Penile Inversion Technique after Circumcision

[Odile]

I'm currently assembling my two referrals for GRS and hope to send them off to a surgeon in June. Based on research I had hoped to go with Dr Brassard. However, I do have a few concerns that maybe I will not be best suited for a penile inversion technique. My problems are:

- Circumcised at birth;
- Length of remaining penis is below average;
- Most of shaft is hair bearing.

There seems to be plenty of information out there about the standard penile inversion when the prepuce is still there but much less so when it isn't. Just wondering if anybody else out there has some information, direct or otherwise, on the following:

  - How it is done in general and by Dr Brassard in particular?
  - Will the lack of remaining material be a problem in my case?
  - Will it compromise other areas of the reconstruction e.g. creation of the labia or vaginal depth?
  - Increase in dilation times?
  - Would a non-penile inversion technique be more appropriate?

Many thanks,
Odile

[Dena]

I was circumcised but had sufficient length for PI surgery. Depending on how much stretch your skin has, I suspect you may need to use flap surgery and that would result in about a year of hair removal before surgery. I would suggest you get a letter off as soon as possible in order to pick a surgeon that can do the procedure you require. Once you know the procedure, you will know how much hair needs to be treated. Also, letters may have a time limit on them so they may need to be reissued if hair removal causes them to age out.

[mmmmm]

- Circumcised at birth; 
Most US patients are circumcised, surgeons in North America and Thailand work their way around that. North American surgeons usually use urethral flap for inner surface of labia minora, while Thai surgeons usually use skin from penile shaft for labia minora in US patients.

- Length of remaining penis is below average;
Most surgeons who do todays variations of penile inversion use scrotal or inguinal skin grafts to compensate for lack of depth.

- Most of shaft is hair bearing. 
Regardless of which surgeon and technique you choose you wanna sort that out long before surgery. Hairs on scrotal grafts can be eliminated during surgery, but hairs on penile flap (and scrotal flap) need to dealt with before, and permanently removed, otherwise you will have hair growth where that tissue is going to be used.

  - How it is done in general and by Dr Brassard in particular?
Dr. Brassard uses penile skin for vaginal lining, and adds scrotal graft at the end for another inch or two. Inner surface of labia minora is made from urethral flap, outer surface from skin on penile shaft. Scrotal skin flaps are used for labia majora. 

  - Will the lack of remaining material be a problem in my case?
That partially depends on your expectations. Techniques were improved and modified because standard penile inversion didnt work for majority of patients.

  - Will it compromise other areas of the reconstruction e.g. creation of the labia or vaginal depth?
With every technique where surgeons use penile skin for vaginal lining, aesthetics and definition of vulva get compromised. There is no other way around that, because penile tissue is being used for vaginal wall.

  - Increase in dilation times? No. That comes with non-penile-inversion "full-graft" techniques (except for colovaginoplasty) 

  - Would a non-penile inversion technique be more appropriate?
That depends on what your preferences and expectations are. Non-penile-inversion technique that dr. Suporn developed and similar techniques that other Thai surgeons started to use, come with its pros and cons.

[Jenna Marie]

I went to Brassard and was circumcised. I'm happy to answer any specific questions you have, but I was very pleased with my result overall - adequate depth, very good aesthetics (a gynecologist assumed I was cis), orgasmic, and self-lubricating. Brassard uses the leftover urethral tissue to form a mucosal clitoral hood and inside portion of the inner labia, so while being uncircumcised allows for more generous material in that regard, circumcised women will still get nice, pink, moist skin in those areas (just like with cis women). North American surgeons are more used to working with circumcised women, as well, since it's more common.

The only woman I know who had issues with depth was less than 1" erect, and in that case Brassard used a small skin graft from her thigh. She still got enough depth from her surgery, with the graft. Dilation time was the same for her as for anyone else, and she reported no additional complications or difficulties.

Also, in general, Brassard recommends AGAINST hair removal; in most cases, it actually makes his follicle scraping efforts during the surgery less effective. You should contact him directly and ask, if you're concerned that you have an unusual situation in terms of hair. Do not start hair removal without getting his opinion unless you can wait at least a year after the final clearing (this is also his advice - and he still prefers that people not do it at all).

[Odile]

Thanks to all of you for taking the time to reply and for all the very detailed information provided. This is exactly the kind of information I have been trying to find out.

