These guidelines include an overview of the surgical procedures, day-by-day details during your stay at the hospital, and a description of hospital services and facilities.

Overview of MTF GRS Surgical Procedure The Latest improvement of the technique Why MTF GRS is done in two stages Skin graft options Surgery Schedule Details Phuket International Hospital Services and Facilities  for Phuket Plastic Surgery patients POST - OPERATIVE CARE AT HOME AFTER MTF GRS

Overview of MTF GRS Procedure

Male to Female Gender Reassignment Surgery is a complex and irreversible sex change surgery. As a rule I require letters of referral from either a psychiatrist, a physician, an endocrinologist or a psychoterapist, before I accept a candidate as my patient for GRS.

The Harry Benjamin Association recommends that six objectives must be met before a sex change operation is undertaken.

• The patient must demonstrate a desire for sexual reassignment at least 2 years.

• A clinical behavioral scientist trained to deal specifically with transexualism must make the diagnosis of gender dysphoria.

• The patient must live and work exclusively in his or her chosen gender for not less than 12 months.

• The patient must be under psychologic or psychiatric care for not less than 6 months before the surgery.

• The patient must have hormonal sex reassignment and treatment for not less than 6 months before the surgery.

• Throughout the evaluation process, peer review should be evaluated and the patient discussed by the appropriate clinicians.

If the patient can follow these guidelines, they will be scheduled for operation.The patient need to fax or send me some documents from her clinician or therapist approving that they are a suitable candidate for gender reassignment surgery. Please inform body weight and height (we prefer the patient to control their weight not exceed the average too much).

Dr. Sanguan performs gender reassignment surgery (GRS) as a penile inversion followed by construction of a vagina (vaginoplasty) using a scrotum skin graft. The surgery is usually accomplished in two stages:

The First Stage

The first stage includes creation of a vaginal tunnel without a skin graft, removal of the penis (penectomy), removal of the testes (orchidectomy), construction of the clitoris (sensate clitoroplasty), construction of labia minora and clitoris hood by using prepuce skin cuff and some part of penile skin flap (labiaplasty), construction of labia majora by scrotal flap and the rest of penile skin flap and construction of new urethra opening (urethroplasty).

The second stage, usually 7 days later, entails a scrotal skin graft inside the vaginal tunnel.

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The Latest improvement of the technique

Since the beginning of 2005, we have improved our technique of MTF GRS by using all the sensitive skin from the penile head ( Glans penis ) and Prepuce skin cuff with it's blood supply and nerves intact, to fashion the clitoris, clitoris hood and the inner side of labia minora. Specifically, the top of the glans becomes the neo-clitoris, the underside forms the inner part of the labia minora and all of it is preserved as one piece of skin. If the color of former prepuce skin is pink, then the new labia minora color will be also pink. The penile shaft skin is used for the outer side of the minora and all of the labia majora , while the scrotal skin is used to line the neo-vagina during the second stage a week later.

After we have used this new technique more and more, we have found that the outcome is so impressive. The appearance of the new genitalia is look more realistic than before. Also, every patients still have high sensitivity around clitoris and labia minora area. In many cases, it seem to be hypersensitive!

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Why MTF GRS is done in two stages 

Dr. Sanguan has found that skin grafts to the vaginal tunnel are less successful if done at the first stage, because some parts of the tissues generally are in poor condition to accept the graft. Some tissue is burned when the surgeon uses an electric cauterizing tool to create the vaginal tunnel. Some tissue is fresh fat, which has very little blood supply. These tissues are not good bases for skin graft survival. However, if they are allowed to heal for about a week, the body begins to cover them with new tissue, called granulation tissue. Granulation tissue has an abundant blood supply to help ensure skin graft survival.

