The Transgender Dictionary
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Vaginoplasty

(also: bottom surgery, full depth vaginoplasty, lower surgery)

Table of Contents

Introduction

Originally developed as a treatment for cisgender women recovering from vaginectomies or trauma; vaginoplasty is a surgery that constructs a neovagina. This page will be discussing vaginoplasty in the context of gender-affirming care.

For many transgender women, as well as some transfeminine nonbinary people, not having a vulva is a major cause of gender dysphoria. It can cause distress to have a bulge visible through clothing, and all of the unfortunately masculine associations that come from that. Some women may try tucking prior to surgery to help alleviate this dysphoria. For those who seek out this gender confirmation surgery, the results can be a major source of gender euphoria.

This surgery is typically performed after an orchiectomy. Labiaplasty is sometimes provided as revisionist or "stage two" surgery, depending on the initial technique that the patient has undergone (it may also be performed on its own, as an alternative to vaginoplasty).

General Information

Vaginoplasty is a surgery which involves the construction of a vulva and vaginal cavity. This can be done through a combination of rearranging the available genital tissue and skin grafts (this will vary based on technique used). It is required to undergo electrolysis treatment starting at least 6 months prior to treatment to prevent internal hair growth. Any skin graft sites that are to be used for surgery must be treated with electrolysis.

As a patient, it is important to do extensive research on your surgeon ahead of time. Look for reviews and results from real people (not just from the surgeon's personal website). Even if you found your surgeon on a website advertising surgeons who do transgender surgeries, be sure to do as much research as possible. Most reputable surgeons will be associated with one or more of the following; the World Professional Association for Transgender Health (WPATH), American Society of Plastic Surgeons (ASPS), International Society of Aesthetic Plastic Surgery (ISAPS), or European Association of Urology. Most surgeons will follow the informed consent model or the WPATH Standards of Care.

If you can, seek out more than one surgeon for conslutations. It is very important to discuss your personal surgical goals with your surgeon ahead of time. Discuss your medical history, experiences with GAHT, and what a realistic outcome looks like for you. If you are interested in your reproductive future, discuss fertility preservation options (saving sperm samples) with your doctor. It is also important to make a postoperative plan with your family and friends for when you are in recovery.

To a surgeon, patients are generally considered good candidates for vaginoplasty if they have gender dysphoria, are at least 18 years of age (though rare exceptions may be made with parental consent), proof of having been on GAHT for at least a year, quit smoking (as it can interfere with wound healing), have good overall health (no major cardiovascular issues, severe metabolic diseases, or bleeding disorders), pass certain blood tests and physical exams, and are informed on the procedure. Many surgeons will require that the patient has 2 referral letters from separate mental health professionals. Some surgeons may disqualify patients with a BMI over 35 or 40.

Pelvic imaging is optional prior to surgery. Patients with a history of radiation treatment (such as treatment for prostate cancer) may be encourage to undergo labiaplasty as an alternative, though an MRI can be used to determine if vaginoplasty is a possibility.

This surgery can cost $20,000 without insurance.

This surgery typically takes 4 to 6 hours to perform. The resulting neovagina typically measures 10–16 cm (4–6.5 inches) in depth, averaging 13.7 cm (5.4 inches). Vaginal depth varies based on the skin available in the patient's genital region prior to vaginoplasty. This is an inpatient procedure. Patients typically stay in the hospital for 1-5 days. During this stay, patients are monitored by doctors regarding their healing process and pain leves. Patients are not sent home until they are able to walk and use the bathroom. Patients are advised to stay within 90 minutes of the hospital for at least 4 weeks after surgery, so that the doctors can follow up and address any potential issues.

Note that while general anesthesia is typically used, some patients may be sedated instead. While an orchi is typically standard along these surgeries, it is possible to have vaginoplasty performed without it (though uncommon). A foley catheter is typically required after this surgery as the body heals. A surgical drain will be placed in the operating room, which is removed before the patient returns home.

