Male To Famela Sex Reassignment Surgery

Table of Contents

Sex-change surgery is known as a synonym for sex reassignment surgery (SRS) or gender reassignment surgery (GRS) for male-to-female (MTF) and female-to-male (FTM) transgender patients. The process of altering one’s sexually-given body is in order to reflect their sexual identity and to help them live better with themselves and society.

Patients who suffer from Gender Identity Disorder (GID) feel that their biological gender does not match their emotional and psychological identity. They dress and present themselves as the opposite sex for a long period, usually longer than a year.

With the evaluation of a multidisciplinary team including plastic surgeons, psychiatrists, endocrinologists, and anesthetists, the patients undergo surgery to eliminate the mental tension. After this surgery, they are able to live the life they wish to live or start a new life more peacefully and comfortably.

Prof. Dr. Barış Nuhoğlu, M.D. is one of the most experienced plastic reconstructive surgeons in the field of male-to-female sex reassignment surgeries (SRS) or gender reassignment surgeries of transgender patients around the world. He has been performing these operations for 20 years with zero morbidity. He has published several original articles and abstracts at international scientific meetings.

Importance and Purpose of Male-to-Female SRS

The surgical theories of male-to-female sex reassignment surgery (MtF SRS) generally focus on creating an aesthetically accepted and functionally suitable genitalia, rather than perineogenital area, in cases where necessary. Regardless of the technique to be used, the empty vaginal canal loses function over time.

The contents of the lost vaginal canal glands can only be partially replaced by the products of the neighboring lighter oral tissue. Therefore, it is aimed to create aesthetic and becoming female-looking female genitalia, but surgeons must be aware of their limitations. Creating aesthetically accepted female external genitalia and a sufficient depth of vagina to allow normal sexual intercourse and sufficient oral lumen for urination is a challenge for the surgeon. An important purpose is to ensure the urine stream enters the toilet without spraying and to draw the flow in the desired direction in order to prevent deterioration of hygiene in the long term.

It is aimed to reduce the patient’s need and dependence on dilator use in the vaginal cavity, and to complete the process by providing adequate oral length. The function of the neovagina at the appropriate length and width plateaus after keeping oral dilators in the neomembrane for 6 months. Due to lack of dilation, shrinkage or recurrence are expected when the neovagina gets shorter than its original length in patients having same experiences.

An appropriately length and width neovagina can therefore contribute to the continuation of normal sexual activity. Neovaginal separation and dilatation are important parts of this process. The second phase of the creation of the vagina is more about the role of the patient in the process. The role of the patient is of importance in not skipping regular dilation and completing the dilatation process successfully, and persisting in maintaining the function of the vagina after vaginal creation. The creation of a vagina is then a process that not only the surgeon but also the patient plays an important role. Having a neovagina will contribute to women’s sense of “wholeness” and “incompleteness”.

Barış Nuhoğlu's Approach and Expertise

Prof. Barış Nuhoğlu approaches sex reassignment surgery fundamentally from a female aesthetic view with a patient-specific touch. He pays attention to the individual profile of each patient who will undergo MTF sex reassignment surgery.

Throughout more than a thousand patients, he successfully worked on discussing the gender reassignment physiologically and functionally, starting from different discussions during the transition process, rather than performing the operation without asking more. In this way, the right candidates are more easily understood and selected, and after surgery, patients are happy and satisfied with themselves.

Prof. Nuhoğlu has been following the latest developments and advances in transsexual surgery. He makes regular visits to doctors in Europe and the United States to exchange ideas, update knowledge, and keep up with developments. Due to his worldwide scientific activities, he can easily and practically learn new things, develop new approaches, and pass on his knowledge.
He is very meticulous about hygiene.

He uses the best quality materials and instruments for MTF sex reassignment surgery. He performs surgery in our well-equipped hospital where experienced and friendly staff work in all departments, including a post-operative ICU. He uses Microsurgical Technique where a 2-layer primary urethral repair without urethral opening is preferred in suitable patients.

He closes the scrotum completely, keeping the labia to the outer edge and serving as a female aesthetic view. He takes his time during surgery; spends 6-8 hours in excess while in other places 2-4 hours these procedures are completed. Prof. Nuhoğlu believes that patience brings happiness, and especially for this type of surgery, he pays great attention to this. After sex reassignment surgery, regular follow-up with patients for 1 year. All of our patients thanked us and were extremely satisfied. We apply the most common techniques and have tips that we add personally to the section.

