MALE TO FEMALE GENDER REASSIGNMENT SURGERY

 

Gender Reassignment Surgery aims to create a functional vagina with an external appearance as close as possible to that of a genetic female, together with the associated sensations and feelings
At P-PS, Doctor Sanguan achieves this via a two stage procedure, to ensure that the necessary skin grafts for the vaginal tunnel are carried out after an initial healing process of approximately 7 days. During this time newly formed granulation tissue provides an abundant blood supply, thus reducing the possibility of the skin graft failing.

STAGE 1

The creation of a vaginal tunnel (Vaginoplasty)
The removal of the penis (Penectomy)
The removal of the testes (Orchidectomy)
The construction of clitoris, clitoris hood, and labia minora (Labiaplasty).
The construction of a new urethra opening (Urethroplasty)

Since 2005 Doctor Sanguan has improved GRS techniques by using all of the sensitive skin from the penile head and prepuce skin cuff, with blood supply and nerves intact, to fashion the clitoris, clitoris hood and labia minora. By this process, the top of the glans becomes the neo-clitoris, and the underside forms the inner section of the labia minora – all preserved as one piece of skin. The color of the new labia minora will match that of the former prepuce skin. This new procedure significantly improves the external appearance of the new genitalia, as well as enhancing sensitivity.

STAGE 2 (after approx. 7 days)

Skin graft using, whenever possible, scrotal skin to line the new vaginal tunnel.

Although many GRS surgeons discard excess scrotal skin, Dr. Sanguan has found it to graft successfully in the majority of cases, thus making additional skin grafts unnecessary. After the scrotal skin is removed during the first stage of surgery, it is safely refrigerated at 4 degrees Celsius (approximately 39 degrees Fahrenheit), where it will remain healthy for up to 3 weeks, far longer than necessary. Before grafting, Dr. Sanguan carefully scrapes the scrotal tissue to remove hair follicles, thus preventing hair growth inside the vagina. This technique means patients do not require expensive and sometimes painful scrotal electrolysis prior to GRS.

The average vaginal depth will be 4-5 inches when grafted from the available penile and scrotal skin.

If, however, Dr. Sanguan concludes that the penile and scrotal skin is not sufficient to construct a functional or sufficiently deep vagina, he will recommend one of the following three skin graft options:

1. Full Thickness Skin Graft.
Excess or loose skin from the tummy, hip area or groin is added to the penile and scrotal skin. The donor site for the graft will leave a linear or horizontal scar. This is the best, and least invasive, choice.

 

2. Split Thickness Skin Graft.
Skin is removed from the thighs or buttocks and is added to the penile and scrotum skin. The donor site for the graft will leave a scar of approximately 50-100 square centimeters (8-16 square inches), similar to a deep abrasion or burn injury. The bandage covering the donor site will dry out and detach approximately two weeks after surgery. In most cases its initial poor appearance improves over time. However in some cases, the donor site may end up with a hypertrophic or keloid scar with little or no visual improvement.

3. Secondary Colon Vaginoplasty.
After a minimum of six months the patient may return for a colon vaginoplasty. This involves removing a section of the colon and constructing a self-lubricating vagina. The abdominal incision for the graft will leave a scar similar to that for women who have given birth by Cesarean Section.
However, this is an invasive and complicated procedure, and complications such as infection, and leakage of anastomoses or fistulas, though not common, may occur. The treatment for these complications is re-operation and on rare occasions, temporary colostomy cannot be avoided.

 

SURGERY SCHEDULE DETAILS

Upon arrival at Phuket International Airport, patients will be met by a representative of P-PS and will be transported to their place of residence or to Phuket International Hospital.

Hospital Admission

Patients will be admitted to hospital one day prior to the operation and will be asked to complete some forms. Chest X-ray and EKG test will be carried out, unless recent, acceptable test results from the patient’s personal physician are available. To avoid unnecessary extra punctures, a complete blood count and other blood tests will be undertaken whilst on intravenous (IV) fluid on the morning of surgery.
In addition, a local Thai psychologist will carry out a brief consultation, as required by the ethics code of the Medical Council of Thailand.

