the internal part of the vaginal canal. This means you will not be able to insert a penis or toys into your vagina. 

Vaginoplasty

Vaginoplasty involves creating a vagina, clitoris, labia majora, and labia minora. The procedure is effective both for people who have and those who have not had orchiectomy in the past. Removal of the testes is required as a part of vaginoplasty.

We perform vaginoplasty under general anesthesia. Most people spend six to seven full days in the hospital after surgery. Recovery from vaginoplasty can take up to three months, and requires intensive post-operative care. It is important to have both someone who can help take care of you after surgery as well as the privacy you need to take care of yourself.

You will need the privacy to dilate at least 30 minutes twice a day. Dilation involves inserting a medical dilator into the vagina. This is important because the vagina will close if people do not dilate.

The gender health team has pioneered an approach using the peritoneal lining, the tissue that lines your abdominal wall and covers most of the organs in your abdomen. The peritoneal lining is hairless and pink. While the peritoneal vaginoplasty does provide moisture, it is not self-lubricating. Patients will still need to use water-based lubricant for intercourse and dilation. This is a new procedure, and we are still gathering data about the procedure's long-term safety and efficacy.

How do I choose between vulvoplasty vs. vaginoplasty?

A vulvoplasty has a much easier recovery. It has a shorter hospital stay and does not require the lifelong maintenance of performing dilations to maintain the vagina.

Some patients know that they’re not interested in having vaginal intercourse. For these patients, a vulvoplasty may be a better choice.

After a vulvoplasty, you can still have orgasms through clitoral stimulation, just like with vaginoplasty. During a vulvoplasty, your surgeon will create a clitoris from the glans or head of the penis.

Metoidioplasty

Metoidioplasty is a procedure for patients who desire a penis. Your surgeon will remove the vagina in those that experience dysphoria from this organ, then release the clitoris from the ligament that holds it in place to lengthen it. Tissue grafting is used to create the penis. The result is a neophallus that can become erect. We are one of the only centers that offer this surgery at the same time as a hysterectomy.

We can perform this procedure with or without extending the urethra to allow urination out of the tip of the penis. The provider can also create a scrotum and insert testicular implants depending on your preference. After metoidioplasty, you will have a three to four day hospital stay. You will go home with a tube in your stomach to help drain your urine, as well as a catheter in the penis. Recovery can take six to eight weeks. Problems with urinary flow are very common, but often resolve on their own.

Phalloplasty

With phalloplasty, a surgeon will create a penis out of skin from somewhere on the body. Faculty at IU School of Medicine currently offer several different techniques. These include the radial forearm flap (RFF) phalloplasty, Anterolateral Thigh (ALT) flap, and Suprapubic.

Phalloplasty can involve several procedures in addition to the creation of a penis. We can close the front pelvic opening (vaginectomy). This often requires a hysterectomy as well.

Urethral lengthening creates a urethra that allows urination from the tip of the penis. Scrotoplasty creates a scrotum. We can perform one or both of these procedures during phalloplasty. Neither is required.

All options for phalloplasty require multiple surgical procedures. Some procedures involve a hospital stay. Some stages of phalloplasty require a hospital stay for up to a week, if not longer.

If you are interested in phalloplasty, we start with a complete consultation. IU School of Medicine providers will discuss the pros and cons of each procedure and help you decide what is right for you. Your care team will be there every step of the way to support you. It is our goal to make sure you feel comfortable and confident with your decision and satisfied with your results.

Hysterectomy and Oophorectomy

Hysterectomy is the removal of the uterus and ovaries. This surgery is part of gender affirming care for transmasculine patients. There is no hospital stay after surgery. Most people recover within two to four weeks. This can be in combination with metoidioplasty or top surgery.

You will have a complete consultation prior to scheduling surgery. At this appointment, your provider will discuss the surgery, review the role of removing the ovaries (oophorectomy) and the route of removing the uterus. For most patients a minimally invasive approach is offered via laparoscopy (making very small incisions on the abdomen).

Should I remove my ovaries?

This is a very personal decision. There is conflicting evidence on the role of the estrogen produced by the ovaries on the risk of heart disease or osteoporosis. Keeping an ovary can mean that you continue to experience cyclic hormonal symptoms, even without a uterus or menstruation.

The ovaries contain eggs for reproduction. Even without a uterus you can still use the eggs for a pregnancy. If you are interested in having children it may be beneficial to keep your ovaries. Your provider will discuss these options in your initial visit and in the surgical planning.

It is likely there is little or no benefit to keeping the ovaries for patients who are not interested in future reproduction and who intend to continue on long term testosterone therapy until at least age 50.

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• Review Article
• Published: 24 September 2021

Vaginoplasty in Male to Female transgenders: single center experience and a narrative review

• Luca Ongaro   ORCID: orcid.org/0000-0001-5649-4095 1 ,
• Giulio Garaffa   ORCID: orcid.org/0000-0001-9834-5098 2 ,
• Francesca Migliozzi 1 ,
• Michele Rizzo 1 ,
• Fabio Traunero 1 ,
• Marco Falcone 3 ,
• Stefano Bucci 1 ,
• Tommaso Cai   ORCID: orcid.org/0000-0002-7234-3526 4 ,
• Alessandro Palmieri 5 ,
• Carlo Trombetta 1 &
• Giovanni Liguori   ORCID: orcid.org/0000-0003-2431-5296 1  

International Journal of Impotence Research volume  33 ,  pages 726–732 ( 2021 ) Cite this article

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Vaginoplasty in Male to Female (M to F) transgenders is a challenging procedure, often accompanied by numerous complications. Nowadays the most commonly used technique involves inverted penile and scrotal flaps. In this paper the data of 47 M to F patients who have undergone sex affirmation surgery at the Department of Urology of the University of Trieste, Italy since 2014, using our modified vaginoplasty technique with the “Y” shaped urethral flap, have been retrospectively reviewed. Moreover, a non structured review of the literature with regards to short and long-term complications of vaginoplasty has been provided. All patients followed a standardized neo-vaginal dilation protocol. At follow up 2 patients were lost. At 12 months 88.9% of patients (40/45) were able to reach climax, 75.6% (34/45) were having neo-vaginal intercourses and median neo-vaginal depth was 11 cm (IQR 9–13.25): no statistically significant decrease in depth was found at follow up. Only one patient was dissatisfied with aesthetic appearance at 12 months. Our technique provided excellent cosmetic and functional results without severe complications (Clavien–Dindo ≥ 3). The review of the literature has highlighted the need to standardize a postoperative follow up protocol with particular regard to postoperative dilatation regimen. Further, larger randomized clinical trials are pending to draw definitive conclusions.

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Bucci S, Mazzon G, Liguori G, Napoli R, Pavan N, Bormioli S, et al. Neovaginal prolapse in male-to-female transsexuals: an 18-year-long experience. Biomed Res Int. 2014;2014:240761.

Papadopulos NA, Zavlin D, Lellé JD, Herschbach P, Henrich G, Kovacs L, et al. Combined vaginoplasty technique for male-to-female sex reassignment surgery: operative approach and outcomes. J Plast Reconstr Aesthet Surg. 2017;70:1483–92.

Cocci A, Rosi F, Frediani D, Rizzo M, Cito G, Trombetta C, et al. Male-to-Female (MtoF) gender affirming surgery: modified surgical approach for the glans reconfiguration in the neoclitoris (M-shape neoclitorolabioplasty). Arch Ital Urol Androl. 2019;91:119–24.

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Luca Ongaro, Francesca Migliozzi, Michele Rizzo, Fabio Traunero, Stefano Bucci, Carlo Trombetta & Giovanni Liguori

Department of Urology, University College London Hospitals, London, UK

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Department of Urology, Molinette Hospital, A.O.U. Città della Salute e della Scienza di Torino, Turin, Italy

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Tommaso Cai

Urology Unit, Department of Neurosciences, Reproductive Sciences, Odontostomatology, University of Naples “Federico II”, Naples, Italy

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Ongaro, L., Garaffa, G., Migliozzi, F. et al. Vaginoplasty in Male to Female transgenders: single center experience and a narrative review. Int J Impot Res 33 , 726–732 (2021). https://doi.org/10.1038/s41443-021-00470-3

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• Tests & Procedures
• Feminizing surgery

Feminizing surgery, also called gender-affirming surgery or gender-confirmation surgery, involves procedures that help better align the body with a person's gender identity. Feminizing surgery includes several options, such as top surgery to increase the size of the breasts. That procedure also is called breast augmentation. Bottom surgery can involve removal of the testicles, or removal of the testicles and penis and the creation of a vagina, labia and clitoris. Facial procedures or body-contouring procedures can be used as well.

Not everybody chooses to have feminizing surgery. These surgeries can be expensive, carry risks and complications, and involve follow-up medical care and procedures. Certain surgeries change fertility and sexual sensations. They also may change how you feel about your body.

Your health care team can talk with you about your options and help you weigh the risks and benefits.

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Why it's done

Many people seek feminizing surgery as a step in the process of treating discomfort or distress because their gender identity differs from their sex assigned at birth. The medical term for this is gender dysphoria.

For some people, having feminizing surgery feels like a natural step. It's important to their sense of self. Others choose not to have surgery. All people relate to their bodies differently and should make individual choices that best suit their needs.

