Gender-affirming surgery (male-to-female): Difference between revisions

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Sex reassignment surgery for male-to-female transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans woman's female identity and functioning.

Often used to refer to vaginoplasty or vulvoplasty, sex reassignment surgery can also more broadly refer to other gender-affirming procedures an individual may have, such as permanent reduction or removal of body or facial hair through laser hair removal or electrolysis, facial feminization surgery, orchiectomy, voice surgery, or breast augmentation.^[1]

Sex reassignment surgery is usually preceded by beginning feminizing hormone therapy.

Genital surgery

The results of a penile inversion vaginoplasty, two years after surgery. Inner labia vary aesthetically based on surgeon; here, they are very minimal. The clitoris is tactile rather than visual, another aesthetic difference by surgeon. A faded surgical scar comes up from the perineum and follows the outer labia in a curved shape.

Vaginoplasty

Vaginoplasty is the process of constructing a neovagina and neovulva from existing genital or abdominal tissue.^[2] There are multiple techniques for performing vaginoplasty. Sexual sensation is typically retained following surgery, and the self-reported rate of personal satisfaction with surgical results across different vaginoplasty techniques is very high.^[3]^[4]^[5]^[6]

Penile inversion

Penile inversion is a common vaginoplasty technique.^[4] The testicles and scrotum are removed and the glans of the penis made into a clitoris. A canal is surgically created between the bladder and the rectum. The foreskin of the penis is inverted to form the interior walls of the neovagina. If the patient had been circumcised before surgery, skin from the scrotum may also be used to construct the walls of the neovagina after cauterising the hair follicles. The urethra is shortened, and the mons pubis, labia majora and minora, and urethral opening are created using scrotal and urethral tissue.^[2]

Because this technique inverts the skin of the penis to form the walls of the neovagina, post-operative depth is limited by the length of the penis prior to surgery.^[4] Following surgery, a patient will need to dilate the neovagina with a vaginal dilator 1-2 times daily to prevent loss of vaginal depth.^[4]^[7] The need to dilate becomes less frequent with time, but is recommended at least once a week after the neovagina has healed completely.^[7]^[8] Having penetrative sex can affect the amount of dilation needed, but additional lubricant is required during penetrative sex as the neovagina created through penile inversion vaginoplasty is not self-lubricating.^[7]

Bowel vaginoplasty

Bowel vaginoplasty is another common vaginoplasty technique that is also utilised for vaginoplasty in cisgender women.^[9] As with penile inversion vaginoplasty, the testicles and scrotum are removed, the glans made into a clitoris, and the neovulva constructed from scrotal and urethral tissue. However, in bowel vaginoplasty a segment of rectosigmoid colon is grafted into a surgically created canal to form the walls of the neovagina.^[6]

As bowel vaginoplasty uses colon to construct the neovagina, post-operative depth is not dependent on the length of the penis prior to surgery. This makes it appropriate for individuals who have already underwent penectomy, orchiectomy, or who had a penis smaller than the desired depth of the neovagina prior to surgery.^[4] Unlike penile inversion vaginoplasty, the neovagina created through bowel vaginoplasty is self-lubricating and does not require further dilation once fully healed.^[4]

Because of the risk of vaginal stenosis (the narrowing or loss of flexibility of the vagina),^[10]^[11] any current technique of vaginoplasty requires some long-term maintenance of volume by the patient using a vaginal expander,^[12]^[13] or vaginal dilation using graduated dilators to keep the vagina open.^[14]^[15]^[8] Penile-vaginal penetration with a sexual partner is not an adequate method of performing dilation. Daily dilation of the vagina for six months in order to prevent stenosis is recommended among health professionals.^[11] ^[8]

Regular application of estrogen into the vagina,^{[citation needed]} for which there are several standard products, may help, but this must be calculated into the total estrogen dose. Some surgeons have techniques to ensure continued depth, but extended periods without dilation will still often result in reduced diameter (vaginal stenosis) to some degree, which would require stretching again, either gradually, or, in extreme cases, under anaesthetic.

