During gender confirmation surgery (GCS), Dr. Alter creates as normal of a vagina and introitus as possible, provides maximal clitoral and vaginal sensation, creates a deep vagina allowing satisfactory sexual intercourse, and minimizes disfiguring scars. To accomplish these goals, many small steps are necessary that require time, patience, and expertise. The operation is both cosmetic and reconstructive, so maximum attention to detail is necessary to achieve the best result for the patient.
Penile Skin Inversion Technique
A portion of the glans (head of the penis) with its nerve supply is converted into the clitoris. This sensitive clitoris maintains normal erogenous sexual sensation and allows patients to have orgasms.
Some other techniques amputate the glans or invert it into the vagina, usually without maintaining normal sexual sensation; these procedures usually use spongy tissue surrounding the urethra to create a clitoris. During the clitoris creation, Dr. Alter uses a small amount of penile skin just below the glans to create a clitoral hood. The testicles are removed.
The skin of the penis is inverted to create the vagina. The depth of the vagina is important to most patients, especially those desiring sexual intercourse. The depth of the vagina is determined by the amount of shaft skin, the anatomical structure of the pelvis, and the patient’s compulsive dilations. Dr. Alter routinely uses a skin graft from extra scrotal skin and attaches it to the deepest part of the penile skin to achieve a deeper vagina. The skin must be hairless in order to prevent hair growth inside the vagina, so the hair is removed first by multiple electrolysis treatments. Occasionally, a patient may not have sufficient penile shaft skin or scrotal skin for a deep vagina, so flank skin is then also used. Usually this results in a linear scar.
Dr. Alter has also expanded the scrotal skin on patients with little penile and scrotal skin in order to provide enough skin for the vagina, eliminating the need for a flank skin graft. This procedure requires inserting a balloon-like tissue expander into the scrotum several months before the GCS and gradually adding fluid to the expander to increase scrotum size. This new procedure has worked well on several of his patients.
The remaining scrotum is tailored to make the labia majora or outer lips, and various other techniques are used to create labia minora or inner lips. Dr. Alter spends considerable time performing intricate maneuvers that give the genitalia a more normal appearance and minimizes scars. Only occasionally does he perform a secondary surgery to enhance the appearance, since most of his patients are very happy with their single-stage operation. Nonetheless, some refinement is usually possible.
Electrolysis Treatments
Electrolysis treatments should be performed on the entire penis and scrotum except for a small area on each side of the scrotum. This allows the use of the maximum amount of scrotal skin for the graft. Even if a scrotal skin graft is not required, electrolysis should be performed on the area just below the scrotum on the midline. This skin is used as a flap to widen the vagina, so hair growth at this location can be uncomfortable or unsightly. A numbing cream can be used to lessen the discomfort from electrolysis. Laser hair removal is not considered permanent at this time, so it is not recommended.
All electrolysis treatments can be performed in Dr. Alter’s accredited operating rooms under sedation. An electrologist performs complete scrotal and penile removal in three extended sessions, which last approximately five hours each. An anesthesiologist performs sedation and local blocks, so the procedure is comfortable.
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Vaginoplasty Using Rectosigmoid Colon
The procedure is performed in the same manner as using full thickness skin grafts, except the vagina is constructed from rectosigmoid colon in place of skin grafts. The advantage is that the vagina is lubricated and deep. However, this lubrication is mucus and can be overly produced by the vaginal lining. A major disadvantage to this procedure is that it is a more invasive operation requiring entry into the abdominal cavity requiring bowel surgery. A rectosigmoid colon vaginoplasty is rarely necessary.
Secondary Genital Reconstruction
Many patientsother surgeons
Some patients may have had narrowing or shortening of the vagina, which prevents sexual intercourse. Colon surgery to deepen and to widen the vagina is very invasive and requires removal of the previous graft or vagina. Dr. Alter rarely performs colon surgery, because he has been very successful opting for full thickness skin grafts to make the vagina deeper. Incisions are made inside the vagina from the 3 to 9 o’clock location, the space is made deeper, and the skin graft is placed. The skin must be hairless, so it is usually taken from the lower abdomen. Dr. Alter does not use split thickness skin grafts, because they tend to contract and are more difficult to stretch. The surgery takes about 5 hours and requires 6 days in the hospital.
