Sex reassignment surgery (SRS)
What is SRS?
Sex reassignment surgery (SRS), also known as gender reassignment surgery or bottom surgery, is a set of plastic and reconstructive surgical procedures with the aim of making the genitalia of the patient congruent with their gender identity.
In the MtF case this means transforming the male genitalia with which the patient was born, into an aesthetically accurate and functional vagina; under the care of an expert surgeon, normal urination, minimal scarring and the preservation of erogenous sensitivity can all be achieved.
Male to female sex reassignment surgery is a set of complex operations such as the orchiectomy (= removal of the testicles), clitoris reconstruction, labia majora and minora reconstruction, mons pubis creation and vaginoplasty which are often bundled together in what is known as sex reassignment surgery or primary vaginoplasty; in some cases, the orchiectomy might be executed some months in advance.
Which method do we recommend?
We recommend the method of:
Dr. Hendrik Schöll & Dr. Susanne Morath „The Combined Method”
Based in Munich in their own practice and additionally head of the plastic surgery department at the Red Cross Hospital in Munich, both aesthetic plastic and reconstructive surgeons, specialized in the fields of SRS, FFS, breast surgery and in the whole field of body contouring. More than 10 years ago, the "Combined Method" for genital reassignment surgery (MtF) was conceived here, and constantly refined, in order to be able to achieve an even more optimal functional and aesthetic result. Since then, this surgical method is performed as standard procedure very successfully several times a week. Unlike the other techniques, such as penile inversion, their technique always uses the scrotal skin and part of the urethral mucosa in addition to the penile skin to line the neovagina. This not only allows for considerable penetration depth, but creates the possibility of a self-lubricating vaginal cavity. A sensitive clitoris is formed out of the glans, which is capable of orgasm. The clitoris itself is protected by a clitoral hood and labia minora, which are formed out of part of the foreskin. Even after circumcision, there is a possibility to form this. Of course, labia majora are also made aesthetically pleasing.
Who can undergo SRS?
The following are the prerequisites to have access to the primary vaginoplasty and set in the Standards of Care 7th edition by the World Professional Association for Transgender Care (WPATH)
- Persistent and well-documented diagnosis of gender dysphoria
- In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
- Be of legal age.
- The absence of absolute medical contraindications (medical conditions which would make it too risky to perform the surgery).
- At least 12 continuous months of feminizing hormone replacement therapy
- At least 12 continuous months of living in a gender role that is congruent with their gender identity.
- The last criterion is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing this irreversible surgery.
Practically, a patient needs a referral letter from the treatment counselor (psychologist, psychiatrist, sexuologist…), needs to be an adult and capable of making decisions, and have taken at least 12 months of cross-sexe hormones (estrogens, Androcur is not sufficient).
On the intake consultation, the procedure is reviewed and explained. Questions are answered. The previous medical and personal history are noted, and it is determined if the patient is a good candidate. The clinical examination will determine the procedure (need of extra skin, specific procedure elements,…).
After all requirements for the surgery are met, your surgery date will be scheduled. The surgery requires a 14 day-hospital stay. On the night before the surgery, bowel cleansing is performed (by drinking fluids).
Surgical wounds are cleaned daily and have to be kept dry and clean until complete healing. The vaginal canal will require daily hygiene to avoid complications and infections.
4-6 weeks after surgery it is generally possible to go back to work (depends on the work).
Dilatation is usually recommended for the first 6 months post-op.
Until the female reproductive organs transplant will be made possible by medical advances, pregnancy is not possible for transgender women.
When revision surgeries are requested it is usually to improve the aesthetics of the results, but sometimes corrective interventions on the neovagina are indicated to improve the functionality of the neovagina. They are usually performed 6 months after the initial procedure.
What to expect after SRS with the “Combined Method”?
- Neo-vagina with considerable penetration depth and possibility of a selflubricating
- Clitoris with sensation, capable of orgasm
- Normal urinating
- Major and minor labiae, clitoral hood
What not to expect after SRS?
- Possibility of getting pregnant
Risks and complications of male to female sex reassignment surgery include general risks which are not specific to this surgery but shared with any surgery such as risks related to general anesthesia, intra-operative and post-operative bleeding, infections, scarring, delayed healing, accidental damage to surrounding tissues.
Among the specific risks related to SRS there are urethral strictures, narrowing of the neovagina, meatal stenosis of the new urethra, rectovaginal fistulae, graft necrosis, loss of sensitivity, unsatisfactory dimensions of the neovagina.
This surgery is irreversible. Therefore you have to be certain. You have to pass the trajectory including psychological guidance, hormone therapy and real-life test. You have to receive clearance from a certified psychiatrist. This is absolutely necessary.
Certain treatment adjustments,medical tests, blood tests or blood donations are required:
- Stop hormone replacement therapy approximately 4-6 weeks prior the surgery (in consultation with the treating endocrinologist)
Permanent epilation of the scrotal skin before the surgery is not mandatory. These hairs can be permanently removed by the surgeon during the surgery, with the aim of a hair-free vagina.
If permanent hair removal is desired before the operation, the electrolysis method is a very suitable method. This can be done under local anesthesia. There is a chance that certain hair follicles are invisible at the time of the operation because they are not yet in their growth stage. Please note that we cannot remove hairs internally after you've had your surgery.
In a pre-operative consultation, we will decide together whether there is a need for additional skin graft to complete the interior of the vagina. This may be necessary if the existing penile skin and scrotal skin is insufficient to line the neovagina due to its size.
Book your appointment with Dr. Hendrik Schöll
For more information visit www.morath-schoell.de or @morath.schoell on Instagram.
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