2. Male-to-Female Sex Reassignment Surgery Procedure

1. Male-to-female Sex Reassignment Surgery (SRS), also called Sexual Reassignment Surgery (SRS), Gender Confirming Surgery (GCS), or Gender Reassignment Surgery (GRS), is the surgical procedure for altering the external genitalia and reconstructing them into the female. It is the last step of the transitioning process from male to female. Sex reassignment surgery for male-to-female involves reshaping the male genitals into a form with the appearance of, as well as the function of, female genitalia.

2. The main aim of the procedure is to create a structurally sound female vagina, external genitalia that appear feminine, a urethra that allows patients to urinate from a standing position without the need to sit down, allow for the patient to experience orgasm, and preserve sensitivity as much as possible. The long-term objective is to provide gender identity to females. The focus of the surgery is to create a vagina by using the penile structures and preserving penile sensation as much as possible. After the surgery, the patients can start to have a normal life with the genital appearance and function appropriate to the female gender, like any other natal females.

Penile Inversion Vaginoplasty

It is the most popular procedure of sex reassignment surgery. The patient should stop smoking 3 weeks prior to surgery. 3 weeks before the surgery, the patient should use testosterone suppressant agents regularly for the shrinkage of the penis skin. The length and diameter of the skin is very important for a nice neoclitoris and labia.

Therefore, a significant shrinkage of the penis skin will be beneficial for a nice neovaginal construction with less scarring. The shaving of all body (including facial) hairs should be done 2 days before surgery. Hairs of the genital area should be shaved daily for 3-6 months after the surgery.

The patient should inform me about all drugs she used in recent times for her general health and any illness she experienced. The HbA1c result is required for taking the preoperative precautions against diabetes. In the preoperative preparation menu, the viewer can reach the subtopics of general preoperative rules, suggestions, and recommendations.

On the operation day, the patient should fast 12 hours prior. She should get 8 hours of sleep. With a cold shower, she should wash her genital area with a brush 3 times. Before coming to the hospital, she should take 2 tablets with a glass of water to calm down, help to sleep, and prevent early ejaculation. When she wakes up (usually in the morning), she should take a taxi and come to the hospital.

Neurovascular Neoclitoris Formation

Currently, the majority of the SRS procedures follow the classic penile disassembly technique. Although this method may still have a place in the treatment algorithm, new treatment strategies continue to be important in the current era, which underlines the emphasis on clitoral formation, clitoral blood supply, appropriate innervation, and self-lubricating mucosal surface creation. In order to preserve enough function of the native penis, truncation of the biggest nerve in the penis, i.e. the neurovascular bundle, could be beneficial.

The principal inspirations for the human neurovascular neoclitoris formation via any SRS techniques are the embryological development of the nervous innervation of the external genital organ, the knowledge of the sensory link between the female clitoris and the optical (consciousness, awareness) and subcortical regions (orgasm), and more physiological self-reports of some patients who had adolescent clitoroplasty or exstrophy epispadias surgery, and many successful animal experiments on the subject in the literature.

Surgical Techniques and Components

Let us start with the surgical technique frequently applied to date for male-to-female SRS. Male-to-female SRS procedure, or more accurately defined, the GRS procedure, is a comprehensive series of procedures strictly requiring the knowledge and experience of several specialties.

Components of GRS are: penile-scrotal skin removal, scrotum inguinal skin graft harvesting, penile bifidization, mucosal dissection, clitoris formation, clitoral hood preparation, labioplasty, vaginal canal creation, vulva formation, and orchiectomy. Female secondary genital appearance and function are affected by the technique to enable vaginal metaplasia. The surgical procedure described below ensures a successful outcome of male-to-female GRS and is the current ‘gold-standard’ technique.

Advanced practice within the context of surgical principle is necessary so as to optimize useful anatomy components for GRS of post-pubertal transsexual patients. Important aspects of the whole procedure are adequate penile skin, preputial flap, scrotal skin graft, and inguinal fold. For penile-scrotal skin and mucosa vaginal colpectomy with mucosa vaginoplasty, penile skin is used prior to the resection of the corpora cavernosa.

Mucosal flaps are cleft and widely used for the denuded corpora, protect urethral blood supply by ensuring the wide dissection of the urethra, the wound bed is created, and corpora cavernosa are excised. The penis is completely degloved and redundant penile skin is interpreted as preputial advancement with or without skin graft.

A penile-scrotal skin flap is required. A scrotal skin graft is required additionally in order to cover vaginal mucosal defects. Mucosa grafts and labia are inserted under pressure to ensure neovaginal formation.

Orchiectomy

When bilateral orchiectomy is required under general or local anesthesia, a horizontal skin incision is placed into the scrotum. The spermatic cords are located with both palms. They are clamped with right-angled hemostats and severed in the mid-region.