Pre-operative evaluation

On the day before surgery, Dr. Sanguan will carry out an evaluation of fitness for surgery. He will review the personal and medical history, including allergies. After a brief physical examination, he will evaluate the quantity and quality of the penile and scrotal skin and will provide an estimate of vaginal depth.

Anesthetic consultation

The anesthetist will either visit on the day before your operation or he will consult with the patient at the start of surgery.

Pre-operative practices

The day before the operation, only light, easily digested, low-fiber meals such as soup, sandwiches, and fruit juices should be consumed. Hot and spicy or hard-to-digest food including meats should be avoided. In the evening, the nurse will shave the genital area and provide a strong laxative solution. After midnight, no food or liquids can be consumed as the stomach must be completely void during the operation.

GRS Stage 1 surgery

On the morning of surgery, the patient will be placed on an IV and, in the operating room (OR), a general anesthetic is administered through the IV. Endotracheal intubation (the insertion of a tube into the windpipe), and epidural catheterization (the insertion of a catheter near the spine in the lower back) are performed. Once the operation is finished, the endotracheal tube is removed in the OR or in the Recovery Room. The epidural catheter is retained for use during later procedures, and removed when these are completed.

Post-operative care

After Stage 1 surgery, patients will be kept in the Intensive Care Unit (ICU) for a few hours or overnight, depending on the speed of recovery. Oral painkillers will be provided and intravenous or intramuscular injections of Demerol or Morphine to relieve pain can be given though only at the request of the patient. Medicines, as ordered by the surgeon, will be given every 2-4 hours

Day 2: Recovery in bed

Patients must remain in bed for the first couple of days after surgery. Standing on the floor or walking is not allowed as this may aggravate bleeding.

Following surgery two catheters emerge from the surgical dressing.
The first is from the urethra (Foley's catheter) and is used to drain urine form the bladder into a urine bag beside the bed. A small amount of blood or white fluid may be mixed with the urine but this need not be of any concern.
The second is from the sponge packing inside the vaginal tunnel (Vacuum Assisted Closure or VAC). The VAC catheter is connected to a pressure-adjustable suction unit on the wall beside the bed. With suction set at approximately 100 mm Hg, the VAC produces negative pressure inside the vaginal tunnel and the perineum wound, enhancing granulation tissue growth, promoting healing, and preventing swelling. The VAC dressing keeps the surgical area dry and relatively comfortable. It is not a problem if some urine runs through the VAC catheter. The VAC catheter will be replaced 3-4 days after surgery.

Administering ice packs can help reduce swelling after surgery. The nurses will provide gel packs, which can be kept cold in your room refrigerator.

Care should be taken not to pull or damage the epidural catheter taped to the lower back, since it will be used in later surgical procedures.

Day 3: Continued recovery

Assuming recovery is proceeding normally, and no bleeding or additional swelling occurs, patients may, with the help of a nurse, get out of bed. Before getting up, the nurse will empty the urine bag and release it from the bed. She will also disconnect the VAC catheter from the suction unit. Both catheter tubes must be carefully carried when walking around. Upon returning to bed, the VAC catheter must be reconnected to the suction unit by a nurse.

Any abnormal sounds from the perineum area, though rare, may be caused by a leakage through the plastic bandage that covers the sponge. If this occurs the nurse should be called attend to this.

It is important to realize that the more time spent connected to the VAC, the faster the healing process will be.

Day 4/5: Changing the VAC dressing

Dr. Sanguan will re-schedule a return to the OR to change the VAC dressing under epidural anesthesia (using the catheter retained in the back). Food and drink are not allowed for 8 hours before the operation and IV fluid will be started again several hours before surgery. The procedure takes about 1/2 hour, and two hours later, patients can again get out of bed if they wish.

Days 5 -7: Continued rest and preparation for second surgery

Patients can resume light activity by walking around the hospital or cafeteria, but as much time as possible should be spent in bed connected to the VAC suction unit.

If there has been no bowel movement during the day before the scrotal skin graft vaginoplasty, the nurse will give an enema the night before. As before, patients are not allowed to eat or drink anything 6-8 hours before the operation and IV fluid will be started again in the morning.