Although many GRS surgeons discard the excess scrotal skin, Dr. Sanguan has found it to graft successfully in most cases, thus making additional skin grafts unnecessary. After the scrotal skin is removed in the first surgery, it is safely refrigerated at 4 degrees Celsius (approximately 39 degrees Fahrenheit), where it can remain healthy for up to 3 weeks, far longer than necessary. Before grafting, Dr. Sanguan carefully scrapes the scrotal tissue to remove hair follicles, thus,even not absolutely, preventing hair growth inside the vagina. This technique means patients do not require expensive and sometimes painful scrotal electrolysis prior to GRS.

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Skin graft options

The average vaginal depth will be 4-5 inches when grafting from the available penile and scrotal skin. If Dr. Sanguan concludes that your penile and scrotal skin are not sufficient to construct a functional or sufficiently deep vagina, he will discuss the following three skin graft options:

1. Full thickness skin graft. Excess or loose skin taken from the tummy, love handles or groin is added to the penile and scrotal skin. The donor site for the graft will leave a linear or horizontal scar. This is the best choice.

2. Split thickness skin graft. Skin removed from the thighs or buttocks is added to the penile and scrotum skin. The donor site for the graft will leave a scar of approximately from 50-100 square centimeters (about 8-16 square inches) similar to a deep abrasion or burn injury. The bandage covering the donor site will dry out and detach about two weeks after surgery. In many cases its initially poor appearance improves over time. But in many cases, the donor site scar may end up with hypertrophic scar or Keloid scar and get little improvement.

3. Secondary colon vaginoplasty. After a minimum of six months you may return for a colon vaginoplasty, wherein a section of the colon is removed and constructed into a self-lubricating vagina. The abdominal incision for the graft will leave a scar similar to that for women who have given birth by Cesarean Section. However, this is an invasive and complicated procedure. The complication, even uncommon, should be aware of such as infection, leakage of anastomosis, fistula, etc. The treatment of these complications is reoperation. In rare occasion, temporary colostomy cannot be avoided.

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Surgery Schedule Details

Following is an approximate schedule for your GRS surgeries.

Arriving in Phuket

Dr. Sanguan will arrange for a driver to pick you up at the airport or wherever you may be staying nearby, and take you to Phuket International Hospital.

Hospital Admission

Upon admission at the hospital, you will be asked to fill out some forms. You will be given a chest X-ray and EKG test, unless you bring recent, acceptable test results from your personal physician. To avoid unnecessary extra punctures, a complete blood count and other blood tests will be done while you are on intravenous (IV) fluid the morning of surgery.

Pre-operative evaluation

On the day before surgery, Dr. Sanguan Kunaporn will visit you at the Out Patient department or in your hospital room to evaluate your fitness for surgery. He will review your personal and medical history, including allergies. After a brief physical examination, he will evaluate the quantity and quality of the penile and scrotal skin and will estimate your vaginal depth.

Anesthetic consultation

The anesthetist may visit you the day before your operation. Otherwise, he will consult with you at the start of surgery. 

Your pre-operative practices

The day before your operation, you should eat only light, easily digested, low-fiber meals such as soup, sandwiches, fruit juice, etc. Avoid hot/spicy or hard-to-digest food such as meat. In the evening, the nurse will shave the genital area and give you strong laxative solution. After midnight, you must not eat or drink anything. To have any food or liquid in your stomach during the operation is to risk life-threatening aspiration.

Day 1: GRS stage 1 surgery

On the morning of surgery, you will be placed on an IV. In the operating room (OR), a general anesthetic is administered in your IV to make you unconscious. It is followed by placing a tube in your windpipe (endotracheal intubation), and epidural catheterization (a catheter is inserted near the spine in your lower back). After the operation is finished, the endotracheal tube is removed in the OR or in the recovery room. The epidural catheter is retained for use during later procedures, and removed when they are completed.

Post-operative care

After your first surgery, you will be kept in the intensive care unit (ICU) for few hours or overnight, depending on how well you recover. You will be given oral painkillers. You may ask for intravenous or intramuscular injections of Demerol or Morphine to relieve pain. Medicine will be given every 2-4 hours or as ordered by the surgeon. Note: pain-relieving injections will be administered only if you request them

Days 2: Recovery in bed

You must remain in bed for the first couple of days after surgery. You may lie on your back,
side or front, or even sit at the bedside. You must not stand on the floor or walk because it may aggravate bleeding.