After removal of the testes, the hemostat is removed. The lumen is oversewed to prevent outpouching of inguinal fat into the incision. The used tissues are sent to the pathology department as a routine practice. As the testes are removed and the androgen is completely stopped, femininity becomes more pronounced.

Usually, breast development and size increases. Lower incidence of deep vein thrombosis after this stage is also stated in a research paper. In this way, the risk of local end organ complications (e.g. phlebitis and pulmonary embolism) is diminished

Labia Formation from Scrotal Skin

Labia majora are the outer side and labia minora are the inner side of the female genital. In vaginoplasty, labia majora and mons pubis are created by using scrotal skin. If the scrotal skin is not sufficient, outer labia are supported with the skin of part of the penis skin. Labia minora are formed from the remaining inner scrotal skin. In some patients, when the scrotal skin is not sufficient, additional skin with mons pubis and outer labia is needed. In this case, skin is required from a different part of the patient.

Labial volume is an important issue in creating the most natural appearance after SRS. Grip clitoris and keep this tissue moist after skin removal until the time of clitoplasty. Labia minora are the inner edges of the female genital. It is an important part of the aesthetic genital. It should be provided with the right length. Inner labia should not be under three fingers vertically. Inner labia should not be too much in front or at the back. The mons pubis is an important component of the female genital.

Liposuction or pubic lifting can be performed to create the mons pubis. The problem that can be seen in the lower part of the female genital can be solved with lifting the inner part of the thigh or with flap operations from the area. The problem that can be seen in the upper part of the genital may occur due to the thinness of the mons pubis. In order to overcome this problem, there has to be an adiposity on the mons pubis. When deciding on skin removal, we should not remove excess skin from the mons pubis. For questions about scrotal surface repair, you may contact us.

Neoclitoris Formation from Erectile Tissue

The corpora cavernosa include the erectile tissue present in the original male genitalia in the preoperative period. The clitoris that is resected from the penis and urethra skin/corpus spongiosum with the penoscrotal part is formed by reducing and reshaping the erectile tissue separately from both the penile shaft and the neovaginal mold.

These pieces are sorted, prepared, and reduced separately. A small amount of tissue collected from the tubercle skin can also be placed between these parts. Subsequently, these parts are brought together with sutures, resulting in a volume reduction and reshaping in the entire tissue block that has been converted into a more suitable form for placing in the neoclitoris elevation side.

With the method of not reducing and reshaping erectile tissue separately but shaping only by moving conventional 90° separation with penile pedicle method, only a three-dimensional natural shape of the penile nostroglanis transformation could not be achieved. In allografts, which have more rigid mechanical properties and are difficult to shape, erectile tissue is treated together with the penile shaft; stiffness is provided to support the neoclitoris and therefore can be shaped appropriately.

After that, the penile erectile tissues are placed to provide resistance under the dermatome pieces obtained from the preserved tubercle skin and positioned to support the penis approximately at the 9 and 3 o’clock positions. Thanks to this support, in the early postoperative period, the shrinkage process, which can reduce the size of the neoclitoris to a great extent, is prevented.

Preservation and Functionality of the Urethra

Preservation of the male urethra is a very sensitive issue. At some centers, our colleagues cut two to three centimeters of the intact part (urethra-linea dentata) and cause some problems for the patient.

If the amputated part is long enough and one cup stitching is a possibility, we aim to do it in two channels. In the first instance, the part to be shortened is taken from the new vagina (nir-type 2 vaginoplasty).

Subsequently, if the urethra diameter reduces at the distal end to the desired caliber, the upper part of the urethra is brought out from this opening again and a retrogressively prepared prolene 3/0 absorb exact suture is applied (SUPORN TECHNIQUE). In this way, although some men have short urethras, they will not lose any part of their urethras.

Tying a string (suture) and occasionally oral and rectal mucosa grafts from excessive lubrication are other details we put forward in preserving urethral sensitivity and functionality over time.

Operative Details and Expected Outcomes

Sex Reassignment Surgery is not a “simple surgery”. The patient and surgeon must plan SRS with attention to detail. SRS has a major impact on body image and self-esteem. It has irreversible results and irreversible consequences. The affected part of the body and the affected patients have a very complex structure like identity, self-esteem, and psychiatric connection.

Surgery is the last but the most important part of the treatment, which needs a multidisciplinary team approach. Before planning gender reassignment surgery, psycho-social evaluation is required by the psychiatrist, and the patient has to receive Hormone Replacement Treatment (HRT) for at least 1 year. Breast augmentation surgery, facial feminization surgery, and other feminizing plastic surgery procedures are usually done before SRS to improve the patient’s self-confidence.

