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In the broadest sense, vaginoplasty surgery is a procedure to construct or reconstruct a vagina. Transgender vaginoplasty is a feminizing genital surgery for trans women and non-binary individuals who desire a surgically created vagina. Depending on your desired outcome and anatomy, the procedure can be performed through several techniques. The intention is to create a vagina with the patient’s ideal depth and girth while still achieving an elegant external appearance. Some patients may prefer a minimal-depth vagina which will not result in deep penetrative intercourse, while others may desire a vagina with maximal depth.
The introduction of gender-affirming vaginoplasty to the medical world dates back to the early 1920s in Germany, where several reports were published. Unfortunately, these important early works were destroyed in 1933, but it is known that the first gender affirming surgeries were performed by Magnus Hirschfeld at the Institute for Sexual Research in Berlin.
It wasn’t until the 1950s that transgender vaginoplasty became widely known. At that time, few surgeons were willing to perform these operations due to legal and professional reservations. The surgeons willing to perform these procedures became pioneers in the field and developed innovative techniques. For example, in 1956, the penile skin flap inversion vaginoplasty technique was developed by Dr. Georges Burou, who performed over 800 transgender surgeries in his career.
Later, in 1980, the controversial addition of “gender identity disorder” to the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-3) ironically paved the way for transgender and non-binary (TGNB) individuals to gain access to gender-affirming healthcare. In 2013, with the release of DSM-5, the term “disorder” was removed and replaced with “gender dysphoria.” Finally, in 2014, a US government panel ruled that Medicare must cover gender-affirming surgeries, including transgender vaginoplasty procedures.
Vaginoplasty can be a significant step in the gender affirmation journey of transgender and non-binary individuals. It can improve the quality of life and mental well-being of TGNB individuals by helping them feel more comfortable in their bodies. Not all trans women and non-binary people decide to undergo feminizing genital surgery, but it can help reduce gender dysphoria by aligning the patient’s anatomy with their gender identity and desired gender expression.
There are several requirements to fulfill before patients can qualify for vaginoplasty surgery as specified by World Professional Association for Transgender Health (WPATH).
To start the process, patients must contact the Hanna Gender Center to schedule a consultation. Patients will have a personal consultation with Dr. Hanna in person or virtually through telehealth. The consultation will include an in-depth discussion about which options are available for the specific individual. After the consultation, patients will receive a surgery date. Once surgery is scheduled, the team at Hanna Gender Center will take care of getting the insurance pre-authorized and patients will receive pre-surgery instructions to help prepare for the surgery.
The penile inversion technique is the most common transgender vaginoplasty method. It is the gold standard against which all others are measured. With this technique, the vaginal lining is constructed with penile skin and augmented with a native tissue graft, the labia majora and minora are created with scrotal skin, and the clitoris is constructed from the sensitive skin and nerves at the tip of the penis. The prostate will be left in its place, continuing to serve as an erogenous zone and the anatomic equivalent to the g-spot.
The intestinal or sigmoid vaginoplasty method, also known as the bowel interposition method, uses a section of the sigmoid colon to construct the vagina. The procedure is often conducted as a laparoscopic surgery, meaning the surgeon utilizes small incisions and thin devices for a minimally invasive process. In some cases, this technique requires an open procedure. With the intestinal/sigmoid method, a small piece of the sigmoid colon is detached and rotated down to form the lining of the vagina. The surrounding colon then gets stitched together to restore its function.
The peritoneal technique uses the peritoneum (the lining of the abdominal cavity) to construct the vagina. During a peritoneal vaginoplasty, the peritoneum is pulled down into the space between the rectum and the urethra to create the vaginal lining. This vaginoplasty surgery is typically a minimal invasive surgery, performed via laparoscopy alone or robotically.
