Vaginoplasty in Gender Confirmation Surgery: Stages, Care, and Results

Vaginoplasty is one of the important stages in gender affirmation surgery for trans women. In this stage, the male genitalia is converted into female genitalia, and the person achieves their gender identity. This surgery is also one of the complex medical procedures that must be performed by a professional and experienced staff. This operation is currently performed in Iran by specialized Iranian doctors, and many individuals undergo it annually. The percentage of patients' sexual satisfaction increases significantly after this procedure, and individuals experience a normal sexual and daily life afterward. Stay with us to fully familiarize yourself with this advanced medical procedure.

What is Vaginoplasty in Gender Confirmation Surgery?

As mentioned in the introduction, Vaginoplasty is one of the stages of gender affirmation surgery. In this procedure, the male genital structures are removed or repurposed. Then, a new vagina with a natural appearance, suitable depth, and function similar to a natal vagina will be constructed. In this operation, various parts of the body such as the skin of the penis, the scrotum, or the intestine are used to construct the vaginal wall. A clitoris is also created in this operation to allow for sexual sensation after intercourse. The main goals of this procedure include:

• Constructing a vaginal canal with sufficient depth.
• Creating a sensitive clitoris.
• Constructing the inner and outer labia.
• Creating a natural vaginal opening.

The Difference Between Vaginoplasty in Gender Confirmation and Cosmetic Vaginal Surgery

Vaginoplasty (gender confirmation) and cosmetic vaginal surgery (like labiaplasty or vaginal tightening) are vastly different. In cosmetic surgery, the genitalia is not changed, but only modifications are made to the existing structure to enhance the appearance. In Vaginoplasty, the person has male genitalia. The surgeon must convert, shorten, or reconstruct the male tissues and transform them into female genitalia. Also, the urethra must be reconstructed in this procedure. In fact, Vaginoplasty is much more complex than cosmetic vaginal surgery.

Types of Vaginoplasty Surgical Methods in Gender Confirmation

Doctors use various methods to perform Vaginoplasty surgery. The doctor considers the patient's condition and goals for the operation and chooses the most appropriate surgical method.

Penile Inversion Method

This method is the most common and main procedure for converting male genitalia to female genitalia worldwide. In this technique, the skin of the male penis is inverted (turned inside out) and used to create the vaginal canal. Scrotal tissue is used to construct the labial tissue. The clitoris is also constructed from the tip of the penis, which has the highest nerve density. As a result, the level of sexual sensitivity in this method will be high. Due to the fact that the appearance of the new genitalia is very natural and even the possibility of experiencing orgasm exists in this method, it is used more than other methods in most countries worldwide. The only limitation of this method is its reliance on the amount of penile skin. If individuals have a small penis or have been circumcised, they may experience less depth than others.

Rectosigmoid Vaginoplasty (Use of the Large Intestine)

If the person's genitalia lack the sufficient skin for the first method, doctors use the second method, which utilizes the large intestine. In this procedure, a section of the sigmoid colon is removed and used to construct the new vagina. This method is a heavier surgery than the first method and requires an abdominal incision or laparoscopy. In this method, the risk of infection is higher, and the recovery period is longer. Individuals must follow post-operative care with greater diligence. The advantage of this method is the natural secretions and permanent moisture of the vagina, as the intestine is naturally moist. In this method, the level of sexual sensitivity is lower than in the first method.

Non-Penile Inversion Method

In this method, the skin of the penis is used again, but combined with a skin graft from other areas such as the thigh or abdomen. Due to the use of sufficient skin, this method will result in greater depth compared to the first method, but it creates more scarring. This method will be used for patients whose genitalia lacks sufficient skin and who want to experience a high level of sexual sensitivity.

Comparison of Methods in Terms of Depth, Sensation, and Appearance

To accurately compare the different methods, a comparative table of the various techniques is provided below.

Preparation Before Vaginoplasty in Gender Confirmation Surgery

For the gender confirmation surgery to be successful, individuals must take the necessary steps and prepare before the operation.