Feminizing surgery may include:

• Removal of the testicles alone. This is called orchiectomy.
• Removal of the penis, called penectomy.
• Removal of the testicles.
• Creation of a vagina, called vaginoplasty.
• Creation of a clitoris, called clitoroplasty.
• Creation of labia, called labioplasty.
• Breast surgery. Surgery to increase breast size is called top surgery or breast augmentation. It can be done through implants, the placement of tissue expanders under breast tissue, or the transplantation of fat from other parts of the body into the breast.
• Plastic surgery on the face. This is called facial feminization surgery. It involves plastic surgery techniques in which the jaw, chin, cheeks, forehead, nose, and areas surrounding the eyes, ears or lips are changed to create a more feminine appearance.
• Tummy tuck, called abdominoplasty.
• Buttock lift, called gluteal augmentation.
• Liposuction, a surgical procedure that uses a suction technique to remove fat from specific areas of the body.
• Voice feminizing therapy and surgery. These are techniques used to raise voice pitch.
• Tracheal shave. This surgery reduces the thyroid cartilage, also called the Adam's apple.
• Scalp hair transplant. This procedure removes hair follicles from the back and side of the head and transplants them to balding areas.
• Hair removal. A laser can be used to remove unwanted hair. Another option is electrolysis, a procedure that involves inserting a tiny needle into each hair follicle. The needle emits a pulse of electric current that damages and eventually destroys the follicle.

Your health care provider might advise against these surgeries if you have:

• Significant medical conditions that haven't been addressed.
• Behavioral health conditions that haven't been addressed.
• Any condition that limits your ability to give your informed consent.

Like any other type of major surgery, many types of feminizing surgery pose a risk of bleeding, infection and a reaction to anesthesia. Other complications might include:

• Delayed wound healing
• Fluid buildup beneath the skin, called seroma
• Bruising, also called hematoma
• Changes in skin sensation such as pain that doesn't go away, tingling, reduced sensation or numbness
• Damaged or dead body tissue — a condition known as tissue necrosis — such as in the vagina or labia
• A blood clot in a deep vein, called deep vein thrombosis, or a blood clot in the lung, called pulmonary embolism
• Development of an irregular connection between two body parts, called a fistula, such as between the bladder or bowel into the vagina
• Urinary problems, such as incontinence
• Pelvic floor problems
• Permanent scarring
• Loss of sexual pleasure or function
• Worsening of a behavioral health problem

Certain types of feminizing surgery may limit or end fertility. If you want to have biological children and you're having surgery that involves your reproductive organs, talk to your health care provider before surgery. You may be able to freeze sperm with a technique called sperm cryopreservation.

How you prepare

Before surgery, you meet with your surgeon. Work with a surgeon who is board certified and experienced in the procedures you want. Your surgeon talks with you about your options and the potential results. The surgeon also may provide information on details such as the type of anesthesia that will be used during surgery and the kind of follow-up care that you may need.

Follow your health care team's directions on preparing for your procedures. This may include guidelines on eating and drinking. You may need to make changes in the medicine you take and stop using nicotine, including vaping, smoking and chewing tobacco.

Because feminizing surgery might cause physical changes that cannot be reversed, you must give informed consent after thoroughly discussing:

• Risks and benefits
• Alternatives to surgery
• Expectations and goals
• Social and legal implications
• Potential complications
• Impact on sexual function and fertility

Evaluation for surgery

Before surgery, a health care provider evaluates your health to address any medical conditions that might prevent you from having surgery or that could affect the procedure. This evaluation may be done by a provider with expertise in transgender medicine. The evaluation might include:

• A review of your personal and family medical history
• A physical exam
• A review of your vaccinations
• Screening tests for some conditions and diseases
• Identification and management, if needed, of tobacco use, drug use, alcohol use disorder, HIV or other sexually transmitted infections
• Discussion about birth control, fertility and sexual function

You also may have a behavioral health evaluation by a health care provider with expertise in transgender health. That evaluation might assess:

• Gender identity
• Gender dysphoria
• Mental health concerns
• Sexual health concerns
• The impact of gender identity at work, at school, at home and in social settings
• The role of social transitioning and hormone therapy before surgery
• Risky behaviors, such as substance use or use of unapproved hormone therapy or supplements
• Support from family, friends and caregivers
• Your goals and expectations of treatment
• Care planning and follow-up after surgery

Other considerations

Health insurance coverage for feminizing surgery varies widely. Before you have surgery, check with your insurance provider to see what will be covered.

Before surgery, you might consider talking to others who have had feminizing surgery. If you don't know someone, ask your health care provider about support groups in your area or online resources you can trust. People who have gone through the process may be able to help you set your expectations and offer a point of comparison for your own goals of the surgery.

What you can expect

Facial feminization surgery.

Facial feminization surgery may involve a range of procedures to change facial features, including:

• Moving the hairline to create a smaller forehead
• Enlarging the lips and cheekbones with implants
• Reshaping the jaw and chin
• Undergoing skin-tightening surgery after bone reduction

These surgeries are typically done on an outpatient basis, requiring no hospital stay. Recovery time for most of them is several weeks. Recovering from jaw procedures takes longer.

Tracheal shave

A tracheal shave minimizes the thyroid cartilage, also called the Adam's apple. During this procedure, a small cut is made under the chin, in the shadow of the neck or in a skin fold to conceal the scar. The surgeon then reduces and reshapes the cartilage. This is typically an outpatient procedure, requiring no hospital stay.

Top surgery

• Breast augmentation incisions

As part of top surgery, the surgeon makes cuts around the areola, near the armpit or in the crease under the breast.

• Placement of breast implants or tissue expanders

During top surgery, the surgeon places the implants under the breast tissue. If feminizing hormones haven't made the breasts large enough, an initial surgery might be needed to have devices called tissue expanders placed in front of the chest muscles.

Hormone therapy with estrogen stimulates breast growth, but many people aren't satisfied with that growth alone. Top surgery is a surgical procedure to increase breast size that may involve implants, fat grafting or both.

During this surgery, a surgeon makes cuts around the areola, near the armpit or in the crease under the breast. Next, silicone or saline implants are placed under the breast tissue. Another option is to transplant fat, muscles or tissue from other parts of the body into the breasts.

If feminizing hormones haven't made the breasts large enough for top surgery, an initial surgery may be needed to place devices called tissue expanders in front of the chest muscles. After that surgery, visits to a health care provider are needed every few weeks to have a small amount of saline injected into the tissue expanders. This slowly stretches the chest skin and other tissues to make room for the implants. When the skin has been stretched enough, another surgery is done to remove the expanders and place the implants.

Genital surgery

• Anatomy before and after penile inversion

During penile inversion, the surgeon makes a cut in the area between the rectum and the urethra and prostate. This forms a tunnel that becomes the new vagina. The surgeon lines the inside of the tunnel with skin from the scrotum, the penis or both. If there's not enough penile or scrotal skin, the surgeon might take skin from another area of the body and use it for the new vagina as well.

• Anatomy before and after bowel flap procedure

A bowel flap procedure might be done if there's not enough tissue or skin in the penis or scrotum. The surgeon moves a segment of the colon or small bowel to form a new vagina. That segment is called a bowel flap or conduit. The surgeon reconnects the remaining parts of the colon.

Orchiectomy

Orchiectomy is a surgery to remove the testicles. Because testicles produce sperm and the hormone testosterone, an orchiectomy might eliminate the need to use testosterone blockers. It also may lower the amount of estrogen needed to achieve and maintain the appearance you want.

This type of surgery is typically done on an outpatient basis. A local anesthetic may be used, so only the testicular area is numbed. Or the surgery may be done using general anesthesia. This means you are in a sleep-like state during the procedure.

To remove the testicles, a surgeon makes a cut in the scrotum and removes the testicles through the opening. Orchiectomy is typically done as part of the surgery for vaginoplasty. But some people prefer to have it done alone without other genital surgery.

Vaginoplasty

Vaginoplasty is the surgical creation of a vagina. During vaginoplasty, skin from the shaft of the penis and the scrotum is used to create a vaginal canal. This surgical approach is called penile inversion. In some techniques, the skin also is used to create the labia. That procedure is called labiaplasty. To surgically create a clitoris, the tip of the penis and the nerves that supply it are used. This procedure is called a clitoroplasty. In some cases, skin can be taken from another area of the body or tissue from the colon may be used to create the vagina. This approach is called a bowel flap procedure. During vaginoplasty, the testicles are removed if that has not been done previously.

Some surgeons use a technique that requires laser hair removal in the area of the penis and scrotum to provide hair-free tissue for the procedure. That process can take several months. Other techniques don't require hair removal prior to surgery because the hair follicles are destroyed during the procedure.

After vaginoplasty, a tube called a catheter is placed in the urethra to collect urine for several days. You need to be closely watched for about a week after surgery. Recovery can take up to two months. Your health care provider gives you instructions about when you may begin sexual activity with your new vagina.

After surgery, you're given a set of vaginal dilators of increasing sizes. You insert the dilators in your vagina to maintain, lengthen and stretch it. Follow your health care provider's directions on how often to use the dilators. To keep the vagina open, dilation needs to continue long term.

Because the prostate gland isn't removed during surgery, you need to follow age-appropriate recommendations for prostate cancer screening. Following surgery, it is possible to develop urinary symptoms from enlargement of the prostate.

Dilation after gender-affirming surgery

This material is for your education and information only. This content does not replace medical advice, diagnosis and treatment. If you have questions about a medical condition, always talk with your health care provider.

Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

Research has found that that gender-affirming surgery can have a positive impact on well-being and sexual function. It's important to follow your health care provider's advice for long-term care and follow-up after surgery. Continued care after surgery is associated with good outcomes for long-term health.

Before you have surgery, talk to members of your health care team about what to expect after surgery and the ongoing care you may need.