With current procedures, trans women are unable to receive ovaries or a uterus. This means that they are unable to bear children or menstruate, and that they will need to remain on hormone therapy after surgery to maintain hormone levels.

Other related procedures

Facial feminization surgery

Occasionally these basic procedures are complemented further with feminizing cosmetic surgeries or procedures that modify bone or cartilage structures, typically in the jaw, brow, forehead, nose and cheek areas. These are known as facial feminization surgery or FFS.

Breast augmentation

Breast augmentation is the enlargement of the breasts. Some trans women choose to undergo this procedure if hormone therapy does not yield satisfactory results. Usually, typical growth for trans women is one to two cup sizes below closely related females such as the mother or sisters.^[16] Oestrogen is responsible for fat distribution to the breasts, hips and buttocks, while progesterone is responsible for developing the actual milk glands. Progesterone also rounds out the breast to an adult Tanner stage-5 shape and matures and darkens the areola.^{[citation needed]}

Voice feminization surgery

Some MTF individuals may elect to have voice surgery, which alters an individual's vocal range or pitch. However, this procedure carries a risk of impairing a trans woman's voice forever. Since estrogen alone does not alter a person's vocal range or pitch, some people take the risk that comes along with voice feminization surgery. Other options, like voice feminization lessons, are available to people wishing to speak with less masculine mannerisms.

Tracheal shave

A tracheal shave procedure is also sometimes used to reduce the cartilage in the area of the throat and minimize the appearance of the Adam's apple in order to assimilate to female physical features.

Buttock augmentation

Some MTF individuals will choose to undergo buttock augmentation because anatomically, male hips and buttocks are generally smaller than those presented on a female. If, however, efficient hormone therapy is conducted before the patient is past puberty, the pelvis will broaden slightly, and even if the patient is past their teen years, a layer of subcutaneous fat will be distributed over the body, rounding contours. Trans women usually end up with a waist to hip ratio of around 0.8, and if estrogen is administered at a young enough age "before the bone plates close",^{[citation needed]} some trans women may achieve a waist to hip ratio of 0.7 or lower.^{[citation needed]} The pubescent pelvis will broaden under estrogen therapy even if the skeleton is anatomically masculine.

History

Lili Elbe was the first well-known recipient of male-to-female sex reassignment surgery, in Germany in 1930, the first being Dora Richter. She was the subject of four surgeries: one for orchiectomy, one to transplant an ovary, one for penectomy, and one for vaginoplasty and a uterus transplant. However, she died three months after her last operation.

Christine Jorgensen was likely the most famous recipient of sex reassignment surgery, having her surgery done in Denmark in late 1952 and being outed right afterwards. She was a strong advocate for the rights of transgender people.

French actress and singer Coccinelle travelled to Casablanca in 1958 to undergo a vaginoplasty by Georges Burou. She said later, "Dr Burou rectified the mistake nature had made and I became a real woman, on the inside as well as the outside. After the operation, the doctor just said, 'Bonjour, Mademoiselle', and I knew it had been a success."

Another famous person to undergo male-to-female sex reassignment surgery was Renée Richards. She transitioned and had surgery in the mid-1970s, and successfully advocated to have transgender people recognized in U.S sports.

The first physician to perform sex reassignment surgery in the United States was Los Angeles-based urologist Dr. Elmer Belt, who quietly performed operations from the early 1950s until 1968.^{[citation needed]} In 1966 Johns Hopkins University opened the first sex reassignment surgery clinic in America. The Hopkins Gender Identity Clinic was made up of two plastic surgeons, two psychiatrists, two psychologists, a gynecologist, a urologist, and a pediatrician.

In 1997, Sergeant Sylvia Durand became the first serving member of the Canadian Forces to transition from male to female, and became the first member of any military worldwide to transition openly while serving under the Flag. On Canada Day of 1998, the military changed her legal name to Sylvia and changed her sex designation on all of her personal file documents. In 1999, the military paid for her sex reassignment surgery. Durand continued to serve and was promoted to the rank of Warrant Officer. When she retired in 2012, after more than 31 years of service, she was the assistant to the Canadian Forces Chief Communications Operator.

