Genital realignment surgery (male-to-female)

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Genital realignment surgery (also known as sex reassignment surgery) from anatomical male to female, involves reshaping the male genitals into a form with the appearance of and, as far as possible, the function of female genitalia. Prior to any surgeries, trans women usually undergo hormone replacement therapy and facial hair removal. Other surgeries undergone by trans women may include facial feminization surgery and various other procedures.

With current procedures, trans women are not implanted with either ovaries or a uterus from a donor, or lab cultured organs. This means that they are unable to bear children or menstruate, and that they will need to remain on hormone therapy after their surgery to maintain female hormonal levels.

Genital surgery

Main article: Vaginoplasty

Genital surgery for trans women consists of a number of procedures that are under the it as an umbrella term. Surgeons vary considerably in their requirements, procedures and skills, as does recommendations for care in the days before and after, and the months following these procedures.

In general the surgery consists of penectomy, orchiectomy, vaginoplasty, labiaplasty, and clitoroplasty. The most important of these procedures to the patient is vaginoplasty although all of them contribute to the perceived success of the operation. The aesthetic, sensational, and functional results vary greatly. Due to the nature of clitoroplasty, there is the chance that the nerves which supply erogenous sensation become severed, resulting in difficulty in achieving genital orgasm.

The most common form of vaginoplasty is penile inversion, often using a scrotal skin graft. In cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from skin grafts from the thighs or abdomen. The surgery can be completed in either a single operation, or less commonly, mulitple surgeries, depending on the surgeon's technique. Labiaplasty may be used as a revision surgery in cases where the labia minora are undefined or absent. Labiaplasty is often performed under twilight anesthesia (using local anesthetic and a medication to relax the patient).

These above mentioned skin graft sources are preferred over colovaginoplasty (the use of a section of colon) because of risk of complications and the increased complexity of the surgery in general. These non-inversion linings may not provide the same sensate qualities as results from the penile inversion method, but the vaginal opening is similar most of the time.

Supporters of colovaginoplasty claim that this method is better than use of skin grafts (or inversion) for the reason that colon is already mucosal, whereas skin is not. Many post-op trans women however, claim that the skin used to line their vagina develops mucosal like qualities[1] from months to years post-op. Another clinical study of post-op women however, contradicts the claim.[2]

Other studies of post-op sexual response recommend the use of a personal lubricant when having sexual intercourse. To be fair, many cis women require personal lubricant and the lack of ability to perform sexually should not be used for or against any form of vaginoplasty.

Inversion in a Nutshell

When changing anatomical sex from male to female, the testicles are removed and the skin of the penis, including foreskin, is (usually) inverted, as a flap while preserving its blood and nerve supplies (a technique pioneered by Sir Harold Gillies in 1951) to form a fully sensate vagina in a process known as vaginoplasty. A clitoris fully supplied with nerve endings (innervated) can be formed from part of the glans of the penis. If the patient has been circumcised (removal of the penile foreskin), or if the surgeon's technique uses more skin in the formation of the labia minora, the pubic hair follicles are removed from some of the scrotal tissue, which is then incorporated by the surgeon within the vagina. Other scrotal tissue forms the labia majora.

If scrotal tissue is used in surgery, follicles are removed either before surgery, via laser hair reduction, and/or electrolysis, or intraoperatively, using an electrosurgical device, and/or physical scraping of the tissue. Hair removal done intraoperatively presents possible issues with healing of the tissues from compromised blood supply.


The tissues of the patient vary in elasticity and healing ability (which is affected adversely by smoking). Any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage. If a skin graft from the thighs or hips was required, there is a minor risk of hypertrophy (swelling). There is significant (approximately 33%) risk in non scrotal skin grafts of not properly integrating with other tissues, which may result in need for revision vaginoplasty.

During healing, the new clitoris may become hypersensitive, this usually settles down over the period of several months.

Initially, urination after surgery is complicated by swelling of the tissues, resulting in uncontrolled spray, this subsides after several weeks, is some cases, revision will be desired to correct the direction of urine travel.

