Introduction to Vaginoplasty

Vaginoplasty is a medical term referring to a plastic and reconstructive surgery to the vagina and its mucous membrane. Vaginoplasty is required on some medical conditions like the absence or deformity of vulvo-vaginal structure because of sexual disease or other genetics problem. Sometimes vaginoplasty is performed for aesthetic purposes. While vaginoplasty scopes only some kinds of cosmetic reconstruction and correction of vagina, neovaginoplasty scopes the procedures of construction or reconstruction of the vulvo-vaginal structure, either partially or entirely. Vaginoplasty is also known as vaginal rejuvenation, cosmetic vaginal surgery, or aesthetic vaginal surgery. The goal of vaginoplasty varies, from increase the function of the vulvo vaginal structure, to reshape the vagina for aesthetic purposes, or to heal diseases or symptoms happened on the vagina due to daily activities, sex, or others. Mostly, the general procedure of a vaginoplasty is lifting the skin of vulva and vagina. It is done by cutting off excess vaginal skin and retightening the soft tissues and muscles around the vagina. Labiaplasty is a plastic reconstruction surgery around the labia to decrease or reshape the small lips (called labia minora) outside the vagina. Sometimes, labiaplasty is combined with vaginoplasty. This surgery is called vaginal rejuvenation. After performing this plastic and reconstructive surgery, a person could still doing sexual activities with opposite sex although sensitivity could be a little bit decreased. Menstruation and fertilization are also possible, as long as the uterus and ovaries function normally. Even vaginal childbirth is also possible.

In case of sex reassignment surgery, vaginoplasty is more to be undergone by transwomen regarding to their physical sex transition. A longer period of recovery (about six weeks) is needed to allow sexual activity after surgery and to have a good sensation in sex. The biggest difference in performing vaginoplasty to transwomen is to dilating the vagina. The vaginal stent is then cut off several days after surgery, and after that, the vaginal dilation is started. It requires a complete set of dilators for every dilation took place, and each of this tool has an increasing size. Smaller dilators are used for the first or the second week (or sometimes the fourth week) for several times. Then the size of dilators used increase once per day, every other day, once in a week, until the largest-sized tool is used. This frequency is sometimes used rarer, especially for trans women who perform vaginoplasty. But, the important thing is the time spared between each dilation (or more specifically, the time after surgery) has too be short enough to decrease any difficulties in re-dilating. Vaginal dilation is important in vaginoplasty, because it allows the patient to do sexual intercourse. Vaginoplasty also requires some reshapement to the dimensions of the vagina, including the depth (Denonvillier’s Fascia), diameter (the Levator ani muscle), and narrowness—especially in transwomen.

To reshape vaginal and vulvo-vaginal areas of the patient, autologous (patient-derived) tissue from the patient is also used. Other tissue that can be used for this surgical procedures are the oral mucosa, the skin flaps, the skin grafts, the vaginal labia, the penile tissue, the penile skin, intestinal mucosa, and scrotal skin. It is also important to clear the follicles from the skin graft (if it grows hairs), usually by electrocauterization, by depilating it intra-operatively, or by manual hands. There are many different procedures of vaginoplasty, but mostly what is discussed here is the general procedure of it. Some advancement of vaginoplasty also exist, regarding to current technologies.

Further Methods of Phalloplasty

As we have known that phalloplasty is a medical surgery to construct, reconstruct, or modify a person’s penis, phalloplasty is mostly performed with skin graft. There are six further methods of phalloplasty, explained below:

Graft from the arm

Graft from arm is actually the easiest method to perform phalloplasty, but it leaves scar on arm—which can not be hidden. Moreover, the function of the arm may be worse if it does not heal properly. A full scale metoidioplasty can be performed several months earlier before phalloplasty. This is to decrease the complications possibilities after the surgery.

Below is the most common steps of this method of phalloplasty. Some variations may apply, but mostly below is the general approaches:

• After the patient is prepared, the surgery starts by marking the forearm with the size of the graft. The graft is then taken. In case the graft is too large, another graft from other parts of the body may be used to reconstruct the arm.
• The graft skin is then separated to see the veins and several antebrachial nerves. This is performed very carefully.
• The urethra and the phallus will be joined at this step, if both requires construction at the same time. If they don’t, the glans is formed.
• To let the joining of the graft and the existing tissues joined easily, a part of vein around the patient’s groin is used.
• The vein is placed to the femoral artery very carefully.
• The flap and the vein to the femoral artery are then joined.
• The ligament and clitoral hood is removed, while the nerve bundle is being untouched for some moments. Some surgeons make an alternative of leaving the clitoral tissue as it is after metoidioplasty.
• Some part of the flap is then placed as the nerve bundles are joined.
• If there is an urethral extension required, the urethra is joined with a catherer. It will be kept in place for two until four weeks recovery. The skin sometimes need to be sealed and the scrotum is also made up.