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Feminizing surgery care at Mayo Clinic

• Tangpricha V, et al. Transgender women: Evaluation and management. https://www.uptodate.com/ contents/search. Accessed Aug. 16, 2022.
• Erickson-Schroth L, ed. Surgical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Coleman E, et al. Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health. 2022; doi:10.1080/26895269.2022.2100644.
• AskMayoExpert. Gender-affirming procedures (adult). Mayo Clinic; 2022.
• Nahabedian, M. Implant-based breast reconstruction and augmentation. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
• Erickson-Schroth L, ed. Medical transition. In: Trans Bodies, Trans Selves: A Resource by and for Transgender Communities. 2nd ed. Kindle edition. Oxford University Press; 2022. Accessed Aug. 17, 2022.
• Ferrando C, et al. Gender-affirming surgery: Male to female. https://www.uptodate.com/contents/search. Accessed Aug. 17, 2022.
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• v.7(4); 2019 Apr

Sigma-lead Male-to-Female Gender Affirmation Surgery: Blending Cosmesis with Functionality

Narendra kaushik.

From the Olmec—The Premier Transgender Surgery Institute, Delhi, India

Devendra K. Bhardwaj

Supplemental Digital Content is available in the text.

Background:

Current male-to-female (MtF) sex-reassignment-surgery techniques have not been fully successful to achieve the ideal objectives. The ordeal of multiple procedures, associated complications, and suboptimal results leads to high rate of dissatisfaction. We have tried to overcome functional inadequacy and address the esthetic issues for outer genitalia and vagina with our innovative “true shape sigma-lead SRS: Kaushik’s technique,” which has now become the technique of choice for MtF genital SRS for our patients.

Between April 2007 and April 2017, authors performed 386 sigma-lead SRS in MtF transsexuals. Results were analyzed based on complications, resurgeries, and esthetic/functional outcomes. Corrective SRS using rectosigmoid constituted 145 cases and is not a part of this study.

Maximum follow-up was 7 years (average 34 months). Seventy-eight (20.2%) patients had complications, majority being minor (97.4%). Forty-four (11.4%) required resurgeries, 10 (2.6%) were corrective for introital stricture and mucosal prolapse, whereas 34 (8.8%) opted for optional minor esthetic enhancement. The overall satisfaction rate for cosmetic and functional outcomes was 4.7 out of 5. In addition to review of the literature, innovations in the technique have been explained.

Conclusions:

Kaushik’s sigma-lead MtF SRS technique is a step short to become the gold standard of genital SRS because it has proven to be safe and reliable. It allows faster healing, minimal dilation, and nearly natural cosmetic results in the form of clitoris/clitoral hood, labia minora, labia majora along with self-lubricating, fully deep, and sensate neovagina with orgasmic capabilities. This is perhaps the largest reported series of rectosigmoid use in transsexuals carried out for primary vaginoplasty.

INTRODUCTION

The ultimate goal of male-to-female (MtF) transformation in transgenders is not only to achieve external anatomy of the female body through a series of complex and staged surgeries but also to supplement the completeness by aligning the physical self with the biopsychosocial framework of a female individual, thereby addressing the basic concept of gender identity disorder. 1 – 3

MtF gender affirmation surgical techniques span from split-thickness graft, full-thickness graft, penile/ penoscrotal inversion, and fasciocutaneous flaps to pedicled intestinal flaps. 4 – 14 Currently, prevalent techniques have not been fully successful in achieving the ideal objective of reconstructing the genitals that resemble the cis-female genitals in full form and function. 4 The search for new and improved solutions continues because there has been a constant scope of improvement for both functionality and cosmetic outcome. 4 Prolonged hormonal intake leads to penoscrotal hypoplasia making penoscrotal inversion vaginoplasty not feasible. 10 , 15 – 19

Thus, we aimed to describe in this article our modified technique which has nearly overcome the functional inadequacy of the existing techniques and has addressed the esthetic issues of reconstructed outer genitalia and vagina. It has now become the technique of choice for MtF gender affirmation surgery for our patients.

PATIENTS AND METHODS

Between January 2008 and April 2017, we performed 386 sigma-lead SRS in MtF transgenders who met the World Professional Association for Transgender Health (WPATH) criteria. A total of 145 cases who underwent corrective SRS using rectosigmoid colon were excluded in the study. These patients had been operated before using other techniques and were dissatisfied with outcomes.

Patient records and interviews focused on age, smoking history, surgical time, complications, resurgeries, and cosmetic and functional outcomes were collected and analyzed. Outcomes were assessed according to 7 parameters (Table ​ (Table1). 1 ). Informed consent was obtained from each patient.

Questionnaire at 12 Months after Surgery

Patient Selection, Surgical Eligibility, and Preoperative Preparation

We excluded patients with body mass index >30. Patients with cardiac diseases, unfit for GA, and sigmoid colon diseases were also excluded. Sigmoid colonoscopy was carried out for those older than 50 years of age or those with a history of bowel problem related to the colon. Estrogen use and smoking were discontinued for at least 2 weeks and 2 months, respectively, before surgery. Over the past 3 years, we have implemented a nonsmoking disclosure to be signed by the patient.

Bowel is prepared using polyethylene glycol with electrolyte solution a day before surgery. Prophylactic antibiotics were administered at the start of surgery. GA with epidural analgesia was used. LMW heparin was administered in patients with a history of DVT. The DVT intermittent pneumatic pumping system was used intraoperatively and for 2 days postsurgery. The patient was placed in lithotomy position during the procedure.

Surgical Technique

We developed this surgical procedure as a modular concept. Module 1 is the creation of vulva, and module 2 is the creation of vagina using penile skin and rectosigmoid colon segment. Both modules are preferably done together as a single stage, although they can be carried out in 2 stages (see video, Supplemental Digital Content 1, which demonstrates surgical technique of sigma-lead gender affirmation surgery and postoperative results, http://links.lww.com/PRSGO/B24 ).

See video, Supplemental Digital Content 1, which displays sigma-lead MtF gender affirmation surgery demonstrating surgical technique and postoperative results, http://links.lww.com/PRSGO/B24 .

Through left lateral Pfannenstiel approach, the rectosigmoid colon was freed. Preferably, the proximal pedicle, a sigmoidal branch of the inferior mesenteric artery, is chosen to get the antegrade segment. If the proximal pedicle was not reliable, a distal pedicle was identified, preferably having 2 vessels consisting of branches of the superior rectal artery. The mesentery was sequentially ligated and divided in between ligatures throughout the length of the selected segment. Bowel was washed through the colotomy incisions at proximal and distal division sites to avoid spillage of colon contents. The colon segment was divided at the proximal and distal sites (Fig. ​ (Fig.1A). 1 A). The proximal end of the graft was closed (distal end in cases of distal pedicle), making it the dome of the neovagina. About 1 cm from the anus, a posteriorly based triangular scrotal flap (4 cm base width × 6 cm length) was raised, and a cavity was created between the bladder and rectum. The colon segment was delivered gently in the created cavity. The distal end of the segment was sutured with the invaginated scrotal flap completing the posterior vaginal wall. The dome of neovagina was fixed with sacral promontory to minimize the incidence of prolapse.

A, Harvested pedicled colon segment. B, Right orchiectomy showing fixation of cord structures until the lower end. This is done bilaterally to achieve bulk of labia majora. C, The penile skin is degloved superficial to the Buck’s fascia, leaving one-third of preputial skin attached to the glans. D and E, Dorsolateral part of glans is elevated along with dorsal tunica vaginalis containing neurovascular bundle. F, Penile skin is slit into 2 flaps except for proximal 1 inch. Clitoral shaft is made. Bilateral triangular back cut flaps to create the clitoral hood. G, Bilateral triangular flaps tucked under the tubed clitoral shaft to achieve a 1-cm hood, and glans is reshaped in the form of clitoris and fed under the hood. H, Distal two-thirds of the preputial flap attached to slit penile flap is lifted up to meet the upper third of the preputial flap attached to glans. The anchor suture being applied to define the groove between the labia majora and minora, and the labia minora are sculptured.

The midline scrotal incision was extended until the penile base ventrally. After orchiectomy, the preserved cord along with fat was fixed until the lower end to enhance labia majora bulk (Fig. ​ (Fig.1B). 1 B). About 3 inches of the proximal urethra was separated off the corpora. Penile skin was degloved superficial to the Buck’s fascia all the way, except for a small flap (4 cm × 2 cm) of inner preputial skin, which was left attached to the glans (Fig. ​ (Fig.1C). 1 C). The dorsolateral part of glans with attached preputial skin flap and dorsal tunica albuginea containing neurovascular bundle were dissected off, until the base of the penis (Fig. ​ (Fig.1D, 1 D, E). Corpora were excised.

Penile skin flap was slit into 2 halves barring a proximal 1 inch. Tube-like clitoral base/shaft was constructed by enfolding the central unslit proximal portion and was anchored to the suspensory ligament with 3-point nylon 4-0 stitch. Some amount of pubic fat is incorporated in the tube to avoid flattening. Small (1 cm × 1 cm) triangular flaps raised akin back cuts on medial aspects of either penile hemiflaps and were stitched under a clitoral tube to create an approximately 1-cm roof, achieving a clitoral hood. The trimmed reshaped clitoris was anchored under this hood (Fig. ​ (Fig.1F, 1 F, G). The side wings of small preputial flaps were sutured to the medial edge of penile skin in a “Namaste” position forming the upper one-third of labium minus.