Possible complications to this surgery, regardless of the type of vaginoplasty performed, include:

  • Post operation infection (as with any surgical procedure)
  • Blood loss either during surgery or afterwards
  • Deep vein thrombosis (preventable with compression stockings and/or drugs)
  • Vaginal stricture, and urethral stricture (the narrowing of either opening; not to be confused with post op swelling which will result in mild difficulty urinating and resulting spray of urine)
  • Pubic hairs in undesirable places, most commonly inside the neovagina (when using a penile inversion technique) and/or (uncommonly) on the labia minora (if the hairs were not adequately cleared either prior to surgery, or as the result of the surgeon scraping off the follicle)
  • Necrosis (death) of the labia and/or the clitoris tissues from the lack of blood supply or the result of a major infection
  • Numbing of the external genitals (vulva, clitoris) due to severing and lack of healing of nerve tissue during surgery (in addition, swelling of the vulva will cause temporary numbness)
  • Excess erectile tissue, resulting in sexual side effects
  • Rectovaginal fistula (a hole between the neovagina and the colon; this is rare but possible in persons with eating disorders or poor diets)
  • Urethral fistula (hole between vagina and urethra, rare)
  • Necrosis (death) of the distal urethra (rare, is when too much corpus spongiosum is removed)
  • Vaginal prolapse (where the vaginal lining comes out along with removal the dressing used to pack the vagina after surgery, this is very rare)[3]

A rectovaginal fistula, should it happen during surgery, is usually diagnosed within 48 hours after removing the vaginal packing dressing. Repair may necessitate use of a temporary colostomy for up to 3 months of time. Afterwords, a review of vaginal dimensions will take place should revision surgery be needed to restore depth.

The most likely source of blood loss is around the urethral opening. Persons with clotting disorders are to have extra time on bed rest to avoid the possibility of "bleeding out" which may require hospitalization or other emergency treatment.

Post op care

Following the removal of dressing in and around the vagina, hygiene of healing genitals will become the most important aspect of post operation care, after dilation. A salt bath is often recommended either in a tub, or with a soaking pan that immerses the external genitals only. Inexpensive "disposable" cotton panties and lose fitting sweat pants are a good choice in the first month of recovery, as blood and other body fluids will likely make their way on to undergarments and clothing. It is important to not lift more then 10 lbs (4.5 kg) to avoid the chance of damage to the stitches. A neck pillow or inflatable "doughnut" is required for usually a minimum of three weeks to reduce pressure on the sutures.

Dilation, as explained further below, requires both use of a sterile water based lubricant, and a cleansing solution, such as chlorhexidine gluconate. (the latter to disinfect the stents after use) A hand held mirror may be desired for ease of dilation and for inspecting both cleanliness, and the surgeons handiwork.

Because the human body treats the new vagina as a wound, any current technique of vaginoplasty will require some long-term maintenance of vaginal volume. This maintenance, vaginal dilation, is done by the patient for the rest of her life with a set of vaginal stents. Some surgeons have techniques to ensure continued depth, but extended periods without dilation will still often result in reduced diameter (vaginal stenosis) to some degree, which would require stretching again, either gradually or, in extreme cases, under anaesthetic. In the case of penile inversion, this is due to the skin used for surgery, being treated by the body as an artificial void, with the body's response being an attempt to fill the void by contracting length-wise and narrowing at the new opening. In the case of colovaginoplasty, the body's only attempt at "wound repair" is the narrowing of the new opening.

Dilation is started in a time ranging from several days to a week after surgery, when the temporary packing inserted during surgery is removed. After a certain number of months of multiple dilations per day, the patient will eventually be able to reduce the number of dilation sessions to once daily and eventually per week, depending on the level of recovery. It is important to note that sexual intercourse with a male bodied partner does not fully count as a dilation - the vaginal tissue requires the hard presence of the stent to keep from losing depth and/or width. Once mostly recovered, application of an estrogen cream into the vagina may help make dilation easier but must be calculated into total estrogen dose.

Future techniques

In further study, is a method of vaginoplasty using stem cells to fabricate autologous (derived from the patient's own body) vaginal tissue.[4]

It has been successfully tested in a patient with Mayer–von-Rokitansky–Küster–Hauser syndrome, by taking a full thickness sample, then converting the tissue into stem cells and cultivating them. After 14 days, she had a modified Abbè–McIndoe vaginoplasty using the cultured tissue. After a 1 month followup, the new vagina retained normal properties of depth and mucosal qualities.

Other related procedures

Facial feminization surgery

Occasionally these basic procedures are complemented further with feminizing cosmetic surgeries or procedures that modify bone or cartilage structures, typically in the jaw, brow, forehead, nose and cheek areas (facial feminization surgery or FFS).