In 2017, for the first time, the United States Defense Health Agency approved payment for sex reassignment surgery for an active-duty U.S. military service member. The patient, an infantry soldier who identifies as a woman, had already begun a course of treatment for gender reassignment. The procedure, which the treating doctor deemed medically necessary, was performed on November 14 at a private hospital, since U.S. military hospitals lack the requisite surgical expertise.^[17]

References

^ "Surgery Funding". www.phsa.ca. Retrieved 2022-09-21.
^ ^a ^b "Vaginoplasty". www.phsa.ca. Retrieved 2022-09-21.
^ Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, et al. (February 2022). "ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery"". Sexual Medicine. 10 (1): 100471. doi:10.1016/j.esxm.2021.100471. PMC 8847816. PMID 34971864.
^ ^a ^b ^c ^d ^e ^f Bizic M, Kojovic V, Duisin D, Stanojevic D, Vujovic S, Milosevic A, et al. (2014). "An overview of neovaginal reconstruction options in male to female transsexuals". TheScientificWorldJournal. 2014: 638919. doi:10.1155/2014/638919. PMC 4058296. PMID 24971387.
^ Li, Joy S.; Crane, Curtis N.; Santucci, Richard A. (3 February 2021). "Vaginoplasty tips and tricks". International Brazilian Journal of Urology. 47 (2): 263–273. doi:10.1590/s1677-5538.ibju.2020.0338. ISSN 1677-6119. PMC 7857744. PMID 32840336.{{cite journal}}: CS1 maint: PMC format (link)
^ ^a ^b Kim SK, Park JW, Lim KR, Lee KC (January 2017). "Is Rectosigmoid Vaginoplasty Still Useful?". Archives of Plastic Surgery. 44 (1): 48–52. doi:10.5999/aps.2017.44.1.48. PMC 5300923. PMID 28194347.
^ ^a ^b ^c "Vaginoplasty". www.phsa.ca. Retrieved 2022-09-21.
^ ^a ^b ^c Erickson-Schroth L (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford University Press. p. 280. ISBN 978-0199325368. Archived from the original on August 6, 2020. Retrieved February 29, 2016. The surgeon will also provide a set of vaginal dilators, used to maintain, lengthen, and stretch the size of the vagina. Dilators of increasing size are regularly inserted into the vagina at time intervals according to the surgeon's instructions. Dilation is required less often over time, but it may be recommended indefinitely.
^ Djordjevic ML, Stanojevic DS, Bizic MR (December 2011). "Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases". The Journal of Sexual Medicine. 8 (12): 3487–3494. doi:10.1111/j.1743-6109.2011.02494.x. PMID 21995738.
^ Carroll L, Mizock L (2017). Clinical Issues and Affirmative Treatment with Transgender Clients, An Issue of Psychiatric Clinics of North America, E-Book. Elsevier Health Sciences. p. 111. ISBN 978-0323510042. Archived from the original on August 6, 2020. Retrieved January 8, 2018.
^ ^a ^b Goldberg AE (2016). The SAGE Encyclopedia of LGBTQ Studies. Sage Publications. p. 1281. ISBN 978-1483371290. Archived from the original on August 6, 2020. Retrieved January 8, 2018.
^ Coskun A, Coban YK, Vardar MA, Dalay AC (July 2007). "The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report". BMC Surgery. 7 (1): 13. doi:10.1186/1471-2482-7-13. PMC 1947946. PMID 17623058.
^ Barutçu A, Akgüner M (November 1998). "McIndoe vaginoplasty with the inflatable vaginal stent". Annals of Plastic Surgery. 41 (5): 568–569. doi:10.1097/00000637-199811000-00020. PMID 9827964.
^ Bigner JJ, Wetchler JL (2012). Handbook of LGBT-Affirmative Couple and Family Therapy. Routledge. p. 307. ISBN 978-1136340321. Retrieved February 29, 2016. Van Trostenburg (2009) stresses the need to maintain dilation and hygiene for the newly created vagina and tissues left vulnerable to infections that may result from surgery. He further notes that transgender women and their male sexual partners have to be advised about vaginal intercourse, since the newly created vagina is physiologically different than a biological vagina.
^ Lev AI (2013). Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families. Routledge. p. 361. ISBN 978-1136384882. Archived from the original on August 6, 2020. Retrieved February 29, 2016. Vaginoplasty surgery increases the size of the vagina, though not without surgical complications, and often requires repeated dilation of the vaginal opening so that it remains open.
^ "The Young M.T.F. Transsexual". The Gender Centre. Australia. Archived from the original on 2020-03-22. Retrieved 2020-02-24.
^ Kube C (November 14, 2017). "Pentagon to pay for surgery for transgender soldier". NBC News. Archived from the original on July 30, 2020. Retrieved November 15, 2017.