Two catheters emerge from your surgical dressing. One is from the urethra (Foley's catheter) and the other is from the sponge packing inside the vaginal tunnel (Vacuum Assisted Closure or VAC).

The Foley's catheter is used for draining urine from the bladder into a urine bag at the bedside. A small amount of blood or white material may be mixed with the urine, and is not worrisome.

The VAC catheter is connected to a pressure-adjustable suction unit on the wall beside the bed. With suction set at approximately 100 mm Hg, the VAC produces negative pressure inside the vaginal tunnel and the perineum wound, enhancing granulation tissue growth, promoting healing, and preventing swelling. The VAC dressing keeps the surgical area dry and relatively comfortable. It is not a problem if some urine runs through the VAC catheter. The VAC catheter will be replaced 3-4 days after surgery.

Administering ice packs can help reduce swelling after surgery. The nurses will provide gel packs, which can be kept cold in your room refrigerator. 

Be careful not to pull or damage the epidural catheter taped to your lower back, since it will be used in later surgical procedures.

Day 3 : Continued recovery

If everything is going well, with no bleeding or additional swelling, you may get out of bed. Do so only with a nurse's help, to prevent losing your balance and taking a bad fall. Before you get out of bed, the nurses will empty the urine bag and release it from the bed. They will also disconnect the VAC catheter from the suction unit. You must carry both catheter tubes carefully when walking around. When you return to bed, the VAC catheter must be reconnected to the suction unit by a nurse. In case that you learn how to manage with those two catheters correctly, you will be allowed to disconnect the VAC by yourself.

If you notice abnormal sounds from the perineum area, it may be caused by leakage of the plastic bandage that covers the sponge. Please call for the nurse to fix it. The more time you spend connected to the VAC, the faster healing will take place.

Day 4 or 5 : Changing the VAC dressing

Dr. Sanguan will schedule you to be taken to the OR to change the VAC dressing under epidural anesthesia (using the catheter retained in your back). You are not allowed to eat or drink anything 6-8 hours before the operation; IV fluid will be started again several hours before surgery. This procedure takes about 1/2 hour, after which you will be returned to your room. Two hours later, you can get out of your bed again if you wish.

Days 5 -7: Continued rest and preparation for second surgery

You can resume light activity by walking around the hospital or cafeteria, but you should spend most of your time in bed connected to the VAC suction unit.

If you have had no bowel movement during the day before your scrotal skin graft vaginoplasty, the nurse will give you an enema the night before. As before, you are not allowed to eat or drink anything 6-8 hours before the operation; IV fluid will be started again in the morning.

Day 8: Scrotal skin graft surgery

The final operation, your scrotal skin graft, is done under epidural anesthesia, again using the epidural catheter implanted in your back during the first surgery. But if the catheter is obstructed or broken down, the anesthetist will redo spinal anesthesia or switch to general anesthesia. Dr. Sanguan will take your scrotal skin from the tissue bank and clear all hair follicles, fascia, sebaceous glands and fat. Then he will create a tube of the scrotal skin around tubular packing material. This process takes about half an hour.

He will remove your VAC dressing, clean the area, and check for any bleeding or blood clotting inside the vaginal tunnel. He then will insert the scrotal skin graft tube into the vaginal tunnel. Both the Foley's catheter and the VAC dressing are retained. The dressing prevents the skin graft tube from sliding out of the vaginal opening.

Days 9-10 : Total bed rest

After scrotal skin graft vaginoplasty, you must stay in bed for 3 full days to help ensure the graft's success. You may lie on your back, sides or front; you may sit up or at the side of the bed, but under no circumstances should you stand or walk. The VAC suction must be connected at all times. If you feel the onset of a bowel movement, ask the nurse for the bedpan. Never get up to go to the toilet! This may have disastrous consequences on the skin graft. Ice packs may be used to reduce swelling if you wish.

