Vaginoplasty: Gender Confirmation Surgery

For transgender and nonbinary people interested in gender confirmation surgery, a vaginoplasty is the process during which surgeons construct a vaginal cavity between the rectum and the urethra. The goal of the vaginoplasty is to create a vagina out of penile tissue — one with the depth and appearance of a biologically developed vagina.

Penile inversion procedure

The most common vaginoplasty technique is a penile inversion procedure. In this technique, penile skin is used to construct the vaginal lining. The labia majora are created using scrotal skin, and the clitoris is built from the sensitive skin at the tip of the penis. The prostate is left in place, where it can serve as an erogenous zone similar to the G-spot.

In some cases, there is not enough skin to achieve the necessary vaginal depth, so surgeons will take a skin graft from the upper hip, lower abdomen, or inner thigh. Scarring from the donation site is typically hidden or minimal.

The use of skin grafting to build the vulva is a topic of controversy among plastic surgeons. Some believe that the extra skin allows for a better cosmetic appearance. Others believe that functionality should not be sacrificed. Skin from donation sites is never as sensitive as skin from the genitals.

The penile inversion vaginoplasty is considered the gold standard genital reconstruction technique among plastic surgeons, and it is recommended by the Center of Excellence for Transgender Health.

Colon procedure

There is another technique that uses the lining of the colon instead of penile skin. Research on the outcomes of this surgery is limited.

One positive aspect of this procedure is that the tissue is self-lubricating, whereas vaginas made from penile tissue are dependent upon artificial lubrication. Because of the associated risks, however, colon tissue is typically used only in the event of a failed penile inversion.

Many people who have a vaginoplasty end up having a second surgery to improve the cosmetic appearance of the labia. A second surgery, called a labiaplasty, provides an opportunity for surgeons to work with healed tissue, where they can correct the positioning of the urethra and vaginal lips. According to the Center of Excellence for Transgender Health, a secondary labiaplasty, which is much less invasive, ensures the best cosmetic results.

On the morning of your surgery you will meet with your surgeon and an anesthesiologist. They will give you an overview of how the day is going to play out. They will probably give you an antianxiety medication or another sedative to help you relax. Then they will bring you to the operating room.

During your penile inversion vaginoplasty, you will be under general anesthesia, lying on your back with your legs up in stirrups.

The procedure is complex, involving delicate tissue, vasculature, and nerve fibers. Here are some of the broad strokes:

• The testicles are removed and discarded.
• The new vaginal cavity is carved out in the space between the urethra and the rectum.
• A penile prosthesis (surgical dildo) is inserted into the cavity to hold the shape.
• The skin is removed from the penis. This skin forms a pouch which is sutured and inverted.
• A triangular piece of glans penis (the bulbous tip) is removed to become the clitoris.
• The urethra is removed, shortened, and prepared for repositioning before the remaining parts of the penis are amputated and discarded.

Everything is sutured together and bandages are applied. The whole procedure takes two to five hours. The bandages and a catheter typically remain in place for four days, after which time postoperative steps should be taken.

There are always risks associated with surgery, but vaginoplasty complications are rare. Infections can usually be cleared up with antibiotics. Some immediate postsurgical risks include:

• bleeding
• infection
• skin or clitoral necrosis
• rupture of the sutures
• urinary retention
• vaginal prolapse
• fistulas

Some of the skin around the scrotum is hairy, as are the areas where skin grafts are taken from. Talk to your surgeon about where your new vaginal skin will be harvested. You may choose to complete a full course of electrolysis to eliminate the potential for vaginal hair growth. This can take several weeks or months.

Follow your surgeon’s instructions on the night before and morning of your surgery. Generally, you should not eat or drink anything after midnight on the night prior to going under anesthesia.

Other presurgery tips:

• Talk to other people who have gotten bottom surgery about their experiences.
• Talk with a therapist or counselor in the months prior to your surgery to mentally prepare yourself.
• Make plans for your reproductive future. Talk to your doctor about your fertility preservation options (saving sperm samples).
• Make a postoperative plan with your family and friends; you will need lots of support.

The average cost for a penile inversion vaginoplasty is around $20,000 without insurance. This includes a few days in the hospital, plus anesthesia. However, this is only for one surgery. If you want a secondary labiaplasty, the costs increase.

Many people who get vaginoplasties also undergo breast augmentation and facial feminization surgeries, which are very expensive. You should also keep in mind the cost of electrolysis, which can add up to thousands of dollars.

Costs will vary depending on your insurance coverage, where you live, and where you get your surgery done.

The long-term success of your vaginoplasty will depend largely on how well you follow the postoperative instructions. Your surgeon will give you a vaginal dilatator to begin using as soon as your bandages are removed. This dilation device must be used daily for at least one year to maintain the desired vaginal depth and girth.

Your surgeon will provide you with a dilation schedule. Typically, it involves inserting the dilator for 10 minutes, three times per day for the first three months and once per day for the next three months. Then, you’ll do it two to three times per week for at least one year. The diameter of the dilator will also increase as the months go by.

Recovery do’s and don’ts

• Don’t take a bath or submerge yourself in water for eight weeks.
• Don’t do strenuous activity for six weeks.
• Don’t swim or ride a bike for three months.
• Showering is fine after your first postoperative visit.
• Do sit on a donut ring for comfort.
• Don’t have sexual intercourse for three months.
• Do apply ice for 20 minutes every hour of the first week.
• Don’t worry about swelling.
• Do expect vaginal discharge and bleeding for the first four to eight weeks.
• Do avoid tobacco products for at least one month.
• Be careful of pain medication; take it only as long as absolutely necessary.