For patients who wish to have an outward-appearing vagina without the desire for penetrative intercourse or the rigorous maintenance of a typical full-depth neovagina, a zero-depth vaginoplasty is another option. This technique uses tissues from the scrotum and the penis to create an elegant appearing vulva with bilateral labia, a functional clitoris, urethra, and minimal depth vagina. This vagina requires minimal maintenance, while maintaining the appearance of a fully functional, penetrative vagina. The procedure takes about 3-4 hours and requires less post-surgery maintenance than maximal depth transgender vaginoplasty methods.
From time to time, certain instances may arise from prior vaginoplasties that lead to unintended outcomes. These issues are usually able to be corrected with a vaginoplasty revision. Inadequate depth and less than satisfactory appearance are a few of the more common concerns that could arise from previously performed surgery. Whether functional, aesthetic or both, the revision can be tailored to the patient’s specific concerns in order to achieve the best possible outcome. Recovery from revision vaginoplasty is generally easier than the primary surgery. Regular maintenance and aftercare will still be required post procedure.
Vaginoplasty surgery is a significant turning point in the lives of many TGNB individuals. Learning to live with and care for a neovagina can take time, but it is also empowering and joyous. If you have decided to embark on this journey, our team would like to say congratulations and offer these tips to help you make the best of this new chapter.
Regardless of the surgery technique, patients must regularly care for their vaginas. Different procedures require different amounts and frequencies of maintenance which will depend on several factors.
For example, with the full depth vaginoplasty, patients will need to dilate their vaginas regularly. Dilation is a process that involves inserting a rigid polyurethane dilator into the vagina for a prespecified time period. Patients may also need to practice medical douching, even after their grafts are completely healed. During penetrative intercourse, patients need to use generous lubrication.
More details on caring for neovaginas can be found below in the “Recovering from Vaginoplasty” section.
Gender dysphoria is defined as the discomfort or distress caused by a discrepancy between a person’s gender identity and assigned sex at birth (as well as the associated gender role and sex characteristics). Transgender and non-binary individuals may experience severe genital dysphoria which affects their everyday lives and relationships. Choosing to undergo a transgender vaginoplasty often results in the improvement of dysphoria related symptoms and helps patients feel more confident and comfortable in their bodies.
After vaginoplasty, most patients will be able to orgasm using the clitoris, which is formed using existing genital tissue to preserve the erotic nerves. During penetrative intercourse, one can expect a pressure-like sensation. Similarly to life pre-surgery, achieving orgasms will require both mental and physical stimulation. After transgender vaginoplasty, most patients can achieve orgasms through clitoral stimulation, if interested.
General risks such as pain, bleeding, infection, and scarring may occur after a vaginoplasty procedure. If the patient is in good health and post-surgical hygiene and care are maintained properly, the surgical risks for wound complications are relatively low.
The most common complication experienced by patients is skin splitting, or wound separation. While this can be visually distressing, this is typically managed conservatively with local wound care. Additional surgery, or suturing is almost never required for resolution.
Local numbness after vaginoplasty surgery is common due to inevitable trauma to the nerve endings in the skin at incision sites. As the nerve endings heal, sensitivity may gradually return to pre-operative levels.
The clitoris is expected to shrink in the postoperative period. To mitigate this, the clitoris is usually constructed larger than the final intended size. Clitoral necrosis may also occur post-vaginoplasty This is not a common risk with a published rate of up to 5% in the literature. Should clitoral necrosis occur, it is typically partial, and most patients should expect to still achieve orgasm. If patients remain anorgasmic after one year, topical testosterone cream in the area of the clitoris has proven helpful in regaining sensation.
Fistulas are unwanted openings that may develop between two body parts after surgical injury. Two types of fistulas may occur after vaginoplasty surgeries: rectovaginal and urethrovaginal. Rectovaginal fistulas is a rare, but unfortunate complication in which an abnormal tract develops between the rectum and the neovagina. Urethrovaginal fistulas are similarly rare, and develop between the urethra and the neovagina. Fistulas may require follow-up surgery for repair. With a skilled surgeon, the risk of fistulas is low in vaginoplasty patients.
