Sex reassignment surgery from female to male: Indications, Contraindications, Preparation, Operation, Rehabilitation, Complications

Today you can meet many transgender people and people who consider themselves to be both genders or neither. Accordingly, gender reassignment operations have also received considerable demand. When a man personifies himself as a woman and wants to become one forever, he often has to resort to the help of surgeons. Namely, to the operation to create a vulva.

Its name is feminizing vaginoplasty, when a vaginal cavity is surgically created between the intestines and the bladder. The purpose of the operation is to create female genital organs from male tissues. Yes, so that the artificially formed vulva is identical to the natural one.

Execution technique i

The most common procedure is to sew the tissues of the penis into the vagina and labia. The labia majora are made from the skin of the scrotum, the clitoris is made from the sensitive skin of the head of the penis. The prostate gland is left in place where it can function as a large erogenous zone, similar to the G-spot.

Since surgeons need to create a vagina identical to the natural one, there is not always enough tissue to recreate the natural depth. Therefore, the skin of the upper half or inner side of the thigh and lower abdomen is taken. The location where additional material is taken is usually minimal and hidden.

Skin grafting from other areas of the body has always been the subject of heated debate among plastic surgeons. Some believe that the extra skin makes the genitals look better. Others believe it hurts functionality. After all, the skin from other parts of the body is not as tender and sensitive as the own tissue of the genitals.

Penile tissue inversion surgery is considered the gold standard for vaginoplasty. It is recommended by the Center of Excellence in Transgender Health.

Read more about who transgender people are and how they differ in our next article.

Types of body modification surgery

1. Breast correction. Breast tissue and excess skin are removed; nipples move.
2. Reductive mammoplasty. Some breast tissue is removed to make the chest look like a man's.
3. Vaginectomy. The vagina is removed.
4. Colpocleisis. The vagina is closed surgically.
5. Metoidioplasty. The clitoris is lengthened to form a small penis.
6. Phalloplasty. The penis is created using tissue from other parts of the body.
7. Ovariectomy. The ovaries and fallopian tubes are removed.
8. Hysterectomy. The uterus is removed
9. Salpingo-oophorectomy. The uterus is removed along with the appendages.
10. Scrotoplasty. The scrotum and testicles are created.

Surgeries such as removing subcutaneous fat (liposuction) and installing implants in the calves, chest and chin are also possible to make these parts of the body look masculine.

Vagina from the colon2

There is another method of creating a vulva - using the large intestine. However, research on the outcomes of this procedure is limited. The advantage of the operation is that the intestinal tissue is capable of producing mucus (lubrication of the future vulva).

While the vaginal hydration from the penis tissue will be artificial. This is the only advantage of colon vulvaplasty so far. The operation is used when the first method fails or when penile plastic surgery is impossible.

Many patients need repeated cosmetic surgery after gender reassignment. This is labiaplasty. Repeated surgery gives doctors the opportunity to work with already healed tissue, giving the lips an aesthetic appearance and positioning the urethra in the right place. This surgery is less invasive and is intended to cosmetically correct the appearance of the vulva.

Sometimes ordinary hormonal pills can do a lot without surgery:

It really works miracles in the literal sense: after a short time, a man can become a girl, and a girl can turn into a man with a rough voice and a beard. But there is no way back after hormones: while a transgender man can still somehow return to the female gender, then trans girls cannot. Under no circumstances will the male body recover from hormonal therapy.

This is what will happen to a man after taking estrogen:

1. Breasts will enlarge: after a couple of years of taking hormonal drugs, men's breasts grow. Sometimes even up to size 2 or 3, which is why some transgender people don't even need breast augmentation surgery.
2. Body hair becomes softer and less noticeable, particularly on the face.
3. The skin takes on a more well-groomed and delicate appearance.
4. Muscle mass disappears - with prolonged use of estrogen, a man’s body begins to lose its “masculine” muscles, and the body acquires femininity.
5. The pattern of fat distribution changes: instead of the abdomen, it begins to be deposited in the thighs and buttocks.
6. The prostate gland and testicles decrease in size.
7. The ability to erect is lost, and there are almost no sperm left in the semen.

