Some questions about GCS techniques

[Veronica90]

Hello everybody,

I'm really sorry my first post here is a question, I wanted to write so many times, but when I read the forum I become really disphoric and sad. I'm sure I'm not the only one feeling this way, I should be stronger than this, because there are so many kind people here.

I'm starting to look into which surgeon would be better for me and I have so many questions, I tried searching for them but didn't find them, I apologise if they were asked already.

After seeing some photos I'm leaning towards going to Thailand. But I'm lost on the technique that would be best.

I... I'm not concerned about depth, but the external appearance.

I know colonvaginoplasty is usually used for depth but so far it's the technique I like more because... all the after photos I have seen with this technique have a beautiful appearance.
While full graft and p.i. seemed to be really scarily varied with some good, and some really bad ones.

With a colonvaginoplasty is the fourchette made during the surgery, since dilation isn't as harsh?

Are there full graft surgeons (there are only three in Thailand, right? Dr chettawut, suporn and Sanguan?)  who also do it, or do it later but during the same stay?

And... about penile inversion, if I understand it right the labia never extend all the way down. Is it always the case, and can a revision be done later to prolong them?


Now I wrote so much ahaha, I'm sorry!
Thank you so much in advance.

[Dena]

Welcome to Susan's Place. If your looking for a particular look, you need to check out each surgeons work because procedure vary from surgeon to surgeon. There are a couple of questions I can answer for you. Colon surgery has been around from at least the 1970's but is somewhat more invasive and could leave additional scars that may not be desirable. That said, it appears to require less dilation and it self lubricates.

PI is a two step operation because the blood supply has to reestablish it's self before the surgeon can apply the cosmetic touchups. You also need to go for about a week without dilating after the touchups so that means the second step has to wait 3-6 months after the initial surgery.

If you don't require a vagina, there are cosmetic versions of the surgery that don't require dilation. They might be preformed as a one step operation because blood supply and dilation aren't an issue. We have a few member on the site who have taken this approach because they aren't interested in penetration or they desire the faster healing after surgery.

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[Veronica90]

Thank you so much Dena, and the girl who sent me a PM, it was very helpful.

I do want to have a vagina, I feel it's still an important part for me to feel like myself after the surgery.
It's actually the thing holding me back from a colonvaginoplasty, it's just unpleasant to think my inside bits will be made from the intestine. But yesterday I talked with my mother and some female friends and they didn't feel weird about it, so maybe I can get over it!

You really asked my questions! I have just a few more  if you don't mind. You said it self lubricates, does it happen only when... aroused, or all the time? Do you need to keep wearing pads?

I'm sorry I'm asking personal questions, I just have one more about this kind of surgery, are... are the sensations inside close to PI and full graft's?

I guess the skin for a cosmetic revision after PI will be taken from elsewhere,  does it look right afterwards?

Gosh, so many questions, bear with me please!

[Dena]

With the colon flavor of the surgery, I only know what others have reported. They claim that normally pads aren't needed however it's possible to get turned on enough to need one so it's advisable to carry a few extra pads just in case.

As for sensations, I really can't answer that one as I am still a virgin. I know that many people are very happy with their surgery no matter which one they had so I suspect all of them produce a reasonable level of sensation.

With a PI revision, you don't need additional skin to complete the surgery. The labia is more or less in place however it's not joined in the front and back. Visibly you could pass in a locker room but close examination would expose the difference. The surgery just joins the front and back using the existing skin producing something that would pass a closer examination. I haven't had the second stage of surgery because I would be comfortable with my partner being aware of my status before sex. If you desire stealth, the second surgery might be more important to you.

[AnonyMs]

I don't know what photo's you've seen but I've not seen any that indicate colon vaginoplasty gives better aesthetic results. I've not even seen many of these results at all. This type of SRS is an old technique that quite rare these days and usually reserved for fixing problems. I think you'd be taking a big risk by doing it. There's a lot of negative posts about it, and a few positive ones. I've also heard 2nd hand of problems. Perhaps you'd get a good result, but its impossible to have any level of confidence beforehand, and too late afterwards.

