• Sex change from Male to Female (MTF)

    See services Male to Female surgery in Bangkok, Thailand

Sex Reassignment procedure is the last move in the procedure of helping individuals who have had issues between their physical appearances and sexual consciousness since they were young. Medically, this consciousness is referred to as Gender Dysphoria.  A sex reassignment procedure changes the genitals to match to the coveted emotional state of the mind for the individual. This enables a person to live a joyful life in the acquired gender.

For one to undergo a Sex Reassignment procedure, considered a very important surgery that will make a way for a new of life, it’s important to be prepared by reading enough details about the procedure before deciding. This is critical especially when choosing the ideal doctor with the best skills and experience in Sex Reassignment procedure. A surgeon who is an expertise will be able to make a female genital organ that appears natural and aesthetically pleasing with a vagina that can perceive intimate sensations. This ensures the person who has undergone the procedure connects both his carnal body and brains, thus enjoying a normal and happier life.

Criteria of approval by WPATH (World Professional Association for Transgender Health)

  1. Patient should have a minimum of 18 years. If below 20 years, the patient should have their parent’s approval.
  2. Patients should have a diagnosis with either of these disorders: gender dysphoria, gender identity disorder, or linked conditions.
  3. Patients should have received a minimum of one year of female hormones and/or antiandrogens.
  4. Patients must have lived a full-time cross-gender lifestyle for a minimum of a year (Identification Documents should be availed)
  5. Patients should be approved by a, psychiatric social worker (PhD), clinical psychologist (PhD) or a psychiatrist (MD).

Not suitable for

  1. Schizophrenia

ADD: Body Dysmorphic Disorder

  1. Patients with sexually transmitted disease
  2. Patients with congenital disease
  3. If your immunity is low or have HIV with a CD4 less than normal rate.
  4. If you live in a conservative country, do not do the surgery

Operation

  1. Operation techniques

1.1 Penile skin inversion

The procedure includes turning inside out the skin on the penis in order to make and improve the vagina.

It’s a common procedure.

  • advantages
  • The procedure is straightforward and not complex.
  • For skilled doctors, this method of sex reassignment procedure will take approximately 4 hours.
  • disadvantage
  • Not recommended for men with penises less than 4 inches as the outcome will be shallow a vagina.
  • Generally, the depth of the vagina is similar to the measurement of skin that covers the penis take away1 inch (it involves the skin needed to create the inner lips)
  • Other patients may require further labiaplasty. Since most areas of the penile skin are turned upside down inside the created vagina for the entire depth, only minimal skin to create the clitoral hood and inner labia is available.
  • In such cases, patients will require further clitoral hood remodelling and labiaplasty.

1.2 SRS using scrotal skin graft

The skin that covers the penis is used to create the labia minora, some glans penis parts to create the neoclitoris together with the scrotal skin graft which shields the vaginal wall.

The final outcome is a functional and deep vagina as anticipated by the individual.

If the depth of the vagina is not up to the expectations of the patient after the scrotal skin graft, the cosmetic surgeon can contemplate making use of skin graft derived from other parts of the body such as lower abdomen or groin to enhance the vagina’s depth.

Advantage

  • The technique offers a one operation that functions and it’s beautiful. A lot of patients don’t require extra touch ups surgeries.
  • The surgery allows them to get a vagina that is deep as desired
  • It’s quick and has minimal complications

 Disadvantage

  • The procedure is complicated and it’s not recommended for people who do not have enough skin.
  • With this technique, highly experienced and skilled plastic doctors in sex reassignment procedure take 4-6 hrs. to finish.

1.3 SRS with skin graft from other part of the body

With MTF SRS patient, the penile skin is often used (penile inversion) and incorporated with the scrotum skin (testicle sack), but in a few male to female patients a minimal quantity of penile and scrotal skin is accessible to create a decent neo-vagina, which finally results to a skin graft.

Unwanted skin from the hip area, tummy or groin is attached to the penile and scrotal skin. The area where the skin was extracted leaves a linear or horizontal scar.

