Male to Female Gender Affirmation Surgery

Male to Female Gender Affirmation Surgery (Sex Reassignment Surgery) involves remodeling the male genitals into a form with the appearance of, and the function of female genitalia.

The Medical Council of Thailand defines “Gender Affirmation Surgery (Sex Reassignment Surgery)” as surgical techniques conducted to change the gender of a patient from male to female or female to male, including the use of hormones from one gender to the other.

A simpler explanation is that it is a surgical procedure in which the patient’s sex organs are altered as well as function to satisfy their desires.

Male to female gender affirmation surgery, then, is surgery that involves transforming the male genitalia into the female genitalia, which comprises the following procedures:

  • Creation of the External Female Genitalia (vulva)
  • Design of the New Vagina (neovagina)

In most cases, your surgeon performs sex reassignment surgery during the last phase of the transgender process.

Transgender reassignment is a complex process that begins with the patient living in the gender they desire for some time, taking hormones to achieve the necessary physical changes, and undergoing surgery on other bodily parts, such as the breasts and genitals.

Gender affirmation surgery is a delicate and complex type of surgery and, once done, cannot be easily reversed. The primary purpose is to fulfill psychological and physical needs.

Patients who wish to undergo this surgery must first meet the World Professional Association for Transgender Health (WPATH) criteria. This criterion ensures that the individual will live happily with the new gender they desire to be transformed to after the procedure and minimize the possibility of making a significant “Wrong Decision” and regretting it for the rest of their life.

Not all transgender people undergo SRS. Those who do have SRS for a variety of reasons.

Some people use it to alleviate bodily dysphoria — intense discomfort caused by a mismatch between identity and body.

Others are comfortable with their bodies but are incredibly uncomfortable with how others see them (social dysphoria) and wish to alter their physical appearance to live a life more consistent with their identity.

Choosing surgery for any health problem is a significant decision, and Sexual Reassignment Surgery is no exception.

This guide’s objective is to:

  • describe MTF-SRS alternatives,
  • identify potential risks and consequences associated with MTF-SRS,
  • detail what to expect before and after MTF-SRS, and
  • explore factors to consider when deciding to have SRS.

MTF patients who are considering SRS will find this guide very helpful. It may also benefit partners, family members, and others curious about SRS.

SRS’s goals for MTFs are to diminish “male” traits and make the body appear more “feminine.”

MTF SRS may entail some or all of the following surgeries. These surgical procedures carry risks but have improved the quality of life for MTFs experiencing physical or social dysphoria.

Breast surgery, facial surgery, and genital surgery are all addressed in length here. In addition, you can read about voice change surgery here.

Estrogen causes breasts and nipples to grow, but there is a limit to how much breasts can grow on their own.

MTFs who want larger breasts or a change in breast shape can have implants inserted through an incision under the breast, armpit, or around the nipple.

Breast Augmentation Thailand Incisions

What will the appearance and feel of my breasts be like after implants?

Surgically augmented breasts typically look and feel different than non-implanted breasts. For example, augmented breasts are generally wider, firmer, and rounder than naturally developed breasts.

This difference is especially true for MTFs or non-trans women who get implants later in life because their breasts have not gone through the age-related process seen in non-trans women without implants (the skin stretches and the breasts droop as we get older).

Furthermore, MTFs frequently have larger chest muscles and a broader chest than non-trans women.

Working with a surgeon who understands how MTF skin, muscle shape, and breast development differs from that of non-trans women can be beneficial in deciding on an implant shape and technique that will produce the desired result.

Viewing photos of MTFs who have had breast implants can give you an idea of what to expect. You can also request that surgeons show you before and after pictures of their patients.

Materials used to make breast implants.

Most breast implants are made of saline (saltwater) or silicone.

A word of caution regarding silicone injections

Semi-solid implants are used for breast augmentation, with the liquid filler surrounded by a solid shell that keeps the fill contained. Some MTFs who cannot afford surgery have attempted to augment their breasts, hips, cheeks, lips, or buttocks by purchasing liquid silicone and injecting it themselves or having an injection performed by a friend or unlicensed health worker.

Injection of liquid silicone (also known as “free silicone”) is extremely dangerous and, as a result, is not permitted as a medical procedure.

There are serious health risks associated with liquid silicone, including permanent disfigurement, lung disease, brain damage, and death.

If you have ever received a liquid silicone injection, you should consult a doctor as soon as possible.

When deciding whether or not to get breast implants, it is essential to keep in mind that all types of breast implants frequently leak or rupture and must be removed.

Breast implants are not considered lifetime devices. Therefore, you will almost certainly require additional surgeries and visits to your surgeon in the future.

Your implants will almost certainly have to be removed at some point, and you will have to decide whether or not to replace them.

Implants stretch the skin. If implants are removed but not replaced, your skin will be wrinkled, dimpled, or puckered.

Breast augmentation timing

In some MTFs, estrogen can significantly alter breast size and shape. While breast growth begins soon after beginning estrogen therapy, it is slow and gradual, and it typically takes two or more years for breasts to reach their maximum size.

If you can take hormones, it is recommended that you wait at least 18 months to allow your breasts to develop.

Hormonal development will aid in the growth of your nipples and the stretching of your chest skin, resulting in a more natural-looking implant.

Instead of being implanted into a flat chest, implants look more natural when augmenting existing breasts.

