Penile Skin Inverstion/Vaginal Plastry

Penile Skin Inversion/Vaginoplasty
Surgical fee

1. Pre-surgery night, five nights recuperation in hospital
2. Doctor's fee
3. Clinical interview/surgical consultation

-    Psychological evaluation
-    Surgical and anesthesia fee
Remark: surgical not include if you have medical diseases such as diabetes mellitus, heart diseases which is this cover during pre-op check up.

  Post Operative Care

1. All medicine supplies: SRS Kit, Donut pillow, dilator, douche kit and medical grade lubricants.
2. Post operative check-up

GRS (or SRS) Certification
  GRS/SRS Certification

Guaranteed Satisfaction

1. No doctor’s fee if any correction is required. (Except medical supplies, medical treatments)
2. All post-operative aftercare is provided without cost.
   (Second stage SRS like colon transposition vaginoplasty is not considered correction, and will incur a separate fee).

  

Facts about the procedure
The technique used is Penile Skin Inversion, sensate glans clitoris, labiaplasty and vaginoplasty in one stage with 3 different techniques:

1. Long Penis (>6 inches) = Penile Skin Inversion (PSI)
2. Medium Penis (2-6 inches) = Penile Skin Inversion (PSI) with Scrotal Skin Graft(SSG)
3. Short Penis (<2 inches) = Penile Skin Inversion (PSI) with Sigmoid Colon Graft(SCG)
   

  
Criteria of Approval

1. Patient must be at least 18 years of age. Patients will require permission from parents if under 20 years old.
2. Patients must be diagnosed with at least one of the following disorders: gender identity disorder, gender dysphasia, or associated conditions.
3. Patients must have undergone at least one year of antiandrogens and / or
   female hormones.
4. Patients are required to have lived full-time in the cross-gender role for at least 1 year (supported by Identification Documents).
5. Patients must have approval from a psychiatrist (MD), psychiatric social worker (PhD), or clinical psychologist (PhD).

Surgical procedure

The M to F SRS surgery is as follow:
1. Creation of vaginal space between urethra, prostate gland, bladder and rectum
2. Bilateral orchiectomy
3. Degloved penis shaft
4. Separation of urethra from penis
5. Isolation glans penis with 2 dorsal nerves and vessels
6. Penile skin inversion to line vaginal cavity with or without scrotal skin graft or sigmoid colon graft
7. Clitoroplasty (Sensate)
8. Urethropalsty
9. Labiaplasty, major and minor


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

The excess erectile tissue around the urethra is 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 (exceeding 8 inches).   

Techniques
There are 3 main techniques:
1. Penile skin Inversion (PSI) only (for the long penis)
2. Penile Inversion with scrotal skin graft. (PSI plus SSG for medium size penis)
3. Penile Inversion with Sigmoid Color Graft. (PSI plus SCG for small size penis)

The SSG or SCG is done in one stage with 5 days hospitalization (average).

  
Results
The Male to Female SRS is done in one stage with result of
a. Sensate Glans Clitoris
b. Neo-urethra
c. Vulva Floor
d. Labia major and minor
e. Neo-vagina of 5-6 inches (Natural Vagina is 4.5 inches)

   
Duration of Operation:

 2½ - 4 hours

  Possible Risks and Complications

i.) Infection: Usually only minor wound infection. There is no pulmonary or
systemic infection.
ii.) Wound Disruption: only at the faucet of the new vagina perineum due to high tension at the area, will require only wound care and heals spontaneously in one month.
iii.) Short Vagina: normally you will get the depth of 5- 6 inches, at first, depth will be deeper after 6- 12 months due to the maturation of scar and more elasticity. In case of a very short vagina, a second operation can be done after 6 months, by using the sigmoid colon procedure.
iv.) Rectovaginal Fistula: where a hole develops between the colon and the vagina. The other complications which are mentioned in the literature such as the urethra vaginal fistula, pulmonary thromboembolism, extensive bleeding, and serious infection have never occurred in our experience.

  
Side Effects

i.) Unable to urinate: it can occur sometime after removing the urine catheter, due to the swollen stump at the opening of the shortened urethra which will need the urine catheter to be retained of a few more days, eventually you will be able to pass urine normally.
ii.) Bleeding: you may experience oozing blood around the gauze dressing the first day after surgery due to bleeding thru the stump of urethral opening, may require repacking or suturing.
   

After Care

Before being discharged from the hospital to your hotel, the nurse will teach you how to take care of your vagina and prescribe some more medications. The stitches will be removed after 7- 10 days. And you will be able to return home.
  

 

Recovery Time
- You need to stay for recuperation in Pattaya for 10-14 days at least before safely flying home. You will also require 4-6 weeks recuperation at home before returning to work. (The neo-vagina can function within 6 weeks)
- The cost of Penile Skin Inversion already includes 5 nights in the hospital private room after surgery and medical treatments, post-op care etc.

 

Hospital Admission

You will be requested to sign the hospital consent form. Then you need five nights admission in hospital for recuperation

Anesthetic
General anesthesia (totally asleep) or you can choose epidural or spinal anesthesia.

 

Post Operative Care
After discharge from hospital, the patient will recover but will need liaison at the hotel. During recovery in the hotel, the patient must follow specific instructions, including:

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

2). Failure to dilate properly can result in serious injury. You will be instructed to gently dilate in the correct direction after the vaginal packing is removed.