In the center of distal third of the penile flap, an anchor stitch was taken and fixed to the crural base deep in the vaginal cavity. This key stitch provided a downward pull and defined the groove between the labia majora and minora creating an inner layer of majora and outer layer of minora. The lower two-thirds of the attached preputial skin were lifted up in “Namaste” position and attached to the upper third of labium, thereby achieving full-length labia minora (Figs. ​ (Figs.1H 1 H and ​ and2A). 2 A). The rest of the penile skin was anastomosed to the colon segment in a zig-zag, tension-free manner to complete the anterior and lateral vaginal walls. The mucocutaneous junction was typically placed beyond 2 inches (Fig. ​ (Fig.2 2 B).

A, Sculptured labia minora with well-defined clitoris and hood. B, Vaginal introitus, zig-zag mucocutaneous junction is placed at or beyond 2 inches. C, Scrotal skin is degloved preserving dartos to achieve additional bulk to labia majora. D, Medialization of labia majora, and margin of scrotal skin is medialized and anchored to crura to place the scar medially. E, Immediate postoperative. F, Two-week postoperative. G and H, One-year postoperative.

Extra scrotal skin was deepithelialized preserving the dartos tissue to achieve the bulk of labia majora (Fig. ​ (Fig.2C). 2 C). The edges of this scrotal skin were medialized and anchored to the crural stump (Fig. ​ (Fig.2D). 2 D). The labia majora were constructed with stitching of medialized scrotal skin with outer half of slit penile flap. The urethra was slit transversely and spatulated, and corpus spongiosum was trimmed. Urethra was placed caudal to the clitoris.

Postoperative Period

Pain relief was achieved with intravenous and epidural analgesia. Intravenous antibiotics were administered for 3–5 days. Use of electrolyte solutions (potassium, calcium, and magnesium) has dramatically improved the recovery and reduced paralytic ileus incidence. Patient passed flatus within 48 hours and was allowed liquids orally. Foley’s catheter was removed after 6 days and ambulation resumed. Daily vaginal wash was done from third day onward. Hospital stay duration was 7 (5–10) days. Dilation schedule was extremely simple, which was started 7–14 days postsurgery. Dilation was performed twice daily with soft deflatable mold for 5 minutes followed by 5–10 minutes using a rigid dilator and continued for 8–16 weeks, as necessary. The patients were advised to maintain hygiene by washing the genitalia with 5% betadine solution for about 3 weeks. Sexual activity can be resumed at 6–8 weeks. Penetrative sex is counted as dilation.

The total number of patients was 386. Average age was 39 (22–63) years. Eighty-two patients (21.2%) had a history of smoking. Average surgical time was 5.2 (4–7) hours. None required emergency reoperation. Average follow-up was 34 (12–84) months.

Seventy-eight patients (20.2%) developed complications, with the majority (97.4%) having minor complications (Table ​ (Table2). 2 ). Minor healing issues were seen in 21 (5.4%) patients and were managed conservatively. Mucorrhea was reported by 24 (6.2%), which resolved after 9 months. Mucosal prolapse was seen in 6 (1.5%), especially those older than 50 years of age (n = 5). Other minor complications include introital stricture, dyspareunia, urinary retention (managed with prolonged catheter and cholinergics), wound infection, paralytic ileus, and clitoral necrosis. Major complications in the form of colon segment vascularity loss were noticed intraoperatively in 2 patients (0.5%), who had a smoking history.

Complications and Patient Follow-up

Touch-up surgeries were performed in 44 (11.4%) patients; of these, 10 (2.6%) were corrective and 34 (8.8%) were for esthetic enhancement of genitals in combination with other surgeries at a later date (Table ​ (Table3). 3 ). Out of the 10 who had corrective touch-ups, 6 (1.5%) were for introital strictures and 4 (1%) for mucosal prolapse.

Description of Corrective/Touch-up Surgeries

The level of satisfaction was assessed using a questionnaire at 12 months postoperatively. Response was received from 329 patients. Average overall satisfaction level was 4.7/5 (Tables ​ (Tables1 1 and ​ and4 4 ).

Questionnaire Results (n = 329 Patients)

MtF vaginoplasty techniques span from split-thickness graft, full-thickness graft, penile/penoscrotal inversion, and fasciocutaneous flaps to pedicled intestinal flaps. 4 – 14 Currently, penile inversion is the most commonly performed sex reassignment surgery (SRS) technique worldwide. 11 – 13 , 20 – 22 This technique was pioneered by Burou, 23 Gillies and Millard, 24 Edgerton and Bill, 25 and Pandya and Stuteville. 8 In this technique, the pedicled sensitive penile skin is used, but it results in inadequate vaginal depth, disfigured outer vulva, constant and unpleasant discharge, possible vaginal vault prolapse, and painful postoperative care. 7 , 9 , 26

Prolonged hormonal intake leads to penoscrotal hypoplasia making penoscrotal inversion vaginoplasty not feasible. 10 , 15 – 19 To overcome the limitation of inadequate vaginal depth in transsexuals, the use of skin graft was introduced by Abraham. 27 The use of full-thickness skin graft from penile skin was first reported by Fogh-Anderson 28 and refined by Preecha 11 and Motta et al. 29

Limitations of skin graft split skin graft (SSG)/full thickness graft (FTG) vaginoplasty are inadequate graft take up, contraction of vagina due to scarring and graft shrinkage, long and painful postoperative aftercare and long-term dilation (even lifetime), introducing skin into a nonphysiological location, a vagina with poor erogenous sensations, no self-lubricating/self-cleaning properties, dyspareunia, neovaginal prolapse, donor area scarring, condylomatosis, intraepithelial neoplasia associated with human papilloma virus, and carcinoma. 4 , 7 , 9 , 26 , 30 , 31

Forceful dilations lead to vicious cycle of breakdown and healing of patchy scars causing further stenosis necessitating lifelong painful dilation to keep the vagina patent. Should the patient leave dilation, patchy healing results in pockets with entrapped skin grafts, leading to repeated bouts of infection with purulent discharging sinuses? We have noticed these findings during corrective SRS. In corrective SRS, detaking this entrapped skin graft is challenging and poses risks to adjacent structures.

First mention of intestinal vaginoplasty in MtF transsexuals dates 1974, when Markland and Hastings used cecum and sigmoid transplants. 32 Ileal, ascending colon, and transverse colon segments have also been used without extra advantage, but added excessive discharge problem. 12 , 14 , 29 , 33

The promising benefits of sigmoid colon vaginoplasty were large lumen, integral strong walls resistant to trauma, mucosal lining with self-lubricating and self-cleaning properties, excellent vaginal sensations, rapid healing, and minimal postoperative care with shorter dilation regimen. 4 , 5 , 7 , 34 , 35 Studies have shown that use of pedicled sigmoid colon flap for vaginoplasty mitigates many of the issues seen with penoscrotal flap. 7 , 36 – 38 Most of the studies relegate rectosigmoid transfer to MRKH syndrome, previously failed skin vaginoplasty, or in patients with previous penectomy and orchiectomy (secondary vaginoplasty). 9 , 39 Many studies have pointed out the following complications in rectosigmoid vaginoplasty: mucorrhea, mucocele, introital stricture, unnatural reddish appearance due to the visible mucosa at the opening, neuroma formation, increased risk of bacteria entering the abdomen, postoperative ileus, and constipation. 4 , 5 , 9 , 22 , 40

These limitations were minimal to nonexistent in our patients. Complications were seen in 78 patients (20.2%), with the majority (97.4%) having minor complications. Only 10 (2.6%) needed corrective surgeries mainly for introital stricture (causing dyspareunia) and mucosal prolapse. In this technique, distal 2–3 inches of penile skin is anastomosed to sensate rectosigmoid in a zig-zag, tension-free manner placing mucocutaneous junction at or beyond 2 inches, thus avoiding the unnatural red appearance and minimizing introital stricture and mucosal prolapse. Minor abdominal wound infection was noted in 3 (0.8%), which were earlier cases. Addition of intraoperative bowel wash dramatically led to practically zero wound infection rate. Incidence of mucorrhea was quite low, which was reported only in 24 patients (6.2%) and resolved within 9 months in all patients. A shorter rectosigmoid , with most parts having dehydrating properties, lessens mucorrhea, but maintains natural self-cleaning and self-lubricating properties. Studies in the literature have reported higher incidence of prolonged mucorrhea. 5 , 9 , 22

Intraoperative colon graft vascularity loss was considered a major complication and was observed in 2 patients (0.5%) who had a history of smoking and claimed quitting for 2 months before surgery. In one case, the ileum was successfully used as an alternative. In another case, the ileal segment was discolored and bowel vaginoplasty was not suitable. Rectovaginal or urethrovaginal fistula in other techniques has been reported in previous studies, 5 , 13 , 26 , 42 – 45 but none of our patients had these.

The primary focus in most of the genital reconstructive surgery has been to develop an optimal method of creating a neovagina that would facilitate sexual intercourse. Clitoris/clitoral hood and labia minora remain among the most difficult structures to reconstruct. Despite increasing concerns for esthetic results of vulva and clitoro-labial creation with erogenous sensations, the ideal clitoro-labiaplasty, which would yield results resembling a biological female in every aspect, has not yet been achieved. 4 , 17 , 45 , 46

Brown used a reduced glans attached to its dorsal neurovascular pedicle. The incidence of clitoral necrosis was very high necessitating modification of techniques and secondary corrective surgeries. 47 – 50 Maintaining the viability of full-length preputial skin necessitates preserving the bulky glans tissue, which results in bulky clitoris leading to hindrance in hood creation. This large clitoris is esthetically unacceptable and is taken as a residual penis by the patient. Additional incisions and corrections in pursuit of the perfect outcome would lead to vascular compromise to the labial minora and occasionally clitoris and hypertrophic scarring, 4 which we experienced in our earlier cases.

