We welcome back physical therapist Dr. Ken McGee to discuss bottom surgeries, wound healing, and granulation tissue in this article.
Bottom Surgeries, Wound Healing, and Granulation Tissue
In healthcare, a wound refers to an injury to the tissue. Surgical wounds heal in one of two ways. In the first way, the edges of the tissue are stitched together and close along a defined line. This healing process, called primary intention, is what we see with most breast augmentation and top flattening surgeries.
In comparison, secondary intention is the healing process for open wounds without defined stitching. Examples of surgical wounds without defined stitching include graft donor sites, which are the locations where surgeons harvest a layer of tissue to help make a new structure. Examples of graft donor site wounds include the areas left behind after tissue is harvested from the forearm, abdomen, or thigh for phalloplasty (construction of a new penis). Healing by secondary intention may also occur if stitching pulls apart soon after surgery. For example, many vaginoplasty wounds, especially inside the canal, heal by secondary intention after some of the stitching comes undone. Secondary intention healing happens when the body fills in an area during healing rather than joining together two edges.
Part of secondary intention healing involves the growth of blood vessels, nerves, and new tissue from the base of the wound (rather than from the edges pulling together). This new tissue filling in the wound space is called granulation tissue. Granulation tissue often looks like bright red ground beef. Granulation tissue can occur with nearly any bottom surgery. Granulation tissue is often very painful to touch and is a common source of pain after many bottom surgeries, particularly vaginoplasty (people might notice pain with dilation and blood on their dilators).
If someone has pain due to granulation tissue, the medical team may wait to see if the wound starts to close on its own, especially if the granulation area is small. If the granulation tissue is not healing as expected, a clinician can dab a cotton swab on the site with a chemical called silver nitrate. Silver nitrate is applied at a frequency determined by the medical provider, ranging from multiple times per week to every few weeks until the granulation tissue is closed. Silver nitrate can even be placed up inside the new vagina after vaginoplasty.
Other topicals for granulation tissue include medical-grade honey, such as Medihoney or First Honey. When granulation tissue has persisted for a long time, a medical provider may even consider prescribing a topical steroid cream, such as triamcinolone. Sometimes, medical honey or a steroid cream are applied on the tip of a dilator for people who have undergone vaginoplasty.
Collagen bandages, such as BioPad, may be applied to a wound, especially if it is stuck in the early stages of healing, and not moving from granulation tissue to mature tissue. A collagen bandage is cut to size and placed into a wet wound bed, where it dissolves and provides a scaffold for healing. Collagen is shown to speed wound healing across many studies. However,many providers are not yet familiar with them, and they are expensive, so they are not yet commonly used. Some collagen products are derived from sources that may be an allergen, and should only be used after ensuring a person will not react. You may have already used collagen bandages: this technology is used in pimple pads!
For those who have undergone vaginoplasty, dilation is necessary to maintain both the length and width of the new vagina. However, dilation can also irritate the healing wound, and irritation is a risk factor for developing granulation tissue or aggravating granulation tissue that is already present. Using a lubricant with the proper osmolarity (how concentrated a liquid is) can decrease irritation of the wound. Ideally, a lubricant should have an osmolarity of around 300 to support wound healing, although occasionally a higher osmolarity might be used to dry out a wound. High osmolarity liquids can pull fluids out of the tissue it is in contact with, while low osmolarity liquids can contribute hydration to an area. Too low of an osmolarity might macerate a wound. Similarly, the pH (how acidic or how basic a liquid is) should be between 6 and 4. Studies show that wound healing is delayed when the pH of a topical is above 7 (more alkaline/basic). Clinically, I see that Good Clean Love, with an osmolarity of 269 and a pH of 4.8, supports wound healing in those clients who are struggling with excessive or slow-healing granulation tissue. For more information, check out Smitten Kitten’s lube guide with rankings of lube osmolarity and pH.
Overall, granulation tissue is a common problem after many different bottom surgeries. Because it is rarely discussed and many people do not understand their treatment options. I hope that this article helps people understand that granulation tissue may be a treatable source of pain after bottom surgery. One of the best ways to get ahead of granulation tissue problems is to establish care with a knowledgeable medical provider who can help you with wound care if issues arise. Some people may also benefit from partnering with a wound care nurse in special circumstances.
The author has no affiliation with any of the brands mentioned in this article.
Dr. Ken McGee, PT, DPT (they/he) is a highly experienced transgender physical therapist who practices from a trauma-informed perspective. They help people of all ages and genders live more active, fulfilling lives. Dr. Ken’s favorite moments are hearing clients say that they are finally back to doing what they love—be it running, playing with their kids, or getting outside.
Dr. Ken McGee received their Doctor of Physical Therapy from the University of Washington in 2014. In 2018, they became one of the few physical therapists in Washington to be board-certified in pelvic health. Dr. Ken enjoys teaching for the Herman and Wallace Pelvic Rehabilitation Institute. Click here to read about Dr. Ken’s perspective on supporting transgender clients.
Dr. McGee’s practice is B3 Physical Therapy & Wellness.
We’re thrilled to have Dr. Ken McGee back to write with us! Previous articles they have contributed to: