Our aim is to create external female genitalia that look as natural as possible. We also focus on a fully sensate and arousable clitoris and fully sensate an arousable labia.
The clitoris is derived from the glans.
The clitoral hood and labia minora are made from penile skin – including penile preputial skin.
The labia majora are made from scrotal and penile skin.
The Procedure and Steps for sex change surgery (Detailed explanation for experts)
After marking the incision lines, infiltration with hemostatic and anesthetic solution is done. This solution makes the tissues numb and thus the overall requirement for general anesthetic drugs gets reduced. In addition, the infiltration leads to the contraction of blood vessels which is avoiding blood loss and makes the surgical site more manageable.
Overall this has a dramatic positive impact on post-operative recovery.
While doing infiltration special attention is given to block the major neurovascular structures like the spermatic cord, the scrotal area, and the pudendal vessels in Alcock’s canal. We must avoid penetrating the urethra to avoid hematoma and the staining of tissues. We ant to avoid over-infiltration of the penile tissue because we need to maintain maximum vascularity of the penile skin.
Vertical central scrotal incision is made. The posteriorly based triangular scrotal flap in the perineum is elevated. In the Central region, dissection is carried out up to the urethra and on either side of the Corpora Cavernosa. The encountered blood vessels are being coagulated with soft coagulation electrocauterization. If penile inversion with scrotal skin graft is planned, scrotal skin gets degloved and kept apart.
Lateral attachment of fat is left intact in the lower aspect to achieve labia majora bulk in the perineal region. At the upper part of the dissection process (at the base of the penis) the thickness of the lower penile skin is preserved. This important step avoids skin necrosis in the lower part of the labia majora/minora to be and is crucial for vaginal introitus healing.
On either side, testicular tissue is separated from the lateral scrotal tissue until it hangs free attached to the respective spermatic cords. In the lower aspect, fat is left attached to maintain the blood supply. Sufficient fat and lateral scrotal tissue (dartos etc.) should be preserved to later achieve enough bulk in the labia majora. Sufficient spermatic cord length should be left to avoid retraction into the groin. After testes removal, the spermatic cords get clamped, transfixed and double ligated. Please note that the cord tissue is fixed to the lateral aspects to enhance labia majora bulk. In skinny patients, the spermatic cords are the main structure to form the labia majora bulk in the lower aspect (form the outer lips of the vulva).
The bulbocavernosus muscle is separated on either side with utmost care. We can see a well defined avascular plain between the urethral bulb and the muscle. This step is extremely important and avoids a bulky appearance of the urethra. The ischiocavernosus muscle is also removed on lateral aspects. Hemostasis must be achieved accurately in the muscle area to avoid secondary hemorrhage. Injury to the urethra should be avoided to prevent bleeding.
Hemostasis must be achieved accurately in the muscle area to avoid secondary hemorrhage. Injury to the urethra should be avoided to prevent bleeding.
About three inches of proximal urethra is separated from the corpora up to the bulbous part. The distal part is left attached with the corpora. During dissection injury to urethra and neurovascular pedicle must be avoided.
The skin is slit in the center up to the frenulum. The skin flap superficial to Buck’s fascia is degloved tall the way to the base – except for the inner pinkish preputial skin which is left attached to the glans. During degloving, the safeguarding of the dorsal neurovascular bundle is extremely important to retain clitoral sensation and hence orgasm.
The degloved penile skin is utilized to create the clitoral hood, the outer layer of the labia minora and the inner layer of the labia majora.
The dorsolateral (upper outer) part of glans is separated and left attached to the inner preputial skin flap. Dissection is carried out on the dorsum of the penis and the neurovascular bundle is dissected off the corpora tall the way down to the base of the penis. The dissection is meticulous and is carried out with utmost care. This is a crucial step in the preservation of blood and nerve supply to the clitoris and the labia minora. It goes without saying that any injury to the vessels will lead to the loss of the clitoris and the labia minora and any injury to the nerve will result in the loss of sensation in the clitoris and the labia minora. This step is the most crucial aspect in achieving a sensate and arousable clitoris and sensate and arousable labia during GCS/SRS. These structures are key to orgasmic capabilities of the patient.
Clamps are applied at the penis base and corpora cavernosa are excised. A ligature is performed on the remaining stump. During this step, utmost care is taken to avoid injury of the dorsal neurovascular pedicle.
The clitoral hood is formed. After slitting the degloved penile skin the clitoris and preputial flap are positioned at the desired location.
The labia minora are being constructed – whereas the preputial skin flap with its pinkish colour is positioned medial and the degloved penile skin takes the lateral labia minora position and both of them are secured in the “NAMASTE” OLMEC TrueShape COSMETIC GCS/SRS for Experts position.
The labia majora are constructed with the degloved penile skin positioned medial and being stitched to the scrotal skin in lateral position.
The urethra is sutured in anatomically correct position after being pulled through the appropriate slit which was made in the penile skin.