SRS techniques have expanded considerably and continue to evolve.
Penile inversion vaginoplasty is now the most common form of SRS.

One of the new methods has an improved neoclitoral hood to form an angle of 120-140 degrees plane with the neovaginal plane, but the detection of this operation is still doubtful. Our method places advantages on the basis of patent request and results.

Duration and Complexity of the Procedure

The duration and complexity of the operation can vary according to the type of surgery. We will discuss these details during our consultation in person. In full assessments of a male-to-female transsexual transplant, skill types are useful in terms of economic planning, but it is crucial to stay open and allow for changes during the surgery.

This process requires more than 6-9 hours to carry out. The complexity of the process will be explained in detail when the individual is chosen through the preoperative planning process and where the optimal surgery technique is preferred from the beginning. Measurements are decided by a rather general assessment of the donor (pubic fat weight and size). Preoperative information is very helpful in speeding up the problem of this surgery.

For patients with arterial insufficiency, we know that the skin and bowel cannot heal or that bowel complications can lead to treatment for a long time after sexual reconstructive transplant surgery. The presence of sufficiently resistant collagen vascular pedestals (usually due to a sexual construct that can be surgically created) of intact problems that would present the risk of failure dictated or suggested avoiding a successful adverse artery with tacking.

Successful adverse artery coaptation surgery can result in rapid failure. If not, everything depends on the presence of a complex surgical injury. With the transplant anastomosis, the mucosa is usually tense and firmly tied together, the arterial and venous dominance of the connective tissue around the suture is placed on the connective tissue created by the use of the suture mucosa. Since this beard is also tension-free due to its increased skin content, neither skin necrosis nor ischemic complications occur in any way. It is loaded on this belly.

The vagina is created by inverting the penoscrotal flap and suturing a molded mold around cotton bolt around it. The base of the inverted urethra system is used as a guide in the scrotal flap cap. Partial-thickness, circumferential dissection above. A soft cotton bolt mold and inflammatory pouch are prepared with wide mobilization of the posterior scrotal margin from the underlying fascia prior to introduction into them.

Aesthetic and Functional Outcomes

Masculinized genital anatomy is surgically reconstructed to achieve the desired female external appearance, as well as urination while sitting, during Sex Reassignment Surgery. For this purpose, the penis is reconstructed into the labia minora and majora, clitoris, and vestibule. 

The vagina is reconstructed by inversion with the penoscrotal skin island flap or with peritoneum, amnion, or sigmoid colon. Complementary surgical management of SRS to improve coital function includes scrotoplasty, creation of an adequate vaginal orifice, labiaplasty, and clitoroplasty to increase clitoris size and sensitivity. In comprehensive SRS, vulvar reconstruction involves the realignment of the urethra to the vestibulum, followed by labiaplasty. Labia majora are created by transposing the scrotal flaps.

When the surgeon performs SRS and uses large penile skin flaps, they can easily create large labia majora. The aesthetic goals of clitoroplasty and labiaplasty in SRS include the creation of labia minora with a smooth appearance, a clitoral hood, and exposure of the clitoris that is sensitive and suitable for sexual stimulation. Aesthetically, there should not be scrotal skin in the introitus, less trans-exposure of the clitoris and vagina, and less injury to the skin. The surgeon sutures the vaginal wall above the clitoris to the remaining penile skin on the backside as high as possible. Small hair follicles should be excised around the clitoral area.

Recovery Process and Timelines

Following the reassignment surgery, our patients are provided with a comfortable, comprehensive postoperative setting at our hospital. Highly qualified medical services are offered to each patient who undergoes gender reassignment surgery or any additional procedure that may be required for an optimal transformation.

During the very first days after SRS, recovery is normal but essential as the body heals. Thus, careful awareness of individual care instructions is a priority in order to achieve satisfactory results. After the surgery, patients will be pain-free and mobile after 10 days. During this time, belt support is available to help provide comfort for the full 10-day recuperation at the hospital.

The laryngeal tube will normally be removed by the end of your hospital stay or depending on the patient’s general medical status. The drain will empty into a small plastic drain bag and will normally be taken out if the surgeon says it should be. You will be discharged one week after your SRS. Regular check-ups are necessary, therefore be sure to book a flight that allows you to stay in Istanbul for one week before seeing us again.

Pre-Surgical Evaluation and Preparation

The transformational process begins with an evaluation to delineate the scope of the treatment plan and to exclude contraindications to the surgery, with provision for any necessary preoperative preparation. Definitive characteristics, such as that of being 18 years of age, are legally binding in our country; similar criteria for other countries can also be considered an inclusion criterion for all studies regarding patients in this group.