Some MTFs are unable to take hormones due to medical reasons, do not want the side effects of hormones, or enjoy breasts without the other effects of hormones. If you are unable to take hormones, implants may be an option.

Breast surgery can be performed as the first (or only) step in surgery or after you’ve had other types of SRS (e.g., genital surgery).

What to Expect Before and Following Breast Augmentation

In a hospital

You will come to the hospital on the day of your surgery to review pre-surgery information and have a last-minute physical exam.

You will be instructed not to eat or drink after midnight the night before surgery.

After your surgery, hospital personnel will monitor you as you awaken from anesthesia.

You will most likely be given antibiotics to help reduce the risk of infection while your wounds heal in the hospital.

Following breast surgery

You will be required to wear a special bra and leave the surgical dressings on for as long as the surgeon requires.

Your surgeon or nurse will determine the right time for you to take a shower.

It is usual for the incisions to be red, but the redness should not extend beyond the incision for more than 1–2 cm (if this occurs, see a doctor immediately because it could be a sign of infection).

It is also customary to see or feel the knot in the stitches at the incision’s end. But, again, the stitch knot is not a problem; it will either dissolve on its own or come to the surface of your skin, where it can be clipped free by a doctor or nurse.

A moderate amount of bruising and swelling is expected. Your breasts will most likely be sore and swollen for at least a month following surgery. Consult a doctor if you have a lot of swelling. During the healing process, sharp shooting pain, burning pain, or general discomfort are expected and eventually subside.

Severe discomfort usually subsides 1–2 days after surgery.

You can resume your routine when you feel well enough to do so (i.e., regular movements do not cause pain). This usually takes 1–2 weeks, but it can take longer in some cases.

For the next 3–4 weeks, avoid any activity that causes your heart rate to rise.

Breast implant dangers and potential complications

Any surgery requiring general anesthesia is a serious medical procedure. There is a risk of blood clots (which can be fatal) or an adverse reaction to the anesthetic with any surgery.

Surgeons, anesthetists, and surgical nurses have extensive experience preventing problems and responding to emergencies during surgery. To avoid blood clots after being discharged from the hospital, move around as much as you feel comfortable and drink plenty of water.

Obtain immediate medical attention if you experience sudden shortness of breath, chest pain, dizziness, or tender, warm, and swollen legs. You may have a blood clot and require immediate medical attention.

Aside from the risks of blood clots, every surgery carries the risk of infection, bleeding, pain, and thick red scars. Antibiotics are commonly administered in hospitals to reduce the risk of infection.

It is usual for the breasts to be sore and the incision line to be red after surgery. If the redness extends more than 1–2 cm beyond the incision, the skin is tender or warm, and you don’t feel well, see a doctor to rule out an infection.

The following are some of the potential complications associated with breast implants:

  • Capsular contracture: thickening and contraction of scar tissue that forms naturally around the implant (some scar tissue is okay; an excess can be problematic).
  • Lopsided breast size, shape, or position (one side appears larger or smaller than the other)
  • Asymmetrical placement of the nipple (one side looks higher than the other)
  • Rippling of the skin over the implant is more likely if you are thin or your breasts haven’t appropriately developed after hormone therapy.
  • Implant problem: leakage, rupture, infection, or implant coming out of the body
    Change in sensation to nipples/breast skin: less or more intense feeling.

You will almost certainly require additional surgery if:

  • there are implant problems: the surgeon will have to remove your implant but can replace it later
  • your breasts or nipples are lopsided: the surgeon will wait 4–6 months after surgery to see how the implant settles
  • you have severe capsular contracture (the scar tissue is making your breasts excessively firm, distorting their shape, or causing you pain)

SRS’s goals for MTFs are to diminish “male” traits and make the body appear more “feminine.”

MTF SRS may entail some or all of the following surgeries. These surgical procedures carry risks but have improved the quality of life for MTFs experiencing physical or social dysphoria.

Breast surgery, facial surgery, and genital surgery are all addressed in length here. In addition, you can read about voice change surgery here.

During puberty, testosterone causes numerous changes in MTF bodies, including the formation of skull and face bones and cartilage in the face and neck.

Although hormone therapy can soften the skin of the face and cause minor changes in the fat/muscle structure of the face after puberty, hormones cannot change the basic structure of the face and neck; only surgery can reshape the contours of bone and cartilage.

MTFs have varying perspectives on face and neck surgery. Some believe it is critical in reducing gender dysphoria and enhancing passability.

Others are concerned that MTFs may feel pressured to undergo face and neck surgery to meet conventional standards of female attractiveness.

There is no right or wrong answer regarding whether to have a face or neck surgery, as with any other type of SRS: it is a personal decision.

Tracheal shave

In the throat/neck, cartilage rings surround the windpipe. The thyroid cartilage juts forward more pronouncedly in “males” than in “females.”

This point is also known as the “Adam’s apple” or the laryngeal prominence.

The thyroid cartilage can be surgically altered (“tracheal shave” or chondrolaryngoplasty) to reduce the size and visibility of the laryngeal prominence.

This surgery can be done concurrently or separately from voice surgery.

Facial feminization surgery (FFS)

FFS techniques are divided into surgery into the bones or cartilages of the skull and work on the soft tissue that covers the bone/cartilage.

The differences between the average “male” and “female” skulls are used to reconstruct bones in FFS. In addition, soft tissue work may be performed to supplement or replace bone reconstruction if only minor changes are desired.