In this technique, 3–4 inches of penile and preputial skin is utilized to create cosmetically appealing vulva parts: clitoris shaft, clitoral hooding, natural size sensate clitoris, full-length labia minora, bulky youthful full-length labia majora, and natural appearing introitus. The unslit proximal central part of penile flap is enfolded (entubed) with a 3-point anchor stitch giving a natural clitoral shaft. The incorporated fat avoids flattening of the shaft.

We developed the innovative idea of using bitriangular flaps, achieving about 1 cm hood/roof over the clitoris as in a cis-female. Clitoral hood gradually transits into the labia minora. Inclusion of dorsal tunica albuginea ensures viability of island neurovascular flap and enables the making of a small anatomical-sized clitoris and larger glanular flaps for the upper part of labia minora. The pedicle is robust and kink resistant with minimal incidence of necrosis and revision surgeries. Moreover, erogeneity is quite high owing to more nerve endings being incorporated. The whole of the preputial skin remains viable as it is used in 2 separate flaps for labia minora creation . Small flap remains attached to the clitoris in the form of glanulo-preputial flap and a larger preputial skin flap remains attached to the penile skin. The groove between the labia minora and majora was defined with an anchor stitch to penile flap, as described previously. We preserved viable fat, cord structure, and dartos tissue to achieve bulky labia majora until the lower end. Medialization of labia majora is a unique modification to achieve more esthetic natural look of the vulva in the form of apposed labia majora, deep commissure, and medially placed scar which becomes inconspicuous over the time.

Minor clitoral and labial necrosis was noticed only in 2 patients (0.5%), which is extremely low as compared to other studies. 47 – 49 Minor healing issues with minor necrosis were noticed in 21 (5.4%) patients with smoking history, which were treated conservatively. The incidence is low as compared with that reported in the literature. 11 , 42 , 44 , 52 Cosmetic enhancement was carried out in 34 patients (8.8%), which is quite low as compared with a previous report. 13 Moreover, these touch-ups were optional rather than required, as these were opted in combination with other surgical procedures during revisits for possible esthetic enhancement of otherwise acceptable genitals. The protrusion of corpus spongiosum was seen in 9 (2.3%) patients in earlier part of our series. Later, we adopted trimming of the corpus spongiosum as described by Preecha. 11 Incidence of protrusion in our study is quite low as compared with other studies. 5

Few studies have focused on functional outcome in the form of sexual outcome after male to female (MtF) SRS. 52 , 53 The latest articles emphasize the need of developing new instruments for evaluating gender confirmation surgery outcome as there are no valid instruments available yet. 54 , 55 In our series, the outcome was assessed in terms of esthetic and functional outcomes, including orgasmic capabilities. Out of 329 patients who responded to the questionnaire, 323 (98.2%) were satisfied with the outcome. Overall average satisfaction level was 4.7/5. The satisfaction rate is much higher than that reported by other studies involving a lesser volume of patients. 5 , 7 , 13 , 56 – 60

There are some limitations of the study. First, even though the plastic surgeon was the same for all patients, the general surgeon involved varied. This could have contributed to some variations in the outcome. Second, even though we have collected subjective data from the patients, we do feel that objective data from physical examinations are lacking. Third, even though the technique has a long learning curve, this study with a long follow-up is evidence that this technique is safe and effective.

CONCLUSIONS

The sigma-lead MtF gender affirmation surgery is a safe and reliable technique. It allows faster healing and very minimal postoperative aftercare while delivering very natural cosmetic results in all major aspects of cis-genitals, namely, the sensate clitoris, clitoral hooding, full-length stand-out labia minora, and appealing apposed youthful labia majora with minimum scarring. It also provides a self-lubricating, fully sensate deep neovagina, allowing for clitoral and vaginal sexual arousal and climaxes with minimal dilation requirement. Complications, though present, can be treated successfully with revision surgery. Moreover, this is perhaps the largest reported series of rectosigmoid transfer in MtF transsexuals performed for primary vaginoplasty.

Published online 2 April 2019.

Presented (Invited lecture for Video Workshop) at the 53rd Annual National Conference of Association of Plastic Surgeons of India (APSICON 2018), November 21, 2018, Lucknow, Uttar Pradesh.

Presented (Invited lecture) at the Annual Conference of Kerala Plastic Surgeons Association (KPSACON 2018), April 21, 2018.

The technique was introduced and explained during a video workshop and symposium on male-to-female sex reassignment.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Supplemental digital content is available for this article. Clickable URL citations appear in the text.

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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-non-conforming people, version 7. Int J Transgend. (2012) 13:165–232. doi: 10.1080/15532739.2011.700873

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4. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int . (2007) 100:607–13. doi: 10.1111/j.1464-410X.2007.07017.x

5. Rossi NR, Hintz F, Krege S, Rübben H, Vom DF, Hess J. Gender reassignment surgery – a 13 year review of surgical outcomes. Eur Urol Suppl . (2013) 12:e559. doi: 10.1016/S1569-9056(13)61042-8

6. Silva RUM, Abreu FJS, Silva GMV, Santos JVQV, Batezini NSS, Silva Neto B, et al. Step by step male to female transsexual surgery. Int Braz J Urol. (2018) 44:407–8. doi: 10.1590/s1677-5538.ibju.2017.0044

7. Aydin D, Buk LJ, Partoft S, Bonde C, Thomsen MV, Tos T. Transgender surgery in Denmark from 1994 to 2015: 20-year follow-up study. J Sex Med. (2016) 13:720–5. doi: 10.1016/j.jsxm.2016.01.012

8. Perovic SV, Stanojevic DS, Djordjevic MLJ. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. (2001) 86:843–50. doi: 10.1046/j.1464-410x.2000.00934.x

9. Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. (2001) 88:396–402. doi: 10.1046/j.1464-410X.2001.02323.x

10. Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, et al. Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients. Urol International. (2010) 84:330–3. doi: 10.1159/000288238

11. Reed H. Aesthetic and functional male to female genital and perineal surgery: feminizing vaginoplasty. Semin PlasticSurg. (2011) 25:163–74. doi: 10.1055/s-0031-1281486

12. Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. (2015) 12:1837–45. doi: 10.1111/jsm.12936

13. Sigurjonsson H, Rinder J, Möllermark C, Farnebo F, Lundgren TK. Male to female gender reassignment surgery: surgical outcomes of consecutive patients during 14 years. JPRAS Open. (2015) 6:69–73. doi: 10.1016/j.jpra.2015.09.003

14. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. J Urol. (2018) 199:760–5. doi: 10.1016/j.juro.2017.10.013

15. Dy GW, Sun J, Granieri MA, Zhao LC. Reconstructive management pearls for the transgender patient. Curr. Urol. Rep. (2018) 19:36. doi: 10.1007/s11934-018-0795-y

16. Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol. (2013) 64:141–9. doi: 10.1016/j.eururo.2012.12.030

17. Horbach SER, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med . (2015) 12:1499–512. doi: 10.1111/jsm.12868

18. Hadj-Moussa M, Ohl DA, Kuzon WM. Feminizing genital gender-confirmation surgery. Sex Med Rev. (2018) 6:457–68.e2. doi: 10.1016/j.sxmr.2017.11.005

19. Salim A, Poh M. Gender-affirming penile inversion vaginoplasty. Clin Plast Surg. (2018) 45:343–50. doi: 10.1016/j.cps.2018.04.001

20. Hess J, Rossi NR, Panic L, Rubben H, Senf W. Satisfaction with male-to-female gender reassignment surgery. DtschArztebl Int. (2014) 111:795–801. doi: 10.3238/arztebl.2014.0795

21. Silva DC, Schwarz K, Fontanari AMV, Costa AB, Massuda R, Henriques AA, et al. WHOQOL-100 before and after sex reassignment surgery in brazilian male-to-female transsexual individuals. J Sex Med. (2016) 13:988–93. doi: 10.1016/j.jsxm.2016.03.370

22. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol . (2010) 72:214–31. doi: 10.1111/j.1365-2265.2009.03625.x

23. Castellano E, Crespi C, Dell'Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest . (2015) 38:1373–81. doi: 10.1007/s40618-015-0398-0

24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

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September 04, 2019 | Caroline Knight

Why Using Dilators is Important After Gender Confirmation Surgery

Today, more people than ever are unhappy with their gender and choose to opt for gender confirmation surgery. although this is not a decision to be taken lightly, it’s becoming increasingly common. you might also have heard gender confirmation surgery referred to as sex reassignment surgery or genital reassignment surgery; when a man changes to female gender (mtf), the operation is called vaginoplasty..

As you might imagine, vaginoplasty is an incredibly complex operation that requires a great deal of aftercare to ensure long-term success. Anyone who is considering gender confirmation surgery should be aware of the aftercare implications, and we’re here to help with that. One of the most important aspects is the use of vaginal dilators , which we’ll also cover in this article.

Post-operative care for gender confirmation surgery

After MtF gender confirmation surgery (vaginoplasty), each person takes a variable amount of time to recover. It is normal to experience some soreness and swelling, and believe it or not, a ‘neo vagina’ is also susceptible to yeast infections and urinary tract infections… so consistent care is needed to prevent these.

After gender confirmation surgery, it is normal for either gauze packing or a stenting device to be placed inside the neo vagina, to be kept in place for up to a week afterward. After this is removed, it is time to start using vaginal dilators . Vaginal dilation is incredibly important after vaginoplasty, but different surgeons will recommend different protocols. Below we’ll offer a common guideline for transgender dilation.

