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Details of Surgery: The goals of this procedure are to create female genitalia that look and function like a natal female and contain tissues that are sensitive, capable of erotic sensation and capable of some natural lubrication. This is accomplished by preserving as much sensate and vascularized penile tissue as possible to create the various details of the female genitalia. The operation begins with the patient
under general anesthesia and in lithotomy position (legs apart and knees
slightly flexed). A large roughly triangular section of skin is excised from the
scrotum and placed on an adjacent sterile table where an assistant removes all
hairs which haven’t been previously removed by laser or electrolysis treatments.
The testicles are then removed after ligating the spermatic cords. The cords are
tied high and their stumps permitted to retract into the distal inguinal canals
to avoid any discomfort which could exist if they were ligated at a lower level
with their stumps in the labia. A small, roughly triangular or heart-shaped flap is incised in the upper portion of the glans penis and is carefully elevated, leaving it attached proximally to its blood and nerve supply. The flap is folded and its edges sutured together, creating the future clitoris. The skin at the distal end of the penis is incised completely around its circumference and the skin is then completely elevated and separated from the underlying tissues. The skin is removed from the penile tissues but is left attached at the pubic area where its nerve and blood supply are located. A long flap is then created on the upper (dorsal) surface of the penis by making two parallel incisions through the fascia about 3 cm apart down the entire length of the penis to connect with the neo (new) clitoris. This flap is made thick enough to preserve the artery, veins and nerve (the neurovascular bundle). This flap with its neurovascular bundle is separated from the corpora cavernosa. A Foley catheter is then placed through the urethra and into the bladder. The urethra and its surrounding vascular tissues, the corpora spongiosum, are dissected free from the corpora cavernosa. The cavernosa are then transected low near their base and their stumps are both cauterized and closed with sutures to prevent future bleeding. The flap containing the neurovascular bundle to the neoclitoris is then folded on itself and sutured in place, anchoring the neoclitoris in its new normal female anatomic position. Excess corpora spongiosum is then resected from the outer walls of the urethra and the urethra is incised vertically, opened and anchored down to the deep tissues, then around and over the neoclitoris. The portion of the urethra above the clitoris is tubed with sutures down to and slightly over the upper border of the neoclitoris and becomes the deep layer of the future clitoral hood. The skin and deeper tissues are opened between the new urethral opening and the anus and a deep cavity is created with mostly blunt dissection between the rectum and the urethra all the way up to the peritoneum of the pelvic floor. If necessary, muscle tissue of the side walls of the cavity is transected to ensure adequate width of the cavity. Any bleeding is controlled with electrocautery and/or suture ligatures and the cavity (the future neovagina) is packed with sterile gauze. The remnants of the glans penis are excised and discarded and the penile skin is then inverted and placed over a stent. The piece of scrotal skin which was depilitated and saved from the earlier stages of the surgery is now wrapped around the stent, trimmed to fit, and sutured to the distal end of the penile skin flap. This has the effect of adding an additional 3 – 4 inches to the skin tube which will soon line the neovagina. The packing is then removed from the recently created cavity and the penile skin flap with attached scrotal skin graft is inserted into the cavity. The stent is removed and the neovagina is packed with gauze packing impregnated with antibiotic gel. The penile skin flap which is now covering the perineum is now split vertically down its midline from the upper border of the neoclitoris to the lower pole of the urethral opening. The inner or medial borders of the flap are sutured to the lateral borders of the urethra from the clitoris down to the urethra and these areas becomes the new labia minora. The portion of the penile skin immediately above the neoclitoris is sutured to the lower edge of the previously tubed portion of urethra located above the neoclitoris becoming the outer skin cover of the clitoral hood. The outer borders of the penile flap are then sutured to the inner borders of the remaining scrotal skin and these become the labia majora. All suturing is done with absorbable sutures so they do not have to be removed at a later time. Antibiotic ointment and sterile gauze dressings are placed over all external incisions. The Foley catheter is left in place, and will be removed one week after surgery. The patient is taken out of the lithotomy position, placed in the supine position, extubated and transferred to the recovery room. During the procedure the patient’s vital signs are monitored continuously and intermittent compression stockings are maintained on the legs to prevent phlebitis and emboli. A moderate amount of blood loss occurs during surgery due to the naturally rich vascularity of the tissues in this anatomic area but to date we have never had to transfuse blood during this surgery. Patients remain in the hospital for 3 or 4 days and then transfer to one of our furnished apartments located in the same building as our offices for another 7 to 10 days. Here they can be checked by the doctor every day and any problems which may occur are handled immediately. The Foley catheter and vaginal packing are removed in approximately one week and, baring any problems, the patient is discharged home. Hormones are restarted postoperatively. Antibiotics are continued until the Foley catheter is removed and in the absence of any infection, are discontinued. The technique described above consistently produces natural looking female genitalia which have good sensation and can function sexually. The neoclitoris is erotically sensitive, the vagina is deep enough and wide enough to accommodate most any size penis and the urethral tissues which form the floor of the perineum are pink and moist as with all natural mucosal surfaces. Because the neovagina is lined by skin and not mucosa, lubrication will be required in order to have intercourse and also for dilation. All patients are followed closely for at least one year postoperatively and then on a regular but less frequent basis for the remainder of their life. We also recommend that patients maintain regular contact with their therapist or other mental health specialist over the long-term and on an as-needed basis. |
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| Case 1 | ||
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Pre Op Male to Female |
Post Op - Male to Female, Full View, Standing |
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Post Op - Male to Female, Oblique View, Standing |
Post Op - Male to Female, Oblique View, Standing |
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Post Op - Male to Female, Full View, Lying Down |
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| Case 2 | ||
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Post Op - Male to Female, Full View, Standing |
Post Op - Male to Female, Lying Down |
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