Soft tissue surgery is less invasive than bone surgery.

FFS can include surgical modifications to any of the following areas:

Forehead

Based on three differences in the facial structure of non-trans women and men, FFS creator Douglas Ousterhout emphasizes the surgical change of the forehead as a crucial part of facial “feminization”:

  1. As shown in the image below, “male” skulls have a relatively flat slope from the hairline to the brows, whereas “female” skulls are more curved.
  2. As shown in the image below, “males” have a thicker bony ridge just above the eyes (brow bossing).
  3. “Males” have a longer distance between their brows and their hairline than “females,” even if they do not have “male”- pattern baldness (which further increases this distance).

The following surgical changes to the forehead can be performed as part of FFS:

  • Brow shave: removing brow bossing by grinding down the orbital rims (upper edge of eye sockets).
  • forehead implant: using synthetic bone-filler to round out a flat forehead;
  • brow lift: tightening of the skin on the brows and raising of the brows
  • hairline and scalp advancement: bringing the hairline and scalp forward

Surgical Procedures of the Chin and Jaws

FFS creator Douglas Ousterhout describes three differences in the structure of non-trans women’s and men’s chins and jaws:

  1. As shown in the image below, “male” chins are broader and squarer, whereas “female” chins are pointed and narrower.
  2. The distance between the bottom lip and the base of the chin is shorter in “females” than in “males.”
  3. “Male” jaws have fuller back corners, with the bone having a sharper angle and flaring out away from the face and a more prominent masseter (chewing) muscle.

Female jaws have a gradual curve from the ear to the chin, with a less square and full shape in the back.

The chin and jaw FFS is performed through the mouth and incisions around the lower gums.

The following surgical changes to the chin and jaw can be performed as part of FFS:

  • removing bone from the back corner of the jaw to make it less prominent;
  • removing bone from the chin and reshaping it to look more tapered, less square, and shorter;
  • using implants if the chin is receding;
  • liposuction under the chin to make the lower part of the face appear less heavy;

Nose

Rhinoplasty is the surgical procedure used to alter the appearance of the nose. Some MTFs want to change the appearance of their nostrils or the tip of their nose.

Other times, MTFs who have forehead surgery will be advised to have surgery on the nose bridge so that the flow from nose to forehead appears smooth.

Among the nose changes that can be made as part of FFS are:

  • removing bone from the bridge of the nose to make it flatter;
  • removing width from the nose to make it thinner;
  • shortening the nose by removing some cartilage at the tip of the nose; and
    narrowing the nostrils

Cheeks

Cheek augmentation can be performed to highlight the “cheekbones” (zygomatic arch), making the cheeks more prominent and the chin/jaw appear smaller.

Bone grafts, synthetic implants, and fat implants can all be used for augmentation.

Lips

Among the lip surgical changes that can be performed as part of FFS are:

  • removing skin from the area between the nose and the top lip to raise the upper lip
  • using implants to make the lips appear fuller

Face/neck surgery timing

Most FFS techniques can be performed at any point in the transition (at the beginning, middle, or end of the process).

If you want both forehead and nose surgery, it is best to have them done simultaneously because changes to the forehead can affect the shape of the nose.

Multiple surgeries close together are generally not recommended because they put a lot of strain on your body.

What to Expect Before and Following Face/Neck Surgery

If you have electrolysis to help remove facial hair, you must stop it at least two weeks before having face surgery.

If you are having chin or jaw surgery, you will not be able to resume electrolysis for at least three months.

Talk with your surgeon about ways to temporarily remove facial hair before and after surgery as part of your pre-surgery planning.

In the hospital

You may be asked to come to the hospital on the day of the surgery to review pre-surgery information and have a last-minute physical exam. In addition, you will be instructed not to eat or drink after midnight the night before surgery.

What to expect immediately following surgery is determined by whether a local or general anesthetic was used.

Minor procedures are typically performed under local anesthetic (similar to having a tooth drilled), and you can return home shortly afterward. However, a general anesthetic is usually required for bone reconstruction or tracheal shave.

If you have a general anesthetic, hospital staff will monitor you as you awaken. For minor procedures, you will be sent home the same day as surgery with pain medication; for more extensive procedures, you will be admitted to the hospital for the night.

You will need to have someone drive you to your hotel or take a taxi when you are discharged because it is unsafe to drive right after surgery.

You will be given antibiotics to help reduce the risk of infection as your wounds heal in the hospital.

Following surgery

The aftercare instructions differ depending on the type of facial surgery and the technique used. Discuss pain management options with your surgeon before surgery to ensure you understand what to expect and what you need to do after being discharged from the hospital.