I may be wrong, but I have a feeling you've latched onto the idea of this type of surgery as being really good without a rational reason for it. I know I've a tendency to do that kind of thing and have to keep a watch out for it.

Of the 3 Thai surgeons you mentioned there's quite a lot of info available online about Suporn and Chettawut, and little about Sanguan.

[Veronica90]

Thank you Dena for answering my questions, and AnonyMs for scolding me. I will try to be more rational about it.
I have read a lot of new threads over the Internet and now I'm more aware of the possible long term effects of this kind of surgery. But I'm still leaning towards it
I would have gone to suporn, but I cannot afford him, so for a graft surgery the choices would be Sanguan, but there is too little information about him, or chettawut, but I have read both great stories and terrible experiences and I have also looked at his results and didn't really like them.
So the choice is between pi and colonvaginoplasty, the results of cvp I have seen on realself and on Dr Kaushik's website were all amazing in my opinion, and not needing a second revision and electrolysis before surgery also mean a lot to me. I think from what I read that there also seems to be less scarring around the vulva than with pi and that would be really reassuring.

[AnonyMs]

There's a number of threads on susans about Olmec if you search.

[Claire_Sydney]

Bizarrely, I'm writing this from my hospital bed in Thailand where I am recovering from a minor cosmetic revision 8 months after my SRS. I think I can answer some of your questions, hopefully.

Sigmoid colon vaginoplasty carries greater risks. You are effectively removing a section of colon to extend the distal (deep) end of the vagina. The surgeon must then re-graft the two colon sections back together so your bowel works properly. Because the colon is mucosal, it is stretchier than skin, is naturally moist and lubricates. However, using internal organs is a much higher risk than using skin which is superficial and plastic. Internal bowel problems can create major life threatening illnesses. Some patients complain of the smell, but I can't comment on this. Some surgeons will only use the colon approach if it's impossible to harvest skin from elsewhere on the body.

A lot of surgeons are also now considering a perioneatal graft as an alternative to colon, because it is more superficial tissue, is very stretchy, and apparently regrows very fast. It is a new technique and and still emerging.

Cosmetically, you will not be able to tell the difference between colon and skin graft SRS unless you are using a speculum to look into the deepest part of the vaginal vault. The penile tissue covers the first few inches of depth.

Proper construction of a fourchette seems to be tough for any surgeon, and I've yet to figure out why. I suspect it has to do with how the tissue contracts as it heals. I've yet to see an SRS in which the labia fully surrounds the vulva - although I know plenty of ciswomen whose labia is not completely circumferential too.

You also asked about two stage SRS, performing orchiectomy and penile inversion in a separate stage to the distal graft. Dr Sanguan uses this technique. He will perform the initial inversion and pack the internal orifice for one week. Scrotal tissue is taken to a lab, where it is kept alive for one week, during which time it is scrapped and cleaned, all the hair follicles removed, and prepared for grafting. The patient's vaginal opening is heavily packed in aseptic technique, and vacuum pressure is used to drain the wound. After one week in bed, the patient returns to surgery and Dr Sanguan will perform the full thickness skin graft. The surgeon will assess in advance if there is sufficient scrotal skin for the depth needed. If not, they will discuss options to take skin from another part of the body - usually the high inner thigh where the underwear line is.

I encourage you to be mindful when looking at photos. When you walk out of hospital, you do not have a shiny new sex organ. You have a huge, invasive wound that will heal into a vagina over many months and years. The photos are radically different between 1 week, 1 month, 6 months, 1 year and 5 years. It takes about three months for the incisions to heal into scarlines, and about 6-9 months for them to become un-noticeable. It takes a good year or three for all the sub-cutaneous fat to settle under the skin graft and the pubic mound to settle into a normal shape.