In terms of my own expectations my main priority for the outcome is to have good outward aesthetics. Also, a dilation routine that is feasible - ideally not the 2 hours/day for life that I have seen on one non-PI surgeon's website. I am not chasing a massive depth by any means, but certainly something greater than "vaginoplasty without cavity" that some surgeons offer. Realistically I would be happy at 3-4 inches given the lack of material.

My main worry at the moment is trying to find out whether I will need to do any hair removal if I go with Dr Brassard and he needs to get additional graft material. Under normal circumstance he advocates no prior hair removal but not sure if a graft approach would change things. I haven't yet been able find this out by contacting the surgeon directly. Really don't want to have to wait for the pre-op consultation to find out the answer.

[Jenna Marie]

Since his technique involves follicle scraping, it is my understanding that he routinely does this for a graft as well (if necessary). Brassard also tries for 5.5" of depth, and nearly always achieves it, even if he has to use a thigh graft. Essentially, the choice between surgeons is down to priorities - personally, I wanted adequate depth but didn't need an excessive amount (which seems to be your preference as well), didn't like larger labia minora (which the Thai surgeons tend towards), and wanted functionality and aesthetics as my top two priorities (in that order).

I'm coming up on four years post-op and I basically dilate once a month or less. Brassard's instructions say to do it once a week for 15 minutes for life, but the thing is, tapering down involves recognizing the signs of when you've gone too long between dilations... and since I no longer have any of those signs even at a month between dilations, I see no reason to do it more frequently. (Well, really, I'm forgetful and lazy. But I did maintain the dilation schedule perfectly despite that, when it mattered.)

[mmmmm]

During surgery hair follicles can be scraped from skin grafts. This is not possible for skin flaps. So if there is any hair on skin which will be used as a flap and inverted for vaginal lining, it needs to be removed before surgery, otherwise it will not be possible to remove later. On skin flaps that will be used on outside, its possible to remove hair later after surgery.

Dilations with non-penile-inversions are strict during first year. After first year dilations become weekly, then monthly...

[Jenna Marie]

mmmmm: Brassard is VERY clear that he advises strongly against hair removal, even on skin flaps. I realize this may not be usual (though my impression is that more North American surgeons are doing scraping), but he says he does hair removal on skin flaps. I've quoted his actual patient information pamphlet below (which does not directly address penile hair, admittedly), and hair removal is also listed as a step in the surgery process (for any hair-bearing skin being used) on his web site.

I took his advice, and I do not have any hair in my vagina - and I did have hair growing on portions of skin which were used as part of the inversion process.

"Hair removal on external genitals before male to female reassignment surgery is debatable.
Hair bearing skin on the penis shaft base with the one step technique stays outside on the neo vulva. The skin
that will become the internal living of the new female genital is the rest of the penis skin, scrotal skin and a
small « perineal flap » (a one square inch of skin that is located one side above the anal margin on the midline)
If you want a perfect hairfree vagina you need to be sure that no regrowth of hair has occured on the area for at
least one year after you have finished electrolysis on laser. Even then this does not garant that no hair will ever
grow.
The hair roots are either killed or weakened by electrolysis or laser. Those only weakered regrow. During
surgery hair roots are killed with the cauthery on the scrotal skin that is used as a graft ( not on the « perineal
flap » ) During surgery the hair roots that were weakered are less visible because they are much smaller than
those found untreated areas and could be missed by the surgeon and regrow later. For this reason, in our
experience expeditive laser or electrolysis treatments are worse than not having hair removal at all. In fact, we
can get most hair roots during surgery if they were not weakened. Regrowth after our surgery is possible but
very sparse.
If you want no regrowth at all you will have to face hours of painstaking hair removal and a one year
nonegrowth period. At this time we do not feel that hair removal is indicated."

[Odile]

Since his technique involves follicle scraping, it is my understanding that he routinely does this for a graft as well (if necessary).

Thanks for this Jenna. I am really hoping that this is the case otherwise it means maybe 6 months hair removal followed by waiting a further year before Dr Brassard would consider surgery.

I just hope the hair on the penile shaft is not going to be a problem. There is some material before the head that is hair free, but only about 1cm in the normal un-stretched state. I was presuming that hair on the  shaft (about 3cm un-stretched) is normal for most people so wouldn't be the bit used for the inner lining anyway. However, for all I know this hairiness is abnormal and might require some pre-operative treatment.