Dr. Douglas Ousterhout, the creator of FFS, provided the following information:

  1. Forehead surgery: Analgesics and pain relievers will be prescribed.
    1. The surgeon usually removes sutures and staples used to close scalp incisions within eight days of surgery. Most people feel well enough to return to work by this point (though vigorous activity should be avoided for the first two weeks after surgery).
    2. Within 10–12 days of surgery: Swelling and bruising around the eyes usually resolve by this time.
  2. Cheek augmentation: Analgesics and pain relievers will be prescribed.
    1. The first 1–3 days after surgery: Temporary numbness and swelling may make it difficult to speak, smile, yawn, or chew. For the first few weeks, avoid foods that are difficult to chew.
      1. Within two weeks of surgery: Swelling should have subsided by this point.
  3. Nose surgery: Analgesics will be prescribed. If you wear glasses, you will be given special instructions because the nasal pads that rest your glasses on your nose are not allowed to touch the nose for one month after surgery.
    1. For the first 1–2 days after surgery, internal nasal packing will be left to support nasal tissues during the healing process.
    2. Bruising around the nose and eyes usually fades within two weeks of surgery.
    3. One month after surgery: It is safe to resume strenuous activity. You can continue wearing your glasses as usual.
  4. Chin reduction: Analgesics will be prescribed. Recovery time varies depending on the technique used; if significant bone reconstruction is performed, recovery can take 4–5 weeks, with swelling lasting up to 3–4 months.
    1. You can usually return to light work 5–6 days after surgery.
    2. The face is usually moderately swollen and bruised after surgery.
  5. Jaw reduction: Pain medication will be prescribed. Most of the swelling fades gradually over 10–14 weeks, but it can be difficult to see improvement until the swelling has completely subsided. You can usually return to work 10–14 days after surgery.
  6. Lip augmentation: This is usually a minor procedure. Swelling may occur, but it usually subsides within 10–14 days of surgery.

Face/neck surgery risks and potential complications

Every surgery carries the risk of infection, bleeding, pain, and the formation of thick red scars. Antibiotics are commonly administered in hospital to reduce the risk of infection.

It is usual for swelling and bruising to occur after facial surgery. If your skin is very tender or warm, and you are not feeling well, consult a doctor to determine whether you have an infection.

Any surgery requiring general anesthesia is a serious medical procedure. There is a risk of an adverse reaction to general anesthesia or, if you are lying flat for an extended period, of blood clots (which can be fatal). However, surgeons, anesthetists, and surgical nurses have extensive experience preventing problems and responding to emergencies during surgery.

To avoid blood clots after being discharged from the hospital, move around as much as you feel comfortable and drink plenty of water. If you experience sudden shortness of breath, chest pain, dizziness, or tender, warm, and swollen legs, seek emergency medical attention. These symptoms may indicate a blood clot, and you may require immediate medical attention.

The following are some of the risks associated with face/neck surgery:

  • numbness, pain, or difficulty controlling the muscles of the operated-on area: this can be temporary (due to swelling) or permanent (from nerve damage)
  • Implant, wire, or screw issue: infection, reabsorption, or coming out of the body
  • tracheal shave: possible voice damage
  • difficulty adjusting to looking different after surgery (some people describe this as feeling like a stranger is looking back at them when they look in the mirror)
  • Disappointment with the appearance of results: eyebrows raised too high, the nose looks unnatural, etc.

Preparation for Genital Surgery at Yanhee hospital

Preparing for Genital Surgery begins with the physician taking a medical history, assessing the patient’s desire to be transgender, and reviewing the transgender procedures done previously.

The doctor will then perform a complete physical examination of the patient and assess if the individual is ready for the surgery according to the following assessment criteria:

  • If you are under the age of 18 years, you are ineligible to have surgery. If you are over the age of 18 but under the age of 20, you must submit consent signed by your legal guardians.
  • The patient must have undergone psychiatric evaluation from 2 psychiatrists and been diagnosed as having “Gender Dysphoria,” to be written by both psychiatrists in two separate medical certificates.
  • The patient must have no underlying physical or psychiatric diseases that will pose potential threats or dangers to the patient when going through anesthesia or the major surgical procedure.
  • The patient must have gone through hormonal replacement therapy for at least one year.
  • The patient must have lived in the opposite gender for at least one year.

After that, the doctor will perform a complete physical examination on the patient, perform blood tests, and do an x-ray. If abnormalities or congenital diseases are detected, the patient will consult with corresponding specialists to participate in the assessment.

A patient must stop taking medicines or supplements which may increase bleeding tendencies, such as aspirin, clopidogrel, herbs like cordyceps, ginkgo, ginseng, garlic, cod liver oil, collagen, and vitamin E at least two weeks before the surgery.

The patient must refrain from taking the hormones for replacement therapy for at least a month before surgery to prevent deep venous thrombosis as a postoperative complication.

Patients who smoke or use products containing nicotine, such as e-cigarettes, nicotine gum, or the nicotine patch, must discontinue using these for at least two months before and after surgery because nicotine slows down the healing process of the surgical wound.

Patients taking alcoholic beverages should refrain from taking these a week before the surgery. In addition, patients should eat soft food with less dietary fiber a week before surgery to avoid the accumulation of much residue in the intestines and leave it cleaner and more ready for the surgery.

Proper genital hygiene must be done by regularly washing well with soap and water.

Patients’ diseases or conditions that require more intensive examination or correction before sex-change surgery can be done:

  • Congenital diseases or congenital disabilities that affect body functions such as heart, lung, liver, or severe kidney diseases
  • Chronic diseases that are in the process of treatment, such as cancer, Systemic Lupus Erythematosus (SLE)
  • HIV, Hepatitis B, and Hepatitis C
  • Reproductive disorders such as phimosis and paraphimosis, hypospadias, cryptorchidism, lumps or tumors of the sexual organ, or a history of introducing foreign substances into the sexual organ, etc.
  • Inguinal and abdominal hernias

Diseases or conditions in patients that will disqualify them from undergoing Sex Change Surgery:

  • Congenital diseases that are not completely treated
  • Unstable patients with psychiatric disorders
  • Patients using illegal narcotics

Techniques for Male to Female Gender Affirmation Surgery

Male to female gender affirmation surgery (sex change surgery) is divided into two major types according to the technique used to create the vagina:

  • Graft Technique (Penile Skin Inversion Technique)
  • Techniques that use tissue from the abdomen, including Colon Vaginoplasty Technique and Peritoneal Vaginoplasty Technique

Male to Female Surgical Techniques

Graft

The Graft Technique means sex change surgery using the same genital skin to create a new vagina. This method does not require abdominal surgery and can avoid scarring around the abdomen.

