A Complete Guide To Male-To-Female Sex Reassignment Surgery (SRS MTF)

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Table of Contents:

• Introduction to gender reassignment surgery
• History of gender confirmation surgery
• What to expect from male-to-female gender reassignment surgery
• Who is a good candidate for MTF sex reassignment surgery
• Types of Vaginoplasty
• Penile Skin Inversion Vaginoplasty
• Sigmoid Colon Vaginoplasty (Intestinal Vaginoplasty)
• Penile and Scrotal Skin Vaginoplasty
• Risk and complications of MTF gender reassignment surgery
• Sex Reassignment Surgery In TransgenderThailand

Introduction to gender reassignment surgery

Sex reassignment surgery is a term used to refer to a series of surgical procedures and reconstructive surgery techniques designed to make the genitalia of the patient into that of their gender identity.

In the case of transsexual women, surgical techniques are used to transform the male genitalia into a natural-looking and functional vagina.   This means transgender women who undergo this surgical procedure would be able to urinate normally and experience erogenous sensitivity during sexual intercourse.

There are many surgical procedures under sex reassignment surgery. These include labia majora and labia minora reconstruction, orchiectomy, clitoris reconstruction, and bottom surgery.

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History of gender confirmation surgery

The first modern sex reassignment surgery was performed in 1931 in Germany. At the time, plastic surgeons attempted to transplant a uterus and one ovary. The patient died three months following sex reassignment surgery.

In 1952, Danish plastic surgeon Paul Fogh-Andersen performed MTF surgery on George Jorgensen, a WWII veteran. George, who later changed her name to Christine, advocated for the sexual health of transgender patients, raising awareness of the medical and surgical options available to trans men and trans women.

Christine's effort to raise awareness about sex reassignment surgery gave hope to transgender patients suffering from gender identity disorder or gender dysphoria. Her efforts also helped propagate transgender health.

In Thailand, the first sex reassignment surgery was performed by Dr. Preecha Tiewtranon and Dr. Prakob Thongpaew at the Chulalongkorn University Hospital in 1975. Transgender surgical techniques and therapies later became the subject of much research and development, with the aim of improving techniques to improve the results of facial feminization surgery and other surgical procedures.

Today, Thailand is considered to be the most advanced country in terms of masculinization and feminization surgeries for transsexual patients.

What to expect from male-to-female gender reassignment surgery

Many health experts believe the ideal goals of every transgender surgery should include:

• The creation of a genital region should be as natural and aesthetically accurate as possible
• The neovagina should be at least 3 centimeters in diameter and have 10 centimeters of vaginal depth
• The neovagina should be capable of self-lubricating
• The vaginal opening should be hairless
• The neovagina should be elastic to allow for penetrative sexual intercourse and sexual satisfaction

As in all surgeries, plastic surgeons have a goal of using a technique that would create give patients the lowest risks and lowest complication rates but creates minimal scarring.

As of today, it is possible for transgender women to obtain a vagina that looks natural and permits penetrative sex. However, there are currently no available plastic surgery techniques that can give transgender women reproductive function.

Who is a good candidate for MTF sex reassignment surgery

There are several prerequisites that female transsexuals must meet to be eligible to get vaginoplasty. These prerequisites are outlined in the Standards of Care 7th edition by the World Professional Association for Transgender Care (WPATH) and include:

• Persistent diagnosis of gender dysphoria
• Ability to make a fully informed decision
• The absence of any pre-existing medical conditions that may make performing the surgical technique too risky
• At least 12 months of continuous hormone replacement therapy
• At least 12 months of living in a gender role that is aligned with their gender identity

Types of Vaginoplasty

Penile Skin Inversion Vaginoplasty

Penile skin inversion or penile inversion is the "gold standard" for a primary vaginoplasty or male to female sex change surgery.

Under penile inversion surgery, the surgeon would perform a penile dissection to create the vaginal canal, labia majora and labia minora, and the clitoris.

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Sigmoid Colon Vaginoplasty (Intestinal Vaginoplasty)

With sigmoid colon vaginoplasty or sigmoid colon graft, the neovagina is created using a section of the intestine.  Sigmoid colon vaginoplasty is typically done when the primary surgery does not yield expected results.

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Scrotal Skin Graft Vaginoplasty – Dr. Suporn's technique

This SRS technique was first used in the year 2000 by Dr. Suporn Watanyusakul and involves using the scrotal skin in creating the vaginal canal. However, if the scrotal skin is not sufficient, the surgeon may also use groin skin flaps.

The technique also uses penile skin to create the labia minora, clitoral hood, and other details of the external genitalia for the transgender woman.

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Scrotal Skin Graft Vaginoplasty – Dr. Chettawut's technique

Dr. Chettawut Tulayaphanich uses scrotal skin graft to create the vaginal lining, sometimes adding groin skin graft if the scrotal skin is insufficient. He also utilizes the penile skin to create the labia majora and minora, as well as the clitoral hood.

Dr. Chettawut's approach generally gives more vaginal depth than penile skin inversion.

In both Dr. Suporn and Dr. Chettawut's surgical approach, the bulbourethral glands are retained. This means the neovagina would be able to lubricate itself naturally. Additionally, the nervous branches are preserved, allowing patients to have sensitivity and reach orgasm during sexual intercourse.

Risk and complications of MTF gender reassignment surgery

The risks and complications of Male to Female Surgery (SRS) are not specific to this surgery but shared with any other surgery. These include:

• Allergic reactions or risks to general anesthesia
• Bleeding (post-operative and intra-operative)
• Infections
• Visible scarring
• Poor healing
• Damage to surrounding tissues

Specific risks of SRS surgery include:

• Urethral strictures
• Narrowing of the neovagina
• Meatal stenosis
• Rectovaginal fistulae
• Graft necrosis
• Loss of sensitivity
• Abdominal adhesions (Sigmoid colon graft)
• Anastomic leaks (Sigmoid colon graft)