Moreover, if the urethra extension is required until the top of the glands of the new penis, a mixture of saline and epinephrine is injected to the labia minora. It is then opened up, and the layers are separated. The layers are then closed around a catheter and sewed up.

Sometimes, in an urethral extension, a mucosal flap from inside the vagina may be used. This requires a separate surgery.

Graft from the side of the chest

Graft from chest is actually not an old method. This is one of the biggest advancement in phalloplasty. Some advantages of this methods are good appearance, no prominent scar, lower potential of complications, and no need of hair removal. This method of phalloplasty requires three parts, spanning over six to nine months. The steps are:

• The surgery starts (after the patient is prepped) with the side of the chest marked for graft size.
• After the patient is prepared, the surgery starts by marking the side of the chest with the size of the graft. The graft is then taken.
• The graft skin is then separated to see the veins and several thoracodorsal nerves.
• With the graft still attached to the blood supply from the vein, the graft is rolled to shape a rough penis.
• To let the joining of the graft and the existing tissues joined easily, a part of vein around the patient’s groin is used.
• The vein is placed to the femoral artery very carefully.
• The flap and the vein to the femoral artery are then joined.
• The ligament and clitoral hood is removed, while the nerve bundle is being untouched for some moments.
• Some part of the flap is then placed as the nerve bundles are joined.
• The new penis is protected from any contact to other muscles and skins during the beginning recovery period. This step requires a constructed dressing to keep away any potential complications of blood supply
• Urethral extension is then started after three months pass.
• The new penis is separated and an oral mucosa graft is laid onto the cavity and extended to the urethra. Both are then joined to let urination while standing.
• A catheter is placed for several weeks to allow for proper healing
• For recovery, a catherer is used for some weeks. After three until six months, the erection device can be placed.

Graft from leg

This method is akin to that of forearm graft, except that the scar of the donor will be easily hidden by socks or pants. The remaining steps are similar to as in the forearm graft method, including the removal of permanent hair before the operation. Sometimes, the graft from the leg may be combined with forearm graft to reshape the glans penis.

Pubic area flap

Graft is taken from the skin around the pelvic bone, across the abdomen around the stomach. There will be a big horizontal scar, making it a little bit unaesthetic. Moreover, the grafts are usually seen unnatural and less permanent to keep an erecticle implant for a further term. Hair removal is necessary before proceeding this method.

Gillies technique

This method of phalloplasty is actually the first phalloplasty method ever used. An abdominal skin is rolled, making a form of tube, to simulate a natural penis. Urethral extenion is performed in another part of the skin, creating a tube within a tube. A flexible rod is required to implant erectile. A more improved method of Gillies technique includes an inclusion of a blood supply pedicle to avoid dead tissue before being transplanted to the groin.

Abdominal muscle

This last method of phalloplasty is rarely undergone. There are three minimum steps in this method, including implantating an expansion balloon to help grafting the necessary skin parts. Finally, the grafts will be a little bit unnatural, and less likely to keep the implanted erectile in a further term.

A Brief Information about Phalloplasty

Phalloplasty is a medical term of constructing, reconstructing, or modifying a person’s penis due to medical condition or cosmetic purposes (also known as penis enlargement). A phalloplasty is usually performed to patients with genitalia deformities like micropenis or hypospadias, patients who lost their penis, or female to male transsexual patients. First phalloplasty ever recorded in history was performed with the aim of female to male sex reassignment surgery, undergone by a trans man, Michael Dillon, in 1946. Dr. Harold Gillies, the surgeon, documented the technique in Pagan Kennedy’s book “The First Man-Made Man”.

Basic Methods of Phalloplasty

Surgeons have four different methods in performing phalloplasty. Basically, these methods include a graft of tissue and skin from donor and an extention of the urethra. Phalloplasty can create a penis up to 7 inches long (approximately 14-18 cm) and 5.9 inches (approximately 11-15 cm) in circumference.

Phalloplasty is simpler for real male (or termed as cis men) than for trans men, because there is no significant requirement of urethra extension. In trans men, the urethra finishes close to the vaginal opening and, therefore, needs to be significantly extended. The urethra extension is the most difficult phase of phalloplasty. In trans men, phalloplasty is also followed by scrotoplasty. Scrotoplasty is a construction of scrotum, where testicles are located. Scrotoplasty can be done by using labia majora or vulva. Then prosthetic testicles can be inserted in the scrotum after scrotoplasty is done.

The success of a phalloplasty can not be measured just by whether the penis has been constructed/reconstructed or not, but by whether the penis could perform similar functions like natural penis. For instance, could it achieve an errection and sexual penetration? In this case, an implanted erectile prosthesis is required in every phalloplasty. Some kinds of this implanted erectile prosthesis include malleable rod-like medical devices—that allow the penis to erect or be flaccid. Still, in this case, the success rate of erectile prosthesis implantation in trans men is lower than that in cis men. But, surgeons usually use their experience in sex reassignment surgery to trick the implantation to lower down the potential risk.