Days 11 : Semi bed rest

You will be allowed to stand on the floor and walk a little bit beside the bed from time to time.But the VAC suction must be connected all the time like the previous days. If you need to have bowel movement, you can ask for a "Com Mode", a special chair for bowel movement at your bedside. You must take care the vagina VAC packing very carefully. If you need to cough or "Push" during bowel movement, you must use your hand to hold at the vagina opening packing to prevent the packing inside the vagina canal from slipping out of the vagina canal.

Days 12-13 : Removal of Packing and starting dilation

Four days after scrotal skin graft, assuming no complications, Dr. Sanguan will remove the Foley's and VAC catheters and the vaginal packing material. He will inspect the new organs and skin graft. He will familiarize you with the anatomy of your new vulva and instruct you how to give it proper care. If you have difficulty urinating, he may retain the Foley's catheter until everything is okay.

You will begin vaginal dilation while still at the hospital. You will be provided a set of dilators free of charge and guidelines for their use. The nursing staff are available to teach and help supervise the dilation process. You will need to practice dilation regularly for 6-12 months.

Day 14 : Release from the Hospital

We will arrange complimentary transportation from the hospital to your hotel or airport. Please inform our foreign coordinators of your departure plans. They will also provide several copies of a medical certificate verifying you have successfully undergone GRS at Phuket Plastic Surgery.

Days 15 -21: Recuperating nearby

Dr. Sanguan recommends that you stay in the Phuket area for 5-7 days following discharge, if possible. One of our foreign coordinators, Poom or Yukari, can make accommodation arrangements for you. They will also make an appointment for a follow-up examination with Dr. Sanguan before you leave Phuket.

Acitivities Limitation

Even most patients can start light activities a few weeks after surgery, but we advise the patient to leave a work for 8 weeks after GRS. They need to do vaginal dilation 3 times a day regularly for 6 months to maintain the vaginal depth and width. Sexual intercourse can be tried 8 weeks after surgery. For heavy exercise like bicycling, horse riding, the patient need to wait 3 months after GRS.

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Phuket International Hospital Services and Facilities 
for Phuket Plastic Surgery patients

Private Room

The new in-patient building is opened since November 2007. Every room is equipped with a private bathroom, a small refrigerator; storage cupboards, private locker, satellite TV and a sliding glass door opening onto a private balcony. Your view is of a fountain and large pond surrounded by greenery and the hills west of Phuket.

If you bring a companion, he/she can sleep on a sofa comfortably but if he/she need a bigger bed, a folding-style bed is provided at 10 US$ per night.

Entertainment facilities

Every room is equipped with a television set and VCR. The nurse has a list of video movies available free of charge, or you can look through them at the nurses' station. Please ask for just enough cassettes to view in one day so that all patients can enjoy them.

Communication facilities

If you bring your own laptop, you can use Internet by WAN of the hospital in your room. Just contact your foreign coordinator for information when you check in. No charge for Internet but you need to pay some deposit for the PCMCIA card to plug into your laptop and you will get the money back when you return that card.

Within reasonable limits, there is no charge for local calls, but you must pay for long distance calls outside Phuket as well as international phone calls. The charge for international phone call is very expensive. Before using this service, you should ask the rate of charging from an operator.

Internet Service

If you have no laptop and would like to use Internet, the hospital provides two PCs at the hospital lobby of the new building with internet services free of charge.

Food

The nursing staff will bring a menu for you (and your companion) to order your meals, which will be delivered to your room. Fresh-cooked Thai and western dishes are available. The cafeteria area is open from 7 am to 7 pm each day. There is also an indoor-outdoor "coffee shop" with snacks and gift items. If you need items warmed, the nursing staff has a microwave. They will also provide hot water in a thermos each day. You may order some food from McDonald or KFC, ask the nurse for the contact numbers. We limit the total coverage of all food and drink that you and your companion can have at 5,000 Bahts (approx. 125US$) during hospitalization. You are subjected to pay for the amount that exceed this limit.

