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MTF Male to Female Bottom Surgery: Vaginoplasty

Vaginoplasty Procedures, Techniques, Advantages, Recovery and Risks

Vaginoplasty Procedures, Techniques, Advantages, Recovery and Risks

Being born with a body that you don’t feel is yours can be the source of significant trauma, unhappiness, and conflict throughout your life. If you feel that you should have been born in a female body and yet are in the body of a male you may feel trapped, helpless, and disingenuous.

These feelings of gender dysphoria don’t improve or wane over time. They usually get worse. And as people go through life day to day in a gender that does not showcase the real you, your mental health will continue to suffer until gender transition is the only viable option to be able to truly live.

Fortunately, this type of gender confirmation surgery is now available to people who want to find their true selves and live by their gender identity. 

Sex Reassignment Surgery (SRS) is usually the definitive step in the gender transition process after pre-operative therapies. Once the surgeries are complete the transformation can feel like being reborn into the life you were truly meant to live.

At Transgender Thailand, we offer the full range of gender-affirming surgeries, including removing breast tissue and inserting a penile implant, suited for everyone at the hands of trained professionals with years of expertise and experience.


Sex Reassignment Procedures (FTM Bottom Surgery Process)

Before we get into the gender-affirming surgery procedures, do note that surgery is only possible after you’ve undergone hormone therapy. Consult a healthcare professional for more information about hormone therapy.

SRS – 1 Vaginoplasty (no vaginal depth):

The Vaginoplasty procedure without vaginal depth involves using the scrotal and penile skin of a patient to construct external female genitalia. This includes inner labia, outer labia, neo-clitoris, clitoral hood, and the female urethra.

Vaginoplasty without vaginal depth is ideal for patients who don’t require vaginal penetration for sexual intercourse. It is also good for patients who don’t want to undergo regular vaginal dilation and vaginal douche maintenance.

At the end of this procedure, the vagina completely resembles a natural vagina minus the vaginal canal.


SRS-2A Vaginoplasty with penile skin inversion:

The penile skin inversion vaginoplasty, was the most known and utilized technique in the past, until new technologies emerged. The penile skin inversion procedure involves inverting the penis skin to create the vaginal canal and the outer vagina. It’s a relatively short procedure that lasts for about 4 hours.

However, this method isn’t for all patients. It is not advisable for patients with deficient penile skin as it will result in a vagina that may be too shallow

SRS-2B Vaginoplasty with scrotal skin graft:

This type of Vaginoplasty uses the skin covering the penis to create the inner and outer labia while parts of the glans penis are used to construct the neo-clitoris. A scrotal skin graft is then used to create the vaginal canal.  This procedure creates a deeper functional vagina.

In case the patient has scrotal skin deficiency and the vaginal depth is not satisfactory, the plastic surgeon may consider a skin graft from different parts of the body including the groin or lower abdomen to help increase the vaginal depth.

This operation generally lasts between 4-6 hours.

SRS-3 Sigmoid Colon Vaginoplasty:

This procedure utilizing the sigmoid colon gives the vagina significant depth as well as the ability to self-lubricate. There are two options for this type of surgery:

  • Open Method –  In this technique, the sigmoid colon is cut as a pedicle flap with the neurovascular bundle intact. This is done via a low transverse abdominal incision on the bikini line. The rest of the colon is then reconnected to ensure the large intestine is normal and separated from the new sigmoid-neovagina. The surgery time lasts about 5 to 6 hours. 
  • Laparoscopic Technique –   In this technique, the sigmoid colon is harvested through 4 tiny microscopic incisions. The colon is then reconnected with stapler tools. The sigmoid colon is closed at the top end and pulled through the neo-vaginal canal and reconnected to the neovagional opening. This procedure lasts for about 6 hours. 

