Vaginoplasty: Overview

A vaginoplasty, also called transfeminine bottom surgery, is a surgery performed in transgender women. It involves creating a new vagina, usually from the inverted skin of the patient's penis. This long and complex operation requires considerable thought and commitment during both the preparatory and recovery process.

What Is a Vaginoplasty?

A vaginoplasty is a type of gender-affirming surgery performed under general anesthesia by surgeons with backgrounds in various areas, including plastic surgery, urology, and gynecology.

Various Surgical Techniques

There are two main vaginoplasty techniques:

• Penile inversion vaginoplasty: A vagina is created from the inverted skin of the penis.
• Intestinal or bowel vaginoplasty: A vagina is made from a portion of the small intestine or colon.

While penile skin inversion vaginoplasty is the more widely used and researched surgical technique, it has not been found to be superior to the bowel technique. However, the comparison is difficult to make based on available data, which is not standardized.

There are several reasons why the bowel technique is less commonly used. Some surgeons who perform vaginoplasty do not offer the bowel technique and some experts feel that the bowel technique has more serious risks due to the required abdominal surgery. It also causes constant vaginal secretions rather than only with arousal, which can be bothersome.

A study comparing the two techniques found that patient satisfaction was high for both, but higher for the inversion technique.

Criteria and Contraindications

Undergoing a vaginoplasty is a lifelong, serious decision. The World Professional Association for Transgender Health (WPATH) has created guidelines to help surgeons determine who is an appropriate candidate for vaginoplasty and other feminizing surgeries (e.g., breast augmentation and facial feminization surgery).

A surgeon may decide not to operate on patients who do not meet these criteria and/or patients may not be able to obtain any insurance coverage for their surgery.

These WPATH criteria require that patients are at least 18 years of age (in most states) and have two letters of support from mental health professionals who are trained in transgender health.

The criteria also require that the patient:

• Has persistent, well-documented gender dysphoria.
• Has the capacity to make an informed decision and consent.
• Has well-controlled medical and mental health conditions.

In addition, patients must live as a female for a minimum of 12 months. The criteria also state that the patient should undergo 12 continuous months of hormone (estrogen) therapy unless they are "unwilling" or "unable due to a medical condition."

Potential Risks

Some of the risks associated with undergoing a vaginoplasty include:

• Bleeding and hematoma formation
• Injury to nearby organs, such as the rectum, bladder, or urethra
• Wound infection or dehiscence
• Rectovaginal or pararectal abscess
• Skin or clitoral necrosis
• Urinary retention
• Neovaginal prolapse or stenosis
• Fistula formation (when an abnormal tract forms between the vagina and the rectum, urethra, or bladder)

Purpose of Vaginoplasty

In the majority of cases, the purpose of a vaginoplasty is to create a new vagina, often referred to as a "neovagina," as part of a male-to-female gender-affirming surgery.

Less commonly, a vaginoplasty may be performed in a woman who has undergone removal of her vagina for vaginal cancer. It may also be performed in female infants with various congenital anomalies (e.g., vaginal agenesis associated with Mayer-von Rokitansky–Küster-Hauser’s syndrome).

How to Prepare

Preparation for a vaginoplasty begins over a year prior to undergoing the operation with the initiation of hormone therapy. Then, about three to six months before surgery, patients will need to undergo permanent hair removal (either by electrolysis or laser hair removal) in the genital area.

Other preparatory strategies include:

• Stopping smoking
• Losing weight (possibly, if obese)
• Undergoing pelvic floor physical therapy

In addition, closer to your surgery date, your surgeon may ask that you stop these medications:

• Estrogen supplements (about two weeks prior)
• Blood-thinning medications like aspirin or ibuprofen (about 10 days prior)

What to Expect on the Day of Surgery

On the day of your surgery, you will be taken to a pre-operative room where you will change into a hospital gown. A nurse will then record your vital signs and place an IV. Once in the operating room, you will be given anesthesia medication to put you to sleep.

A vaginoplasty procedure, which lasts for four to seven hours, will then generally proceed with the following steps:

• The testicles will be removed (called an orchiectomy)—this is sometimes done in a prior surgery.
• The skin from the penis will be removed and turned inside out in order to make the new vaginal lining.
• A clitoris will be made from part of the head of the penis.
• The labia majora will be made from scrotal skin and tissue.
• A vaginal canal will be made from extra skin from the scrotum or from a skin graft.
• A new opening for the urethra will be created in the "neovagina" to allow for urination.

Recovery

After recovering in the hospital for your vaginoplasty (which is about five to seven nights), your surgeon will provide you with various post-operative instructions.

These instructions may include:

• Taking various medications to control symptoms like pain, nausea, constipation.
• Applying a cold compress to your perineum (the area between your vagina and your anus) to reduce swelling and discomfort.
• Avoiding certain activities for a period of time (e.g., strenuous activity for six weeks and sex for 12 weeks).
• Keeping your genital area clean and dry to prevent infection.

You will also be given detailed instructions on performing vaginal dilation. This is absolutely critical for maintaining the integrity of the new vaginal canal.

Long-Term Care

After a vaginoplasty, most patients are very satisfied with the operation both functionally and cosmetically. It's important, though, that patients remain committed to various lifelong practices and follow-up care, which may include:

• Restarting estrogen therapy about one to two weeks after surgery
• Re-starting pelvic floor physical therapy about four to six weeks after surgery
• Periodic visits with their surgeon to monitor for potential complications, such as neovaginal prolapse or vaginal stenosis
• Routine preventive care, including prostate cancer screening as appropriate. Your providers may also consider a yearly visual pelvic exam to look for cancers that occur on the penile and scrotal skin (if the inverted penile skin technique is used) or screening of the colon tissue as typically done if the bowel technique is used.
  
• Lifelong vaginal dilation

A Word From Verywell

No doubt, preparing for and healing from a vaginoplasty is a major undertaking. Only you can decide if the risks and lifelong commitment to having this operation are right for you.

During your decision-making process, do not hesitate to reach out to your surgical team with questions. Be sure to obtain emotional support as well—whether that's through a therapist, support group, or loved one.