Why are dilators important after gender confirmation surgery?

Post gender confirmation surgery, your body is likely to register your vagina as a wound, and therefore try to heal it. This would result in some shrinkage at the very least – if not total closure and/or development of scar tissue. For this reason, transgender dilation therapy is crucial; it can prevent all of these possibilities from happening.

You will want to maintain the depth and width of your new vagina, so your surgeon is likely to recommend using dilators a few days after surgery is complete. From this point, you will need to keep using the vaginal dilators ongoing - but less often as time goes on, of course.

Guidelines for using a dilator after vaginoplasty

Your surgeon should have the final say on this, so do check with them before starting dilation therapy. Also ensure that you are using the right sized dilators, according to your surgeon’s recommendation.

• Clean your dilator with warm soapy water, then rinse and dry it (the same goes after each use!)
• Use a water-based lubricant to coat the dilator before insertion
• Gently insert your dilator at a 45 degree angle; when it is under the pubic bone, continue insertion in a straight direction
• Once you have inserted it fully and are experiencing some resistance, leave the dilator in place for ten minutes
• Dilate three times each day for a period of three months, as soon as the gauze has been removed
• After three months, stat using a larger dilator for a further three months
• At between three and six months, use the dilator once per day for ten minutes
• After six months, use it two or three times per week for ten minutes
• After nine months, use it once or twice per week

Note that if your neo vagina seems tight at any point, you can increase the frequency of dilation. It’s also important to stop dilator therapy if you are experiencing excessive resistance, pain or tenderness – a little is normal, a lot is not.

A final word on genital reassignment surgery

We thought you might be interested in this helpful tip for resuming sexual intercourse: you may find the Ohnut ring useful, since this intimate wearable helps your partner to control the depth of penetration. Using an Ohnut ring means you’re less likely to feel any pain, and your partner will barely notice it.

The bottom line is that gender confirmation surgery requires regular self-care, so you’ll need to be disciplined with your dilator use. VuvaTech stock a range of vaginal dilators and we’re always happy to help, so feel free to ask if you have any questions!

Other VuVa Helpful Links:

7 Reasons for a Tight Vagina and How to Loosen 

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Home » Blog » How does dilation work after Gender Confirmation Surgery?

How does dilation work after Gender Confirmation Surgery?

Both the patient and the surgeon share a key responsibility in achieving the best surgical outcome and maintaining functional vaginal depth following gender confirmation surgery (GCS). During your procedure, your surgeon utilises the penile and scrotal flaps safely to create the maximum depth of the vaginal canal and form the internal lining of the vagina.

As the patient, it is your responsibility to ensure you strictly follow the Vaginal Dilation Schedule to maintain the depth and calibre of your vagina. The stretching effect from vaginal dilation can prevent wound contraction, in addition to providing optimal elasticity of the vaginal walls to accommodate penetration. Without adequate and consistent dilation, the skin inside the vagina will shrink and contract, which may ultimately lead to shortening and/or narrowing of the vaginal canal; this is known as stenosis.

A shortened vaginal canal resulting from contraction inside the vagina is an irreversible process which means you cannot regain your original vaginal depth by resuming or increasing vaginal dilation.

Everything you need to know about Gender Confirmation Surgery

According to our surgeon’s GCS technique, packing will be used to stabilise the skin flaps inside the vagina, which is then removed at approximately 5 days post-operation. When the vaginal pack is removed, a speculum is inserted into the vagina to examine the healing of the skin flaps.

Following this, your first vaginal dilation will be demonstrated by your surgeon or a senior member of the clinical team. Your vaginal depth will be confirmed by the measurement scale on the dilator shaft; this is measured at the point of the vaginal opening.

You will be provided with a set of vaginal dilators prior to your discharge from the hospital. These dilators will vary in diameter and you will be advised by your surgeon or a senior member of the clinical team which sized dilators to use during your vaginal dilation. It is recommended that you continue with daily vaginal dilation up to 3 months following your GCS. After 3 months, once a week or alternative weeks as required is acceptable. Once vaginal intercourse is commenced, you may only need to dilate once a month as necessary.

Dilation essentials

Wash your hands and dilators both before and after vaginal dilation using warm water and mild soap. The use of water-based lubricating jelly is mandatory for the first year following your surgery to prevent tearing of the delicate skin inside the vagina. Prior to commencing dilation, plenty of lubricating jelly must be applied to the tip and shaft of the dilator, as well as the vaginal opening to ease insertion. Please re-apply more lubricating jelly during dilation if necessary.

Lie on your back in a semi-recumbent and comfortable position with your knees slightly bent. Position the lubricated dilator against the vaginal opening. Slowly push the dilator at an angle toward your lower back or tailbone until it occupies the full depth of your vagina. Whilst inserting the dilator, slow and gentle rotation can help expand the vaginal opening.

Gentle and constant pressure is required in order to sufficiently stretch the skin and maintain vaginal depth. You should frequently check the measurement scale on the shaft of the dilator to ensure you are maintaining depth with at least the smallest size dilator supplied. You must not attempt to push or force the vaginal dilator against the end of your vaginal canal to increase existing depth; this can result in tearing of the vaginal wall, bleeding, or a vaginal fistula.

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Gender-Affirming Surgery

OHSU surgeons are leaders in gender-diverse care. We provide specialized services tailored to the needs and goals of each patient. We offer:

• Specialists who do hundreds of surgeries a year.
• Plastic surgeons, urologists and other specialists who are leading experts in bottom surgery, top surgery and other gender-affirming options.
• Vocal surgery with a highly trained ear, nose and throat doctor.
• Peer volunteers who can provide support during visits.
• Welcoming care for every patient, every gender and every journey.

Our surgical services

We offer many gender-affirming surgery options for transgender and nonbinary patients, including options within the following types. We also welcome you to request a procedure that isn’t listed on our pages.

Top surgery:

• Gender-affirming mastectomy
• Gender-affirming breast augmentation

Bottom surgery:

• Phalloplasty and metoidioplasty , including vagina-preserving options
• Vaginoplasty and vulvoplasty , including penile-preserving options

Hysterectomy

Nullification surgery, oophorectomy, orchiectomy.

Bottom surgery options also include:

• Scrotectomy
• Scrotoplasty
• Urethroplasty
• Vaginectomy

Additional gender-affirming options:

• Adam’s apple surgery

Vocal surgery

Face and body surgery, preparing for surgery.

Please see our patient guide page to learn about:

• Steps to surgery
• WPATH standards of care
• The letter of support needed for some surgeries

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Request services.

Please fill out an online form:

• I am seeking services for myself.
• I am seeking services for someone else.

Other questions and concerns

Contact us at:

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• Please complete our  Request for Transgender Health Services referral form   and fax with relevant medical records to  503-346-6854 .
• Learn more on our  For Health Care Professionals  page.

At OHSU, our gynecologic surgeon, Dr. Lishiana Shaffer, specializes in hysterectomies (uterus and cervix removal; often combined with oophorectomy, or ovary removal) for gender-diverse patients. She does more than 150 a year.

We also offer a Transgender Gynecology Clinic with a gender-neutral space. Services include surgery. Referrals and appointments are made through the OHSU Center for Women's Health, though the space is not in the center. Call 503-418-4500 to request an appointment.

Some patients choose hysterectomy to:

• More closely align their bodies with their gender identity.
• With ovary removal, to remove a main source of the hormone estrogen.
• To end pain caused by testosterone therapy that shrinks the uterus.
• To end the need for some gynecologic exams, such Pap smears.

Preparation: We usually recommend a year of hormone therapy first, to shrink the uterus. We don’t require a year of social transition.

Most often, we use a minimally invasive laparoscope and small incisions in the belly. We usually recommend removing fallopian tubes as well, to greatly reduce the risk of ovarian cancer.

Most patients spend one night in the hospital. Recovery typically takes about two weeks. You’re encouraged to walk during that time but to avoid heavy lifting or strenuous exercise.

Hysterectomy is usually safe, and we have a low rate of complications. Risks can include blood clots, infection and scar tissue. Because of a possible link between hysterectomy and higher risk of cardiovascular disease, your doctors may recommend regular tests.

Removing the uterus also ends the ability to carry a child. OHSU fertility experts offer options such as egg freezing before treatment, and connecting patients with a surrogacy service.

OHSU offers nullification surgery to create a gender-neutral look in the groin area.

Nullification surgery may include:

• Removing the penis (penectomy)
• Removing the testicles (orchiectomy)
• Reducing or removing the scrotum (scrotectomy)
• Shortening the urethra
• Removing the uterus (hysterectomy)
• Removing the vagina (vaginectomy)

The procedure takes several hours. Patients can expect to spend one to two nights in the hospital. Recovery typically takes six to eight weeks. Patients are asked to limit walking and to stick to light to moderate activity for four weeks. They should wait three months before bicycling or strenuous activity.

Nullification surgery cannot be reversed. Risks can include:

• Changes in sensation
• Dissatisfaction with the final look
• Healing problems

Removing the penis and testicles or the uterus also affects the ability to conceive a child. OHSU fertility experts offer options such as freezing eggs and connecting patients with a surrogacy service.

Having a gynecologic surgeon remove one or both ovaries is often done at the same time as a hysterectomy. We do nearly all these surgeries with a minimally invasive laparoscope and small incisions in the belly.

Most patients spend one night in the hospital and return to their regular routine in about two weeks.

The ovaries produce estrogen, which helps prevent bone loss and the thickening of arteries. After removal, a patient should be monitored long-term for the risk of osteoporosis and cardiovascular disease.