[RubyAliza]

For me, I was circumcised, average to below average length at 5 inches erect, but pretty darn wide I had ALOT of hair on the shaft too! I had electrolysis though. I had GRS with Dr. Satterwhite and the techniques sounds like Brassards (and probably Bowers). The difference though is somehow my doctor was able to give me really nice, generous labia minora while still making the incisions almost completely in the groin creases. However, I only got exactly 5 inches of depth. Basically my vagina is very comparable to a cisgender woman. It's possible to do with advanced penile inversion and not have a comprised depth/aesthetics if you have enough material to begin. You might want to go to Suporn in your case for the absolute best result because the meshed scrotal grafting will really make an extra difference and allow you to get both the depth and adequate labia minora that perhaps you seek. All imo.

-Ruby

[Odile]

mmmmm and Jenna: Thanks for your supplementary information on the feasibility of removing hair from non-scrotal grafts and flaps. It sounds like Dr Brassard may be somewhat atypical if he is indeed offering this capability. I must admit I was unsure when I read his data pack if it was only the scrotal skin that could be scrapped and as to what consequences there would be for hair on the perineal flap which would not be scrapped.

[veritatemfurto]

I was circumcised but had sufficient length for PI surgery. Depending on how much stretch your skin has, I suspect you may need to use flap surgery and that would result in about a year of hair removal before surgery. I would suggest you get a letter off as soon as possible in order to pick a surgeon that can do the procedure you require. Once you know the procedure, you will know how much hair needs to be treated. Also, letters may have a time limit on them so they may need to be reissued if hair removal causes them to age out.

Indeed, a lot of us have been circed, as was common practice for births in the 80s, 90s, and 2000s at many hospitals. Some people have been able to reverse the process by months of constant stretching and moisturizing to grow new foreskin, but that's a long process, and really not necessary if the cells convert to mucosa anyways after surgery.

As for the letters expiring, the thing about that is that most insurance covered GRS requires one letter be within a year from registering for (or actual date of) the operation, while the other letters can be from whenever, as long as the most recent letter cites the previous letters' findings as still valid. My three letters (yes, 3- long story) spanned 14 years apart and still worked! If you are paying out of pocket, some surgeons will need only one letter if it is over 5 years old and you stayed full time while still being a client of the LMHP or PHD that wrote the report.

I wouldn't fret too much about the hair either... I've found that it may go away eventually as the cells adapt. The hairs I did find didn't grow back. Also I thought there was something about follicles dying and being replaced every 7 years... its the hairs that get under the hood that can be the real bugger!

[mmmmm]

mmmmm: Brassard is VERY clear that he advises strongly against hair removal, even on skin flaps. I realize this may not be usual (though my impression is that more North American surgeons are doing scraping), but he says he does hair removal on skin flaps. I've quoted his actual patient information pamphlet below (which does not directly address penile hair, admittedly), and hair removal is also listed as a step in the surgery process (for any hair-bearing skin being used) on his web site.

I took his advice, and I do not have any hair in my vagina - and I did have hair growing on portions of skin which were used as part of the inversion process.

I dont see where he mentioned that he can remove hair on skin flaps, nor did I ever see any information about it elsewhere (from any surgeons). To my knowledge (I definitely dont claim its 100% correct) its not possible to remove hair from skin flaps, with either cauterization or scraping. But thats, as he wrote, isnt necessary as in most cases penile shaft doesnt have hair. Hair usually stops at the base or couple centimeters from the base of penis (stretched skin). This part of flap is not going to be used for vagina, but for outer surface od labia minora, and part of labia majora. Thats for most people. But some have hair higher on the penile shaft. Odile wrote  - Most of shaft is hair bearing., this is why this might be a problem, as this skin with hair will end up inside the vagina. Now if dr. Brassard removes hair from skin flaps somehow, great, thats not a problem then. Odile you should contact them soon, and clear this question directly with him (or administration), because if he only removes hair from grafts, and not flaps, you will need to have this hair removed.
Perineal area isnt a problem, because hair from perineal flap can be accessed after surgery and removed later.   

[Odile]

... in most cases penile shaft doesnt have hair. Hair usually stops at the base or couple centimeters from the base of penis (stretched skin).

Ah, I did wonder if I was a bit abnormal. Mine extends close to 3cm and only about 1cm of the remaining is hair free. That's annoying.