The advantages of the Sigmoid Colon Vaginoplasty are:

  • It is ideal for patients who already had sex reassignment surgery.
  • This procedure works for those with deficient penile and scrotal skin
  • With this procedure, the vagina will be self lubricated.
  • The length of the surgically constructed vagina can be predetermined. 

The disadvantages include:

  • For the open technique, there will be a visible 8 cm bikini line scar.
  • The surgery is more complicated as it requires cutting off a part of the colon. Due to this, the colon must be cleansed via an enema one day before surgery.
  • Patients may suffer from indigestion or dyspepsia for a few days after the procedure.
  • Both the open and the laparoscopic technique can’t be performed in those patients who have a fatty abdomen or who are overweight.
  • There may be an unpleasant odor if the vaginal canal daily cleansing is not done adequately.

Post-Operative Care for SRS-Sigmoid Colon:

  • Patients can’t eat or drink for about 2 to 3 days until the intestines are functioning again. In the interim, intravenous fluids will provide nourishment.
  • Patients must avoid excessive or large amounts of food in the first month.
  • Regular daily light activities can be resumed after 3 weeks post-operation while strenuous activities such as running, weight training, swimming etc., can be resumed 3 months post surgery.

SRS-4 Revision Vaginoplasty:

A Vaginoplasty revision is required when the primary vaginoplasty left the patients unsatisfied with its depth or its general result, or  for patients who want to upgrade to newer techniques such as the Penile-Peritoneal Vaginoplasty (PPV) technique. With the PPV surgery, a patient will benefit from a self lubricating vaginal canal, good elasticity of the vaginal walls and the overall feeling and look, almost indistinguishable from a biological vagina. ‍

SRS-5 PPV Penile Peritoneal Vaginoplasty:

This is the most advanced and innovative procedure utilizing the peritoneal tissue that lines the abdomen. This tissue is the most similar to that of the vagina – it is elastic and self-lubricates. It also doesn’t have the odor sometimes associated with sigmoid colon vaginoplasty surgery. With PPV, patients also don’t require regular dilation.

PPV uses a small amount of penile inversion combined with a peritoneum pull-through technique that creates the neovaginal canal. The labia and visible vagina are created using the penile skin inversion technique while the inner vaginal canal are made using peritoneal tissue.

The only drawback for this revolutionary treatment is that there is no long-term data on trans-patients who have had this surgery carried out.  Currently the data available showcase that the only difference between trans-women and cis-women after this procedure is the lack of the internal female’s organs.  

PPV is not only the most innovative and advanced technique to create a realistic and functional vagina but it is also a good option as a revision surgery for patients who had Male to Female sex reassignment procedures elsewhere, but were unhappy or unsatisfied with the results. It’s also good for patients who want to upgrade to a more functional and natural vagina.

Transgender Thailand’s partner doctors are among some of the only surgeons who perform this technique and have a record for highly successful outcomes. The surgery usually takes between 5 to 6 hours and requires a 7-night hospitalization stay and a recommended recovery time in Thailand of  3 to 4 weeks.

The advantages of this procedure are:

  • The SRS PPV can be either a primary or a secondary neovaginal reconstruction.
  • T can be performed in patients who underwent previous SRS procedures but experienced loss of depth or function, or in patients who want to upgrade to a more natural vagina with less maintenance.
  • PPV vaginas have a natural lubricant without the odor associated with the sigmoid colon procedures.
  • The vagina is less likely to shrink or prolapse.
  • There are fewer risks to intestinal functions.
  • Peritoneal tissue is highly elastic that means the surgically created vagina won’t require dilation after one year post-procedure.
  • Recovery is significantly faster than colon-vaginoplasty and penile inversion.
  • No visible scars on the vagina but 4 small laparoscopic keyholes
  • The peritoneal pull-through technique has been used on cisgender women for years and is well documented and understood.