Vaginal stenosis is a condition that occurs when the vaginal canal becomes narrower and shorter, or in other words, loses depth and girth. Vaginal stenosis after transgender vaginoplasty is a risk. This complication is usually due to non-compliance with, or inappropriate technique with dilation. Alternatively, some patients with rare phenotypes may inevitably develop neovaginal stenosis despite meticulous technique with dilation.
Please refer to the “Recovering from Vaginoplasty” section for more information.
After vaginoplasty, one is at the same risk of developing a UTI as a cis-gender female. This is due to loss of urethral length. To lower the risk of UTI after vaginoplasty, patients should empty their bladders regularly, consume a plethora of fluid, and adopt appropriate hygiene methods.
During the pre-op consultation, Dr. Hanna will thoroughly discuss the best surgery techniques based on the patient’s unique anatomy and desired results.
Dr. Hanna specializes in the single stage Penile Inversion Vaginoplasty technique, regarded as the gold standard for male-to-female (MTF) vaginoplasty surgery. This procedure requires a single perineal incision, resulting in minimal scarring and an elegant external outcome. Compared to others, this technique offers an excellent result with maximum depth and girth. Moreover, there are minimal intraoperative, and long-term complications relative to other techniques.
In addition to this method, Dr. Hanna offers the following techniques:
Ultimately, your desires and health will be the focus of the surgery.
At the Hanna Gender Center, most patients do not need painful and costly hair removal before surgery. During your consultation, this specific requirement will be discussed in detail. Dr. Hanna’s preference is to remove the hair while patients are under anesthesia. It is unlikely for hair to regrow, but if it does, the follicles are typically lighter in color and fewer in number.
Pre-operative preparation is critical to ensure the patient has the best possible outcomel with little to no complications. Please make sure to read through the written instructions provided by the Hanna Gender Center after your consultation. If you have any questions or concerns, do not hesitate to reach out to our office. We will be happy to clarify everything and help you get through the process.
Patients will need at least 6 weeks to rest and heal after the surgery, so we advise you to save enough money to cover all your expenses for at least 6 weeks postoperatively. For patients with more rigorous and physical professions, consider saving about 12 weeks of funds. Plan thoroughly and make the necessary arrangements for the postoperative recovery period.
It is preferred that you stop using all nicotine products for three months before vaginoplasty surgery to facilitate healing with minimal risk.
If patients are from outside the Dallas/Fort Worth area, book a hotel no further than a thirty-minute drive from the hospital. Our office has negotiated rates with several local hotels which offer a significant discount if needed. Patients must stay local for at least one week after surgery.
Laboratory work and a physical examination are required no sooner than 30 days prior to undergoing vaginoplasty surgery.
The day before surgery, patients must follow a clear liquid diet. This is to ensure there is little undigested residue left in the gastrointestinal tract so that the risk of rectal and bowel injury can be further reduced during surgery.
The day before surgery, patients must perform a bowel cleanse. For more details on the bowel preparation procedure, please contact our office. Bowel preparation is a full day process and must be followed exactly as prescribed. Failure to do so may result in the cancellation of surgery.
Patients must not eat or drink anything after 11 pm the evening prior to surgery–this means no food, or oral fluids.
Postoperative care is crucial to ensure proper healing after surgery. If you have any questions or concerns in the process, reach out to our office by email or call.
Patients can expect to stay at the hospital for about 5 days (+/-) following their vaginoplasty procedure. Once discharged, patients will stay local until one week from the date of surgery. Patients should have a caregiver present to help with postoperative care requirements.
During the first postoperative week, patients may walk carefully around their hotel room, home, or apartment by taking slow steps with assistance. Excessive walking can result in poor wound healing and increase the risk of complications.
Patients will be given a perineal cushion to help them sit comfortably. When seated, patients should shift their weight approximately often to allow healthy blood circulation through the surgical site.