Former methods of this implantation require a bone graft as part of the phalloplasty. Studies from Germany and Turkey have given proof that these reconstructions can hold the stiffness without any further complications. However, in this case, the penis will not have the ability to become flaccide without breaking the bone graft apart.

In penis enlargement, phalloplasty is sometimes performed by cutting the suspensory ligament that hold the penis near to the upper skin. It allows the penis to grow toward the outside of the body instead of upward. This is done by doing a horizontal incision around the pubic bone region, where the pubic hair will help covering the incision part. After all, the penis is free from any incisions.

There is still research in progress about synthesizing corpus cavernosa, or the erectile tissue, performed on rabbits in laboratory. This is done to dig more about eventual use in patients who require phalloplasty. The last report of this research tells that the rabbits give response to sexual stimulation, just like to the tissue of male rabbit which is not any parts of the research.

Patient Satisfaction

Approximately 90% of the patients undergoing phalloplasty is satisfied, while only 9% of them complain about the sensitivity of their new penis. Meanwhile, 51% of them are able to do sexual penetration without pains or difficulties. Moreover, 40% of these patients are able to apply for a job they can not apply for when they were still female. There is 27% of them who needs temporary use of anti-depressants, while 93% (or mostly) of them said that they were happy with their new penises.

Definiton of Sex Reassignment Surgery

Sex reassignment surgery, or also known as gender reassignment surgery, sex affirmation surgery, sex realignment surgery, genital reconstruction surgery, or sex change operation, is a medical procedures to change the existing sexual characteristics from physical appearance and function of a person into opposite sex. Sex reassignment surgery is sometimes undergone to treat people with gender identity disorder, transsexual or transgender people, and intersex people (mostly in infancy). The people who undergone a sex reassignment surgery are usually addressed as transsexual, meaning literally as “person who change his or her sexual characteristics”. Trans women are former men who perform specific sex reassignment surgery to change male to female sexual characteristics, while trans men are former women who perform specific sex reassignment surgery to change female to male sexual characteristics.

Definition

Although people mostly imagine a sex reassignment surgery as a procedure to reshape the genitals of a person, the World Professional Association for Transgender Health (WPATH) has included larger scope to the procedures defined as sex reassignment surgery. Some of these medical procedures are chest and breast reconstruction or augmentation, genital reconstruction, and certain facial plastic reconstruction. This larger definiton also includes some medically non-surgical procedures like facial electrolysis.

To protect patients with gender identity disorder who needs to perform sex reassignment procedure, the American Medical Association House of Delegates declared that the denial to these patients is a form of discrimination and supported public and private health insurance to cover sex reassignment surgery as a treatment recommended by physician. This statements are also issued by other organizations like American Psychological Association and the National Association of Social Workers.

Male to Female or Female to Male Sex Change Difference

Male to female sex reassignment procedure for trans women is different with female to male for trans men. Sex reassignment procedure for trans women includes medical construction of a vagina, facial feminization surgery, and breast augmentation. For trans men, besides medical construction of a penis, several other procedures like mastectomy (breast removal procedure) and hysterectomy or male chest reconstruction are necessary. But, in both cases, sex surgery also includes several necessary ancilliary procedures like orchiectomy or vaginectomy.

In trans women, medical advancement has made it possible to childbearing, by using a donor uterus from other natural women that is strong enought to carry an infant without having any implication from the anti-rejection drugs. A DNA transfer is also possible by removing DNA from the donated ovum to be replaced by the DNA of the receiver.

Health Considerations

Not all people could undergo a sex reassignment surgery. There are several health considerations to pass before performing the surgery. For example, the patient with HIV or hepatitis C may find it difficult to do a sex reassignment surgery. Many surgeons avoid these kinds of patient due to the safety problem. Although some medical experts agree that avoiding patients with HIV or hepatitis C to undergo a sex reassignment surgery is a form of discrimination, the patients themselves are willing to pay higher fees in order to recruit a surgeon to perform the surgery safely.

Not only HIV and hepatitis C, other health conditions like diabetes, abnormal blood clotting, and obesity must be considered by the patient. Obese patient, for example, is suggested to lose weight before performing surgery. Meanwhile, smoking patient is suggested to quit before and after surgery. This is necessary to avoid any problems after the surgeons.

Standards of Care

While sex reassignment surgery sometimes feels so difficult to be performed due to financial difficulties or minimum experienced surgeons, a document called Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People becomes a guidance or a governance by some individuals who wants to perform the surgeries. With an increasing number of surgeons in this field in many regions, Standard of Care is widely spread and sometimes revised by the World Professional Association for Transgender Health. The Standard of Care is also becomes a guidance by many countries, including the United States, to treat transsexualism. Standard of Care includes a period of full time life as a member of the target sex before performing the sex reassignment surgery.

