From now until sometime in early 2023, we’ll be writing about gender affirming surgeries and procedures. We’re starting with bottom surgeries and will end with office visit procedures such as fillers and botox. This week, we’re discussing vaginal-preserving phalloplasty. It is sometimes shortened to VPP.
Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.
What is vaginal-preserving phalloplasty?
Traditionally, it has been assumed that an individual who wants phalloplasty would also want vaginectomy (removal of the vagina,) and perhaps urethral lengthening (to be able to pee out of the tip of their penis) and scrotoplasty (creation of a scrotum and potentially testicle implants.) But that doesn’t have to happen! We are thrilled that surgical techniques are catching up to the many ways in which humans envision their bodies. A vaginal-preserving phalloplasty (VPP) is the creation of a penis without removing the vagina. For people who want to keep the V and get the P. Embrace the power of “AND”!
There are many possible genital configurations, and which ones are chosen can change the complexity and risk of gender affirming surgery. With VPP, an individual may:
- retain labia
- remove labia
- use labia for scrotoplasty and/or urethral lengthening
- have a hysterectomy (removing the uterus) and keep their cervix, or remove the cervix
- if a hysterectomy is chosen, oomphorectomy may be included (removal of the ovaries)
- egg harvesting may be done at the same time
- not have a hysterectomy and retain potential fertility
- choose between different phalloplasty techniques (stay tuned for our phallo blog on 12/5)
- radial arm flap
- thigh flap
- dorsal flap
- bird wing
- can choose to modify the clitoris or place the penis (and scrotum, if desired) in front of the clitoris, allowing for direct physical stimulation
- opt for urethral lengthening (UL) to be able to pee from the tip of the penis
- evidence indicates that UL without vaginectomy has higher complication rates
- retain the position of urethra
- move urethra along the perineum
- have scrotoplasty, with or without implants
- have penile implants for erectile function
Phallo.net has a discussion of vaginal preserving phalloplasty, and there are several posts and personal reflections in the r/phallo and r/salmacian communities on Reddit. If you’re feeling nerdy, here’s an article published in the Journal of Surgical Case Reports on VPP. Note – there are pictures of genitals pre-, during, and after surgery at these sites.
When: Expected Prep and Recovery for VPP
Prep is similar to phalloplasty prep. Hair removal will be required for the donor flap site.
More information about surgery prep at Your Bottom Line: Preparing for Bottom Surgery . If you’re a smoker, your surgeon will require that you stop smoking a few months before surgery. You’ll need to arrange transportation, housing, a caretaker, and time off from work. Phallo.net has a fairly comprehensive guide to preparation for phalloplasty. OHSU publishes a detailed booklet on phalloplasty, and provides VPP as an option.
Recovery is also similar to other bottom surgeries. Patients will stay in the hospital for up to a week post-op. The average time off from work is four to eight weeks. Lifting and activity restrictions will apply for up to eight weeks, and significant restrictions will apply for the first month. Activity restrictions may depend on whether or not other procedures were done along with the phalloplasty. Your surgeon may want you to stay in the area for a month after phalloplasty, so you may need to arrange housing. Patients may have a catheter for up to a month if urethral lengthening is chosen.
How: Common Surgeon and Insurance Requirements for VPP
Like other lower surgeries, you will likely need two letters from mental health providers for your surgeon, along with letters from your surgeon and/or hormone provider for insurance. They may require hormone use for a certain period of time or want documentation for why hormones were not part of your journey. The current WPATH SOC 8 recommendation is six months of hormone use unless hormones are not desired or are medically not appropriate. Testosterone can cause bottom growth, which may be desired or useful for your chosen procedures or desired outcomes.
Some insurance policies may require that you document your support and housing plans during recovery. Your surgeon will want to know that your health is optimized for surgery, so you’ll likely have a physical/health exam and lab work ordered prior to surgery.
If you are a smoker, you will need to quit smoking approximately three months before surgery. If you are a diabetic, your blood sugars should be well-controlled.
Why: Some Things To Think About When Choosing VPP
Form: what do you want your genitals to look like?
Function: what do you want to do with your genitals?
- The donor site for the skin that will be used to create the shaft affects the length and girth achievable. It also affects sensation. (We’ll go over this in detail next week in our blog dedicated to phalloplasty!)
- Are erections important to you? Do you want to use your penis for penetration? Do you want to keep vaginal penetration as an option?
- Scrotum: yes or no? Silicone implants? Fat transfer?
- Labia: yes or no? Maybe keep some labia and get a scrotum, too?
- Placement: the clitoris can be buried in the base of the penis or left as is, with the new penis “foreward” of the clitoris. The clitoris can also be in front of or behind a scrotum. (Placement choices can affect sensation and accessibility for direct manipulation.)
- How you’ll pee: if urethral lengthening is chosen, the new opening for urination will be at the end of the penis.
- Reproductive: if a future pregnancy is desired, keeping the uterus and ovaries can help preserve that option.
A surgeon practiced in vaginal-preserving phalloplasty will discuss all the options with you and take sufficient time to understand your specific goals for your body.
Where: Surgeons Who Offer Vaginal-Preserving Phalloplasty
These are the surgeons and clinics that we know about. There are surely more, and we’d love to hear about them!
- Align Surgical Associates
- Dr. Shane Morrison at UW
- The Crane Center
- Dr. Daniel J. Freet (University of Texas)
- OHSU (Dr. Blair Peters is pioneering in this field.)
Do you know of other surgeons offering VPP? Please let us know!
- Christopher J Salgado, Kerstin Yu, Maria J Lalama, Vaginal and reproductive organ preservation in trans men undergoing gender-affirming phalloplasty: technical considerations, Journal of Surgical Case Reports, Volume 2021, Issue 12, December 2021, rjab553, https://doi.org/10.1093/jscr/rjab553 (note – pre, during, and post-surgical images of genitals)
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