Vaginoplasty is a surgical procedure for feminizing gender affirmation. Fan Liang, M.D., medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health, and Andrew Cohen, M.D., director of benign urology at Johns Hopkins' Brady Urological Institute, review the options for surgery.

What is vaginoplasty?

Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum.

During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a feminine-appearing outer genital area with a shallow vaginal canal that cannot be used for receptive penetrative intercourse.

What are the different types of vaginoplasty?

There are two main surgical approaches for this gender affirming surgery.

Vaginoplasty with Canal

This surgery is also known as full depth vaginoplasty. Vaginoplasty with canal creates not only the outer vulva but also a complete vaginal canal that makes it possible for the person to have receptive vaginal intercourse.

Vaginoplasty with canal requires dilation as part of the recovery process in order to ensure a functioning vagina suitable for penetrative sex. There are two approaches to full depth vaginoplasty.

Historically, surgeons have used penile inversion vaginoplasty to create the vaginal canal using a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

Some surgical centers have shifted to the robotic-assisted peritoneal flap vaginoplasty. Robotic-assisted peritoneal flap vaginoplasty, also called a robotic Davydov peritoneal vaginoplasty or a robotic peritoneal gender affirming vaginoplasty, is a newer approach that creates the vaginal canal with the help of a single port robotic surgical system.

The robotic system enables surgeons to reach deep into the body through a small incision by the belly button. It helps surgeons visualize the inside of the person’s pelvis more clearly and, for this procedure, creates a vaginal canal.

There are several advantages to this surgical technique. Because using the robotic system makes the surgery shorter and more precise, with a smaller incision, it can lower risk of complications. Also, the robotic vaginoplasty approach can create a full-depth vaginal canal regardless of how much preexisting (natal) tissue the person has for the surgeon to use in making the canal.

Not every surgical center has access to a single port robotic system, and getting this procedure may involve travel.

Vulvoplasty

This procedure may be called shallow depth vaginoplasty, zero depth vaginoplasty or vaginoplasty without canal. The surgeons create feminine external genitalia (a vulva) with a very shallow canal that is for visual aesthetics only, and cannot be used for penetration of any kind. The procedure includes the creation of the labia (outer and inner lips), clitoris and vaginal opening (introitus).

The main drawback to this approach is the person cannot have receptive vaginal intercourse because no canal is created.

There are advantages, however. Because this is a much less complicated approach than vaginoplasty with canal, vulvoplasty can mean a much shorter operation, with less time in the hospital and a faster recovery. Vulvoplasty also involves less risk of complications, and does not require hair removal or postoperative dilation.

Do I need to have hair removal before vaginoplasty? When should I start?

Permanent hair removal (to remove the hair follicles to prevent regrowth) before surgery is recommended for optimal results. Patients are advised to start hair removal as soon as possible in advance of vaginoplasty, since it can take six months to one year to complete the process. The hair removal process readies the tissue that will be used to create the internal vaginal canal. For people who are not able to complete the hair removal in advance, there may be residual hair in the canal after surgery.

How long is vaginoplasty surgery?

Most vaginoplasty surgeries last between four and six hours. Recovery in the hospital takes three to five days.

Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital, and the days spent at the hospital will be dependent on the surgery performed and your personal recovery. You will spend most of this time in bed recovering. Your care team will monitor your pain, and make sure you are healing appropriately and are able to go to the bathroom and walk.

On average, you will need to take 6-8 weeks off of work, and it can up to a year to fully recover from vaginoplasty. Every person’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery. Patients who have had vaginoplasties need to stay within a 90-minute drive of the hospital for four weeks after surgery so doctors can follow up and address any issues.

Consistent daily dilation for the first three months is essential for best outcome. Before you go home, you will be taught how to dilate if you have a vaginoplasty with canal. At most surgical centers, you will be given dilators before discharge to use at home.

What is dilation after vaginoplasty?

Dilation is the act of inserting a medical grade dilator into the vagina to keep your vaginal canal open.

Dilation is only required (and possible) if you opt to have a vaginoplasty with canal. Dilation sessions can take between 30-60 minutes from start to finish including prep and clean up. A dilator must be in place at it's full depth for 20 minutes.

Before and after your surgery, you may meet with a pelvic floor physical therapist to discuss pelvic floor exercises. Your care team should work with you to teach you proper dilation techniques. It is very important that you continue dilating at home, especially during your immediate post-operative period, or you will permanently lose vaginal depth and width.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate.

Will I have a catheter?

Yes. While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different after vaginoplasty different?

When going to the bathroom, you should always wipe front to back. This helps keep your vagina clean and helps prevent infection from the anal region. Additionally, it is very common to experience spraying of your urine stream while the tissues around your urethra are still swollen. This will improve over time. You can also strengthen your pelvic floor with physical therapy to help address this issue.

Is the vagina created by vaginoplasty sexually functional?

Yes, the clitoris and surrounding tissue will have sensation; therefore, you may engage in sexual activity involving the vulva, clitoris and anus. The vast majority of people will be able to orgasm after surgery, although the sensation associated with an orgasm may feel different. You will only have the option to engage in receptive penetrative vaginal intercourse if you choose to have a vaginoplasty with a vaginal canal.

Most surgeons recommend patients wait at least three months after their surgery before beginning to explore sexual activity. You can work with a pelvic floor physical therapist to assist strengthening the area for sexual and urinary function.

What will my vagina look like?

Vulvas and vaginas are as unique as a fingerprint, and there are many anatomic variations from person to person. Surgical results vary, also. You can expect that the surgery will recreate the labia minora and majora, a clitoral hood and the clitoris will be under the hood. Make sure you discuss your concerns with your surgeon, who can help you understand what to expect from your individual surgical results.

What is the average depth of a vagina after vaginoplasty?

The depth of a fully constructed vaginal canal depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 4 and 6 inches deep. Vaginal depth may depend on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts.

Newer robotic techniques may be able to increase the vaginal depth for those people with less existing tissue for the surgeon to work with.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of your new vagina and vulva. Revisions to improve aesthetic appearance may not be covered by insurance if there are no functional problems. Check with your insurance provider to see what is covered. 

Vaginoplasty Complications

Vaginoplasty is safe, overall, and newer techniques are reducing the risks of problems even further. But sometimes, patients experience complications related to the procedure. These can include:

• Bleeding
• Slow wound healing
• Narrowing of the vaginal canal (regular dilating as prescribed can lower this risk)

Some rare complications may require further surgery to repair:

• A fistula (an abnormal connection between the new vagina and the rectum or bladder)
• Injury to the urethra, which may require surgery or a suprapubic catheter
• Rectal injury (very rare) may require a low-fiber diet, a colostomy or additional surgery.

Be sure to discuss your concerns with your surgeon, who will work with you for optimal results.