The depth of the vagina depends mainly on the natural anatomy of the patient’s pelvis. However, on average, the vaginal depth is 5.5-6 inches.

The graft technique is the standard method used for the first sex-change surgery, is not very complicated, and does not put the patient at high risk. However, after the surgery, the new vagina must be taken care of by regularly dilating the vagina, especially during the first year.

The graft technique is used to create a complete external female genitalia, including the clitoris, clitoral hood and frenulum, labia majora, labia minora, and urethral orifice. It can also keep the sensory nerves in different strategic points entirely.

Suppose the patient has less genital skin, which may not be enough to perform the graft method, but does not want to undergo abdominal surgery. In that case, he may still choose the graft method using skin from other areas, such as from the groin or thigh, but the disadvantage is that there will be additional scars in those areas.

Advantages-Disadvantages of Graft Technique Sex Change Surgery

Advantages:

  • Able to create a complete external genitalia
  • Create a vagina that is deep and functional
  • No abdominal surgery is required

Disadvantages:

  • The vagina can be constricted or shallower if not adequately and adequately dilated.
  • No lubricant inside the vagina
  • There may be additional scars if graft from the other areas is used.

Colon Vaginoplasty Technique

The Colon Vaginoplasty Technique requires abdominal surgery, and the colon is used to create a vagina. This method has the advantage of creating a deeper, more durable vagina without any constriction.

However, the “vulvar entrance” area may still be constricted or narrowed due to the contraction of the wound. Therefore, the transgender patient who underwent this method still has to dilate the vagina to prevent narrowing at the area of the vaginal entrance.

The Colon Vaginoplasty Technique is often used in corrective surgery to increase vaginal depth. It may also be done as the first surgery if the patient has less genital skin. The appearance of the external genitalia is the same as that of the graft method in all aspects.

The walls of the vagina formed from the colon have mucous membranes that look sticky and stagnant inside so that the entrance area is often dry.

Consequently, doctors recommend that patients use lubricants each time they engage in sexual intercourse to prevent abrasions due to excessive friction.

Patients who have had recto-sigmoid vaginoplasty sex change will need more long-term self-care than those using the other surgical techniques. In addition, patients must have regular follow-up visits to the doctor.

The patient must monitor the patency of the entrance and see that it is always open so that the mucus can be drained. Otherwise, the neovaginal closed-loop obstruction may occur. If patients want to be examined or screened for colon cancer by colonoscopy, an endoscopic examination of the internal aspect of the vagina will also be required.

In addition, intra-abdominal surgery may create an adhesion band, which may later cause abdominal pain.

Advantages-Disadvantages of Colon Vaginoplasty Technique

Advantages:

  • The vagina is deep and has strong durability.
  • Creates a mucous membrane inside the vagina
  • Able to develop a complete external genitalia

Disadvantages:

  • Entails abdominal surgery where the colon is cut and sutured
  • The entrance to the vagina created may be constricted if the dilation is not good.
  • There is a chance of the patient’s developing various colonic diseases such as colon cancer and inflammatory bowel disease.
  • May develop peritoneal adhesions due to intra-abdominal surgery.
  • It creates a scar on the abdomen.

Penile-Peritoneal Vaginoplasty technique (PPV)

The PPV technique entails abdominal surgery, but it will use the peritoneum to create a new vagina (not the colon). This technique is often used for reconstructive surgery but can also be done as a first surgery if the patient does not have enough genital skin for grafting.

The peritoneum can produce a lubricant which is a clear yellow liquid.

However, the entrance to the vagina is still made of skin so that it can be dry and prone to abrasions as well. Hence, the doctor always recommends using a lubricant each time the patient engages in sexual intercourse.

The characteristics of the external genitalia created through peritoneal surgery are the same as those made through the grafting and bowel technique in all aspects.

Pros-Cons of the PPV Technique

Advantages:

  • The vagina is deeper than that created through the grafting technique.
  • Lubrication present inside the vagina
  • Creates a complete and functional external genitalia

Disadvantages:

  • Entails abdominal surgery
  • If not dilated well enough, the peritoneal junction at the entrance may be constricted.
  • Peritoneal tissues may form adhesions due to abdominal surgery.
  • There will be scar formation on the abdomen.

How deep will the vagina be after gender affirmation surgery?

Gender Affirmation Surgery can create a vagina with a depth equal to its usual depth in a patient’s pelvis, about 5.5 – 6 inches. However, the vagina created may be deeper by about 1-2 inches more, depending on where the surgery was done using the PPV technique.

Will the new genitals have sensation?

The surgeon will collect sensory nerves to build a new genitalia sensation spot which consists of the clitoris, inner labia, and around the urethra, all of which can be capable of external sexual stimulation. The internal aspect of the vagina will not have direct sensory nerves. However, the patient may still feel sexual pleasure by external stimulation around the prostate gland area in some cases.