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What happens to a woman after taking androgens:

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1. Facial features become rougher.
2. The voice becomes hoarse.
3. Hair appears on the chest and face.
4. The size of the legs may increase, and the hands become thicker.

Testosterone (a type of androgen) is prescribed only by injection.

Special project participant: 24-year-old Zhora, who used to be a girl

How does operation 3 work?

The morning before the procedure, the patient is examined by the operating surgeon and anesthesiologist. Doctors will briefly outline the course of Day X. The patient will be offered a sedative to calm and reduce anxiety. He will then be taken to the operating room.

The operation is performed under general anesthesia. The patient lies on his back with his legs spread up and to the sides. The operation is complex and involves working with thin skin, vasculature and nerve fibers. Here are the key steps of the entire procedure:

• the testicles are isolated and discarded;
• a hole is made in the space between the rectum and the bladder for the future vagina;
• a prosthesis (surgical dildo) is inserted into the allocated cavity to maintain its shape;
• the skin is separated from the penis, a pouch is formed from it, which is stitched and turned inside out;
• a triangular segment from the foreskin and glans penis is released to form the future clitoris;
• The urethra is separated, shortened and prepared for implantation in a new location before the remaining parts of the penis are amputated.

The formed vulva is sutured, bandages and bandages are applied. The entire procedure takes from 2 to 5 hours. The bandages and catheter are usually removed after 4 days. After which comes a period of postoperative rehabilitation.

Surgical gender reassignment

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Anesthesiology and resuscitation

Service code	Internal code	Name	Price, rub
B01.003.004.007	37.1.1	Spinal anesthesia lasting up to 1 hour	8 000
B01.003.004.006	37.1.2	Epidural anesthesia lasting up to 1 hour	14 000
B01.003.004.008	37.1.3	Spinoepidural anesthesia lasting up to 1 hour	20 000
B01.003.004.009	37.1.4	Total intravenous anesthesia up to 20 minutes	6 000
B01.003.004.009	37.1.5	Total intravenous anesthesia from 20 minutes to 60 minutes	12 000
B01.003.004.010	37.1.6	Endotracheal anesthesia from 1 hour to 2 hours	20 000
B01.003.004.010	37.1.7	Endotracheal anesthesia from 2 hours to 3 hours	26 000
B01.003.004.010	37.1.8	Endotracheal anesthesia from 3 hours to 4 hours	34 000
B01.003.004.010	37.1.9	Endotracheal anesthesia from 5 to 6 hours	58 000
B03.016.011	37.1.10	Express analysis of blood gases and electrolytes	2 000
B03.016.011	37.1.11	Advanced express analysis of blood gases and electrolytes	2 500
B03.016.011	37.1.12	Artificial ventilation for 12 hours	7 200
B01.003.004.010	37.1.13	Endotracheal anesthesia up to 1 hour	14 000
B01.003.004.010	37.1.14	Endotracheal anesthesia from 4 to 5 hours	40 000
B01.003.004.002	37.1.15	Conduction anesthesia of the 1st category of complexity	4 000
B01.003.004.005	37.1.16	Infiltration anesthesia (large volume or area) up to 30 minutes	3 000
B01.003.004.005	37.1.17	Infiltration anesthesia up to 15 minutes	1 400
B01.003.004.004	37.1.18	Application anesthesia	1 000
B01.003.004.009	37.1.19	Drug sedation with hemodynamic monitoring	3 000
B01.003.004	37.1.20	Prolonged regional anesthesia (days)	8 000
A11.12.001	37.1.21	central vein catheterization	10 000
B01.003.004.007	37.1.1.2	Spinal anesthesia from 1 hour to 2 hours	14 000
B01.003.004.007	37.1.1.3	Spinal anesthesia from 2 hours to 3 hours	17 000
B01.003.004.007	37.1.1.4	Spinal anesthesia from 3 hours to 4 hours	20 000
A11.23.003.001	37.1.2.1	Placement of an epidural catheter	8 000
B01.003.004.006	37.1.2.2	Epidural anesthesia from 1 hour to 2 hours	17 000
B01.003.004.006	37.1.2.3	Epidural anesthesia from 2 hours to 3 hours	21 000
B01.003.004.006	37.1.2.4	Epidural anesthesia from 3 hours to 4 hours	24 000
B01.003.004.006	37.1.2.5	Epidural anesthesia from 4 hours to 5 hours	28 000
B01.003.004.008	37.1.3.1	Spinoepidural anesthesia from 1 hour to 2 hours	22 000
B01.003.004.008	37.1.3.2	Spinoepidural anesthesia from 2 hours to 3 hours	26 000
B01.003.004.008	37.1.3.3	Spinoepidural anesthesia from 3 hours to 4 hours	27 000
B01.003.004.008	37.1.3.4	Spinoepidural anesthesia from 4 hours to 5 hours	30 000
B01.003.004.009	37.1.5.1	Total intravenous anesthesia from 1 hour to 2 hours	20 000
B01.003.004.009	37.1.5.2	Total intravenous anesthesia from 2 hours to 3 hours	24 000
B01.003.004.010	37.1.9.1	Endotracheal anesthesia from 6 to 7 hours	65 000
B01.003.004.010	37.1.9.2	Endotracheal anesthesia from 7 to 8 hours	70 000
B01.003.004.002	37.1.15.1	Conduction anesthesia of the 2nd category of complexity	5 000
B01.003.004.002	37.1.15.2	Conduction anesthesia of the 3rd category of complexity	6 000