Day 8: Scrotal skin graft surgery

The final operation, the scrotal skin graft, is done under epidural anesthesia, again using the epidural catheter implanted in the back during the first surgery. If, however, the catheter is obstructed or broken down, the anesthetist will redo spinal anesthesia or switch to general anesthesia. Dr. Sanguan will take the scrotal skin from the tissue bank and clear it of all hair follicles, fascia, sebaceous glands and fat. He will then create a tube of the scrotal skin around tubular packing material. This process takes about half an hour.

He will remove the VAC dressing, clean the area, and check for any bleeding or blood clotting inside the vaginal tunnel. He will then insert the scrotal skin graft tube into the vaginal tunnel. Both the Foley's catheter and the VAC dressing are retained. The dressing prevents the skin graft tube from sliding out of the vaginal opening.

Days 9-10: Total bed rest

After scrotal skin graft vaginoplasty, patients must stay in bed for 3 full days to help ensure the graft's success. Patients may lie on their back, sides or front and may sit up at the side of the bed, but under no circumstances should standing or walking be attempted. The VAC suction must be connected at all times. In the event of the onset of a bowel movement, the nurse should be asked to provide a bedpan. No attempt to get up to visit the toilet must be tried as this could have disastrous consequences on the skin graft. Ice packs may be used to reduce swelling if desired.

Days 11: Semi bed rest

Some standing and a little walking is permissible but the VAC suction must be connected at all time. If a bowel movement is needed, a "Com Mode", a special chair for bowel movement placed at the bedside, will be provided. Great care of the vagina VAC packing must be taken. If there is a need to cough or "push" during bowel movements, patients must use their hand to hold the vagina opening packing to prevent the packing inside the vagina canal from slipping out.

Days 12/13: Removal of packing and starting dilation

Four to five days after the scrotal skin graft, and assuming no complications, Dr. Sanguan will remove the Foley's and VAC catheters and the vaginal packing material. He will inspect the new organs and skin graft. He will familiarize the patient with the anatomy of the new vulva and instruct on proper care and attention. If urination is still difficult, it may be necessary to retain the Foley's catheter until this difficulty is resolved.

Patients will begin vaginal dilation while still at the hospital. A set of dilators are provided free of charge together with guidelines for their use. The nursing staff is available to teach and help supervise the dilation process. Dilation needs to be regularly carried out for at least 6 months after the operation

Day 14: Release from Hospital

P-PS will arrange complimentary transportation from the hospital to the patient’s hotel or directly to the airport, and to facilitate this patients are requested to inform the clinic’s foreign coordinators of departure plans. Several copies of a medical certificate, verifying that successful GRS has been undertaken at Phuket Plastic Surgery, will be provided.

Days 15 -21: Local Recuperation

Dr. Sanguan recommends that, if possible, patients stay in the Phuket area for 5-7 days following discharge. One of the clinic’s foreign coordinators can make accommodation arrangements, at a residence of the patient’s choice. A follow-up appointment with Dr. Sanguan can also be arranged before departure from Phuket.

 

POST OPERATION ACTIVITIES

The majority of patients can start light activities within a few weeks after surgery. However, P-PS recommends that patients do not return to work until 8 weeks after GRS. Vaginal dilation needs to be undertaken 3 times a day regularly for at least 6 months in order to maintain vaginal depth and width. Sexual intercourse can be tried 8 weeks after surgery. For heavy exercise such as cycling and horse riding, the patient should wait for at least 3 months after surgery.

 

POST - OPERATIVE CARE AT HOME

Usually it takes six months for complete recovery of the vulva and the vagina canal. During the first few weeks, patients may experience some minor inconveniences such as vaginal spotting, difficult scarring, skin irritation, asymmetrical swelling of the vulva and tight vagina canal.


DILATION PROGRAM

To keep the vagina open, patients must dilate the vagina with the dilators provided by the clinic for a minimum of 6 months.
A set of 6 dilators made from hard transparent resin plastic will be provided free of charge. The diameters of the dilators range from 26 mm. (No.1) to 34 mm. (No.6). The surface of the dilators is very smooth and can be used directly.

