There is no one best, there are choices that for most people will be bounded by cost or insurance coverage. 6 months post op I have cleared had a well established vaginal microflora (primarily lactobacillus) from the first few weeks in. I established that quite intentionally using the vinegar douche my surgeon recommended and added lactobacillus from a supplement occasionally (my doc wanted douches every few days for the first few weeks).
I have never once used soap inside my vagina (my doc would have had me do so but didn't complain when I said I'd rather use occasional rinse with salt water). Because I had some very slow healing areas externally I had to wash well outside the vagina to avoid buildup of exudate and I still have a bit of that where there's some granulation tissue on one side of my clitoris -- that's finally being addressed by my new gynecologist and I hope to be free of the choice between panty liners and staining my underwear within a few weeks.
So at 6 months I really feel it's like a natal female vagina except for that granulation tissue which could have been taken care of at 2-3 months but my old healthcare practice didn't allow use of silver nitrate. I expect things to continue to improve out to about a year but for all practical purposes, the only difference for me now is some soreness persisting in the outer labia, most noticeable with activity, such as biking.
The major changes in pi technique have been placement of the fully innervated glans as a clitoris and most surgeons today are doing a single procedure in place of a planned second minor surgery to form the inner labia. My doc said only 20% of the patients in their practice want a modification to improve the appearance of the labia. I believe Meltzer still does a 2 step method and I've never heard a bad thing about his results. Personally I couldn't afford a second trip cross country for the revision so I was only interested in the more current method.
The other small advancement has been that the excess urethra is now used to put a bit of mucosal skin into the vagina, my doc uses it to form part of the inner labia, I've heard of other uses. Lubrication, btw is also gotten slightly during arousal from the Cowper's glands which remain intact and when we were male we're the main cause of 'precum'.
An average penis is sufficient to create a full depth vagina and as I was quite well endowed, there was never any question of needing an additional skin graft, (my doc said just before I was put under that she'd take some skin from my thigh if necessary). Even if I'd started with a micropenis, I'd have stuck with the pi technique, as that's the only method being practiced in the US and I had good insurance. Personally, I see no advantage to the Thai surgeons however some of them are noted for making very pretty genitalia, pornstar worthy. Also the Thai surgeons generally have linger healing times, that would be a problem for me.
I also like that what little sensation that used to go with my penile skin is still there. I can only assume that grafts have no sensation.
Use of a bit of sigmoid colon for lubrication didn't appeal to me, women I know who've gone that way have lubrication 7*24; not something I want and the procedure is certainly more invasive.
Confidence in your doc is the biggest for me. I was incredibly glad when Heidi told me the procedure had been done in 2.5 hours, quite an accomplishment for a doc working solo, no assistant cutter.