General hospital services

Service code	Internal code	Name	Price, rub
S01.001.001	37.0.1	Stay in a hospital ward (daily)	6 000
S01.001.002	37.0.2	Stay in a hospital ward (daytime until 21:00)	3 000
S01.001.003	37.0.3	Stay in the ward for accompanying persons (daily)	6 000
S01.001.004	37.0.4	Stay in hospital room VIP 1 (daily)	10 000
S01.001.005	37.0.5	Stay in hospital room VIP 2 (daily)	16 000
S01.001.006	37.0.6	Stay in a hospital ward (daily, without meals)	3 400
S01.001.007	37.0.7	Stay in the intensive care unit from 6-24 hours	8 000
B01.047.009	37.0.9	Supervision by a therapeutic physician (1 visit)	2 500
A11.12.003	37.0.10	Infusion therapy of expensive drugs	4 000
A23.01.001	37.0.11	Extraction of surgical material using delivery means (calculated price)	1 000
A18.05.013	37.0.22	Treatment using blood products (calculation, price)	1 000
A11.12.003	37.0.23	Treatment using additional drug therapy (calculation, price)	1 000
A23.01.001	37.0.24	Selection of implants (calculation, price)	1 000
S01.002.001	37.0.25	Selection of compression garments (calculation, price)	1 000
B01.057.001	37.0.28	Appointment with an operating specialist	0
A11.01.014	37.0.29	Hemostasis using local hemostatic agent Zhelplastan 2.5 g	6 600
A11.01.014	37.0.30	Hemostasis using local hemostatic agent Zhelplastan 5.0 g	12 700
S01.001.008	37.0.1.1	Stay in a hospital room (overnight)	3 000