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[Claire_Sydney]

I'm not sure that you are likely to end up with less scarring by account of using a non-inversion technique. What makes you believe that?

Most surgeons also do not require electrolysis anymore. They will scrape the hair follicles at the time of excision.

I was monitoring Dr Supporn's calendar for a while. He is retiring very soon, and I doubt if there are any appointments remaining before he does so - unless you can get a cancellation which would require you to travel at short notice for surgery.

Good luck.


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[SadieBlake]

My fourchette is quite reasonable from single stage pi technique by Heidi Wittenberg last April. I'll be glad to provide photos if you want to PM me.

I think far too much attention is paid to discussion of technique and choice of surgeon. PI is the only method practiced in the US, however if there is insufficient donor skin, e.g. in the case of a micropenis, the surgeon will take a graft from the patient's leg or similar. As a urogynecological surgeon Dr Wittenberg performed vaginoplasties on natal females to create vaginal cavities for women  born without a vaginal canal long before she started MTF procedures.

Personally I wanted no part of a procedure without hair removal. I've heard of numerous women who relied on surgical scraping of follicles and had hair growth inside the vagina post op. Electrolysis wasn't fun and involved substantial time commitment, however any chance of internal hair wasn't acceptable.

Best wishes in choosing, the positive news is many good optioms, there's no shortage of excellent surgeons with proven results.

[AnonyMs]

I think far too much attention is paid to discussion of technique and choice of surgeon.

I think everyone's different. I've met women who pick a surgeon because their friend did and think no more of it than that. Personally I can't relate to that and want to know with 100% certainty that I've picked the "best", and what that actually means

I'm sure some surgeons and techniques are better than others, just like in every other human endeavor. Whether those differences are important to you or not is a different matter. Some are just different and have pro's and cons and it depends on your personal preferences how you judge it.

I find the main difficulty is that there's not enough solid information to work out the pro's and con's of each surgeon. There's a lot of subjective opinions on the quality of the surgery, and very few photo's to allow you to judge for yourself (and most of those are not good enough to work it out). I've seen a number of photo's for certain highly respected surgeons where I can't for the life of me work out why women think that they are acceptable.

I want to hear every complaint about a surgeon. Not everyone agrees.

A lot of information that's accepted truth is just plain wrong, but its difficult to find out what's true and false (Suporn's meshing the scrotal skin to get depth is a good example, because its not true). In the end I find myself buried in low quality data, its very hard sifting though it, and I end up guessing (which disturbs me greatly).

Then I have to think about FFS, and I find it even more difficult.

Personally I wanted no part of a procedure without hair removal. I've heard of numerous women who relied on surgical scraping of follicles and had hair growth inside the vagina post op. Electrolysis wasn't fun and involved substantial time commitment, however any chance of internal hair wasn't acceptable.

The more I hear about that the more worrisome it is. I don't know why but in the last few years we seem to hear about it so much more than before.

[Claire_Sydney]

I find the main difficulty is that there's not enough solid information to work out the pro's and con's of each surgeon. There's a lot of subjective opinions on the quality of the surgery, and very few photo's to allow you to judge for yourself (and most of those are not good enough to work it out).

Then I have to think about FFS, and I find it even more difficult.

I agree! It's like wading through poor quality data trying to gain the most basic of insights.

It's not like anyone has had SRS multiple times and could make a direct comparison between different surgeons. And the results vary so dramatically with patient lifestyle, age, skin quality. Then there is the airbrushing, and photos taken at different stages of recovery. It's impossible to compare. And everyone is very loyal to their own surgeon.

For me, I placed a much bigger emphasis on risk minimisation than aesthetics. Colon graft was out for me - I did not want to destroy my bowel system. I also gathered as much data as the surgeons were willing to give me about incidents of fistulas, vaginasmus, and tissue necrosis. There are some real horror stories out there, but it's almost impossible to put a probability figure on them.