Disadvantages include:

  • Patients will need 3-6 sessions of hair removal treatment covering 5cmx6cm at the base of the penis before the operation.
  • Patients may experience dyspepsia or indigestion symptoms.
  • The technique is not suitable for those who are overweight or have fatty abdomens.
  • In rare complicated cases, the surgeon will have to switch from laparoscopic technique, to an open procedure or to the sigmoid colon surgery

This procedure utilizing the sigmoid colon gives the vagina significant depth as well as the ability to self-lubricate. There are two options for this type of surgery:

Sexual function and sensation in SRS techniques

TransgenderThailand’s partner’s surgeons, use techniques to carefully identify and preserve all the nerves from the penis’ glans, creating 5 points of sexual arousal:

  • The neoclitoris
  • The inner sides of the labia minora, where additional nerve endings from the nerve trunk are found
  • The bilateral ridge of the neo urethral plate, created from the skirt of the penis’ glans containing the nerve ending.
  • The bulbourethral glands in front of the prostate glands, containing the nerve ending and mucous secretion
  • The “G-spot”, located at the most lower part of the prostate glands which consist of sensory nerve endings. 

Post-Operative Care Guide:

SRS (non-colon):

The following steps should be maintained for complete and successful healing:

  • After surgery, for the first several days, patients should not have high-fiber food and drink as these can trigger waste excretion which should be avoided as much as possible to prevent wound contamination.
  • Immediately after surgery, for 2 days, patients should lay down on their backs and keep their hips raised with legs slightly separated to help bring down the swelling.
  • After 3 days, patients may sleep on their sides.
  • 3 days after surgery, the doctor will remove the draining tube and dress the wound.
  • Patients who opted for SRS with skin graft must stay in bed until the sixth day when the urine catheter will be removed.
  • Patients will need vaginal dilation to maintain width and depth. This will be done at least twice a day for 1 hour. This can be done with the help of the nurses, till the departure of the patients to their home countries.
  • Patients must keep the wound clean.
  • Patients must refrain from intercourse for a minimum of 3 months.
  • Patients should keep regular appointments with the doctor once a week until their departure, to ensure successful long-term results.

SRS (Sigmoid colon):

  • Patients won’t be able to eat or drink until the intestine recovers its function – usually 3 days. Intravenous fluid is utilized for nourishment.
  • Patients should avoid overeating for at least one month. 
  • Patients can resume light activities 3 weeks after surgery and can resume regular daily activities 3 months after surgery.

Male-to-Female Sex Reassignment Surgery Criteria (Based on Thailand Medical Council)

  • Patients have to be 20 years old. If not, authorization is required from parents or legal guardians prior to surgery.
  • Hormonal therapy of at least 1 year is required.
  • Female feelings as long as living a life as a woman is a predetermined condition in order to carry out the sex reassignment surgery. 
  • Patients will have to undergo a mandatory psychiatric test from a certified Thai psychiatrist to confirm Gender Dysphoria.
  • Patients must be physically fit and in overall good health.

Risks and Possible Complications of Male-to-Female Reassignment Surgery:

SRS procedures are safe but patients should be aware of potential complications of male-to-female sex reassignment surgeries.

Rare complications include:

  • Swelling
  • Bruising
  • Bleeding
  • Hematoma
  • Infection
  • Slow to poor healing
  • Flap necrosis

Very rare complications (in < 1% of patients)

  • Urethral stenosis
  • Decreased sensation
  • Deep vein thrombosis
  • Risk from anesthesia
  • Recto-vaginal fistula

There are also some potentially unfavorable results that may happen when post-operative care is not followed.

Why choose Thailand as your plastic surgery destination?

On the whole, Thailand is an open and accepting society for transgender women and transgender men and this allowed hospitals for gender transformation to flourish and grow. Facilities in Thailand provide first-class treatments, cutting-edge technology, and world-class surgeons performing hundreds of SRS surgeries per year.

Plus, Thailand has another big advantage as a highly competitive destination for reassignment surgeries as it’s also less expensive compared to other destinations. You still get the best treatments and facilities, but you pay less.

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