Surgical gender reassignment

Service code	Internal code	Name	Price, rub
A16.20.085.007	37.27.1	Masculinizing mammoplasty (1 category)	40 000
A16.20.085.007	37.27.2	Masculinizing mammoplasty (2 cat)	60 000
A16.20.085.007	37.27.3	Masculinizing mammoplasty (category 3)	80 000
A16.20.011.003	37.27.4	Laparoscopic hysterosalpingo-oophorectomy	100 000
A16.20.011.002	37.27.5	Hysterosalpingo-oophorectomy (laparotomy approach, according to Pfannenstiel)	80 000
A16.21.019.003	37.27.6	Phalloplasty using a musculocutaneous thoracodorsal flap (1 cat)	100 000
A16.21.019.003	37.27.7	Phalloplasty using a musculocutaneous thoracodorsal flap (2 cat)	150 000
A16.21.019.003	37.27.8	Phalloplasty using a musculocutaneous thoracodorsal flap (category 3)	200 000
A16.21.019.003	37.27.9	Metoidioplasty	70 000
A16.21.019.003	37.27.10	Metoidioplasty with urethroplasty	90 000
A16.21.029	37.27.11	Perineal urethroplasty	50 000
A16.21.029	37.27.12	Stem urethroplasty using a radial fasciocutaneous radial flap (1 cat)	120 000
A16.21.029	37.27.13	Stem urethroplasty using a radial fasciocutaneous radial flap (2 cat)	170 000
A16.21.029	37.27.14	Stem urethroplasty using radial fasciocutaneous radial flap (4th category)	220 000
A16.21.036, A16.21.016	37.27.15	Scrotoplasty with testicular replacement	35 000
A16.28.025	37.27.16	Suturing of urinary fistula with epicystostomy	40 000
A16.20.024	37.27.17	Vaginoplasty using modified penal inversion method (1 category)	100 000
A16.20.024	37.27.18	Vaginoplasty using modified penile inversion method (2nd category)	130 000
A16.20.024	37.27.19	Vaginoplasty using modified penile inversion method (category 3)	150 000
A16.08.041	37.27.20	Resection of the thyroid cartilage (reduction of the Adam's apple)	80 000
A16.20.068	37.27.21	Clitoroplasty, perineal correction	80 000
A16.20.085.001	37.27.22	Feminizing mammoplasty with endoprosthetics of the mammary glands (1 category)	100 000
A16.20.085.001	37.27.23	Feminizing mammoplasty with endoprosthetics of the mammary glands (2 categories)	150 000
A16.20.085.001	37.27.24	Feminizing mammoplasty with endoprosthetics of the mammary glands (category 3)	200 000
A16.01.026.001, A16.03.034.001	37.27.25	Facial feminization – correction of facial contours, cheekbones, brow ridges, chin (1 cat)	200 000
A16.01.026.001, A16.03.034.001	37.27.26	Facial feminization – osteoplastic reconstructive surgery (category 2)	250 000

How to prepare for surgery 5

Hair usually grows on the skin of the scrotum and other parts of the body where skin grafts are taken during surgery. It is worth asking your doctor where exactly he intends to extract additional skin material. And several weeks and even months before the appointed time, undergo a full course of laser or electrolysis in order to permanently get rid of hair in the areas of the future vulva.

It is necessary to strictly follow the doctor's instructions the day before and the morning before the operation. Usually you cannot eat anything in the evening, since the patient will have to be put into general medicated sleep.

And a few more tips:

• It’s worth talking to people who have already walked this path, asking about their experiences, feelings and impressions.
• Do not be afraid to consult with a doctor as much as necessary, ask all the questions you are interested in, no matter how stupid and inappropriate they may seem.
• Write down a plan for your new future, in particular, reproductive. It may be worth talking to your doctors about freezing your sperm sample.
• Enlist the support of family and friends. It will be very useful after surgery.

The operation costs, on average, about $20,000. This is only the first procedure. A second labiaplasty operation requires additional costs. In addition, some patients also undergo mammoplasty and other procedures for complete transformation. The total cost of a new life in a new body depends on the patient's financial well-being, insurance and region.

Before surgery

No matter how much you run away from reality, there are actually only two ways out: try to change your gender through surgery or try to pull yourself together and come to terms with the current situation. Let's face it, the latter is more difficult - it is a thorny path through self-digging, developing the skill of ignoring and depression. If you give up, the consequences can be the most catastrophic. But, unlike in previous centuries, surgery is relatively accessible to every person, and the main difficulty here is more financial than psychological. So how much does gender reassignment surgery cost?

First you need to know what is required for the operation itself. Prepare in advance for the fact that you won’t be able to take this difficult step quickly.