[1] "Surgery Funding". www.phsa.ca. Retrieved 2022-09-21.

[:0-2] "Vaginoplasty". www.phsa.ca. Retrieved 2022-09-21.

[3] Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, et al. (February 2022). "ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery"". Sexual Medicine. 10 (1): 100471. doi:10.1016/j.esxm.2021.100471. PMC 8847816. PMID 34971864.

[:1-4] ^ ^a ^b ^c ^d ^e ^f Bizic M, Kojovic V, Duisin D, Stanojevic D, Vujovic S, Milosevic A, et al. (2014). "An overview of neovaginal reconstruction options in male to female transsexuals". TheScientificWorldJournal. 2014: 638919. doi:10.1155/2014/638919. PMC 4058296. PMID 24971387.

[5] Li, Joy S.; Crane, Curtis N.; Santucci, Richard A. (3 February 2021). "Vaginoplasty tips and tricks". International Brazilian Journal of Urology. 47 (2): 263–273. doi:10.1590/s1677-5538.ibju.2020.0338. ISSN 1677-6119. PMC 7857744. PMID 32840336.{{cite journal}}: CS1 maint: PMC format (link)

[:4-6] Kim SK, Park JW, Lim KR, Lee KC (January 2017). "Is Rectosigmoid Vaginoplasty Still Useful?". Archives of Plastic Surgery. 44 (1): 48–52. doi:10.5999/aps.2017.44.1.48. PMC 5300923. PMID 28194347.

[:2-7] "Vaginoplasty". www.phsa.ca. Retrieved 2022-09-21.

[Erickson-Schroth-8] Erickson-Schroth L (2014). Trans Bodies, Trans Selves: A Resource for the Transgender Community. Oxford University Press. p. 280. ISBN 978-0199325368. Archived from the original on August 6, 2020. Retrieved February 29, 2016. The surgeon will also provide a set of vaginal dilators, used to maintain, lengthen, and stretch the size of the vagina. Dilators of increasing size are regularly inserted into the vagina at time intervals according to the surgeon's instructions. Dilation is required less often over time, but it may be recommended indefinitely.

[9] Djordjevic ML, Stanojevic DS, Bizic MR (December 2011). "Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases". The Journal of Sexual Medicine. 8 (12): 3487–3494. doi:10.1111/j.1743-6109.2011.02494.x. PMID 21995738.

[Carroll-10] Carroll L, Mizock L (2017). Clinical Issues and Affirmative Treatment with Transgender Clients, An Issue of Psychiatric Clinics of North America, E-Book. Elsevier Health Sciences. p. 111. ISBN 978-0323510042. Archived from the original on August 6, 2020. Retrieved January 8, 2018.

[Goldberg-11] Goldberg AE (2016). The SAGE Encyclopedia of LGBTQ Studies. Sage Publications. p. 1281. ISBN 978-1483371290. Archived from the original on August 6, 2020. Retrieved January 8, 2018.