We encourage patients to keep at least one ovary to preserve fertility without egg freezing. This also preserves some hormone production, which can avoid early menopause.

At OHSU, expert urologists do orchiectomies (testicle removal). Patients may choose this option:

• To remove the body’s source of testosterone
• As part of a vaginoplasty or vulvoplasty (surgeries that create a vagina and/or vulva)
• To relieve dysphoria (some patients choose only this surgery)

Removing the testicles usually means a patient can stop taking a testosterone blocker. Patients may also be able to lower estrogen therapy.

The surgeon makes an incision in the scrotum. The testicles and the spermatic cord, which supplies blood, are removed. Scrotal skin is removed only if the patient specifically requests it. The skin is used if the patient plans a vaginoplasty or vulvoplasty.

You will probably go home the same day. Patients can typically resume normal activities in a week or two.

Reducing testosterone production may increase the risk of bone loss and cardiovascular disease, so we recommend regular tests. Without prior fertility treatment, orchiectomy also ends the ability to produce children. Serious risks are uncommon but include bleeding, infection, nerve damage and scarring.

Adam’s apple reduction (laryngochrondoplasty)

Dr. Joshua Schindler, an ear, nose and throat doctor who does Adam’s apple and vocal surgeries, completed his training at Johns Hopkins University.

Laryngochrondoplasty is also known as Adam’s apple reduction or a tracheal shave (though the trachea, or windpipe, is not affected).

A surgeon removes thyroid cartilage at the front of the throat to give your neck a smoother appearance. This procedure can often be combined with facial surgery.

Thin incision: At OHSU, this procedure can be done by an ear, nose and throat doctor (otolaryngologist) with detailed knowledge of the neck’s anatomy. The surgeon uses a thin incision, tucked into a neck line or fold. It can also be done by one of our plastic surgeons, typically with other facial surgery.

In an office or an operating room: Our team can do a laryngochrondoplasty in either setting, which may limit a patient’s out-of-pocket expenses.

OHSU also offers Adams’ apple enhancement surgery.

Many patients find that hormone therapy and speech therapy help them achieve a voice that reflects their identity. For others, vocal surgery can be added to raise the voice’s pitch.

Voice therapy: Patients have voice and communication therapy before we consider vocal surgery. Your surgeon and your speech therapist will assess your voice with tests such as videostroboscopy (allowing us to see how your vocal cords work) and acoustic voice analysis.

Effective surgery: We use a surgery called a Wendler glottoplasty. It’s done through the mouth under general anesthesia. The surgeon creates a small controlled scar between the two vocal cords, shortening them to increase tension and raise pitch. Unlike techniques that can lose effectiveness over time, this surgery offers permanent results.

Hormone therapy can bring out desired traits, but it can’t change the underlying structure or remove hair follicles. Our highly trained surgeons and other specialists offer options. Patients usually go home the same day or spend one night in a private room.

Face options:

• Browlift (done with the forehead)
• Cheek augmentation
• Chin surgery (genioplasty), including reductive, implants or bone-cut options
• Eyelid surgery
• Face-lift, neck lift
• Forehead lengthening
• Forehead reduction, including Type 3 sinus setback and orbital remodeling
• Hairline advancement (done with the forehead)
• Jawline contouring
• Lip lift and/or augmentation
• Lipofilling (transferring fat using liposuction and filling)
• Nose job (rhinoplasty)

Body options:

Hormone treatment may not result in fat distribution consistent with your gender. We offer liposuction and fat grafting to reshape areas of the body.

Gender Confirmation Surgery

Gentle, safe, discreet care for postsurgery and beyond.

We don’t need to tell you that changing your physical sex as an adult by undergoing gender confirmation surgery (aka sex reassignment surgery or genital reassignment surgery) is a huge decision. It takes genuine inner strength to become who you are and we want to congratulate and celebrate you, wherever you are on your journey.

If you’re preparing to take the last step to transition from male to female (MtF) with gender confirmation surgery, The Pelvic Hub can help you take care for yourself after surgery, and help you maintain your neo vagina in the long term.

• Written by Emma McGeorge

Related Conditions

Want to learn more about related conditions? Follow the links below to gain a better understanding of the symptoms and treatments.

After Your SRS Surgery

Each person’s experience of MtF gender confirmation surgery— and the recovery that follows— is different. Everyone heals at a different pace. As with any surgery, it’s normal to have symptoms like swelling and soreness.

Vaginas are complex things, and generally higher maintenance than penises. Your neo vagina may be susceptible to yeast infections and urinary tract infections, just like a natal vagina is.

Dilation Therapy for Transgender Patients

After surgery, it’s normal for your body to register your neo vagina as a wound. And similar to with a new piercing, your body will try to heal. Because of this, your neo vagina may start to shrink or develop scar tissue called granulation.

Dilation therapy is an absolute must to keep your neo vagina functional, to minimize scars from forming in your vaginal lining, and to prevent you from losing vaginal depth and width. Usually, MtF transgender patients start using vaginal dilation a few days after surgery and continue to use vaginal dilators, to some degree, for the rest of their lives.

Your surgeon will let you know how to safely use a vaginal dilators, what size to use, and how often you need to employ post-operative vaginal dilation to maintain your neo vagina. If they don’t, you should definitely ask.

Recommended Products for Post-Op Care

We love that these products can help you take care of yourself discreetly from home. However,  we always recommend that you check with your surgeon or physician before using any products on your neo vagina or inside your vaginal opening.

Natural cooling relief

Reusable perineal cooling pads are perfect for cooling the most sensitive and delicate area of your body. Comfortable, cooling and discreet, they are perfect for reducing pain and swelling post-surgery. Also great if you’re prone to yeast infections or urinary tract infections.

Comfortable sitting

You may need a little help sitting without pain in the first few weeks after surgery. A foldable travel pelvic cushion or deluxe foldable travel pelvic cushion are uniquely designed to take the pressure off your neo vagina, helping you sit a little more comfortably.

Gentle, worry-free sex

Using an intimate wearable that allows you to control the depth of penetration into your neo vagina during sex can help you manage any pain you may experience during sexual intercourse. The Ohnut is designed to not just comfortably accommodate penetrative sex but also to feel just like skin. It’s so comfortable (like a gentle hug) you and your partner will barely notice it’s there. And because you no longer have to worry about whether penetration will hurt, this wearable allows both you and your partner to focus on what matters most, connection, enjoyment, and fun.

Are you looking for top-of-the-range, world-class transgender dilators?

Intimate Rose’s vaginal dilators were designed by a pelvic floor health physical therapist and are made from a smooth, body safe, medical grade silicone that's 100% BPA free and designed to glide into your neo vagina for more comfortable use during dilator therapy. They are designed to maintain your neo vagina’s integrity and vaginal depth and are recommended by pelvic floor specialists around the world. Not only are the Intimate Rose vaginal dilators more comfortable and easier to use, but they are also the only FDA registered vaginal silicone dilator and are used in the official Academy of Pelvic Health training courses.

They can also be chilled to help with post-surgical swelling, or used at room temperature. Always check with your surgeon or physician before using any dilator in your neo vagina to make sure you have the size, technique and frequency that is safe for your body, as dilation involves inserting into your neo vaginal canal for maintaining vaginal depth. Your doctor can recommend a dilation regimen that will provide you the most support during the healing process and beyond.

Invest in your health and yourself

Gender confirmation surgery is a big investment, and it doesn’t end when you leave the hospital. It’s  important to take gentle care of yourself after surgery and in the long term.

Related Products

Sweden passes disputed gender reassignment law

Stockholm (AFP) – Sweden's parliament on Wednesday passed a controversial law lowering the minimum age to legally change gender from 18 to 16 and making it easier to get access to surgical interventions.

Issued on: 17/04/2024 - 18:15

The law passed with 234 votes in favour and 94 against in Sweden's 349-seat parliament.

While the Nordic country was the first to introduce legal gender reassignment in 1972, the proposal, aimed at allowing so-called "self-identification" and simplifying the procedure, sparked an intense debate in the country.

The debate has also weakened conservative Prime Minister Ulf Kristersson's standing, after he admitted to caving into pressure from party members on the issue.

"The great majority of Swedes will never notice that the law has changed, but for a number of transgender people the new law makes a large and important difference," Johan Hultberg, an MP representing the ruling conservative Moderate Party, told parliament.

Beyond lowering the age, the new legislation is aimed at making it simpler for a person to change their legal gender.

"The process today is very long, it can take up to seven years to change your legal gender in Sweden," Peter Sidlund Ponkala, president of the Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL), told AFP.

Two new laws will go into force on July 1, 2025: one regulating surgical procedures to change gender, and one regulating the administrative procedure to change legal gender in the official register.

No diagnosis needed

People will be able to change their legal gender as of age 16, though those under 18 will need the approval of their parents, a doctor, and the National Board of Health and Welfare.

A diagnosis of "gender dysphoria" -- where a person may experience distress as a result of a mismatch between their biological sex and the gender they identify as -- will no longer be required.

Surgical procedures to transition would, like now, be allowed from the age of 18, but would no longer require the Board of Health and Welfare's approval.

The removal of ovaries or testes will however only be allowed from the age of 23, unchanged from today.

A number of European countries have already passed laws making it easier for people to change their legal gender.

Citing a need for caution, Swedish authorities decided in 2022 to halt hormone therapy for minors except in very rare cases, and ruled that mastectomies for teenage girls wanting to transition should be limited to a research setting.

Sweden has seen a sharp rise in gender dysphoria cases.

The trend is particularly visible among 13- to 17-year-olds born female, with an increase of 1,500 percent since 2008, according to the Board of Health and Welfare.