Advantage

  • Enough quantities of skin to get the wanted depth or length of vagina
  • Patients enjoy a deeper vagina they wish to have

Disadvantage

  • A scar is left on the donor area

1.4 The Sigmoid Colon Vaginoplasty

In primary sex change surgery and corrective surgical procedure for SRS patients who have not acquired the desired depth of vagina, colon graft can be used as an alternative surgical procedure.

This procedure is used in cases where the patient has a short penis, or to help a patient with an obstructed vagina.

It can be used with patients who haven’t gone through sex reassignment surgery

Since the vagina is part of the colon, it will have a good lubricant and enough depth.

Advantage

  • The technique assists people who had gone through sex reassignment procedure, who had their vaginas become blocked and are not able to enjoy penetrative sex.
  • It assists patients who have short penises. Here, the doctor will have made up his mind that SRS-penile skin inversion type of surgeries cannot be successfully carried out.
  • The female sex organ has a lubricant that’s natural
  • It’s possible to control the deepness of the new created vagina

Disadvantages

  • In open method, a visible scar on the bikini line can appear, right over the pubis on the left.
  • The procedure is difficult to execute, and it requires invasive procedures like cutting some areas of the colon. The colon should also be cleaned a day before the surgery.
  • The person may suffer from indigestion symptoms/ dyspepsia3-5 days when the procedure is completed.
  • The open, laparoscopic or sigmoid colon method is not recommended for those who are overweight or have fatty abdomen. Patients who ask for Sigmond colon SRS require a physical examination before finally deciding on the surgery.
  1. Special equipment

Prolonged surgery time may result to blood clot and necrosis thus, the following equipment will be required during the procedure;
2.1 air pumper to improve blood circulation
2.2 cushion gel pillow placed under the knee to enhance blood circulation and necrosis

2.3 cushion gel pillow placed under the head to remove the pressure off and shield the patient from long operation.

  1. Hair removal before the operation

  • Use ND-YAG LASER
  • Laser to get rid of all hair on the area to be operated on for hygiene purposes
  • Surgeon informs you to laser 3-4 weeks prior to surgery
  • Patients will cater for their hair removal expenses in other clinics

Our Special technique

This technique is an improvement of the second technique that adds the width of the vagina with a scrotal flap. It also adds the depth with all reminders of scrotal skin graft.

  1. result

Dorsal Neurovascular Glans Penis Preputial Flap

Secondary Sexual Sensated Organ

First stage with complicated scrotal penile flap and scrotal skin graft. This can create a promisable deepness of neovagina and full length of vagina can be made by complete scrotal skin graft.

Extended posterior scrotal skin flap is made in a way that provides a thick sensitive posterior wall of the vagina.

When compared with graft and flap on rectal wall, scrotal flap produces soft sensations and it’s more elastic than skin graft especially during sexual arousal.

The scrotal flap can widen and lengthen the neo-vagina during penetrative sex period and shrinks and becomes narrow and shallow any other time similar to a female vagina. In addition, the posterior sensitive scrotal flap can initiate orgasm through its own sensations that was protected. It can then move the sensation to anterior rectum wall that is the organ that involves orgasm complex.

Clitoris from glans penis with entire sensory vessels and nerves

Vestibule of vagina in between the labia minora and urethral flap to appear same to female vestibule from glans penis with complete sensory vessels and nerves.

Thin narrow neurovascular flap to make narrow hood of clitoris and to appear similar to genital female.

Fine pedical flap sensate clitoris technique. The surgeon makes the neo-clitoris by putting sensory nerves very close. The surgeon also makes the neurovascular pedicle extremly small without having unwanted fascia, thus giving a more natural look.

Clistoroplasty; makes use of the top skin on the glans penis

Sensitive inner labioplasty.  The penile skin that encompasses the glans penis appears a like to the skin in the inner labia. However, its finer and flaccid.

  1. Procedure

The surgeon uses the skin of the glans and prepuce, with all nerves and blood vessels uncut. The penile skin that encompasses glans penis appears similar to the skin of the inner labia, but its finer and flaccid. This is not used for the entire inner labia. The surgeon makes use of two different types of skin to make inner labia appear natural. The exterior part is from scrotal skin, whereas the interior part is from prepuces, which are sensitive similar to neo-clitoris.