[12] Coskun A, Coban YK, Vardar MA, Dalay AC (July 2007). "The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report". BMC Surgery. 7 (1): 13. doi:10.1186/1471-2482-7-13. PMC 1947946. PMID 17623058.

[13] Barutçu A, Akgüner M (November 1998). "McIndoe vaginoplasty with the inflatable vaginal stent". Annals of Plastic Surgery. 41 (5): 568–569. doi:10.1097/00000637-199811000-00020. PMID 9827964.

[Bigner-14] Bigner JJ, Wetchler JL (2012). Handbook of LGBT-Affirmative Couple and Family Therapy. Routledge. p. 307. ISBN 978-1136340321. Retrieved February 29, 2016. Van Trostenburg (2009) stresses the need to maintain dilation and hygiene for the newly created vagina and tissues left vulnerable to infections that may result from surgery. He further notes that transgender women and their male sexual partners have to be advised about vaginal intercourse, since the newly created vagina is physiologically different than a biological vagina.

[Lev-15] Lev AI (2013). Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families. Routledge. p. 361. ISBN 978-1136384882. Archived from the original on August 6, 2020. Retrieved February 29, 2016. Vaginoplasty surgery increases the size of the vagina, though not without surgical complications, and often requires repeated dilation of the vaginal opening so that it remains open.

[16] "The Young M.T.F. Transsexual". The Gender Centre. Australia. Archived from the original on 2020-03-22. Retrieved 2020-02-24.

[FirstMilitarySRS-17] Kube C (November 14, 2017). "Pentagon to pay for surgery for transgender soldier". NBC News. Archived from the original on July 30, 2020. Retrieved November 15, 2017.

