Penile inversion is the most common surgical technique as part of genital reassignment used to construct a neo-vagina from the skin tissues of a penis for trans women. Sometimes this technique is also for intersex people although material limitations call for other techniques such as colovaginoplasty. It is popularly used in conjunction with a scrotal skin graft so that there are more skin materials available for labiaplasty.
The penile inversion technique was initially improved by Georges Burou during his pioneering work in sex reassignment surgery. The technique has been further advanced by Neal Wilson, Toby Meltzer, and Suporn Watanyusakul (who made the use of scrotal skin grafts more popular).
The way the tissues are utilized varies by surgeon to surgeon as is the amount of tissue available. The description below is a general overview of the most common technique.
- The procedure starts after initial prep, including bowel prep, with an incision in the scrotum to harvest some of its skin. The the gonads are discarded in the majority of cases.
- Now the penile skin is degloved (the outside skin cut and separated from the tissues underneath it) and skin tissues may be set aside for processing (the actual vaginal vault creation part). This part is medically known as a penectomy although complete removal of the penis is rarely done because of the need to reuse portions of it.
- The details on the way the vaginal lining is constructed, varies by surgeon, along with how much skin material he or she has to fashion with. If the patient lacks adequate skin tissue, the surgeon will often advise (before hand) for the taking of a skin graft using tissue from the scrotum, thigh, or abdomen. If hair follicles are to be removed from the graft intraoperatively, it is done so at this time.
- At this point, some surgeons will begin to create a vaginal cavity using blunt dissection to avoid damage to the colon and bladder, while others will continue separating the tissues of the penis into the soon to be cut away corpora cavernosae, (erectile tissue) glans, (head of the penis) and urethra.
- Usually now the clitoris is fabricated from the previously separated glans, being careful to preserve the blood supply and nervous tissues, and placed approximately where it will be permanently located.
- The newly constructed vaginal lining should, at this point, be ready for insertion and is secured into the cavity created in the perineal body (the space in between the urethra and bladder, and the colon).
- The last steps in the operation include trimming the urethra and securing it in its final location, the final touches to the labia, and preparing the patient for recovery. (which includes packing the new vagina with gauze, and temporarily sewing the labia majora together to keep everything in place during the first 5 or so days of recovery)
In some cases, a later operation, labiaplasty, is advised to make more aesthetic and/or functional results; or if the surgeon believes it is better to wait until the body heals than complete it all in one go. The posterior fourchette (most distal/rear part or the labia minora where it intersects with the vaginal opening) must be fabricated during secondary labiaplasty due to complications of infection and/or dilation after vaginoplasty.
This photo (to the right) was taken 79 days post op and depicts fairly typical results by Dr Brassard who uses the penile inversion technique. In this picture there is still some swelling in the tissue above the clitoral hood, and the scaring is fading as expected.
The advantages to this procedure include:
- Less out of pocket costs
- Less post surgical complications
- Faster recovery
- Aesthetic and functional results that are “good enough” for most people
The disadvantages to this procedure include:
- Patients without adequate skin tissue may require skin grafts to achieve desired depth
- The aesthetic and functional results vary greatly between the best and worst surgeons
- Best results may require a second stage labiaplasty
- Requires life-long dilation
- Self-lubricating properties vary from person to person
Maintenance of any skin tissue based vagina generally involves a varying amount of vaginal dilation using a stent. This is a life-long process although the demand to perform it varies by surgeon and how long it has been since surgery. Some surgeons state that sexual intercourse can replace dilation after healing has taken place. This should not be a recommendation to engage in risky sexual behaviour or to neglect dilation with a stent because of the general pliability of a penis or soft sexual toy.
- Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients by S. Krege, A. Bex, G. Lümmen and H. Rübben (BJU International, Volume 88 Issue 4, Dec 2001)
- Vaginoplasty in male transsexuals using penile skin and a urethral flap by S.V. Perovic, D.S. Stanojevic and M.L.J. Djordjevic (BJU International, Volume 86 Issue 7, Dec 2001)
- Surgical conversion of genitalia in transsexual patients by L. Jarolím (BJU International, Volume 85 Issue 7, Dec 2001)
- Dr. Toby Meltzer Performs SRS (A graphic walkthrough of the procedure)
- Dr. James Bellringer Performs SRS (A graphic walkthrough of the procedure)
- Video: Dr. Marci Bowers Performs SRS
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