1. It is necessary to undergo a special psychiatric commission so that it confirms the diagnosis of “transsexualism” (in Russia it is generally considered a disease) and does not give verdicts such as “schizophrenia”. Sometimes people with schizophrenia suffer from an obsession with gender reassignment.
2. For some time, the future patient will have to live as a member of the opposite sex so that psychiatrists are convinced of the firmness of the decision. This can last up to several years.
3. She will have to undergo hormone therapy for about a year. The number of drugs is determined individually, but in any case, hormones are not cheap, and you can’t get men’s hormones without a prescription, for which you need to say “thank you” to unscrupulous athletes who abuse them. The price of hormonal drugs also varies; for example, let’s say that the cost of one standard box is about 1,000 rubles. In Russia, the diagnosis of “transsexualism” does not provide any benefits for hormonal products.

If everything went well, and you have enough money for an armful of hormonal supplements, you can move on to the most important thing: gender reassignment surgery. Until this moment, you will definitely have to understand whether you want to continue or not. And if your wallet is now significantly thinner after a year of drugs, it looks like your answer will be in the affirmative.

Rehabilitation 6

The long-term outcome of the operation largely depends on rehabilitation. You must strictly follow the doctors' instructions. After surgery, patients are given a vaginal dilator, which should be used as soon as possible after the bandages are removed. It should be used daily for a year to give the desired depth and circumference to the vagina.

The doctor will also provide a schedule for this procedure. Typically, the dilator needs to be inserted into the vagina for 10 minutes 3 times a day for the first 3 months and 1 time a day for the next 3 months. Then the time of use is reduced to 2-3 times a week for a year. The diameter of the device also needs to be increased every month.

Finally, a list of restrictions during the rehabilitation period:

• Avoid swimming or getting your genitals wet for 8 weeks. After the first visit to the doctor after surgery, the issue of the ability to shower is decided.
• Do not expose yourself to physical stress.
• Do not swim or ride a bike for 3 months.
• Buy a donut-shaped seat (with a hole in the middle) and sit only on it.
• No sexual intercourse for the first 3 months.
• Apply ice for 20 minutes throughout the day for the first week.
• There will be swelling and swelling - this is normal.
• Vaginal bleeding in the first 4-8 weeks is also normal;
• Avoid smoking at least for the first month.
• Do not rely on painkillers. Take them only if absolutely necessary.

We read about the intricacies of intimate plastic surgery, which is used not only for gender reassignment, in our article further on the link.

Contraindications for operations are considered

• alcoholism
• mental illness
• too young or old
• homosexuality
• serious illnesses

Before the procedure, you need to undergo thorough preparation. What actions need to be taken?

• Register with a psychiatrist, undergo a thorough examination and be observed for at least two years.

• At the end of this period, the patient undergoes a special commission of three or more doctors.

• Upon successful completion of the commission, a certificate of “transsexualism” is issued.

Once the diagnosis is confirmed, hormonal treatment is selected, the course of which is supervised by a doctor. This step is necessary because after the transformation you will have to use hormonal drugs throughout your life.

During the course of medication, women undergo first surgery to remove the breasts, followed by the fallopian tubes, uterus and ovaries. The last stage is neophaloplasty, which forms the male reproductive organ. Its length will depend on the length of the femoral artery. Once healing is complete, a silicone prosthesis is placed into the genital organ.

For men, on the contrary, a vagina is formed in place of the genital organ, sutured to the peritoneum. Sometimes maxillofacial correction is required.

