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Gender reassignment surgery

What is the Gender reassignment surgery?

Sex reassignment surgery (gender reassignment surgery, sex realignment surgery or sex-change operation) is a term for the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble that of the other sex. It is part of a treatment for gender identity disorder/gender dysphoria in transsexual and transgender people.

The best known of these surgeries are those that reshape the genitals, which are also known as genital reassignment surgery or genital reconstruction surgery. However, the broader meaning of sex reassignment may include any of a larger number of surgical procedures (like complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation, breast prostheses, etc.).

Transsexual / Gender Dysphoria patients suffer from a long lasting, continuous discomfort with their gender with a desire to live as a member of the opposite sex. They have a strong wish to be rid of their external genitalia and alter their appearance to fit their chosen gender.

There are two main types of the surgery: male to female surgery and female to male surgery (rarer).

What is the procedure?

Male to female surgery

This procedure is a combination of a penile skin inversion and an immediate full thickness skin graft. The vaginal canal and opening is created beneath the urethral opening and prostate gland. Vaginal depth is of concern to most patients. The most important factor in creating this depth is the amount of penile shaft skin.

A portion of the glans (head of the penis), with its nerves and vessels, is converted into a clitoris. In so doing, the clitoris will be functional in sensation as well as in appearance

The excess erectile tissue around the urethra should be removed in order to avoid symptoms that stem from engorged erectile tissue during sexual arousal that may result in the narrowing of the vaginal opening.

Colon transposition is used for patients who need more depth.

Female to male surgery

Female to male surgery involves phalloplasty whish refers to the construction of a penis. The penis is constructed essentially using skin flaps from the abdomen, groin, or thigh. The scrotoplasty procedure uses labial tissues to construct a scrotum, into which implants can be inserted to simulate testicles. Testicular implants can be placed into the labia majora if a scrotoplasty is not desired. Glansplasty refers to the shaping of the head of the neopenis to simulate a circumcised penis.

Some patients opt for clitoral release surgery (metoidioplasty) when they don’t want to have a complete phalloplasty. With the effects of testosterone treatment, the clitoris enlarges, over time, to an average of 4–5 cm. In a metoidioplasty the enlarged clitoral tissue is released from its position and moved forward to more closely approximate the position of a penis. Metoidioplasty is technically simpler than a phalloplasty, and has fewer complications. The surgery itself is also considerably shorter (2–3 hours vs. 8–10 hours overall) and it is much less expensive. Unlike a phalloplasty, an erectile prosthesis is not needed to achieve erection, although the erection is usually not so hard. Because metoidioplasty can not achieve penile dimensions comparable to a penis prothesis, the neo-penis is usually not capable of penetrative sexual intercourse. Genital orgasm is almost always retained after surgery.

What kind of result can you expect?

After surgery, the vast majority of transsexuals are happy with their new sex and feels comfortable with their gender identity.

After male to female surgery the patient should be able to engage in vaginal intercourse after 6 weeks. During sexual arousal, there is some vaginal lubrication - though in most cases the patient should apply lubricant jelly at the vaginal opening prior to intercourse (as with dilation). During sex, sensation at the vaginal opening, inner labia, and clitoris can be comparable, and certainly more sustained after climax, than previously in the male sex.

After female to male surgery sexual intercourse is possible after phalloplasty. Although a penile prosthesis can be implanted in order to simulate the function of erection, it is associated with a high incidence of extrusion (the implant comes out).

Patients can also enjoy sexual/erotic sensation via the clitoris, which can be repositioned upward to the base of the neopenis.

Recovery period and recommendations

After the male to female surgery, there will be strong tension in the area around the fourchet of the new vagina perineum. Wound care will be required, but will heal within one month.

Urination difficulty sometimes occurs after the urine catheter is removed, due to the swollen stump at the opening of the shortened urethra. In such cases, the urine catheter should be retained for several more days. Eventually urination will return to normal.

The stitches will be removed after seven to ten days.

Dilating is the most important thing the patient can do to ensure the success of the surgery. If the patient does not dilate appropriately, this can result in the shortening of depth and width of the newly made vagina because of the scar contracture.

Failure to dilate properly can result in serious injury. The patients are instructed by the surgeons how to dilate into the right direction after the vaginal packing is removed. Dilation can be painful for the first weeks, but is essential for developing maximum depth and ensuring post operative functioning of the newly created vagina.

After female to male surgery the patient will follow-up with the plastic surgeon and urologist frequently in the early post-operative period. Sites to be inspected regularly include the neo-phallus and neo-scrotum. The neo-phallus is inspected for quality of wound healing (dehiscence, infection or hypertrophic scarring), ability to void, and presence of urinary fistulae or stricture (typically a late finding). In the patient who has undergone phalloplasty, vascularity of the neo-phallus (color, temperature, turgor, pulse, capillary refill) will be evaluated, along with quality of wound healing and hand/wrist sensation and function in the donor forearm.

Possible side effects and complications

Risks and complications of male to female surgery may include:

- infections. Infections are usually only minor and do not cause pulmonary or systemic infections;

- short vagina. Depth usually continues to extend after 6-12 months due to the maturation of scar tissue. In case of very short vagina, the second operation can be done after 6 months by using the sigmoid colon procedure;

- rectovagina fistula. This is a very rare although serious complication when a hole develops between the colon and the vagina;

- other complications such as urethra vaginal fistula, pulmonary thromboembolism, extensive bleeding.

Risk and complications of female to male surgery may include:

- loss of the phallus from either disease or blood supply issues;

- cephalic vein thrombosis (blood clot);

- arterial ischemia (shortage of blood supply);

- infection;

- distal limited necrosis (death of parts of the penis);

- hematoma (bruise).

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