While tolerance for gender transitions has long been high in the progressive and liberal country, political parties across the board have been torn by internal divisions over the new proposal, and academics, health care professionals and commentators have come down on both sides of the issue.

'Deplorable'

A poll published this week suggested almost 60 percent of Swedes oppose the proposal, while only 22 percent back it.

Far-right Sweden Democrats leader Jimmie Akesson lamented the result of Wednesday's vote.

"I think it's deplorable that a proposal that obviously lacks support among the population is so casually voted through," Akesson told reporters.

Some critics had expressed concerns about biological males in women's locker rooms and prisons, and fear the simplified procedure to change legal gender will encourage confused youths to embark down the path toward surgical transitions.

Others had insisted that more study was needed given the lack of explanation for the sharp rise in gender dysphoria.

In a sign of the strong feelings it stirred, members of parliament spent six hours debating the proposal.

"There is a clear correlation with different types of psychiatric conditions or diagnoses, such as autism," Annika Strandhall, head of the women's wing of the Social Democrats (S-kvinnor), told Swedish news agency TT ahead of the vote.

"We want to pause this (age change) and wait until there is further research that can explain this increase" in gender dysphoria cases.

Kristersson, the prime minister, had defended the proposal as "balanced and responsible".

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Sweden passes law to make it easier to change legal gender

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A British man has been charged over alleged hostile state activity intended to benefit Russia, including by allegedly recruiting others for an arson attack on a Ukrainian-linked commercial property in London.

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British security firm Ambrey said on Friday that three missiles had been sighted approximately 15 nautical miles southwest of Yemen's Mokha.

Ohio police released video of a Black man who died at a local hospital after repeatedly telling officers "I can't breathe" as they pinned him to the floor of a bar and handcuffed him, evoking memories of the killing of George Floyd in 2020.

Danielle Laidley among advocates to welcome bid to scrap WA Gender Reassignment Board

Western Australians will no longer have to undergo medical or surgical reassignment in order to change their sex or gender, under the state government's proposed law reforms.

The state's Gender Reassignment Board, which manages applications to legally change a person's gender, would be abolished under the new laws.

Attorney-General John Quigley said the legislation would bring WA in line with the rest of Australia.

"This is not radical legislation … we're only bringing Western Australia out of the dark ages, up to a level of social reform that the rest of the country already respects and enjoys," he said.

Reforms will save lives, advocate says

Danielle Laidley is an AFL premiership winner, and one of the youngest senior coaches in the sport's history.

Laidley was outed as a trans woman by police, had her family turn their back on her, and survived the drugs she turned to as her life spiralled out of control.

"Today I can finally stand here, as a proud Western Australian and transgender woman," she said.

Laidley said the abolition of the Gender Reassignment Board was a step forward for WA.

"It was wrong for someone to sit there and tell me who I was. They haven't walked a mile in my shoes, they don't know how I feel," she said.

Transfolk of WA deputy chairperson Dylan Green said the reform was a significant step to creating a pathway for transgender and gender-diverse people to align legal documentation with their gender identity.

"This will improve the lives, and save the lives, of many trans and gender diverse people in Western Australia," he said.

However, Mr Green noted the state government's proposal did not meet all of the recommendations made by the state's Law Reform Commission in 2018.

"We will be making further recommendations to the government regarding the regulations for this proposed bill, and advocating for further law reform," he said.

"We've seen in other states … certain requirements for clinical evidence have been removed for adults over the age of 18, so they use the self-determination model.

"That is what is widely considered best practice."

More change to come

Under the new laws, adults who have received counselling would be able to apply for a sex-change through the Registry of Births, Deaths and Marriages.

Teenagers between 12 and 18-years-old would need the consent of both parents, and children under 12 would need approval from the WA Family Court.

The legislation also includes clauses prohibiting certain types of offenders from applying to change their gender.

"You don't want someone who, for example, has been convicted of a nasty, aggravated sexual offence, then changing gender so they can access women-only areas," Mr Quigley said.

The proposed bill would also make the sex descriptors "non-binary" and "indeterminate/intersex" available, alongside "male" and "female".

The reforms would not change the existing procedure for registering the sex of a newborn. It also contains a requirement for the legislation to be reviewed after three years.

Mr Quigley has flagged the proposed legislation is only the first tranche of a multitude of changes to remove barriers for, and improve the lives of, the LGBTQIA+ community.

The WA government is chasing further reforms, including the development of a new Equal Opportunity Act and banning conversion therapy practices, which the attorney-general said would have to wait until after the 2025 state election.

"The federal government has announced the Australian Law Reform Commission findings, and the Prime Minister has come out and said on some contentious areas he is hopeful of getting bipartisan support," Mr Quigley said.

"I don't want to come in from left field and upset the applecart."

Reform follows landmark UK review

The proposed law reform comes after a landmark investigation into gender-affirming care in England, known as the Cass Review.

It recommended significantly limiting the prescription of medications, known as puberty blockers, for people aged under 18.

Federal health minister Mark Butler described the review's findings as "significant" but said the clinical treatment of transgender children in Australia was very different than in the UK.

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A review into how children with gender dysphoria are treated in england has been released. here's what it means for australia.

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Nh senate committee hears testimony on bill to ban some gender-confirmation surgery for children.

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Lawmakers in Concord heard testimony Thursday on a bill to ban genital gender-confirmation surgery for children under the age of 18.

The Senate Judiciary Committee heard hours of testimony on House Bill 619, amended legislation that would ban genital gender-confirmation surgery for children under 18. The bill has already passed the New Hampshire House.

The legislation would also class referrals for reassignment surgery outside the state as "unprofessional conduct."

"Children are, by definition, immature," said Jennifer Black, of Windham. "We don't allow them to vote, enter into contracts, get a tattoo or smoke, because we know they lack the capacity to understand what they are doing."

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Some argued that allowing children, with parental consent, to get an irreversible surgery at such a young age is a form of cruelty. Others noted that such procedures are only being performed on a small number of older teens nationwide.

"Twenty times per year in the United States, never in New Hampshire, and virtually all of these surgeries are vaginoplasty for 17-year-old transgender girls right before heading off to college, while they can still recover in their parents' home with their parents' love and support, rather than in a college dorm with other students who may not even know they're transgender," said Chris Erchull, of GLAD Legal Advocates & Defenders.

There is a battle over data in the debate. Lawmakers who sponsored the bill said there isn't enough data for patients or families to give informed consent with a full understanding of the risks involved.

"I'm not trying to say that to trivialize this, but if you have to wait until you're 18 to use a tanning bed with those known risks, why would be endorsing something with completely unknown risks that have many people talking about the challenges they never knew or expected from these surgeries?" said state Rep. Erica Layon, R-Derry.

Dr. Ketih Loud, chairman of the Dartmouth Health Department of Pediatrics, urging senators to reject the bill.

"We prefer to use scalpels, and this statute feels a little more like a machete and does not allow for the nuance that we need in clinical practice," Loud said.

Tennessee nears law banning adults from helping minors find, receive sex reassignment care

Tennessee lawmakers in the GOP-dominated Statehouse on Thursday passed legislation making it illegal for adults to help minors find and receive sex reassignment care without permission from the child’s parents. The bill is now heading to Gov. Bill Lee’s desk, where it could be signed into law.

Last week, the state’s senate passed its version of the bill before sending it to the House for approval.

The law would penalize any "adult who recruits, harbors, or transports an unemancipated minor" in Tennessee "for the purpose of receiving a prohibited medical procedure for the purpose of enabling the minor to identify with, or live as, a purported identity inconsistent with the minor’s sex or treating purported discomfort or distress from a discordance between the minor’s sex and asserted identity, regardless of where the medical procedure is to be procured," and classify the crime as a felony.

TENNESSEE LAWMAKERS PASS BILL CRIMINALIZING ADULTS WHO HELP MINORS GET TRANSGENDER PROCEDURES

On Wednesday, Tennessee Republican lawmakers passed the so-called "anti-abortion trafficking" proposal, which has almost identical language but geared toward stopping adults from helping young people obtain abortions without parental consent.

Lee, also a Republican , has not commented on either bill. He also did not respond to inquiries from Fox News Digital on the matter.

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Still, supporters of the bill are confident the governor will sign both bills into law.

MAINE CONSIDERS BILL THAT WOULD ESTABLISH 'LEGAL RIGHT' TO ABORTION, TRANSGENDER SURGICAL PROCEDURES

Lee has yet to issue a veto as governor, and he approved the state’s ban on abortion and sex reassignment care for minors.

Tennessee  Democrats opposed both bills and critics worried about the bills’ possible broad application.

GOP AGS WARN MAINE TO KILL ‘TOTALITARIAN’ BILL MAKING SANCTUARY STATE

Charges could stem from talking to a minor about a website on where to find care, to helping a minor travel to another state with looser restrictions on sex reassignment services.

Currently, Idaho is the only other state in the U.S. that has a law to crack down on adults who help facilitate abortions for minors. But Tennessee could become the first that applies penalties to adults relating specifically to gender-transition procedures and treatments.

Recently, Maine drew the attention of more than a dozen Republican attorneys general for a bill under consideration that would effectively establish Maine as a sanctuary state for both abortions and procedures like sex-change surgeries for minors — a move the  AGs say is "totalitarian." Providers would be shielded from so-called "hostile" lawsuits if the bill passes. 

Fox News Digital’s Brianna Herlihy and The Associated Press contributed to this report.

Original article source: Tennessee nears law banning adults from helping minors find, receive sex reassignment care