Recovery Time for each Surgical Technique

The Grafting Technique

  • The patient will stay in the hospital for a total of 9 days.
  • The doctor will not allow the patient to get off the bed for the first three days after the surgery, will only allow him to eat soft meals, and will see to it that the wound is covered with two layers of gauze urinary catheter and drainage.
  • During the 4th day after surgery, the doctor will remove the outer layers of gauze and allow the patient to get off the bed.
  • During the 7th day after surgery, the doctor will remove the remaining gauze, the urinary catheter, and drainage and give the patient instructions about vaginal dilation. The patient will then be discharged from the hospital if no complications are encountered.
  • After surgery, the patient should rest for about one month to recover from all the inconvenient movements. Vaginal dilation has to be performed every day.

The Colon and PPV techniques

  •  For the colon and PPV techniques, the patient has to stay in the hospital for 9 days. The doctor will remove all gauzes, urinary catheter, and drainage on the 4th day and give the patient instructions on dilating the vagina. The patient will be discharged from the hospital if no complications are encountered.
  • The patient should rest for full recovery after sex reassignment surgery with the colon and PPV technique, for about one month if it is the first operation and for about two weeks if it is reconstructive surgery.

Postoperative care

External Wound Care

There are two kinds of medications for external use to be used for dressing:

  • Povidone Iodine Solution – to be applied over the wound around the outer labia
  • Povidone Iodine Gel – to be applied over the wound around the inner labia and around the urethra

Always dress the wound using these two medications for external use after urination and vaginal dilation. In addition, the patient has to wear sanitary napkins to absorb any bloodstains. Usually, the surgical wound will be healed within 2-3 weeks without post-surgical complications.

Vaginal Care

The patient must use the douching method after performing vaginal dilation by mixing the saline solution with Povidone Iodine Solution with a 1:10 ration (Ex. Saline 100 cc. with Povidone Iodine Solution 10 cc) and douche for 100-200 cc. at a time.

Postoperative Instructions

Do not squat or spread the legs before the surgical wound is completely healed, as activities like these may cause surgical wound dehiscence. Also, do not use soap and water for douching the vagina as these may irritate.

The doctor will usually allow the patient to engage in sexual intercourse after the surgery (if the wound in the vagina is already completely healed). However, an unpleasant vaginal odor may be present during the first 3-6 months due to the residual bloodstains.

The patient must avoid sour or fermented food because it may cause the surgical wound area to swell for a long time.

Information/Instructions about Vaginal Dilation

  • Vaginal dilation is essential, especially during the first year after surgery, due to the wound healing process, which causes the contraction of the vagina (contraction can occur in whatever surgical technique is used). Contraction is more intense during the first year after surgery but will gradually decrease after one year.
  • The patient should use the rigid dilators properly prepared by the doctor. The patient should perform vaginal dilation two times a day for 30-60 minutes per session, increasing the size of dilators according to the doctor’s instructions during the first year after surgery. After one year, the patient should perform vaginal dilation once a week, using the dilator with the biggest size.
  • For additional vaginal dilation, the patient is instructed to insert a soft silicone dilator into the patient’s vagina before she goes to sleep. The patient must also wear panties to prevent the soft silicone dilator from slipping out.

Information by: Dr.Worapon Rattanalert

Frequently asked questions (MTF)

Q: In the Transgender by Penile Peritoneal Vaginoplasty (PPV) technique, lubrication is like in the vagina. Is there no need to use a lubricating gel when having sexual intercourse?

A: The entrance to the vulva is still a graft (skin), so it tends to be dry. Lubricants are still recommended every time you engage in sexual intercourse to prevent abrasions due to friction at the vulvar entrance.

Q: Is there a need to dilate the genitalia in Penile Peritoneal vaginoplasty (PPV) technique?

A: Yes, because the contraction of the wound can also narrow the entrance to the vagina.

Q: Is there a chance of contracting sexually transmitted diseases in the new genitalia?

A: There is a chance of contracting STDs by sexual intercourse at the new genitalia.

Q: Should a patient take hormone replacement therapy after sex reassignment surgery?

A: After sex reassignment surgery, female hormonal drugs must be used under the supervision of a physician to prevent “surgical menopause” or a sudden lack of sex hormones. Transgender women taking estrogen and anti-testosterone medication before surgery must stop taking the anti-testosterone medicines after surgery, and estrogen can be used singly.

Q: How often should patients visit the surgeon for a follow-up?

A: The patient should visit the hospital for follow–up during the first year after surgery to check the wound healing process and depth of the genitalia. After one year, the patient should see the surgeon at least once a year for an external genital examination and internal endoscopy.

Deciding to have SRS

Am I sure?

There is no single correct way to decide whether or not to have surgery. It is natural to have doubts, fears, and anxieties about SRS, as with any significant life decision. However, as part of the decision-making process, you must be sure to proceed with surgery.

From our own experiences and from listening to many other people, we know that each person’s situation is unique, that there is no one way to decide, and that it is not as simple as a one-time yes or no. Instead, it is often a lengthy process shaped not only by internal feelings and beliefs but also by ever-changing external circumstances that are not always under your control (health, money, family responsibilities, limited access to services, etc.)