Patients must avoid strenuous activities for an extended period after surgery until cleared by Dr. Hanna. Additionally, patients must abstain from having sex for up to three months or until cleared by Dr. Hanna.
Patients will have a urinary catheter and drains in place for 5-7 days post-surgery to help pass urine. Do not wait for the drains to become completely full; empty them regularly, as instructed. The drains and catheter will be removed at our office during the first postoperative visit.
Antibiotics will be prescribed to help prevent bacterial infections and reduce the risk of wound complications. Patients will also be prescribed a limited amount of narcotic pain medication. If the narcotic prescription is finished prior to follow up, patients are not usually provided additional narcotic medication unless otherwise specified by Dr. Hanna. To help with pain management, non-narcotic pain medication such as acetaminophen may be utilized.
Patients must avoid showering, bathing, or swimming until cleared by Dr. Hanna following the first postoperative visit. Do not clean or wipe anything in the vicinity of the surgery site. Doing so could result in the skin edges (suture lines) coming apart.
Patients may experience inflammatory fluid leakage from the surgical sites. This is expected and is part of the normal healing process. Within the first 4-6 weeks after surgery brownish/pinkish/yellowish vaginal discharge is expected. Within the first 8 weeks, bleeding and spotting are expected as well. Discharge after this period of time may be indicative of granulation tissue, which should be treated. Alert Dr. Hanna or his staff if this occurs. To help with postoperative hygiene patients can purchase absorbent underpads, adult diapers, and other disposable garments. It is common for patients to experience labial swelling and will gradually resolve within 6-8 weeks following the vaginoplasty.
Dr. Hanna will place a gauze packing or stenting device in the vagina and this will remain in place until removed by our office. Patients must avoid picking or pulling the vaginal packing. To avoid pushing the vaginal packing out, patients must also be careful when having bowel movements and not strain excessively.
Our office will schedule the first postoperative appointment about one week after surgery. During the first follow-up, our team will remove the drains and tubes. Dr. Hanna will personally instruct patients on vaginal dilation and medicated douching. Patients will be provided verbal and written instructions on caring for their neovagina and overall health.
After the vaginal packing is removed, patients must begin a regular dilation procedure unless they have chosen a zero-depth (minimal depth) vaginoplasty. Dilation is important for maintaining vaginal depth and girth and, if neglected, may result in vaginal stenosis. The exact schedule and frequency of dilation will vary depending on the technique and outcome of the vaginoplasty.
Patients will receive a set of vaginal dilators along with clear instructions from our office during the first postoperative appointment. Dilators are medical instruments made of rigid polyurethane with a slight curve at the tip for ease of use. The set contains three different colored dilators, each with different diameters. Each dilator has dots alongside the length to indicate the different depths so patients can track their progress easily.
Before each dilation session, clean the dilator with warm water and antibacterial soap, rinse it thoroughly and dry it with a clean cloth or paper towel. During dilation, we recommend patients lie down on their backs and prop their heads up slightly with pillows to lie almost flat. Remember to take deep breaths and relax your muscles throughout the session.
We recommend patients apply a generous amount of lubricant to the dilator. It’s best to use a water-based lube like Surgilube or KY Jelly and avoid silicone or petroleum based options.
The frequency of dilation is dependent on the patient’s unique anatomy, type of vaginoplasty, and Dr. Hanna’s instructions. As patients progress in their dilation routine, the frequency of dilation may be slowly decreased with approval from Dr. Hanna. If the vagina begins to feel tight or dilation becomes difficult, reach out to our office.
Since the neovagina does not contain natural vaginal mucosa, patients should follow a douching regimen to maintain proper hygiene. Douching helps keep the natural flora under control, and washes out any remnants of lubrication. Douching is especially important during the healing process when the skin of the vaginal cavity will regenerate and produce small pieces of dead skin.
After Dr. Hanna removes the vaginal packing following the vaginoplasty, patients should start douching regularly, as directed.