Gender Reassignment / SRS

Gender Affirmation Surgery

With so many advances in gender affirming surgeries recent years, many debuted right here, gender dysphoria need not be a lifetime of struggle and depression and is in fact a highly treatable condition. A combination of therapy and surgeries can help assure a happy and full life for those born in the wrong body. At the Komal Cosmetic Hospital, our compassionate staff, our expertise, and our reasonable prices will make dreams a reality. We have performed over ten thousand gender affirmation surgeries, and our facilities are purpose build for our client’s comfort. 

Since 1997 Dr Kamol has performed over 10,000 csmetic procedures on patients and over 5,000 gender affirmation surergies. Recognized and respected throughout the medical community as one of the most experienced surgeons working in gender reassignment care. Dr. Kamol currently performs more than 500 male-to-female gender reassignment surgeries each year. He is the chief plastic surgeon at Kamol Cosmetic Hospital in Bangkok, where he leads the team.

See more Dr. Kamol's Profile

Sexual function and sensation by Dr Kamol's techniques.

1. Background: The nerve ending to the clitoris and the glans penis is similar with approximately 8,000 nerve endings.
2. Dr. Kamol technique uses the surgical techniques to precisely identify and preserve all the nerves from glans penis and creates 4 points of special
   sexual arousal as the follows:
   a.The first point is the neoclitoris.
   b.The second area located at the inner sides of the labia minora, that contained the additional nerve ending from the nerve trunk.
   c.The third point is the bilateral ridge of the neo urethral plate that Dr. Kamol creates from the skirt of glans penis containing the nerve ending.
   d.The fourth spot is located at the bulbourethral glands in front of the prostate glands. Dr. Kamol always keeps the bulbourethral glands containing the nerve ending and mucous secretion.¹
   e.The fifth spot (G-spot) is at the lower part of the prostate glands and consists of sensory nerve endings. Dr. Kamol creates the neo-vagina very close to the surface of the prostate glands.²
3. Some surgeons claimed his/her technique is the only one (in the world) that preserves the erotic nerve ending to the neo-vagina but this is simply not true. 
4. Schematic of the glans penis and the areas are moved to reconstruct the neo vagina (Figure 1)
5. Dr. Kamol creates the minimal-short scar comparison to other conventional techniques (Figure 2).

 

The area from the glans penis to the neo vagina

Figure 1. The areas from the glans penis make the neo vagina,
the tip of the glans penis makes the neo clitoris (1),
skirt of the glans penis makes the second spot sensation (2).

 

Figure 2. Dr. Kamol’s technique (Short-scar)

 

Figure 3. Other techniques (Long-scar)

 

Sex Reassignment Procedures:

Kamol Cosmetic Hospital provides many techniques for male-to-female sex reassignment surgery. We create and design neovagina for transwomen exclusively in accordance with their biological structure. There are unique and need different techniques. 

SRS-1 Vaginoplasty without vaginal depth:

The technique involves using penile and scrotal skin to construct the external genitalia such as inner and outer labia, clitoris, clitoral hood, and female-located urethra. This procedure is suitable for those who do want or need vaginal penetration. The vagina looks like a perfectly natural vaginal but doesn't have a vaginal canal. This technique has a quick recovery.

SRS-2A Vaginoplasty with penile skin inversion:

This surgery involves inverting the skin of the penis to create the vagina. This is the oldest method and was the standard procedure until newer techniques emerged.

The operation time is around 4 hours.

The disadvantage is that it is not suitable for people with deficient penile skin because this will result in a vagina that is not deep enough. The patient might also need hair removal on the penile shaft prior to surgery to avoid hair deep inside the vaginal canal where removing it is difficult. If there is not enough depth a skin graft can also be used to increase depth. We prefer to use the skin graft technique below as in this technique the hairs are removed and the depth is sufficient.

SRS-2B Vaginoplasty with scrotal skin graft:

This technique involves using the skin covering the penis to construct the inner labia, parts of the glans penis to construct the neo-clitoris, and scrotal skin graft to cover the vaginal wall. This results in a sufficiently deep and functional vagina. Hairs are removed during the surgery.

In case of scrotal skin deficiency if the vagina depth is still not satisfactory to the patient and then the plastic surgeon will consider using a skin graft from other areas such as the groin or lower abdomen to further increase the depth of the vagina.

The operation time generally takes about 4-6 hours to complete.

SRS-3 The Sigmoid Colon Vaginoplasty:

Using a sigmoid colon provides a vagina with sufficient depth and also a self-lubricant. At Kamol Cosmetic Hospital, there are 2 options for Sigmoid Colon SRS:

         Open Technique:

         The surgery is done via a 6-7 cm incision at the bikini line. The average length of the sigmoid colon segment vaginal canal is approximately 7 inches. The rest of the colon is re-anastomosis (re-connected) to make the large intestine normal. The operation lasts approximately 6 hours.

