How to choose the right technique for trans vaginoplasty

Vaginoplasty for trans women aims to recreate a vagina that closely resembles a cisgender vagina both visually and functionally. This includes ensuring proper urination and the ability to engage in sexual relations, depending on each patient’s needs.

The procedure involves creating a vaginal canal for patients who desire penetrative sexual relations, reconstructing the labia majora and minora, and forming a clitoris that retains sensitivity. A specialized medical team tailors the surgical approach to meet each patient’s unique needs, considering both preferences and anatomical or medical factors that may affect outcomes.

For those who do not desire a deep vaginal canal, a vulvoplasty, also known as zero-depth vaginoplasty, is an option. This procedure focuses on constructing external genitalia resembling a cis vulva that is functional and erogenous but without creating a vaginal tunnel. Recovery from vulvoplasty is quicker than other vaginoplasty techniques.

Several types of vaginoplasty are available, and the choice of technique depends significantly on factors such as the quality and quantity of genital tissue, the patient’s medical history, and their expectations or lifestyle. Each technique has its unique characteristics, benefits, and limitations, which must be thoroughly evaluated by the surgeon and patient.

Penile inversion vaginoplasty is the most common technique and is used when penile tissue is sufficient to form the vaginal canal.

In this procedure, the surgeon inverts the penile skin to create a vaginal tunnel and uses other genital tissues, such as scrotal skin or part of the urethra, to construct the labia majora, labia minora, and clitoris. This technique is typically chosen for patients with a sufficiently sized penis (usually more than 12 centimeters at rest) with good thickness and skin elasticity. Penile inversion vaginoplasty often yields highly satisfactory functional and aesthetic results. However, it may not be viable in cases of extensive circumcision or limited penile development due to early use of puberty blockers.

This technique is often chosen when the stretched penile tissue measures less than 12 centimeters, in cases of extensive circumcision, or for patients with prior unsuccessful surgeries that resulted in insufficient vaginal depth. While the procedure is more complex, involving longer surgical times and recovery, colovaginoplasty has become increasingly popular due to early support and treatment for trans individuals. At IM GENDER, this technique accounts for over 66% of the vaginoplasties performed.

Graft vaginoplasty uses skin from other areas of the body, such as the thighs or abdomen, to extend the vaginal canal by a few centimeters. This procedure is suitable for patients who lack sufficient genital tissue for complete penile inversion but do not require a procedure as complex as colovaginoplasty. While less invasive than colovaginoplasty, this technique requires meticulous postoperative care to ensure the grafts integrate successfully.

Vulvoplasty, or zero-depth vaginoplasty, is an option for patients who do not need or desire a deep vaginal canal. This procedure focuses exclusively on creating external genitalia, achieving a functional, erogenous, and visually similar vulva to that of a cisgender woman, but without a vaginal tunnel. It is less invasive than other techniques and offers a shorter recovery time, though it is not designed for patients who wish to engage in penetrative sexual activity.

Deciding on the appropriate trans vaginoplasty technique is complex and should be based on a comprehensive evaluation of each patient. The process begins with a detailed analysis of genital anatomy, assessing the quantity, quality, and elasticity of available tissues. Additionally, the patient’s lifestyle and needs are considered.

• Penile Inversion Vaginoplasty: Suitable when the size, thickness, and quality of penile tissue allows for creating a vaginal tunnel with sufficient width and dimensions for normal sexual activity.
• Colovaginoplasty: Recommended for patients with a small penis, significant prior circumcision, or underdeveloped genital tissue due to early puberty blocker use. Penile inversion is unsuitable in these cases as it would result in insufficient vaginal depth.
• Graft Vaginoplasty: A minority option for trans women lacking adequate penile dimensions for inversion yet not requiring colovaginoplasty. IM GENDER is a pioneer in this technique.

Beyond medical factors, understanding the patient’s needs and expectations is crucial. The surgeon must provide a realistic view of the benefits and limitations of each technique, ensuring the final decision is informed and respects the patient’s preferences.