Beside that, Standards of Care lists several minimum requirements as guidelines for treating transsexualism. Some of these requirements is accessing hormone replacement from the opposite sex and other surgical interventions. Here then comes the controversy. Many countries do not follow the right Standards of Care, some of them insert their local standards of care in it, like Netherlands, Germany, and Italy. Some European Standards of Care are even based on older versions of the standards. That makes some standards are stricted than other standards, mostly the latest revision of Standards of Care. However, in the United States, many professional sex reassignment surgeons apply the Standards of Care in a more flexible term, regarding to how the patient’s condition is, as long as it is consistent to the Standards.

Surgeons require at least one suggestion from an experienced mental health professional who works in diagnosing sex identity disorder for a patient more than a year. This suggestion is compulsory because it becomes a sign that sex reassignment surgery is the one and only treatment to be performed. Moreover, many medical professionals and associations stated that no surgical interventions are required during performing the sex reassignment surgery procedures. But, laws in many countries are still unable to list transsexual and transgender people as the opposite sex in the public records, except if they attach a testimonial letter from a physician or medical experts that said that the sex reassignment surgery has been undergone. Several strict countries do not even allow any kind of sex change, even after sex reassignment surgery has been performed.

Sex Change Plastic Surgery

Sex change, or sometimes called sex reassignment therapy, is a medical procedure to change sex from male to female or female to male under a genitalia surgery or any other sexual reassignment surgeries. Sex change is usually undergone by transgender people or intersexual people, specifically children. The larger definition of sex change is scoping not only the medical procedures associated with it, but also the whole process of changing roles and responsibilities in life. This affects the life of the person undergone the procedures, since it gives impact to the surrounding and people around him or her. That is why, confirming sex change as just a medical procedure to change sex is an inaccurate approach because it ignores the social and legal impact.

Human sex change

In fact, sex change is more specifically defined as sex change in humans. This refers to sex reassignment surgery that people may undergo in certain conditions. However, many people see “sex change” or “sex reassignment procedure” from an inaccurate definition. Biologically, human sex is determined by four factors: chromosomes, gonads (ovaries or testicles), hormonal status, and primary or secondary sex characteristics. In a sex reassignment procedure to make a male to female or female to male, not all those four factors can be changed. Chromosome is the main thing that cannot be changed because it is inherited. Ovaries or testicles can be removed, but cannot be replaced one to another. Hormonal status is dynamically changed. Only primary or secondary sex characteristics can be changed, but it is only until a certain boundaries.

By this condition, changing a male genitalia into a perfect and excellent female genitalia with a good function is complicated but still possible. However, changing female genital anatomy into a functioning, good male genital anatomy is also complicated, but hardly succesful.

Before undergoing a sex reassignment surgery, the patient must be under a period of feminization or masculinization, regarding to what gender he or she wants to be. This is commonly two years before the sex reassignment surgery, just like what is ruled by the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. In this period, some synthetic or natural hormones like estrogens, androgens, progesterons, and antiandrogens are used. Counselling is also compulsory to start the body changing hormones. In this counselling, a period of full days living in the target gender for at least six months is also accomplished.

Natural sex change in humans

Not only via sex reassignment surgery, sex change in humans also happened naturally. Some specific medical conditions can result to sex change. This is can be seen after a long period of a lifetime. So, a human who is born and appears of one sex can transforms into the other sex after a long period. Female to male sex change is mostly happened in this natural sex change, because of either 5-alpha-reductase deficiency (5alpha-RD-2) or 17-beta-hydroxysteroid dehydrogenase deficiency (17beta-HSD-3). Meanwhile, male to female sex change is a rare occurence and still can not be understood well by experts.

Genetic females (with two X chromosomes) with congenital adrenal hyperplasia lack an enzyme needed by the adrenal gland to make the hormones cortisol and aldosterone. Without these hormones, the body produces more androgen, a type of male sex hormone. This causes male characteristics to appear early (or inappropriately).

The lack of certain enzymes can also cause in a natural sex change, although not an obvious one (but only by appearance). Females (with two X chromosomes) with congenital adrenal hyperplasia (or lack of enzyme for the adrenal gland to produce hormones cortisol and aldosterone) can show male characteristics and appearance early and inappropriately because the body will produce more androgen, which is a type of male sex hormone. In the other hand, males (with one X and one Y chromosome) with androgen insensitivity syndrome (AIS) is not sensitive to androgen. It results to the person showing an entire or partial characterisitic of a woman. AIS sometimes include other diseases like Reifenstein syndrome which cause men to develop breast on their chest.

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