         Laparoscopic Technique:

         The sigmoid colon is harvested through 4 small incisions using the laparoscopic technique (keyhole surgery) The average length of the sigmoid colon is approximately 8-9 inches. The average operation time is 6 hours. 

         Advantages of Sigmoid Colon Vaginoplasty:

1. This technique helps patients who have previously undergone sex reassignment surgery and who want a deeper vaginal canal.
2. This technique can be used in patients who have a very short penis.
3. The vagina has a natural lubricant.
4. It is possible to pre-determine the depth of the newly constructed vagina. This method provided the deepest vaginal canal of any technique.
5. This technique provides a very strong and tough vaginal canal and doesn't require lifetime dilation.
6. This is a well-understood technique and has been performed for many years.
7. Contrary to rumor the sigmoid colon vagina doesn't smell. Less than 4% can experience an odor and this is fixed with improved hygiene.

        Disadvantages and limitations:

1. In the open technique, a scar can be visible at the bikini line, just above the left side of the pubis.
2. The surgery is more complicated to complete with invasive procedures required such as cutting off parts of the colon. The colon must be thoroughly cleansed (by an enema) 1 day prior to the surgery.
3. The patient may experience dyspepsia / indigestion symptoms 3-5 days after the surgery.
4. The recovery is slightly slower by about one week when a soft diet must be had.

SRS-4 Revision Vaginoplasty:

We perform hundreds of revision surgeries a year on patients that have received poor results elsewhere or from patients that simply want to “upgrade to a newer technology such as PPV (below) or sigmoid colon which has self-lubrication, elasticity and is easier to maintain. For full information on revision please see the following page   See more

SRS-5 SRS-PPV Penile-Peritoneal Vaginoplasty technique:

Penile Peritoneal Vaginoplasty (SRS-PPV) is the newest SRS technique. Kamol hospital is one of the few hospitals in the world performing it. Peritoneal tissue is the tissue that lines the abdomen. It is wet, elastic and self lubricates. The healing is generally quick with little pain.

The procedure uses a small amount of penile inversion combined with a peritoneum pull-through technique to create the neovaginal canal. Using a peritoneal pull-through to create the vaginal canal is not in fact new, it’s just new for transgender women. This technique has been used in cisgender girls for over 45 years. Known as the Davydov technique it is the only treatment for girls born without a vaginal canal. Known as “MRKH Syndrome” this congenital defect affects a huge one in 4500 girls. Peritoneal tissue is the only tissue used to make a vagina canal connect the vulva to the womb of girls with MRKH. After 9 months in cis girls, this peritoneal tissue is indistinguishable from vaginal tissue under a microscope.

With the PPV technique, the outer labia and visible vagina are made using penile and scrotal skin whilst the inner vaginal canal is made using the peritoneal.

This technique is also extremely good for revision surgery for patients who have previously undergone gender reassignment surgery and who are unhappy with the result or who simply want a more functional realistic, elastic, self-lubricating vagina.

       Advantages of Penile Peritoneal Vaginoplasty SRS-PPV:

1. The vagina has a self-natural lubricant with no unpleasant odor.
2. The vagina is elastic and stretches like a biological vagina
3. Less chance of vaginal prolapse and shrinkage compared to all other types of SRS.
4. The vagina is elastic and dilation can be reduced after a year.
5. Natural lubrication is similar to vaginal lubrication.
6. Recovery is quick and there are fewer risks compared to the sigmoid colon.
7. Peritoneal pull-through (Davydov technique) has been performed on cisgender girls for over 40 years and is well understood.

       Disadvantages and limitations of Penile Peritoneal Vaginoplasty SRS-PPV:

1. The patient may experience dyspepsia / indigestion symptoms 2-3 days after the surgery.
2. This technique is not suitable for those who are overweight or have fatty abdomens as visceral fat (internal fat) makes the surgery difficult.
3. Not suitable for patients with a very small penis.
4. No long-term data on this surgery on transgender patients.
5. If dilation is not performed as directed in the first year the joint between the penile skin and the peritoneal skin can fail and require revision surgery.

Why BMI and weight are important for SRS?

Surgery risks are increased due to obesity. Obesity can pose additional challenges in surgery, it can increase risks of complications such as infections, blood clotting, unsuccessful surgery, delayed wound healing, and respiratory issues. The optimal weight and BMI can decrease risks and complications. Over weight combine with the other factors including aging and medical illness increase the likely hood of intra and Postoperative complications. The patient has to inform the doctor all the medical background before making the operative schedule.