G spot neovagina is a merge of clitoris, sensitive labia minora and reminer of urethral flap between dissection. The cavity will be formed just below the capsule of prostate gland that will be over the penile skin. When the neovagina dilates, you sense sensitive prostatic capsule. The complexity of sensated 5 organ can form sensitive neovagina.

Extended urethral flap technique. The surgeon makes use of middle section of the outside, and over urethral opening to make a urethral mucosa, which is lubricated, smooth, varnish and a pinkish color similar to natural appearance.

Labia minora which are at the front enough to shield the clitoris, vaginal cavity and urethra just like it is genetic in women.

The labia minora can be manually pulled

Red or pink color in the inner surface of the labia minora

Total anotomic smiliarity between the reconstructed neovagina and the inborn female genitalia.

The fenulum which expands below the clitoris and extends to either sides of the labia minora.

The advantage of Our Technique

  • One step procedure
  • A natural and beautiful vagina
  • Minimal amount of skin hanging underneath the urethral opening from an oversize inner labia
  • Increased vaginal depth about 5-7 inches
  • Reduced recovery time;2-3 weeks after procedure
  • Enhanced elastic vaginal wall that has a sensitive G-spot at the posterior and anterior vaginal wall
  1. Criteria of patients that suitable for our technique
  • Should be less than 60 years old
  • The penis should be longer than 5cm
  • Must have excess scrotal skin to elevate scrotal flap
Pre-Operation
  1. Pre operation consultation

You require 2 medical certificates from different psychiatrist. (If you are a foreigner, you will require 1 medical certificate from your country and another from Thailand)

The deepness of the vagina

The size of the inner and outer lips

The clitoris size

The patient should be approved by WPATH (World Professional Association for Transgender Health)

  1. Pre operation preparation
  • A recommendation letter from the S.R.S. from either; Psychiatrist, Endocrinologist, Therapist or General Practitioner
  • Stop any hormone treatment 14 days before surgery. Hormones should be stopped to minimize the danger of blood clots (thrombosis). Oral tablets should be discontinued 2 weeks before the surgery, whereas injectables should be discontinued 4 weeks before surgery. Oral antiandrogens can be stopped 3 days before surgery.
  • Let your private doctor perform preoperative physical checkup within 3 months before SRS. Patients should be confirmed by a physician free from any fatal medical diseases and should pass the below blood tests and results emailed;
  • SGOT LDH EKG
  • Alkaline Phosphatase, Chest X-ray
  • CBC, HIV Electrolytes, FBS, Creatinine Urinalysis
  • Stop smoking and avoid aspirin, ibuprofen and vitamin E
  • To book the appointment, G.R.S date, a fax or email should be send one month before the surgery date
  • HIV + patients can be operated on, but the costs will increase by 200% because of the need of using disposable instruments
  • Stop all form of alcohol consumption a week before the surgery
  • One day before the surgery, the bowel is cleaned and prepared.
  • Before scheduling your flight, plan for your entire stay. It’s important to arrive in Bangkok 2-3 days before the surgery.
  • All female hormones, even spironolactone should be halted before surgery to stop the risk of thrombosis.
  • You will not require any type of vaccination except for patients who come from countries where there are cases of Yellow Fever.
  • Do not carry any unneeded drugs or personal items in your luggage. It’s recommended you wear thin cotton clothes.
The Procedure

The posture is set in normal lithotomy.  Prior to the surgery, the cushion made from silicone is used to hold the weight holding area. (Buttock and back)

The perineal skin flap is outlined in a good size and shape and will eventually be connected with the penile flap that’s inverted for reconstruction of the vaginal opening.

The vaginal opening and space are formed under the urethra (urinary tube) and the prostate gland. When it has gone through the capsule at 4 inches depth, the plane will become loose and there will be a downward direction towards the recto-vescicle pouch. The deepness of the recently formed space often 6-7 inches, or even more in some cases relies on the structure of some people.

Bilateral orchiectomy (removal of testes and spermatic cord)

The turned upside down skin flap from the penis is used for the skin lining of neovagina. In this procedure, the scrotal skin graft will be regularly added for the extra depth.

The penis shaft is extracted except for some minor areas of the gland penis and its sensory vessels and nerves for creating the sensitive clitoris.