Odile you should contact them soon, and clear this question directly with him (or administration), because if he only removes hair from grafts, and not flaps, you will need to have this hair removed.   

Yes, I am resending my email and hoping to get this answered. Wish now I'd done the hair removal before the RLE and avoided the problem. Big mistake on my part to wait till now to consider my particular circumstances.

Perineal area isn't a problem, because hair from perineal flap can be accessed after surgery and removed later.   

May still be worth considering removal before the op though? Still have to get my referrals back and checked before I can get on the waiting list (4-6 months). Might be easier access to laser some of it off before rather than after.

[AnonyMs]

Regarding Brassard and hair, KayXo made a post about that.

Hair inside the vagina and scars outside vagina
https://www.susans.org/forums/index.php?topic=203188.15

[mmmmm]

May still be worth considering removal before the op though? Still have to get my referrals back and checked before I can get on the waiting list (4-6 months). Might be easier access to laser some of it off before rather than after.

Yes, technically it would be more convenient to remove it before surgery than after. I didnt... even the thought of having electrolysis done there and lying on the table with legs spread for hours was too much. If I had dark enough hair, I probably would have that removed with laser before surgery. I had dr. Suporn do my surgery, so there isnt any hair directly around vaginal entrance, as he uses penile skin for that area. Perineal flap ends lower, completely outside. Im not familiar with this detail on dr. Brassards technique. Maybe Jenna or someone else can give more exact answer about where perineal flap ends.

[AnonyMs]

I had dr. Suporn do my surgery, so there isnt any hair directly around vaginal entrance, as he uses penile skin for that area. Perineal flap ends lower, completely outside.

I've heard of a few cases where there's hair remaining with Dr Suporn, but it is rare. I understand that if it does occur with Suporn its only near the entrance so its not difficult to remove post-op if necessary.

[Odile]

Yes, technically it would be more convenient to remove it before surgery than after. I didnt... even the thought of having electrolysis done there and lying on the table with legs spread for hours was too much. If I had dark enough hair, I probably would have that removed with laser before surgery.

Yes, I tried electrolysis over a year ago. Very unpleasant and didn't seem to work well on me.

If I was to get the perineal area done sounds like it might also be worth doing the penile shaft too with laser. Unless Dr Brassard can scrape that area - which I need to double check.  I know Dr Brassard likes to discourage hair removal but I don't see why he should object to getting the non-scrape areas done even within his one year rule? 

[mmmmm]

I've heard of a few cases where there's hair remaining with Dr Suporn, but it is rare. I understand that if it does occur with Suporn its only near the entrance so its not difficult to remove post-op if necessary.

Hair can be on perineal area, or outer surface labia minora and of course labia majora. But whole vaginal entrance is made from penile flap, from skin at the end of the penis (minus prepuce flap which is used for inner labia minora) so its completely hair free. If you would see photos taken during surgery, its very easy to understand and imagine. Its not so easy to explain. Anyway, any hair that might bother someone, is on the outside, like few centimeters from actual vaginal orfice.
There is practically zero chance that any hairs would be inside the vagina, because meshed graft basically looks almost transparent. Any follicle, even if non-active (due to previous laser/electro) would be noticeable on meshed graft.

Yes, I tried electrolysis over a year ago. Very unpleasant and didn't seem to work well on me.

If I was to get the perineal area done sounds like it might also be worth doing the penile shaft too with laser - unless Dr Brassard can scrape that area which doesn't sound likely from his data-pack. Most of the hairs are still quite dark. I know Dr Brassard likes to discourage hair removal but I don't see why he should object to getting the non-scrape areas done even within his one year rule? 

I dont believe he objects to hair removal on perineal area. Its just not essential to have hair removal prior surgery. He and other surgeons who use scrotal grafts only recommend against hair removal on scrotal area.

You tried electrolysis on genital area? Galvanic and blend electrolysis should work well. Thermolysis doesnt work well for scrotal skin or perineal area (or mons pubis), because hairs are too deep rooted. Its more likely to cause burns and scars than hair root destroyed.

Anyway, I hope you find conclusive answer soon.

[Odile]

Thanks. I really appreciate everyone who has contributed to this thread. I've learnt more today in the last few hours than days of trawling through the internet. At least I have a possible plan now, one which doesn't involve having to delay the SRS (hopefully). The detail will depend on whether Dr Brassard can remove non-scrotal graft hairs. I'll post any useful information I get from emailing his office about this.