The Transgender Dictionary
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Penile Inversion

(also: bottom surgery, lower surgery, vaginoplasty)

Table of Contents

Introduction

Many transgender women, and some transfeminine nonbinary people, experience gender dysphoria regarding the lack of a vulva and/or vaginal canal. Having a vulva and/or vaginal canal procured through surgical means can be a great source of gender euphoria. This page will be discussing the technique known as "penile inversion vagnioplasty" - also known as the "gold standard" for vagnioplasty. For general information on vaginoplasty, click on the underlined word to go to the general vaginoplasty page, or navigate to it using the alphabet menu at the top of this page.

This is the most commonly available and chosen method for vaginoplasty. Penile inversion is the least invasive vaginoplasty surgery avaliable.

General Information

This surgery is best performed on women who have no severe scarring from previous surgeries that could reduce the avaliability of penile skin (such as circumcision), have generally good health, are free of conditions that could impair healing (such as uncontrolled diabetes), have sufficient tissue (ideally a minimum stretched penile length of 12cm or 4inches) for genital skin flaps.

Most patients are required to undergo GAHT for at least 12 months (1 year) prior to surgery to support tissue feminization and to demonstrate mental readiness (note that estrogen therapy is typically paused around a month prior to surgery to reduce blood clotting risks, but anti-androgen therapy is typically continued). Hormone therapy is typically resumed in full around 3 weeks post-op.

This method of vaginoplasty requires lifelong dilation, and external lubrication during penetrative sexual intercourse. This is a difficult surgical procedure involving complex, delicate tissue, vasculature, and nerve fibers. This surgery requires electrolysis to be done at least 6 months prior to surgery. Bowel preperation (thorough cleansing using laxatives and antibiotics) is required prior to surgery to minimize infection risks.

In cases where there is not enough skin to achieve necessary vaginal depth, skin grafts may be taken from the upper hip, lower abdomen, or inner thigh. There is typically minimal scarring at the donation site in these such cases. Skin from donation sites is never as sensitive as the skin taken from the genitals. Some surgeons believe that using a skin graft results in a better cosmetic appearance, while others are against sacrificing functionality during this surgery. The average vaginal depth achieved by this surgery is 12-16cm (4-6inches), depending on the quantity of available tissue.

The dilation timeline post-penile inversion vaginoplasty is as follows; three times daily for 10 to 30 minutes each session for the first 0-3 months, once daily for 10 to 20 minutes each session from 3-6 months, every other day (or three to four times per week) from 6-9 months, and one to two times per week from 9 months and beyond. Dilation is vital to maintain depth and prevent narrowing.

88%-99% of patients are satisfied with the aesthetic and functional outcomes of penile inversion vaginoplasty. 71% of patients report no longer experiencing gender dysphoria after this surgery. 91% of patients experience increased quality of life in terms of increased social comfort and improved emotional well-being. 70% of patients report increased self-confidence after surgery. Up to 92% of patients are able to achieve orgasm post-surgery.

Many surgeons require that a patient have a BMI under 30. Patients who smoke are encouraged to quit smoking at least 6-8 weeks prior to surgery to ensure proper healing. A mental health evaluation, as well as 2 letters of recommendation confirming gender dysphoria, is generally required prior to surgery to ensure that the patient understands the impact of this surgery.

As a patient, it is very important to discuss your options with your surgeon ahead of time, and your personal goals regarding surgery. It is a good idea to research your surgeon ahead of time, and look for reviews and images from real people (not just the photos from the surgeon's personal website). Have consultations with more than one surgeon surgeon if possible, to make sure that you have the outcome and surgical team that is right for you.

How It Works

During penile inversion vaginoplasty, the patient is placed under general anesthesia. She is positioned laying on her back, with her legs held up in stirrups. An orchiectomy is performed (if it had not been already), as well as a penectomy.

The neovaginal canal is carved out between the rectum and the urethra. A vaginal stent/packing/penile prosthesis/surgical dildo is inserted into the cavity to help it hold its shape.

The skin is removed from the penis. This skin forms a pouch, which is sutured, inverted, and grafted into the carved out space. Erectile tissue is removed to prevent the vaginal opening from narrowing while aroused.

A triangular piece of the glans is removed to be correctly positioned and reshaped as the clitoris and clitoral hood (providing sexual sensation). The scrotal skin is used to form the labia.

The urethra is removed, shortened, and prepared for repositioning before the remaining parts of the penis are amputated and discarded. Everything is sutured together with absorbable sutures to minimize scarring and bandages are applied. Excess urethral tissue may be used to enhance the labia minora or vagina lining.

The prostate is unaffected. 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.

Recovery

Patients stay in the hospital for 5-7 days post-op while being closely monitored. Doctors manage the patient's pain, drainage, and any potential early complications. On day 5, the packing being used to maintain the shape of the vaginal canal is removed. The urinary catheter remains up until 10-14 days post-op.

From weeks 2-4, the patient may engage in limited activity at home (no heavy lifting or strenuous exercise). Swelling gradually subsides during this time, though mild discomfort may persist. The patient will begin dilation under the management of her physician.

From months 1-3, dilation becomes a part of daily life for the vaginoplasty patient to maintain vaginal depth and width. Surgical scars start to fade. Any potential redness or stiffness should be monitored. Patients can typically resume light (non-physical) work within 4-6 weeks.

Most swelling should subside around 3-6 months, and patients should experience increased comfort. Most patients are cleared for penetrative intercourse around 3 months.

Around 6 months, most patients can reduce dilation freqnency. At this time, patients are able to return to normal routines and regular excercise.

If a patient experiences extreme vaginal stenosis, the peritoneal technique is available as a revisionist surgery.