Pubic Hair Removal (Laser)

One of the important steps that individuals must take before Vaginoplasty is the complete laser removal of hair in the penile and scrotal areas. If this stage is not completed, hair follicles in these areas will remain active. As a result, hair will grow inside the vagina after the operation, which will be very painful and problematic. Therefore, individuals must undergo about six to eight laser sessions before the surgery to completely remove their hair.

Stopping Medications and Sexual Preparation

Individuals must stop taking certain medications about two weeks before the operation. For example, blood thinners like aspirin or warfarin should be discontinued two weeks before the surgery. Also, estrogen consumption is stopped a few days before the operation to reduce the risk of blood clotting. At this stage, the individual's iron level, vitamin status, and heart condition are also checked to ensure the doctor that the person is ready for the surgery. Smokers must also quit or reduce their consumption to the absolute minimum a few weeks before the operation.

Psychological Evaluation and Obtaining Legal Authorization

Before any procedure, it must be psychologically confirmed that the person truly needs a change in gender identity. In Iran, and according to WPATH standards, the individual must have been on hormone therapy for at least one year, and a psychologist and psychiatrist must confirm the need for surgery. Only after this confirmation is the legal authorization for the operation issued.

Nutrition and Pre-operative Recommendations

Nutrition and diet before and after the operation are very influential in the success of this surgery. The consumption of low-fat foods, fresh vegetables, sufficient water, and avoidance of excessive salt is recommended. It is better for the person to consume light and low-fat foods 24 hours before the operation and to fast on the day of the surgery.



Stages of Vaginoplasty in Gender Confirmation Surgery

Vaginoplasty is performed under general anesthesia in all methods. This surgery will take about three to six hours, depending on the method used. After anesthesia, the testicles are first removed, and then the penile skin is separated. In the penile inversion method, which is the most common procedure, the skin is inverted and returned inside the body to form the vaginal canal. Then, another section of the skin is used to construct the labia, and the clitoris is created from the tip of the penis. The surgeon must carefully preserve the sensitive sexual nerves. Also, the urethra is relocated to a new position so that the person can urinate like an ordinary woman. In the final stage, a dressing and a vaginal mold (stent/dilator) are placed inside the vagina.

Operation Duration and Hospital Stay

The duration of the hospital stay after Vaginoplasty is between four to seven days. During these few days, dressings are checked and changed daily. Also, necessary instructions regarding post-operative care will be provided to the individuals during these days, as they need to be followed up and cared for for several weeks after the operation.

Satisfaction Rate with Gender Confirmation Vaginoplasty

Studies and statistics show that between 80% and 95% of individuals are satisfied with the result of the operation. Most patients gain more self-confidence after the operation, and their quality of life increases significantly. Studies have shown that individuals are highly satisfied with the appearance of the vagina, engaging in sexual intercourse, the ability to achieve orgasm, the depth and function of the vagina, and their quality of life after the operation.

Post-Vaginoplasty Care and Recovery Period

Care after Vaginoplasty starts from the first day and during hospitalization, and complete recovery requires two to three months. The individual must fully adhere to all medical instructions. They should take antibiotic and anti-inflammatory medications on time and avoid heavy activities in the first few weeks. Also, activities such as long periods of sitting, cycling, or any activity that puts pressure on the genital area are prohibited for a few months. The sutures used in this operation are absorbable and will disappear completely within a few weeks. As a result, the vagina takes on a natural appearance after a few weeks.

Proper Nutrition in Gender Confirmation Vaginoplasty

After the surgery, the person must consume light foods, sufficient protein, fruits, and vegetables, and drink plenty of water. These nutrients speed up the wound healing process. Also, soft foods should be consumed in the first week to reduce pressure on the abdomen and pelvic area. White meat, eggs, fish, leafy green vegetables (like bell peppers), carrots, colored fruits (like strawberries, oranges, and kiwi), and high-fiber foods (like bran) are among the nutrients the person should consume after the operation.