Accepted for surgery in case of:

SRS- PPV Penile-Peritoneal Vaginoplasty technique                         BMI Less than 30 and Weight Less than 90

SRS- The Sigmoid Colon Vaginoplasty Laparoscopic technique      BMI Less than 30 and Weight Less than 90

SRS- Vaginoplasty with scrotal skin graft                                          BMI Less than 30 and Weight Less than 90                 

SRS- The Sigmoid Colon Vaginoplasty Open technique                   BMI Less than 26 and Weight Less than 80

      Why genital hair removal is important for SRS?

      Kamol cosmetic hospital provides many procedures for sex reassignment surgery/SRS. But not all procedures require genital hair removal to be done. We recommend:

1. SRS without a vaginal cavity, this procedure does not need to do genital hair removal.
2. SRS skin inversion, this technique requires genital hair removal in areas 1,2,3 in picture 1.
3. SRS skin graft technique needs to remove the hair at around 5x6 cm at the base of the penis as in picture 1.
4. SRS with colon graft we need the patient removes the hair at the vaginal entrance at around 5x6 cm at the base of the penis as in picture 1.
5. SRS-PPV, the patient needs to do the hair removed in areas of 1,2,3 in picture 1.

Picture 1. Shows the area of the hair removal

1. The patient needs hair removal around 5x6 cm at the base of the penis as in picture 1.
2. The patient may experience dyspepsia / indigestion symptoms for 2-3 days after the surgery.
3. This technique is not suitable for those who are overweight or have fatty abdomens due to the difficulty reaching the peritoneal.
4. In a complicated case the patient might have the possibility of conversion to open technique or sigmoid colon neovagina reconstruction.

Post-Operative Care for non-colon SRS:

The patient must be hospitalized for 4-6 days, depending on the technique. For the healing process to be complete and successful, patients advise to:

1. During the first two days after surgery, the patient must not take food that has fiber contents and beverages such as fruit juice, milk, and yogurt as these will trigger waste excretion. It may lead to contamination of the wound by the faces.
2. During the first 1-2 days after the surgery the patient should lie on her back, with hips raised and legs slightly apart as this will help reduce swelling.
3. On the third day after the surgery the patient may lie on her side.
4. On the third day after the surgery the surgeon will remove the draining tube, open and dress the wound. The patient who has undergone Sex Reassignment Surgery with Skin Graft or Sex Reassignment Surgery with Colon Graft must remain in bed until day six when the urine catheter will be removed.
5. On the sixth day after surgery patients of Sex Reassignment Surgery with Skin Graft surgery will have their urine catheter removed. The wound will be dressed, and the patient may be transferred to the serviced apartment for further recovery.
6. The patient needs dilation of the vagina using dilators. For the patient to maintain the width and depth of the vagina, the patient should dilate the vagina at least twice a day for about an hour each time. This process can be done at the serviced apartment where we have nurses to help.
7. The patient needs to keep the surgical wound clean.
8. The patient must refrain from sexual intercourse for at least three months.
9. The patient must ensure that she keeps her appointment with the doctor once a week for one month in order to maintain satisfactory results from the surgery.

Postoperative Care for SRS-Sigmoid colon:

1. During the first three days, the patient cannot eat or drink until intestinal function recovers. In this period, the patients will have fluid via intravenous lines.
2. The patient needs to avoid eating large meals in the first month.
3. The patient may do light activity after three weeks and may resume regular daily activity after 3 months.
4. The patient who has sex reassignment surgery with a sigmoid colon graft must refrain from drinking water or taking any food until she can pass gas. After this, the patient may sip a small amount of water or consume soft food. If the food is eaten too quickly, indigestion or dyspepsia symptoms may occur. The patient of this technique must strictly abide by the recommendations of the doctors and nurses.

Risks and potential Complications:

Although an extremely safe surgery patients should be aware of all the likely and rare complications of sex reassignment surgery. Complications by Dr. Kamol are exceptionally low.

Rare but minor complications that are not considered dangerous:

• Swelling
• Bruising
• Hematoma
• Bleeding
• Infection
• Poor healing
• Flap necrosis

Very rare complications - less than 1%:

• Urethral stenosis
• Decreased Sensation
• Deep vein thrombosis
• Risk from anaesthesia
• Recto-vaginal fistula

Unfavourable results can either be from those who don’t follow postoperative care such as dilating or from those with unrealistic expectations. Unfavourable results could be as follows:

• Unsatisfied size or shape of vaginal urethral and clitoris
• Asymmetry of the labia
• Loss of vaginal depth
• Vaginal stricture

See more

 

See more results of vaginoplasty

 

Why Kamol Cosmetic Hospital is the best choice for gender-affirming vaginoplasty?