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@@ Line 20: / Line 20: @@
 === Vaginoplasty ===
 {{Further information|Vaginoplasty}}
-Vaginoplasty is the process of constructing a neovagina and neovulva from existing genital or abdominal tissue.<ref name=":0">{{Cite web |title=Vaginoplasty |url=http://www.phsa.ca/transcarebc/surgery/gen-affirming/lower-body-surgeries/vaginoplasty#Surgery |access-date=2022-09-21 |website=www.phsa.ca |language=en-CA}}</ref> There are multiple techniques for performing vaginoplasty.
+Vaginoplasty is the process of constructing a neovagina and neovulva from existing genital or abdominal tissue.<ref name=":0">{{Cite web |title=Vaginoplasty |url=http://www.phsa.ca/transcarebc/surgery/gen-affirming/lower-body-surgeries/vaginoplasty#Surgery |access-date=2022-09-21 |website=www.phsa.ca |language=en-CA}}</ref> There are multiple techniques for performing vaginoplasty.  Sexual sensation is typically retained following surgery, and the self-reported rate of personal satisfaction with surgical results across different vaginoplasty techniques is very high.<ref>{{cite journal |display-authors=6 |vauthors=Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, Bizic MR, Djordjevic M, Falcone M, Christopher NA, Simon D, Capitán L, Motmans J |date=February 2022 |title=ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery" |journal=Sexual Medicine |volume=10 |issue=1 |pages=100471 |doi=10.1016/j.esxm.2021.100471 |pmc=8847816 |pmid=34971864}}</ref><ref name=":1" /><ref>{{Cite journal |last=Li |first=Joy S. |last2=Crane |first2=Curtis N. |last3=Santucci |first3=Richard A. |date=3 February 2021 |title=Vaginoplasty tips and tricks |url=http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1677-55382021000200263&tlng=en |journal=International Brazilian Journal of Urology |volume=47 |issue=2 |pages=263–273 |doi=10.1590/s1677-5538.ibju.2020.0338 |issn=1677-6119 |pmc=PMC7857744 |pmid=32840336}}</ref><ref name=":4" />
 ==== Penile inversion ====
 Penile inversion is a common vaginoplasty technique.<ref name=":1">{{cite journal | vauthors = Bizic M, Kojovic V, Duisin D, Stanojevic D, Vujovic S, Milosevic A, Korac G, Djordjevic ML | display-authors = 6 | title = An overview of neovaginal reconstruction options in male to female transsexuals | journal = TheScientificWorldJournal | year = 2014 | volume = 2014 | pages = 638919 | pmid = 24971387 | pmc = 4058296 | doi = 10.1155/2014/638919 | doi-access = free }}</ref> The [[Testicle|testicles]] and [[scrotum]] are removed and the [[Glans penis|glans]] of the [[Human penis|penis]] made into a [[clitoris]]. A canal is surgically created between the [[Urinary bladder|bladder]] and the [[rectum]]. The [[foreskin]] of the penis is inverted to form the interior walls of the neovagina. If the patient had been [[Circumcision|circumcised]] before surgery, skin from the scrotum may also be used to construct the walls of the neovagina after [[Cauterization|cauterising]] the hair follicles. The [[urethra]] is shortened, and the [[mons pubis]], [[labia majora]] and [[Labia minora|minora]], and urethral opening are created using scrotal and urethral tissue.<ref name=":0" />
-Because this technique inverts the skin of the penis to form the walls of the neovagina, sexual sensation is typically retained.<ref>{{cite journal | vauthors = Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, Bizic MR, Djordjevic M, Falcone M, Christopher NA, Simon D, Capitán L, Motmans J | display-authors = 6 | title = ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery" | journal = Sexual Medicine | volume = 10 | issue = 1 | pages = 100471 | date = February 2022 | pmid = 34971864 | pmc = 8847816 | doi = 10.1016/j.esxm.2021.100471 }}</ref> Following surgery, a patient will need to dilate the neovagina with a [[vaginal dilator]] 1-2 times daily to prevent loss of vaginal depth.<ref name=":1" /><ref name=":2">{{Cite web |title=Vaginoplasty |url=http://www.phsa.ca/transcarebc/surgery/gen-affirming/lower-body-surgeries/vaginoplasty#After--surgery |access-date=2022-09-21 |website=www.phsa.ca |language=en-CA}}</ref> The need to dilate becomes less frequent with time, but is recommended at least once a week after the neovagina has healed completely.<ref name=":2" /><ref name="Erickson-Schroth" /> Having penetrative sex can affect the amount of dilation needed, but additional lubricant is required during penetrative sex as the neovagina created through penile inversion vaginoplasty is not self-lubricating.<ref name=":2" />