The urethral opening is conveniently placed over the introitus (vaginal opening) and the urethral mucosal set in the space separating the clitoris and urethral opening can replicate the pink wet vulva mucosa.

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

The unwanted erectile tissue encompassing the urethra should be extracted so as to keep off symptoms that arise from engorged erectile tissue during sexual arousal that may cause the shrinking of the vaginal opening. Still, thin lip appearance of the inner labia can be redone during the labiaplasty stage.

A vaginal packing is put in the neovagina for 5-6 days.

Post Operation
  1. Post-Operative period in the hospital

Tube drains and catheter

The urinary catheter and tube drains will stay in place for 5 days when the anesthesia wears off and you will you will be feeling the tube drain. Due to the catheter irritating the bladder, you will always feel like urinating. However, this shouldn’t worry you as the urine will slowly pass through the catheter. The patient is not allowed to walk on their own. The surgeon will start training the bladder by holding the urine catheter every 4 hours to maintain bladder muscle tone and function normally to minimize the dilemma of urination. When the catheter is removed, you will be able to urinate on your own while seated.

Pain:  when the anesthesia wears off, you will experience pain but it’s minimal and lasts for one day and will slowly subside. You will get IV fluid and strong antibiotics. On the first day, IV morphine will be issued for pain. On the second day, the pain will have reduced and oral analgesia can reduce pain. However, if it’s extremely painful, you can request for occasional morphine injection.

Food: when you wake up, you can take soft meals and drinks in the first few days and you will begin consistent meals after your bowel movements become regular. Avoid vegetables, fruits and fiber packed foods so that you do not pass stool.

However, if it’s a must you pass stool, you can still do it but ensure the anal area is thoroughly cleaned since it’s next to the surgical wound. On the third day, bladder training commences. You can stand up and walk around the room or sit on the bedside sofa.

Vaginal stent: the vaginal packing will remain in the same position for 5 days. On the 5th day, tube drain, vaginal packing and catheter will be removed at the same time to keep it clean and off infection.

The post-operative period requires one to stay in the hospital for 6 days. When the vaginal packing is removed, the patient is able to walk and leave the hospital. However, you will need another 7-14 days to recover and be ready to travel. It’s best to stay in a hotel near the clinic so that our team can attend to you until you leave Thailand.

When the vaginal packing is removed, one might experience bleeding from the urethral and vaginal opening. We recommend that you stretch your leg, put your knees together and remain still for 30 minutes, the bleeding will stop. If it doesn’t stop, pressure compression by gauze can assist to halt bleeding.
After vaginal packing is removed, the nurse will assist you to the toilet to shower for the first time and begin urinating. At the first time to void with all bladder power because it is swelling around the urethral opening. To pass the urine to this area you need more power than normal voiding.  If you can void, you can move to the nearby hotel.

If you are unable to pass urine, you may have to remain in hospital and may require catheter retaining for another week.

If you have already moved to the hotel and experience problems while urinating, it’s recommended to get back to the hospital or call the hotline number to advice and put another catheter by the nurses.
If you are able to pass urine, you can leave the hospital. Here is a checklist of items that we will give you to carry to the hotel:

  • Appointment card: we will book an appointment on 12-14 day after operation or day 7 after discharge from the hospital for sectional stitch off, assess the vaginal cavity and begin dilation. During this appointment, please come with a small dilator and a piece of napkin with you to the clinic on day 10 after procedure to assess the surgery wound, day 14 for vaginal assessment and complete stitch off final check on same day before you leave Bangkok.
  • Namecard of our hospital and staff should any problems arise concerning urination and wound care.