91% of transfeminine vaginoplasty patients report improved quality of life, while 98% report satisfaction with their results. 86% of patients are able to achieve orgasm after surgery. 94.5% of patients do not experience severe complications. Complications may include bleeding, slow healing, infection, skin or clitoral necrosis, rupture of the sutures, urinary retention, vaginal prolapse, and the narrowing of the vaginal opening (this risk is lowered through the use of dilation). Rare complications include like fistulas (an abnormal connection between the new vagina and the rectum or bladder), urethral injury (which may require surgery or a suprapubic catheter), or rectal injury (which may require additional surgery, a low-fiber diet, or a colostomy).

Recovery after vaginoplasty is typically 6-8 weeks. Showering is ok after your first postoperative visit (if your surgeon gives the ok). Sitting on a donut ring pillow is recommended for comfort after surgery.

For the first week, it is recommended to apply ice for 20 minutes every hour to manage swelling. Speaking of swelling - don't worry about it. Swelling is normal immedeatly after surgery. Pain is common post-op, and can be managed with perscribed medication (only take pain medication when absolutely necessary). A stool softener may be perscribed if the painkillers result in constipation. Patients can switch to over the counter medication over time as the pain deminishes.

Patients are advised to clean the neovagina daily with mild soap and water. Wiping from front to back after urination is important to avoid infection (this is not only important for vaginoplasty patients immediately post-op, but for anyone who is alive and possesses a vulva). Wearing loose, breathable fabrics is a good idea to promote comfort. Dilating daily and pelvic floor therapy are important for the healing process. Some patients may notice "spraying" during urination, a common issue that can be addressed with physical therapy to help strengthen the pelvic floor.

For the first six weeks, avoid strenuous activity.

For at least the first month, avoid tobacco products.

For the first four to eight weeks, brownish-yellow discharge and light bleeding are common.

For at least the first 8 weeks, don't take any baths, or submerge in water.

For the first three months/twelve weeks, avoid swimming, sexual intercourse, or riding a bike.

Types of Surgery

There are several main types of bottom surgery. The different techniques mainly revolve around the anatomy that the patient has prior to surgery. Different techniques are more effective for those with more or less penile skin available. Discuss surgical goals with your surgeon to figure out the right technique for you!

Additional methods currently without their own pages include the jenjum method, non-penile inversion/Suporn technique/the Chonburi Flap method (which uses the scrotum as the vaginal lining), and a method involving tilapia fish.

Dilation

Being the recipient of penetrative vaginal intercourse is possible once the patient has healed from vaginoplasty. Dilation is required for this to be possible, as it prevents the loss of vaginal depth and width. Dilation is necessary for the length of time set by the surgeon. Depending on the surgery, continued dilation is a lifelong requirement. This can be difficult to maintain for patients with regular work schedules, as it requires privacy and to be done quite frequently, especially immedeately after surgery.

Dilation can be uncomfortable at first, but not severely painful. If a patient is experiencing pain while dilating, it is important to stop and reposition to a more comfortable angle. It is advised to use pillows for support and lay comfortably. Most patients adjust to the discomfort it within a few weeks. Using water-based lube can help minimize discomfort. Seeing a pelvic floor therapist can make it easier by improving muscle control and relaxation.

Dilation must be started as soon as the bandages come off. A set of different sized dilators will typically be given to the patient by the surgeon. The dilation devices must be used reguarly to maintain vaginal depth and girth. The dilation schedule will be provided by the doctor. The diameter of the dilater will increase over time, as the patient adjusts, and as larger sizes are approved by the doctor.

It is important to make sure that the dilator is clean and sterilized before every dilating session.

The risk of stenosis (vaginal narrowing, one of the most common potential complications for vaginoplasty) is lower if the patient dialates. While missing an occasional dilation session is not harmful, prolonged neglect of dilation can result in narrowing. In a way, it is comparable to how a piercing may close up if no jewlery is placed in the hole for prolonged periods of time. The risk of stenosis varies depending on the surgical technique undergone by the patient.

One of the reasons why vaginoplasty surgeons typically require that patients have lower bmi is due to the difficulties that larger patients can have with the physical act of dilation.

Dilation is largely unnecessary past the 6 month mark, but still generally advised.

Jenjum Vaginoplasty Resources