A diagnosis of gender identity disorder according to the criteria of DSM-IV-TR indicates that the patient is experiencing a high level of discomfort in their current gender role or identity as male and wishes to adopt the role of female. Before SRS, the patient should engage in at least a one-year trial period in the desired new sexual role. In our country for pre-operative candidates, the report of a psychiatrist consists of a diagnosis of gender dysphoria, the necessity for transsexual surgery, an understanding of the surgical procedure’s outcome, the necessity for continuing medical care after the surgery, and the patient’s ability to give voluntary informed consent.

A comprehensive preoperative evaluation will also consider specific ethic and legal criteria that should have been met before your surgery. Preoperative hair removal is recommended. In our study, 133 male patients were approached, and 232 responded, representing a response rate of 83%. Preoperative hemoglobin (Hb) levels may be a good indicator since blood transfusion requirements are related to hemoglobin levels. When a cut-off level for preoperative Hb levels was established with patients’ outcomes of postoperative Hb levels below 11 mg/dl, the transfusion rate was 25% and the complications rate was 38.8%. These rates increased with each additional point or greater.

Additional “non-definitive” characteristics may include a clean criminal record, a negative serological test for human immunodeficiency virus, a diagnosis of transsexualism but not be suffering from another major medical disorder, at least 18 years of age, and adequate psychological capacity to give fully informed consent. A male-to-female candidate who meets these criteria and is voluntarily seeking treatment may then have a hormonal, endocrinological, and genetic evaluation, including at least a chromosomal analysis and a determination of serum testosterone, luteinizing hormone, and follicle-stimulating hormone levels as described in the Standards of Care.

Some diseases, such as diabetes mellitus, must be controlled preoperatively, which increases the time of preparation or exhibited a complication of chronic diseases. The well-known standards and guidelines include preoperative laboratory investigations, preoperative electrolyte balance, hematologic investigations, organ functions, stage assessment for chronic disease, and compliance with standards. Although there is no recommendation for a prostate ultrasound and the monitoring of prostatic-specific antigen (PSA) values, it could be a useful procedure for patients with advanced age.

The well-known surgical techniques are penectomy with the preservation of a neoclitoris in patients with minimal penile enlargement (about 1-2 cm long) or the use of a mucosal tube that includes the entire glans, achieving a vaso-urethral pedicle. In some cases, the vaginal orifice should be increased postoperatively. At that time, penile inversion provided promising results with a low complication rate. The objective of these studies was the analysis of a large group of transsexual patients who had undergone this surgical procedure to evaluate the correlation between surgical complications in relation to known risk factors.

Frequently Asked Questions about Male to Female Surgery

What is the age requirement for Sex Reassignment Surgery?

The minimum age requirement for the sex change to be implemented on the individuals is controversial among the authors. Dr. Baris Nuhoglu offers this surgery in suitable conditions to individuals over the age of 18 to 65. In this regard, only individuals who have completed their psychotherapeutic and endocrine treatments are offered an appointment for gender change surgery.

What is sex reassignment surgery male to female?

The male to female sex surgery is the surgery that is applicable to transgender or transsexual individuals that involves the transition of male to female patients who had the biological birth with male secondary sexual characteristics by removing the penis and creating a neo-vagina to match the psychological gender.

Both hormonal therapy to develop secondary sexual characteristics matching to gender identity and sex surgery are successful methods for the gender dysphoric individuals for attaining the body image that matches their gender identity. The goal of the surgery is to remove traumatic male genitalia and establish a normal female appearance.

Along with a good surgical result, the patient’s anatomy that is consistent with the female undergarments and other clothes, that allow normal urination standing or sitting, that allows orgasm completes the sexual intercourse to make the patients satisfied with their sex reassigned as a woman. The patient’s ability to have normal erections and enjoy sexual intercourse should not be altered as a result of surgeries.

Why do we need a vaginal canal in transgender people and why should it be at a certain length, not too long and not too short?

It is very normal for people to feel the need to look full and complete with their vagina when they look in the mirror. This comprehension will make the person feel complete. Furthermore, it is very important for the person to integrate with the genitalia of their loved partner during sexual intercourse.

If the vaginal canal is too long, you will have to constantly use vaginal candles and the sexual organ will never be fully integrated. If the vaginal canal is too short, the sexual organ may not have completed it. Of course, aesthetic worries are well-suited because the surgical outcomes play a role in the patient’s psychology and sex life.

However, paying more attention to those rules and the inner biology of the body will bring better postoperative anatomical and physiological results. In this way, the body complies with femininity, the true appearance, and smooth intercourse during sexual intercourse, resulting in superior aesthetic outcomes.


      

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