People, in our experience, make decisions about SRS in the same way they make decisions about the rest of their lives. For example, some trans-people seek a solid internal feeling that SRS is correct and do not want to be influenced by others. In contrast, others seek advice from friends, family members, other trans-people, counselors, or other health professionals as part of the decision-making process.

Some questions to consider are listed below, regardless of how you think things through. Of course, there are no correct answers to these questions; they are prompted for you to consider various aspects of SRS better to understand your feelings, values, and expectations.

  • Do you have a clear mental image of how you want to appear after SRS?
  • What do you think you’ll feel if the results don’t match your mental image?
  • Do you expect SRS to fix anything, and if so, what?
  • What aspects of your life might change as a result of SRS?
  • What would you like to see change, and what would you like to stay the same?
  • Do you believe your expectations for SRS are realistic? How can you tell if they’re genuine or not?
  • How well do you understand the SRS options? What else do you need to know to make an informed decision?
  • Do you consider the parts of your body that SRS will alter to be a part of your sexuality? What if you lose that aspect of your sexuality?
  • Will your decision have an impact on anyone else in your life? How do you think they’ll react to the fact that you have SRS? What effect will their reactions have on you?
  • What do you consider a “wrong reason” for having SRS? What do you consider to be the “right reasons”?

What SRS cannot provide for You

SRS can provide significant relief to trans-people and live more comfortably. But there are some things that SRS will not do.

1. SRS will not solve all body image issues.

The goal of SRS is to make you feel more at ease in your own skin by bringing physical characteristics closer to your internal sense of self. This alleviation can boost your self-esteem and make you feel more confident and attractive.

However, you will discover that there are attractiveness standards after SRS that you may not meet.

The social pressures and gender stereotypes about appearance make it difficult to be comfortable in your own skin. Unfortunately, some MTFs respond by obsessively dieting, exercising, or undergoing endless surgical revisions to achieve an idealized stereotype of attractiveness.

It can be challenging to distinguish between gender dysphoria and body image issues. Professional and peer counseling can help you sort out your appearance expectations and work toward greater self-acceptance after SRS.

2. SRS will not solve all sexual issues.

Wanting to feel more comfortable about sex is essential for some trans-people to have SRS. This is because SRS can help alleviate dysphoria, which harms sexuality. However, dysphoria is not the cause of all sexual problems.

Sexuality is a complex issue that various factors can influence, including physical problems, stress, relationship dynamics, body image issues, past sexual abuse or other types of trauma, and cultural and personal beliefs about sexuality.

SRS will not automatically resolve all of these issues in your life. If you are experiencing sexual difficulties, consider seeking peer or professional counseling to investigate the causes and learn about sexual health treatment options. If you need help finding a trans-positive sexual health professional, the Transgender Health Program can help.

SRS frequently has a positive effect on sexuality. Most Trans people who participated in numerous studies reported increased sexual satisfaction after SRS. However, SRS can have a negative impact. Changes in sensation are widespread following surgery. You may discover that touch is less intense or more intense (to the point of being uncomfortable or painful).

Some MTFs report difficulty reaching orgasm following genital surgery or that orgasm is less intense. When deciding whether to have surgery, you must consider the possibility that SRS will harm your sexuality and how you will cope with that possibility.

Whether or not you choose SRS, some trans-people find that counseling can help them deal with the effects of internalized transphobia on their sexuality. Many trans-people internalize negative messages about being Trans due to growing up in a transphobic society. This can include feelings of shame about erotic cross-dressing or other trans-specific sexual desires and fantasies, as well as feelings of guilt about having a body that does not conform to societal norms.

Peer or professional support can be beneficial in achieving greater self-acceptance of your sexuality (with or without SRS).

3. SRS will not transform you into someone else.

SRS causes many people to experience positive emotional changes. However, once the excitement wears off and you’ve incorporated the changes into your daily life, you’ll likely discover that if you were shy, you’re still shy. If you didn’t like your laugh, you still don’t, and you’re still afraid of spiders.

Whatever you consider being, your strengths and weaknesses will remain. Hopefully, you will be happier, which is beneficial to everyone. SRS may assist you in becoming more accepting of yourself. However, if you expect that all of your problems will go away and that everything will be easy emotionally and socially from now on, you will most likely be disappointed.

This includes mental health issues as well. Trans-people who are depressed due to gender dysphoria may find that SRS significantly reduces their depression. However, if your depression is caused by biological factors, transphobia-related stress, or unresolved personal issues, you may still be depressed after SRS. Similarly, if you have a problem with drugs or alcohol, SRS will not necessarily solve your problem.

4. SRS will not provide you with an ideal community.

For some trans-people, SRS is a ritual that confirms that they are who they claim to be. Making physical changes is a way of exposing yourself to the rest of the world so that others can see who you are. This process of self-discovery can be very liberating, but it does not guarantee acceptance or understanding.

Some MTFs believe that by undergoing physical transformations, they will be validated as “real” women or feel more accepted by the trans-community. However, the notion that trans-people aren’t “real” unless they change their bodies is transphobic, and communities or groups that hold this belief are unlikely to be fully respectful of trans-people’s identities and bodies.

It’s common to fantasize about finding an ideal community of trans-people during the various stages of transition. There may be a strong desire to connect with others who have gone through similar experiences when undergoing SRS.

There are a lot of really cool trans-people to talk to about SRS. However, having SRS does not automatically make trans people welcoming, approachable, or sensitive to the needs of others, and you will likely find that no trans person will exactly mirror your personal experiences, identity, and beliefs.