I went down the route of following the marketing on the FFS decision. One particular group markets hard in our region, and there were just too many good outcomes to ignore. By the time I had seen 50 good outcomes, and not a single person who had been anywhere else for FFS, it seemed like the only viable option for me. It's just impossible to get any useful data on FFS, but I'm sure outcomes could have been equally as good or better elsewhere.

The community seems to be divided on the SRS hair removal question for the last few years. Half the patients have surgeons telling them not to do electro, as it will reduce skin elasticity and make the graft less viable and prone to infection. Others have surgeons telling them to proceed with electro just to be sure. Who knows what to believe?

There is just not enough quality data out there for any of these decisions.

My point to the OP, I guess, would be to exercise prudence and critical thinking when making decisions about a surgical approach based only on website photos.



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[IsabellaSwan]

For me, I placed a much bigger emphasis on risk minimisation than aesthetics. Colon graft was out for me - I did not want to destroy my bowel system. I also gathered as much data as the surgeons were willing to give me about incidents of fistulas, vaginasmus, and tissue necrosis. There are some real horror stories out there, but it's almost impossible to put a probability figure on them.
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I have never heard a SRS surgeon talk about vaginismus! What did they say about it?

[Claire_Sydney]

I have never heard a SRS surgeon talk about vaginismus! What did they say about it?

Not much. I showed them several stories of patients who claimed they had been unable to dilate because of PC muscle problems, cramps, pains and spasms. Some went on to lose all depth. It was all anecdotal evidence from the internet, so it's also plausible that poor patient adherence to the dilation regime was a contributing factor. I have no idea how true the stories even are.

Most of the surgeons stood by their work. They all claimed that problems with dilation were all caused by patient non-conformance. Maybe they are right. I have no way of knowing. Two of them pointed out that their nurses verified that every patient could dilate by themselves to full depth before discharging them from the hospital.

But it's hard to overlook the stories out there of women who said they did everything humanly possible but just couldn't dilate and lost all depth. Some of them are harrowing stories to read. I'm sure they are not all caused by vaginismus or PC muscle problems. I guess there are all kinds of other issues with grafts too.

There is another story of a woman who broke her pelvis in the months after SRS and could not dilate at all. She lost everything, but I think she went for a revision a few years later. I think the message thread is here on Susan's somewhere?




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[IsabellaSwan]

Girl, that is literally me. I had a hard time dilating from the get go. I had FFS with Suporn 3 weeks after my SRS and he said he could only get the dilator to 17cm (my original depth was 18.5). When I told him I still managed to get to that depth fully awake (and he couldn't while I was under general anestheia) he looked shocked for a split second, and then just told me to not dilate deeper than 17cm. Not that it was ever easy to get there, it took me literally a minimum if 4 hours. Dilation, seberal yeare later, never took me less than 1.5 hours to get to full depth.

[AnonyMs]

The community seems to be divided on the SRS hair removal question for the last few years. Half the patients have surgeons telling them not to do electro, as it will reduce skin elasticity and make the graft less viable and prone to infection. Others have surgeons telling them to proceed with electro just to be sure. Who knows what to believe?

I think it's not clear because the rate of problems is quite low for most surgeons. Since most get lucky you keep hearing it's not required, and I believe surgeons are being irresponsible saying that as they should advise patients of the actual risk and consequences. It should be up to the patient to make an informed choice.

There may be an important difference with Suporn as he has a different technique. He does reccomend no hair removal, but definitely has cases of vaginal hair. I've an impression it's around 1 or 2%. The women who wrote that pdf had it, but was able to remove it as it's confined to the entrance due to his technique. Perhaps it can go deeper, but presumably at even lower risk. I don't know.

[SadieBlake]

Sure, nominally a small chance (though my electrologist has known multiple women with the problem). However the downside of being in that small percentage, whatever it is, isn't one I'd consider acceptable risk.