The clinic will offer a home set for those patients that insist on the following items:

  • Donut ring seat. This makes it comfortable and will protect you from sitting on surgical wounds.
  • 2 different sizes of mold or dilator
  • 5 packets of condom
  • A syringe ball for vaginal douches
  • Post op medication
  • A bottle of betadine
  • A tube of sterile gel
    1. Post-Operative Care

2.1 Wound Care

  • The wound should thoroughly washed with betadine solution in the shower, then douche when seated on the toilet seat.
  • Douche solution (measurements) = 5-10 ml (cc) of Betadine solution combined with 1L of water or until the container is full.
  • Put the douche completely inside, squeeze and tightly hold the container
  • Remove the douche while you are tightly holding the container
  • Ensure the wound remains dry and apply betadine solution with cotton balls. In case there is any bleeding, apply pressure with a dry cotton ball to the area for 15 minutes. On the first weeks after surgery, tampons must be changed often during the day because of usual vaginal bleeding during the recovery period.
  • After a month of SRS operation, you will be expected to begin applying premarin cream on your neo-vagina. Apply twice a day to make your neo-vagina supple. This will take about 6 months.
  • Before you are discharged from the hospital, the nurse will show you how to take care of your vagina and prescribe some medicines. The sutures will be removed 7-10 days after surgery and you can go back home.

2.2 Dilation: when recovering on your first day in the hotel, you must follow the following instructions:

  • To ensure your procedure is successful, dilating is crucial. If you do not dilate as instructed by the doctor, it cause the newly created vagina to shorten both in depth and width because of the scar contracture.
  • Lack of proper dilation can also cause fatal injury. You will be showed how to slowly dilate towards the right direction when the vaginal packing is removed.
  • Dilation can be painful during first weeks, but it’s important for creating total depth and ensuring post-operative functioning of the neovagina.

Insertion the dilator

Before you begin, semiflex your knee and relax the muscles.

Cover the dilator with a condom, apply KY-jelly and slide slowly and keep it up for approximately 15-30 minutes. When done, clean as instructed and apply antibiotic ointment on the stitching and any other area where there is a fresh wound.

Begin with a small dilator and gradually progress to the bigger ones offered.

Do not skip dilation even it feels painful. If you do, it may result in partial or total collapse.

Clean out the lubricant after dilation and smear antibiotic ointment or betadine solution until the wound completely heals.

A month after SRS operation, you will be expected to begin applying Premarin cream on your neo-vagina. Apply twice a day to make your neo-vagina supple. This will last about 6 months.

Intercourse:

Four weeks after surgery you will be able to engage in neo-vaginal intercourse. The neo-vagina will require some kind of lubrication. Generally, patients will enjoy sexual intercourse after successfully dilating the neo-vagina to the last size of vaginal dilators.

Sex partner should put on a condom and smear lubricant in the vaginal cavity during neovaginal penetrative sex in the 1st month to stop trauma effect from lack of lubricant. On the 2nd month, intercourse can be done with no condom but lubricant must be used.

Return to female hormones:

Patients can recommence taking oral female hormones 2 months after procedure. However, the need for female hormones is minimal than before procedure.

 Medical certificate

You will be issued with documents to certify that you have successfully gone through sex reassignment surgery.

Insurance and Legal issues

Insurance companies may omit transsexual treatment similar to the way they do on aesthetic surgery

Legally changing your name and birth certificate are achieved according to the laws of your given country or state.

Side Effect

Inability to urinate. This can result sometimes after the urine catheter is removed because of the sore stump at the opening of the shortened urethra. This often requires the urine catheter to be retained for 7 days, eventually, you will be able to urinate normally.

Bleeding: the area around the gauze dressing may bleed the first day after surgery. This is caused by bleeding through the stump of urethral opening. In some cases, it may need suturing or repacking.

Shrinking of the vagina

To stop the new vagina from closing, a vaginal stent is put and stays in position for the duration of the hospital stay. This is about a week.

Demerol or morphine are intravenously given to reduce the pain. Ice is put on the surgical area to stop and minimize swelling and bleeding. The surgical area is kept cool with ice to reduce bleeding and swelling.

Most patients opt to come back and undergo cosmetic revisions after sex reassignment surgery.

A common complication that arises with MTFs is that the vagina tries to contract as it heals. Procedure to rectify this is complicated and extensive than the first surgery. It includes creating incisions in the turned upside down penile skin and introducing full thickness skin grafts. Therefore, it’s best to wear vaginal dilators for all your life. This is like wearing retainers after acquiring braces.

The patient can get back to female hormones as prior to surgery after two months. It’s important to talk to your endocrinologist to modify the dosage. An abrupt change in the hormone levels, for some people may cause emotional fluctuations.