Hygiene Care (Showering, Toileting, and Clothing)

Observing hygiene after the surgery plays a crucial role in preventing infection, reducing inflammation, and quickening wound healing. It is best for the person to avoid full showering for two to three days after the operation. A damp sponge or soft cloth and lukewarm water can be used to clean the genital area. After three days, a short shower with lukewarm water can be taken. A short daily shower is sufficient in the first week. Also, it is better to use a Western-style toilet (sitting toilet) in the first two to three weeks to reduce pressure on the body and genital area. Underwear should be chosen from cotton and loose-fitting types so that air circulates well and moisture does not remain in the genital area. Also, avoid wearing tight and restrictive trousers as much as possible.

Dilation After Vaginoplasty

The vaginal opening may develop adhesions after the surgery. Therefore, dilation must be used after the operation to keep the vaginal canal open. Dilation is one of the most important stages after Vaginoplasty, starting about one week after the operation. It is usually needed three times a day in the first month, one to two times a day in the second and third months, and a few times a week from the sixth month onward.

Sexual Function After Vaginoplasty

If the sensory nerves are correctly preserved during the surgery, the individual can experience sexual sensation and even orgasm after gender confirmation surgery. It usually takes three to six months for the new genital area to regain its natural sensitivity. Statistics show that individuals have been able to have completely normal sexual activity after a maximum of one year.

Potential Complications of Vaginoplasty and Prevention Methods

If this surgery is performed by specialist doctors, it will have very few complications. However, in very rare cases, Vaginoplasty may have complications such as bleeding, infection, urethral stricture, reduced depth, or fistula.

Cost of Vaginoplasty in Iran and Other Countries

Vaginoplasty is considered a costly surgery both in Iran and in other countries worldwide. However, its cost in Iran is lower compared to other countries. In Iran, the cost of Vaginoplasty varies between 140 to 300 million Tomans, depending on the surgeon's conditions, the type of method used, and the surgeon. The cost of this operation in Europe and the USA will be between $25,000 and $50,000. In other Asian countries like Thailand, this operation will cost around $10,000 to $18,000.



Physiotherapy and Rehabilitation After Vaginoplasty in Gender Confirmation Surgery

After the surgery, some physiotherapy movements greatly help reduce pain and prevent vaginal narrowing. For example, pelvic floor physiotherapy helps reduce pain, better muscle control, and improved sexual intercourse. Physiotherapy is prescribed by a specialist doctor if needed, and the person must perform it after the surgery.

Conclusion

Vaginoplasty is a very important stage in gender identity affirmation surgery. In this stage, the male genitalia is converted or repurposed into female genitalia. This surgery is performed using various methods, such as inversion or the use of other body tissues like the intestine. Studies show that after the surgery, individuals are highly satisfied with their new identity, sexual life, and general health, and have gained more self-confidence.

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Frequently Asked Questions

When should I start dilation?

It should usually be started from the first week under the supervision of the surgeon.

When can I have sexual intercourse?

About eight to twelve weeks after the operation, depending on the condition of the stitches and the patient's condition.

Will I need revision surgery?

Approximately 10% to 20% of individuals may need minor corrections.

What is the role of exercise in returning to sexual activity after Vaginoplasty?

Pelvic floor exercises increase muscle control and reduce pain.

Is it possible to have an orgasm after surgery?

Yes, if the sensory nerves are properly preserved, the possibility of orgasm is very high.

 What are the necessary conditions for Vaginoplasty or Vulvoplasty in trans patients?

Formal diagnosis, hormone therapy, physical health, and psychiatrist confirmation must be present to undergo this procedure.

What is the natural depth of the vagina after Vaginoplasty?

Depending on the method used, the depth of the vagina after the operation can range from 12 to 15 cm in inversion and up to 18 cm in the intestinal method.

Does the constructed vagina have sexual function?

Yes, the ability to have sexual intercourse and sexual pleasure exists after the operation.

Does urination change after Vaginoplasty?

The direction of urine flow changes, but normal function will be preserved.

What will my vagina look like?

A few weeks after the operation, as the stitches are absorbed, the vagina will be very close to a natural appearance.