Modern vaginoplasty techniques

• Penal inversion. The most common method of surgery today is penal inversion. In this case, the vagina is formed from the skin of the patient's penis, turned inside out. When more skin is required for feminizing vaginoplasty, for example if the foreskin has been trimmed, tissue from the scrotum, lower abdomen and buttocks is used. Thanks to the so-called patch technique, the erectile tissues of the penis are removed, and the skin with blood vessels and nerve endings is used for the labia majora and minora. The material for the clitoris is the head of the penis.
• Colovaginoplasty or sigmoid method. The other vaginoplasty technique used is less popular because it is believed that after surgery the vagina becomes less sensitive than with penile inversion. But they still resort to this method, because outwardly the vagina completely corresponds to a woman’s. The method is called colovaginoplasty or sigmoid method - part of the sigmoid colon is used during the operation. This operation is more complicated and much more expensive than penal inversion. Its main advantage is the natural hydration of the new vagina, because part of the intestine is transferred while maintaining the nutrition of the blood vessels and nerve endings. In addition, after such vaginal plastic surgery, such intensive and constant bougienage is not required as after penal inversion. But this operation is more traumatic and even if it is performed laparoscopically, the risk of complications remains high, especially the risk of infection. In the first years after feminizing vaginoplasty, the degree of vaginal moisture is very high, then it decreases. But hydration does not depend on excitement, but on physiological reasons. And after vaginal plastic surgery, it is imperative to always carefully observe hygienic rules, otherwise an unpleasant odor may occur due to the constant release of secretions. Experts believe that this vaginoplasty technique is suitable for those patients who have already undergone penile inversion and were dissatisfied with the results, especially its size.

Typically, vaginoplasty involves simultaneously removing male genitals and creating female ones. It is necessary not only to create a natural-looking vagina, but also to give it sensitivity. The urethra is also shortened and displaced, so that it is natural for the patient to urinate in a sitting position. An important aspect of vaginoplasty is the removal of all unnecessary erectile tissue because it can swell and interfere with sexual intercourse. The prostate gland remains and is not removed. By the way, by contracting, it allows the patient to achieve orgasm.

During the consultation, you need to discuss in detail all the nuances of the operation and specifically dwell on the desired size of the vagina, its width and depth.

After feminizing vaginoplasty

First, bed rest is required, and the total stay in the hospital is about 8 days. You will need to take painkillers and antibacterial medications, as well as medications to help prevent blood clots.

A special prosthesis will be kept in the vagina for two months, the purpose of which is to help the skin integrate with the walls of the vagina. You will need to urinate for five days through a catheter placed in the urethra. In the meantime, the doctor will carefully explain the hygienic rules for caring for the new genitals in order to avoid complications.

After vaginal plastic surgery, every morning you will have to douche with a weak soap solution, then with chamomile infusion or warm water. You can also use a solution of potassium permanganate once a week. Then Levomekol ointment is applied with a hand wearing a medical glove. You should also treat the stitches with wound care products once a day. Probiotics or prebiotics are taken internally. 3 weeks later, the turn of regular lifelong bougienage will begin - stretching of the vagina. This can be done with your hands or with a dildo or dildo. A month and a half after vaginoplasty, you will be able to have sex, which will also be an additional stretch for the vagina. Bougienage is an extremely important point, because if these measures are neglected, the vagina can become very short and narrow or become overgrown altogether. Lubricants are required, but they should not contain glycerin. It is better if the moisturizers are water-soluble and silicone-based. Condoms should be used in any case.

You will not be able to squat for at least six months after vaginoplasty. Any intra-abdominal tension should also be avoided. If constipation occurs, it is recommended to do a cleansing enema rather than take a laxative - it increases gastrointestinal motility.

The state of health usually returns to normal after two weeks, but the pain may continue to bother you for a long time, so you will have to take painkillers. It will be absolutely impossible to sit for three weeks. The exception is carefully sitting on the edge of the toilet. It happens that you cannot sit even for a month after vaginal plastic surgery.

Once a month you need to come to the surgeon for an examination. Then the visits will not be as frequent, but the doctor's visits will be regular. Evaluation of feminizing vaginoplasty is usually based on the following indicators: satisfaction with respect to cosmetic results, depth and diameter of the vagina, ability to have intercourse and orgasm, presence of pain and need for additional hydration, presence of bleeding and discharge for more than a month after surgery, hair growth inside the vagina (this, of course). , there shouldn't be).

The prosthesis placed in the vagina is worn continuously for two months after vaginoplasty; it can be removed only once a day during washing. Then the prosthesis will need to be worn less and less. As for physical activity, in the first months everything must be coordinated with the surgeon. Estrogen intake will also be resumed, albeit in a lower dosage.