Security

There is a lockable drawer in your bedside stand. If you prefer, you can store valuables such as jewelry, travelers' checks and cash in a personal safe at the cashier's office.

Foreign Coordinators

Poom , the hospital liaison to westerners, speaks English. Yukari, the hospital's Japanese staff person, is fluent in English and Japanese. Both Poom and Yukari can help you make hotel room and transportation reservations for your post-hospitalization recuperation. They are available as well for general trouble shooting.

Hospital Staff

You will find the hospital staff to be friendly and plentiful. Most staff nurses can communicate in English (try to use simple vocabulary!). If you have language difficulties, call Poom or Yukari to help communicate your message.

Nearby facilities

Less than a quarter of a mile from the hospital are several large supermarket and shopping centers; Tesco Lotus and Big C and Central Festival, for purchasing groceries, clothing, pharmacy and toiletry items, toys, stationery items, stereo equipment, sporting goods, and more .

Costs of GRS

About the costs of surgery ; After 1 July 2008
SRS with sensate clitoroplasty and labiaplasty using prepuce skin flap and scrotum skin graft costs 320,000 Thai Bahts ( Approx. 10,200 US$, 12,000 AUS$, 1,000,000 Yen, 6,700 Euro, 5,100 Eng Pounds ) and if extra skin graft is needed to provide more depth , it will cost 1,500US$ in additional.

Tracheal shave costs 38,000 Thai Bahts ( 1,200US$, 120,000 Yen, 1,300 AUS$, 800 Euro, 600 Eng Pounds)
Mammaplasty costs 105,000 Thai Bahts (Approx. 3,400 US$, 330,000 Yen, 2,200 Euro, 3,600AUS$, 1,700 Eng Pounds).
This is including the surgeon's fee, anesthesia, operation cost, hospitalization, and no deposit needed. But it is not including hotel room before or after hospitalization.

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POST - OPERATIVE CARE AT HOME
AFTER MTF GRS

     Usually it takes six months to complete recovery of the vulva and the vagina canal. During the first few weeks, you may have some inconveniences which are usually minor (vaginal spotting, difficult scarring, skin irritation, asymmetrical swelling of the vulva and tight vagina canal, etc.).

     To keep the vagina opened, you must dilate the vagina with the many sizes of dilators you have got from our clinics complimentarily. One must never stop these dilations before 6 months.

DILATION PROGRAM

     To keep the vaginal canal opened, you must dilate the vagina with many sizes of dilators. We normally provide a set of 6 dilators made from hard transparent resin plastic without extra charge. The diameters of the dilators range from 26 mms. (No.1) to 34 mms.(No.6). The surface of dilators is very smooth so you can use it directly.

     During the first two months, we recommend the patients to dilate the canal every days 3 times a day. It is not necessary to do it every 8 hours, anyone can set her own schedule to fit daily activities. After 2 months, the patients might reduce dilation from 3 times to 2 times a day if they find that there is no difference or difficulty to keep the vaginal canal open. One must never stop these dilations before 6 months. Then they would dilate the canal just 2-3 times a week or once every alternate day. The patients who have sexual intercourse with the male partner regularly might not need any dilation, just clean it from time to time.

     The dilators (stents) must be clean by antiseptic like Alcohol, Dettol or Betadine before using. You might clean the vagina orifice before and after dilations by using diluted Dettol solution while lying on the portable bidet ,in the bath tub or even standing in the shower room.

     For the first dilations, you use a mirror to localize the vaginal opening. Applying a lubricant ( Water based jelly like KY Jelly,etc.) either on the dilator or to the vagina and then directing the dilator anteriorly (towards the umbilicus/navel) and not too much posteriorly towards rectal wall. The more you are relaxed, the easier the dilations will be.

     FIRST WEEK of dilation, In most cases, when the skin graft along the vaginal canal is not strong enough to tolerate the pressure and friction of the dilators, we recommend not to retain the dilators inside the canal too long. Just let it in and take it out slowly and gently, starting from the smallest dilator No.1, then No.2, No.3...until the largest you can accommodate. The patients are encouraged to use large dilators if it does not cause so much pain.