+Because this technique inverts the skin of the penis to form the walls of the neovagina, post-operative depth is limited by the length of the penis prior to surgery.<ref name=":1" /> Following surgery, a patient will need to dilate the neovagina with a [[vaginal dilator]] 1-2 times daily to prevent loss of vaginal depth.<ref name=":1" /><ref name=":2">{{Cite web |title=Vaginoplasty |url=http://www.phsa.ca/transcarebc/surgery/gen-affirming/lower-body-surgeries/vaginoplasty#After--surgery |access-date=2022-09-21 |website=www.phsa.ca |language=en-CA}}</ref> The need to dilate becomes less frequent with time, but is recommended at least once a week after the neovagina has healed completely.<ref name=":2" /><ref name="Erickson-Schroth" /> Having penetrative sex can affect the amount of dilation needed, but additional lubricant is required during penetrative sex as the neovagina created through penile inversion vaginoplasty is not self-lubricating.<ref name=":2" />
 ==== Bowel vaginoplasty ====
-Bowel vaginoplasty is another common vaginoplasty technique that is also utilised for vaginoplasty in cisgender women.<ref>{{cite journal | vauthors = Djordjevic ML, Stanojevic DS, Bizic MR | title = Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases | journal = The Journal of Sexual Medicine | volume = 8 | issue = 12 | pages = 3487–3494 | date = December 2011 | pmid = 21995738 | doi = 10.1111/j.1743-6109.2011.02494.x }}</ref> As with penile inversion vaginoplasty, the testicles and scrotum are removed, the glans made into a clitoris, and the neovulva constructed from scrotal and urethral tissue. However, in bowel vaginoplasty a segment of [[Large intestine|rectosigmoid colon]] is grafted into a surgically created canal to form the walls of the neovagina.<ref>{{cite journal | vauthors = Kim SK, Park JW, Lim KR, Lee KC | title = Is Rectosigmoid Vaginoplasty Still Useful? | journal = Archives of Plastic Surgery | volume = 44 | issue = 1 | pages = 48–52 | date = January 2017 | pmid = 28194347 | pmc = 5300923 | doi = 10.5999/aps.2017.44.1.48 }}</ref>
+Bowel vaginoplasty is another common vaginoplasty technique that is also utilised for vaginoplasty in cisgender women.<ref>{{cite journal | vauthors = Djordjevic ML, Stanojevic DS, Bizic MR | title = Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases | journal = The Journal of Sexual Medicine | volume = 8 | issue = 12 | pages = 3487–3494 | date = December 2011 | pmid = 21995738 | doi = 10.1111/j.1743-6109.2011.02494.x }}</ref> As with penile inversion vaginoplasty, the testicles and scrotum are removed, the glans made into a clitoris, and the neovulva constructed from scrotal and urethral tissue. However, in bowel vaginoplasty a segment of [[Large intestine|rectosigmoid colon]] is grafted into a surgically created canal to form the walls of the neovagina.<ref name=":4">{{cite journal | vauthors = Kim SK, Park JW, Lim KR, Lee KC | title = Is Rectosigmoid Vaginoplasty Still Useful? | journal = Archives of Plastic Surgery | volume = 44 | issue = 1 | pages = 48–52 | date = January 2017 | pmid = 28194347 | pmc = 5300923 | doi = 10.5999/aps.2017.44.1.48 }}</ref>
-As bowel vaginoplasty uses colon to construct the neovagina, post-operative depth is not dependent on the length of the penis prior to surgery. This makes it appropriate for individuals who have already underwent penectomy, orchiectomy, or who had a penis smaller than the desired depth of the neovagina prior to surgery.<ref name=":1" /> The existing structure of the colon also reduces the amount of dilation required following surgery, making it "temporary and well tolerated by the majority of patients."<ref name=":1" />
+As bowel vaginoplasty uses colon to construct the neovagina, post-operative depth is not dependent on the length of the penis prior to surgery. This makes it appropriate for individuals who have already underwent penectomy, orchiectomy, or who had a penis smaller than the desired depth of the neovagina prior to surgery.<ref name=":1" /> Unlike penile inversion vaginoplasty, the neovagina created through bowel vaginoplasty is self-lubricating and does not require further dilation once fully healed.<ref name=":1" />
-[[File:ZSI 200 NS Vaginal Expander in Neovagina.jpg|thumb|280 px|ZSI 200 NS vaginal expander placed in the neovagina after vaginoplasty]]
-Surgeon's requirements, procedures, and recommendations vary enormously in the days before and after, and the months following these procedures.
-The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons vary considerably in their techniques and skills, patients' skin varies in elasticity and healing ability (which is affected by age, nutrition, physical activity and [[Tobacco smoking|smoking]]), any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage.