I can make a fairly solid logical argument that any time spent under anesthesia doing things that could be accomplished beforehand is a bad idea. Time under GA is extremely hard on the body. This was my choice, however as you say other choices are certainly valid.

[Kendra]

Regarding hair, the decision for me was easy.  I never want any hair in there and I see additional time under anesthesia as a risk.  I had a full year of electrolysis down there twice per month before surgery. 

[SadieBlake]

I think everyone's different. I've met women who pick a surgeon because their friend did and think no more of it than that. Personally I can't relate to that and want to know with 100% certainty that I've picked the "best", and what that actually means

I'm sure some surgeons and techniques are better than others, just like in every other human endeavor. Whether those differences are important to you or not is a different matter. Some are just different and have pro's and cons and it depends on your personal preferences how you judge it.

I find the main difficulty is that there's not enough solid information to work out the pro's and con's of each surgeon. There's a lot of subjective opinions on the quality of the surgery, and very few photo's to allow you to judge for yourself (and most of those are not good enough to work it out). I've seen a number of photo's for certain highly respected surgeons where I can't for the life of me work out why women think that they are acceptable.

I want to hear every complaint about a surgeon. Not everyone agrees.

A lot of information that's accepted truth is just plain wrong, but its difficult to find out what's true and false (Suporn's meshing the scrotal skin to get depth is a good example, because its not true). In the end I find myself buried in low quality data, its very hard sifting though it, and I end up guessing (which disturbs me greatly).

Then I have to think about FFS, and I find it even more difficult.

The more I hear about that the more worrisome it is. I don't know why but in the last few years we seem to hear about it so much more than before.

Of course, and yes survivorship bias, a form of selection bias is going to be a factor for virtually all post-op women. It's certainly a factor in my feelings below.

I personally disagree that there's a single best method. First off, choice of surgeon is more than just technique and result, we are also all bounded by financial, schedule and geographic factors. It's pretty clear that most women without insurance travel outside their home nation and mostly to Thailand.

Your points for suporn and his meshing technique are noted but honestly I don't accept suporn's own story about the reason. He's running a business and he and the other Thai surgeons are relatively silent on their methods.

My own choices, as I've written many times started with a limitation of taking insurance, and a desire to go with the most technically skilled surgeon available. I've spent a lot of time in ORs and so my selection criteria are somewhat exact and feeling confident in my choice did a lot to affect my stress levels which in turn is what this whole thing is about.

The main differences I can see between the top surgeons in the US amount to whether two stage and single with revisions being looked for by about 20% of patients and how the urethra is used to provide some lubrication. In the US most seem to be using that for lining the inner labia (Oates at BMC does something different, I forget what).

As I said above, I'm happier with the results than I'd expected to be, was that more Heidi's skill or the fact that I'm a generally good surgical candidate and known to heal well after injures and prior surgeries? Don't know, don't care. Fact is I got it done on a schedule i could live with and on a shoestring budget with my first choice surgeon.

Survivorship bias? You betcha :-)

[AnonyMs]

I personally disagree that there's a single best method. First off, choice of surgeon is more than just technique and result, we are also all bounded by financial, schedule and geographic factors. It's pretty clear that most women without insurance travel outside their home nation and mostly to Thailand.

Perhaps we agree? I don't think there's a single best for everyone, but I do think there is for a particular criteria. For me it would be quality of work and risk, nothing else.

Your points for suporn and his meshing technique are noted but honestly I don't accept suporn's own story about the reason. He's running a business and he and the other Thai surgeons are relatively silent on their methods.

I know a number of people who've met him and I don't think he's running business in the usual sense. He's more a surgeon who happens to have a business and is not interested in doing anything except surgery. Its others that do the business side, and if they were better at it they would be making a lot more money.

I've seen two photo's of Heidi Wittenberg's work, and they do look very promising. Its a shame there's not more posted, but can't complain too much because I wouldn't either.