During the first two months, it is recommended that patients dilate the canal every day, 3 times a day. After 2 months, the patients can reduce dilation to 2 times a day if they find that there is no difficulty in keeping the vaginal canal open. After 6 months dilation should be continued once every other day, although patients who have sexual intercourse with a male partner regularly might not need further dilation. The vaginal channel should be cleaned regularly.

The dilators (stents) must be cleaned by antiseptic such as Dettol or Betadine before use, and the vaginal orifice should be cleaned before and after dilations by using a diluted Dettol solution. For the first dilations, patients may find it useful to use a mirror to localize the vaginal opening. Users should apply a water based lubricant such as KY jelly either on the dilator or to the vagina and then direct the dilator towards the navel (forward) rather than towards rectal wall. The more relaxed, the easier the dilations will be.

During the first week of dilation, the skin graft along the vaginal canal is not strong enough to tolerate too much pressure and friction from the dilators and, therefore the dilators should not be held inside the canal for too long. Patients should insert and remove the dilator slowly and gently, starting from the smallest dilator and working up to the larger sizes. Patients are encouraged to use the larger dilators provided there is not too much pain.

From the second week, after the skin graft has become stronger, the dilators can be retained inside the vaginal canal for longer periods. Again, patients should dilate from the smallest up to the largest that can be accommodated. It is recommended that users should retain the largest dilator for 15 minutes. It is common that a small level of pain or discomfort will be felt and possible that some blood spots and discharge will occur during dilation. If more bleeding occurs, dilation should be stopped for one day and tried again once the bleeding has stopped.

It is important that the dilation process is not rushed, and if insertion of the larger dilators is difficult it should be delayed until it is more comfortable. If the patient is relaxed and the vaginal swelling is not too bad, the dilation will be easier. Note that the small dilators help maintain the depth and the large one will maintain the width.

After the operation, the vagina is approx. 4.5–5.5 inches in depth and 1.0-1.3 inches in diameter. Most patients can maintain this initial depth and diameter by regular dilation, and, indeed some may see an increase in size later.

 

VAGINAL DOUCHES

For a few weeks after surgery, patients may notice some discharge of fragments from the vagina. This is exfoliation of the scrotal skin that covers the interior of the vagina, and is quite normal. The regular use of vaginal douches is very important in order to clean the vagina of this exfoliation and also to promote interior healing. Normally, 3 cc. of Dettol (approx. half of a cap) mixed with 200-300 cc. of drinking water or tap water is generally used. It is recommended that patients take a vaginal douche every time after dilation until there is no more discharge. It is then only necessary to clean the inside of the vaginal canal with other female hygienic solutions or just pure water. In the rare event that the vaginal discharge is heavy or is foul smelling, it may be a sign of infection or non-healing of the wound. In this instance patients should consult their gynecologist or physician to assess the cause.

 

BOWEL MOVEMENTS

During the first 3 - 4 weeks after the operation, it is essential to take a bath or shower after each bowel movement to clean the anal and genital area, because there are still some small wounds in the genital area. The anus should be wiped towards the rear so as not to contaminate the vulva and the vagina.

URINATION

For the first 3 - 4 weeks, it may not be possible to urinate normally. Due to the build up of fluid in the tissues locally (edema) the urine may come out as a spray or in a crooked direction. This will improve and, with time, patients will be able to urinate normally.

Whilst in hospital following the operation, some patients may experience an obstruction to the urethra opening due to local swelling. If this occurs, the nurse will reapply the urine catheter and leave it for a little longer until the swelling subsides. During that period, the bladder is trained by clamping the catheter and releasing it every 4 hours. This technique will help revive the bladder’s function. Very few patients need more than 2-3 repetitions of catheterization before they can urinate successfully.

 

SEXUAL INTERCOURSE

Normally, patients may start to have sexual relations after the vaginal discharges have ceased, usually 6 - 8 weeks after the operation.

Some patients may experience some small clear viscous fluid being released through the urethra during sexual arousal. This fluid is produced from the Cowper’s gland located within the prostrate gland. It contains no sperm since both testes are removed during surgery. However, the prostrate gland itself is not removed, so patients may still have some risk of prostrate cancer and therefore require PSA screening tests from time to time.

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