Breast augmentation

Breast augmentation is the enlargement of breasts, which can be necessary if hormone therapy did not yield satisfactory results.

The surgeon should have training about the minor but still significant differences in the chest wall between trans women and assigned at birth women. This can include the pectoralis major muscle, the space between the breasts and placement of the nipples. Many trans women also are low on the tanner stage of breast development making the skin taunt and resistant to creating a pocket necessary for the implant size desired.

Voice feminization surgery

Some trans women may elect to have voice surgery altering the range or pitch of the person's vocal cords. However, this procedure carries the risk of impairing a trans woman's voice forever, as happened to transsexual economist and author Deirdre McCloskey. Because estrogens by themselves are not able to alter a person's voice range or pitch, some people proceed to seek treatment. Other options are available to people wishing to speak in a less masculine tone. Voice therapy lessons are available to train trans women to practice feminization of their speech.

Tracheal cartilage shave

Tracheal shaves are also sometimes used to reduce the cartilage in the area of the throat to conform to more feminine dimensions, to greatly reduce the appearance of an Adam's apple.

Buttock augmentation

Because male hips and buttocks are generally smaller than those of a genetic female, some trans women will choose to undergo buttock augmentation.


GRS techniques evolved from the early vaginal absence work of Beck and Graves. Pioneers of GRS were Sir Harold Gillies in England and Georges Burou of Casablanca. In the 1950s, they both used invagination of the penile skin sheath to form a vagina.[5]

The first physician who performed sex reassignment surgeries in the United States was Dr. Elmer Belt. He stopped performing reassignment surgery in the late sixties. The most famous surgeon in the United States was Dr. Stanley Biber, his practice was passed on to Dr. Marci Bowers.

The first male-to-female surgeries in the United States took place in 1966 at the Johns Hopkins University Medical Center.[6] Howard Jones, of Johns Hopkins, later published the second classic technique using penile and scrotal skin flaps. These two methods form the basis of the majority of male-to-female GRS techniques today.

Famous patients

Lili Elbe was the first known recipient of male-to-female sex reassignment surgery in Germany in 1930. She was the subject of five surgeries- penectomy and orchidectomy, one intended to transplant ovaries, one to remove the ovaries after transplant rejection, and vaginoplasty. Tragically, she died three months after her fifth operation.

Christine Jorgensen was likely the most famous recipient of sex reassignment surgery, having her surgery done in Denmark in late 1952 and being outed right afterwards. She was a very strong advocate for the rights of transsexual people.

Another famous person to undergo male-to-female sex reassignment surgery was Renée Richards. She transitioned and had surgery in 1975, and initially was a source of awareness, she has since detransitioned.


  1. Adaptation process of the skin graft to vaginal mucosa after McIndoe vaginoplasty by M. Bekerecioglu, O. Balat, M. Tercan, M. Karakok, M. G. Ugur and D. Isik (Archives of Gynecology and Obstetrics, Volume 277 Number 6, June 2008)
  2. Do Histologic Changes in the Skin-Lined Neovagina of Male-to-Female Transsexuals Really Occur? by Dekker, Judith; Hage, J Joris; Karim, Refaat; Bloemena, Elisabeth (Annals of Plastic Surgery: November 2007 - Volume 59 - Issue 5 - pp 546-549)
  3. Repair of Vaginal Prolapse following Penoscrotal Flap Vaginoplasty in a Male-to-Female Transsexual by Giuseppe Loverro, Carlo Bettocchi, Michele Battaglia, Gennaro Cormio, Gennaro Selvaggi, Pasquale Di Tonno, Francesco Paolo Selvaggi (Gynecologic and Obstetric Investigation: Vol. 53, No. 4, 2002)
  4. Vaginoplasty using autologous in vitro cultured vaginal tissue in a patient with Mayer–von-Rokitansky–Küster–Hauser syndrome by Pierluigi Benedetti Panici, Filippo Bellati, Terenzio Boni, Federica Francescangeli, Luigi Frati and Cinzia Marchese (European Society of Human Reproduction and Embryology, Volume 22, Number 7)
  5. Development of Feminizing Genitoplasty for Gender Dysphoria by Jonathan Charles Goddard, Richard M. Vickery and Tim R. Terry (Journal of Sexual Medicine: Volume 4 Issue 4i, 19 Apr 2007)
  6. (2007) "Identity Crisis". Baltimore Style (January/February). Retrieved on 2009-10-12.

See also

List of surgeons

External links


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