-Supporters of colovaginoplasty state that this method is better than use of skin grafts for the reason that colon is already mucosal, whereas skin is not. Lubrication is needed when having sex and occasional douching is advised so that bacteria do not start to grow and give off odors.
 Because of the risk of [[vaginal stenosis]] (the narrowing or loss of flexibility of the vagina),<ref name="Carroll">{{cite book| vauthors = Carroll L, Mizock L |title=Clinical Issues and Affirmative Treatment with Transgender Clients, An Issue of Psychiatric Clinics of North America, E-Book|isbn=978-0323510042|publisher=[[Elsevier Health Sciences]]|year=2017|page=111|access-date=January 8, 2018|url=https://books.google.com/books?id=lvwTDgAAQBAJ&pg=PT111|archive-date=August 6, 2020|archive-url=https://web.archive.org/web/20200806191009/https://books.google.com/books?id=lvwTDgAAQBAJ&pg=PT111|url-status=live}}</ref><ref name="Goldberg">{{cite book | vauthors = Goldberg AE |url= https://books.google.com/books?id=736zDAAAQBAJ&pg=PA1281 |title=The SAGE Encyclopedia of LGBTQ Studies |publisher=[[Sage Publications]] |year=2016 |isbn=978-1483371290 |page=1281 |access-date=January 8, 2018 |archive-url=https://web.archive.org/web/20200806191021/https://books.google.com/books?id=736zDAAAQBAJ&pg=PA1281 |archive-date=August 6, 2020 |url-status=dead}}</ref> any current technique of vaginoplasty requires some long-term maintenance of volume by the patient using a [[Vaginal dilator|vaginal expander]],<ref>{{cite journal | vauthors = Coskun A, Coban YK, Vardar MA, Dalay AC | title = The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report | journal = BMC Surgery | volume = 7 | issue = 1 | pages = 13 | date = July 2007 | pmid = 17623058 | pmc = 1947946 | doi = 10.1186/1471-2482-7-13 | doi-access = free }}</ref><ref>{{cite journal | vauthors = Barutçu A, Akgüner M | title = McIndoe vaginoplasty with the inflatable vaginal stent | journal = Annals of Plastic Surgery | volume = 41 | issue = 5 | pages = 568–569 | date = November 1998 | pmid = 9827964 | doi = 10.1097/00000637-199811000-00020 }}</ref> or vaginal dilation using graduated dilators to keep the vagina open.<ref name="Bigner">{{cite book| vauthors = Bigner JJ, Wetchler JL |title=Handbook of LGBT-Affirmative Couple and Family Therapy|isbn=978-1136340321|publisher=[[Routledge]]|year=2012|page=[https://archive.org/details/handbookoflgbtaf0000unse/page/307 307]|access-date=February 29, 2016|url=https://archive.org/details/handbookoflgbtaf0000unse|url-access=registration|quote=Van Trostenburg (2009) stresses the need to maintain dilation and hygiene for the newly created vagina and tissues left vulnerable to infections that may result from surgery. He further notes that transgender women and their male sexual partners have to be advised about vaginal intercourse, since the newly created vagina is physiologically different than a biological vagina.}}</ref><ref name="Lev">{{cite book| vauthors = Lev AI |title=Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families|isbn=978-1136384882|publisher=[[Routledge]]|year=2013|page=361|access-date=February 29, 2016|url=https://books.google.com/books?id=mwYsBgAAQBAJ&pg=PA361|quote=Vaginoplasty surgery increases the size of the vagina, though not without surgical complications, and often requires repeated dilation of the vaginal opening so that it remains open.|archive-date=August 6, 2020|archive-url=https://web.archive.org/web/20200806191026/https://books.google.com/books?id=mwYsBgAAQBAJ&pg=PA361|url-status=live}}</ref><ref name="Erickson-Schroth">{{cite book| vauthors = Erickson-Schroth L |title=Trans Bodies, Trans Selves: A Resource for the Transgender Community|isbn=978-0199325368|publisher=[[Oxford University Press]]|year=2014|page=280|access-date=February 29, 2016|url=https://books.google.com/books?id=oZeAAwAAQBAJ&pg=PA280|quote=The surgeon will also provide a set of vaginal dilators, used to maintain, lengthen, and stretch the size of the vagina. Dilators of increasing size are regularly inserted into the vagina at time intervals according to the surgeon's instructions. Dilation is required less often over time, but it may be recommended indefinitely.|archive-date=August 6, 2020|archive-url=https://web.archive.org/web/20200806191015/https://books.google.com/books?id=oZeAAwAAQBAJ&pg=PA280|url-status=live}}</ref> Penile-vaginal penetration with a sexual partner is not an adequate method of performing dilation. Daily dilation of the vagina for six months in order to prevent stenosis is recommended among health professionals.<ref name="Goldberg" /> <ref name="Erickson-Schroth" />