     Then from the SECOND WEEK, after the skin graft heals better and stronger, you can retain the dilators inside the vaginal canal for longer period. It will help you to step up to larger dilators and finally the largest No.6. Some patients set up a simple scheme like this; No.1 for 1 minute, No.2 for 2 minutes, No.3 for 3 minutes…….. until they can reach the largest one. But if you find that the longer period is helpful, you just follow your own scheme. There is no definite rule, just listen to your own body. Then, it is recommended that you should retain the largest dilator you can reach each time for 15minutes. It is common that you would feel small pain or discomfort and experience some blood spot and discharge during dilation. But if you have more bleeding, you need to quit dilation for a day and try again when the bleeding stop.

     If ever it is too difficult to insert the larger dilator, it need not to rush too much. After a few dilations or a few days, try inserting the larger dilator again. If you are well relaxed and the vaginal swelling is not too bad, the dilation should be easier. Do remember that the small dilators help maintaining the depth and the large one will maintain the width.

     At the time of your operation, the vagina is approx. 4.5–5.5 inches in depth by 1.0-1.3 inches in width/diameter. Most of the patients can maintain the initial depth and width/diameter by regular dilation. Few of them can increase its later. Some patients lose a bit of depth and width either from healing process or not adequate dilation. Very few patients lost all. Using our stents with careful dilation, we have never had patients complicated by fistula.

VAGINAL DOUCHES

     Few weeks after surgery, you will notice fragments which will be discharged from your vagina. These are the exfoliation of the scrotum skin which covers the interior of your vagina. This is quite normal. The vaginal douches are very important to clean the vagina of these exfoliation and also promote the interior healing. Normally, 3 ccs of Dettol (approx. half of the cap of Dettol bottle) mixed with 200-300 ccs. of drinking water or tap water is generally used. Therefore, it is recommended to have a vaginal douche every times after dilations until there are no more discharge. Then you just clean inside vaginal canal with other female hygienic solution or even pure water. If the vaginal discharges is heavy or extremely foul smelling, it would be a sign of infection or non-healing wound. You should consult your Gynecologist or your physician to do vaginal examination and assess the cause.

INTERCOURSE

     Normally, you may start to have sexual relations after vaginal discharge cease. Usually 6 - 8 weeks after operation is acceptable.

DEFECATION ( BOWEL MOVEMENTS )

     During the first 3 - 4 weeks, you must take a bath or shower to clean the anal/genital area after each bowel movement, because there are still some small wounds in the genital area. You must wipe the anus towards the rear so it will not contaminate the vulva and the vagina.

URINATING

     During the first 3 - 4 weeks, you may not urinate normally. Because of the local edema, the urine will come out as a spray or crooked. Then the direction of the stream will be better and you can urinate properly, especially when sitting on the bidet.

     Some patients have complication of urethra opening obstruction from local swelling or bladder atony. So after the urine catheter is removed, they cannot urinate and suffer from full bladder. If it happen, the nurse will reapply urine catheter and leave it for a few more days until the swelling subside. During that period, the bladder is trained by clamping the catheter and release it every 4 hours. This technique will help reviving the bladder function after it lose its tone for a few weeks after surgery. Very few patients need 2-3 repetition of catheterization before they can urinate successfully.

SEXUAL INTERCOURSE

     Normally, you are able to have sexual intercourse after vaginal discharge cease, or Approximately 6 - 8 weeks after the first operation. Some patients have small clear viscous fluid releasing through the urethra when they have sexual arousal. This fluid is produced from Cowper’s gland inside Prostrate gland, it contains no sperm since both testes are removed during surgery already. But the Prostrate gland is not removed, so the patients still have some risk of Prostrate cancer and need PSA screening test from time to time. If there is no self lubrication, Water based KY jelly is needed to aid sexual intercourse. The patients who have Colon Vaginoplasty do not need lubrication since there is mucous secretion from the colon mucosa along the vaginal canal.

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