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 use?
The method used in our clinic is largely the same as the following surgeons use:
- Prof. Dr. Stanislas Monstrey
Based in Belgium, Dr. Monstrey is a Professor in Plastic Surgery and a leading member of Gent University Hospital’s Centre for Sexology and Gender, where both FTM and MTF surgeries are performed weekly. Apart from that, he is the head of the Burns Centre at Gent University Hospital (UZ Gent).
- Dr. Suporn Watanyusakul
Dr Suporn Watanyusakul MD is an aesthetic plastic and reconstructive craniofacial surgeon specializing in the fields of SRS, FFS and Augmentation Mammaplasty (AM) operations, and whose Clinic is in Chonburi, Thailand.
Following their method, the penile skin (if abundant) is used to create the lining of the vagina. If insufficient, grafted scrotal skin (or from another donor site such as the lower abdomen). Scrotal and penile skin therefor need to be hairless first. Sometimes a part of the native urethra can be used as part of the lining. A vaginal orifice and considerable penetration depth can thus be achieved. Part of the glans is retrieved to create a clitoris with sensation, capable of orgasm. The urethra is shorthened and located between clitoris and vaginal orifice, to allow for normal urinating. Major and minor labiae are created in an aesthetically pleasing way.
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 (amount of skin, need for epilation, specific procedure elements,…).
A surgery date is planned. The surgery requires a 7 day-hospital stay. On the night before the surgery, bowel cleansing is performed (by drinking fluids). Alternatively, patients can take astronaut nutritient (completely digestable, no rests) for 7 days before and 7 days after surgery. This is sometimes better tolerated and prevents soiling of the post-op bandage.
After surgery, the vaginoplasty bandage remains closed for 5 days, and is opened after for inspection.
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.
Dilatation is usually recommended for the first 6 months post-op. After 6 months, if the patient has regular sexual intercourse the use of dilators will not be needed. The dilation regimen requires the use of tutors increasing in diameter from 20mm to 32mm with a length of about 13cm; initially they are used three times a day for about 50 minutes each time. Once the desired dimensions are reached, it will be sufficient to use them 2-3 times a week, or less if the patient has regular sexual intercourse. It is required to apply a generous amount of water-based lubricant before using the dilators, to avoid tissue damage and pain.
Until the transplant of the female reproductive organs 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 a secondary vaginoplasty is indicated to improve the functionality of the neovagina.
What to expect after SRS?
- Neo-vagina with vaginal orifice and considerable penetration depth
- Clitoris with sensation, capable of orgasm
- Normal urinating
- Major and minor labiae
What not to expect after SRS?
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.
Sigmoid colon vaginoplasty (as a secondary procedure mostly) also carries the risk of abdominal adhesions and anastomotic leaks.
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 and endocrinologist. This is required by law.
Certain treatment adjustments,medical tests, blood tests or blood donations are required:
- Autologous blood donation for intraoperative and postoperative use
- Stop hormone replacement therapy with estrogens 1 month prior to surgery to decrease the risk of cardiovascular events
Permanent epilation prepares the skin we need to displace for this surgery. This includes the scrotum and the shaft of the penis. Electrolysis is preferred.
In a pre-operative consultation, we will decide together where to obtain the skin graft to complete the interior of the vagina. Also the desired depth of the vagina shall be discussed.
Before the surgery:
- Prophylactic antibiotic therapy - 24h prior to surgery
- Bowel preparation with liquid diet, enemas and/or laxatives, depending upon the chosen surgical technique and the surgeon. Alternatively astronaut nutritients.
Location of the surgery:
The surgery will take place in the Sint-Elizabeth Ziekenhuis in Zottegem (NOT at 2pass Clinic in Antwerp) with a 7 day admission in the hospital.
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