Being realistic about the possibility of feeling lonely and alone after starting hormone therapy is an integral part of emotionally preparing for SRS.

Am I Prepared?

It’s not enough to know if SRS is suitable for you; you should also see if it’s the right time in your life for SRS. Your readiness determines this for the physical stress and mental adjustment that SRS entails and your willingness to deal with the reactions of others.

As discussed in the booklet Getting surgery (available from the Transgender Health Program), the patient must be physically and psychologically prepared for any surgery. Physical readiness denotes that you are in generally good health and have completed any physical requirements imposed by your surgeon (e.g., electrolysis before vaginoplasty).

Physical readiness also includes making plans for the physical care you will require following surgery, such as having a safe place to recover after surgery, understanding what is involved in aftercare, and having friends, family, or health professionals who can assist you.

Mental readiness does not imply that you are free of mental health issues or life stresses; instead, it means that you have:

1. A strong sense of one’s gender identity

SRS is not for people just beginning to question, explore, and think about gender identity issues. Allow yourself some time to get a clear sense of how you identify and how the surgery will contribute to this sense of self if you consider SRS as part of your initial process of exploring gender issues before making a decision.

2. Mental stability is sufficient to make an informed decision about your medical care

Making significant decisions during chaos and crisis is not a good idea. When you’re in a crisis, it can be challenging to think clearly and make fully informed decisions. If you’re having trouble making general life decisions because you’re overwhelmed by anxiety, depression, or drug or alcohol issues,

You’re not in a good place to make a big decision like whether to have surgery and what kind of surgery to have if you’re dealing with family problems, work problems, or other issues. So instead, seek peer or professional help to address whatever is interfering with your ability to think clearly, and then return to the question of whether SRS is necessary when your mind is clearer.

3. Sufficient coping skills and supports to withstand the typical SRS stresses after SRS, trans-people often feel exhilarated and liberated, but it is also common to experience emotional ups and downs. It can be challenging to adjust to changes in your body’s appearance and feel, to deal with pain or other physical complications, and to deal with the reactions of others.

For some loved ones, SRS is the first time it truly sinks in that gender issues aren’t going away and that you are, in fact, Trans. This can be a complex emotional process for them, affecting the support they can provide. SRS is not for you if you do not believe you have the emotional fortitude to deal with these possibilities.

If you are confident that SRS is suitable for you but are unsure whether you are ready at this time in your life, you do not have to abandon SRS entirely. Instead, you can still work towards SRS by considering what might help you get to the point where you are ready – counseling, advocacy, peer support, and so on – and gradually but steadily making life changes to get closer to readiness.

What Happens If I Change My Mind About Having Surgery?

Surgery is a humbling experience. Dissatisfaction, disappointment, and doubt are relatively common after any surgery, and (for Trans and non-trans people) typically relate to post-operative pain, surgical complications, the discrepancy between hoped-for and actual results, a sense of “now what?”, and other people’s reactions. These are normal parts of the adjustment process and usually resolve within the first year after surgery.

According to studies, approximately 1% of MTFs who undergo SRS have profound and long-lasting regrets.

If you are having difficulty coping with the ups and downs of surgery, peer and professional counseling can be beneficial. However, it is critical that the counselor has extensive experience with Trans issues and understands surgical matters.

Many people who have persistent regret come to terms with their decision to have surgery – even if they wouldn’t do it again, they believe it was the right decision at the time. On the other hand, some people decide that surgery and transition were not for them and wish to return to their pre-transition state. This is a significant decision that should not be made without professional advice.

Male to Female Surgery – Additional FAQs

Q1: Will I be asleep during the male to female sex reassignment surgery?

The anesthesiologist will administer general anesthesia to keep you asleep and pain-free during surgery.

Q2: How long will I be in the hospital?

Answer : After surgery, you will be admitted for at least 7 – 9 days.

Q3: What will the post-op period be like?

Answer : To protect the surgical site, you will need to sleep with your legs separated for 5-7 days. During this period, you will be on a liquid diet with low fiber content so frequency of defecation is decreased. After about a week, you will be encouraged to start walking. Depending on your rate of healing, your doctor may also resume your hormone prescription after one week.

Q4: How do I care for myself after the surgery?

Answer : After surgery, you will be admitted for at least 14 days.

Q5: What will the post-op period be like?

Answer : To protect the surgical site, you will need to sleep with your legs separated for 5-7 days. During this period, you will be on a liquid diet with low fiber content so frequency of defecation is decreased. After about a week, you will be encouraged to start walking. Depending on your rate of healing, your doctor may also resume your hormone prescription after one week.

PRICE AND PACKAGES

Take the first step and contact us through our no-cost virtual consultation. During this process, we will recommend options that will work best for you. Every client is different, so our virtual consultants and surgeons tailor the procedure to match each person’s needs.

Procedure

Penile Skin Inversion

PRICE: 380,000 THB | with 9 days stay

Colon Vaginoplasty

PRICE: 480,000 THB | with 9 days stay

Penile-Peritoneal Vaginoplasty

PRICE: 680,000 THB | with 9 days stay

Laparoscopic Colovaginoplasty

PRICE: 780,000 THB | with 9 days stay

Available Doctors

Dr. Kittichai Sipiyarak

Specialty: Plastic Surgery

Dr. Worapon Ratanalert

Specialty: Plastic Surgery

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