3). Dilation can be painful for the first weeks, but is essential for developing maximum depth and ensuring post operative functioning of the neo-vagina.


During the recovery period, after each dilation session:

The wound should be washed gently with Hibiscrub (pink color) in the shower followed by douching while seated on the toilet:
(i) douche solution (proportion) = 5-10 ml (cc) of Betadine solution mixed with 1L of water or until the container is full
(ii) insert the douche to full depth, squeeze, and hold the container tightly;
(iii) while holding the container tightly, extract the douche;
(iv) keep the wound dry and apply Betadine solution with cotton balls; and
(v) apply Kemicitine ointment with a cotton applicator. If there is some bleeding, press or apply pressure with a dry cotton ball to the site for 15 minutes. During the first weeks after surgery, sanitary pad should be changed several times per day due to normal vaginal bleeding during recovery.

One month after SRS operation you will be required to start applying Premarin cream to your neo-vagina. Apply two times a day to soften your neo-vagina. This would generally take around six months.

Patient can return to using female hormones two months after surgery. You should consult your endocrinologist to re-adjust the dosage. A sudden change in hormone levels, for some individuals, may result in the fluctuation of emotion.

 

Preparation

Preparation before operation

We follows the HBIGDA criteria, you should have
1). One letter recommending the S.R.S. from; either
i. Therapist,
ii. Psychiatrist,
iii. Endocrinologist or General Practitioner

2). Discontinue hormone treatment at least 14 days prior to surgery. Hormones should be halted to reduce the risk of thrombosis (blood clots). Oral tablets should be halted two weeks prior to surgery and injected type should be halted four weeks prior to surgery. Oral antiandrogens can be halted three days before surgery (four weeks if injected).

3). Have your private doctor perform pre-operative physical check up within three months prior to SRS. Patients must also be confirmed by a private physician to be free from serious medical diseases and must pass the following blood tests:
- CBC, HIV, Electrolytes, FBS, Creatinine Urinalysis
- Alkaline Phosphatase, Chest X-ray
- SGOT LDH EKG
and e-mail the results.

4) Reduced smoking, No aspirin or ibuprofen (Advil etc.) and Vit. E.
5) G.R.S. date; should send a Fax or email for appointment one month prior to surgery date and itinerary.
6) If patient is HIV positive operation can be done but will cost 30% extra due to the necessity of using disposable instruments.
  
   
Appointment with Surgeon
The operation can be arranged once you have all the required papers ready. Just inform us of your convenient date at least one month in advance prior to arrival, either by e-mail at inquiry@bph.co.th, or by calling us at (66) 3825-9999.

Patients are required to submit following documents before operation: (International patients only – email or fax)
1) one item of photo identification (e.g. drivers license, Passport, etc)
2) bank confirmation of 10% wire transfers (please check at term and payment)
3) copy of the flight reservation itinerary
4) original signed (hard-copy) documents of claimed diagnoses or referrals. We will collect your hard documents during consultation.
5) Once the applicant has been approved for Penile Skin Inversion (MtF) Surgery,
the patient can then make the flight arrangement.

Patient can e-mail to inquiry@bph.co.th
Bangkok Hospital Pattaya
301 moo 6, Naklua, Banglamung, Chonburi 20150

 

Surgery Schedule Detail

DAY 1
- Arrive in Bangkok International Airport. Meet BPH staff and be escorted to the hospital.
- Pre-surgery night in the private deluxe suite in Hospital

DAY 2
- Meet with your appointment doctor for clinical interview / surgical consultation.
All questions will be clarified personally and the surgery technique will be discussed and interview with Psychiatrist (if necessary)
- Check medical documents
- Admission to hospital. You will be requested to sign hospital consent forms.
- The operation date and time will be arranged within twenty-four hours after
pre-operative consultation.

On the day;
1.The nurse will carry out an enema to clean rectum.
2. Take very shower.
3. Pre-operative intravenous fluid and sedation.
4. In operating theater under general anesthesia.
Surgery takes about 2 ½ to 4 hours

DAY 3-5
The day after;
Upon waking up, able to have regular meals, and move freely in bed. Do not be alarmed by the catheter for urine and drainage tube full of blood, this is normal at first, it will stop in twenty-four hours. You may feel like you want to urinate, but it is due to the urinary catheter irritation. Pain is usually minimal only during the first twenty-four hours. It then subsides gradually, and you can be ambulated with help daily. The dressing gauze and the catheter will be removed on the 6th days. You can urinate, take a shower and be discharged back to your hotel on the 6th day. A nurse will come and bath you twice a day and change your bedding as often as necessary

DAY 6
Your doctor will remove the dressing and bandages. Upon checking the results you may leave the hospital and check in to your chosen hotel.

DAY 6-10
These five days should be spent resting

DAY 11
You may go sightseeing or shopping (depending upon on doctor’s advice).

DAY 12
Please return to the hospital where the doctor will remove sutures from the labia and do a final examination. You will receive a final postoperative recovery check up and some medications. You will also receive a medical certificate that authenticates the surgery and recommends that you receive a legal change of sex.

DAY 13
Transfer to Bangkok International Airport for Departure.