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Sex Reassignment Surgery (SRS/GRS)
Male to Female Surgery

Sex Reassignment Surgery is the final step in the process of assisting people who have experienced conflicts between their sexual perceptions and their physical characteristics since birth, which in medical terminology is Gender Dysphoria. The sex reassignment surgery will transform the sexual organ to conform to the desired inner state of mind in order for the person to lead a happier life with the new chosen gender.

Therefore, in order to undergo Sex Reassignment Surgery which is considered the most important surgery of all, paving the way to a new way of life, it is necessary to prepare one self by seeking pertinent information about the surgery before making a decision. This is especially important when selecting the right surgeon equipped with appropriate experience and expertise in Sex Reassignment Surgery who can then create a female sexual organ which looks beautiful and natural, with a deep vagina, proportionate to the physical condition, capable of better perceiving sexual sensations. This will help the patient who has undergone surgery connect his physical and mental state of mind, and be capable of leading a normal happy life.

Characteristics of those who qualify for Sex Reassignment Surgery from male to female are as follows:

1. The patient must be at least 20 years of age. For those below the age of 20, it is required that the legal parents or guardian authorize their permission to the surgery.
2. The patient must have continuously taken female hormone for at least one year.
3. The patient must have had feminine feelings for a long time or since initial/first recollections.
4. The patient must have led a woman’s life for at least 1 year.
5. The patient must feel disgusted with his sexual organ as if it were an excess part of his body.
6. The patient has undergone a mental test, and been certified by a psychiatrist as in normal mental state, and suited for the Sex Reassignment Surgery.
7. The patient must be in physically fit condition.

The plastic surgery undertaken to reassign the patient’s sex from male to female involves the use of skin, tissues and sexual sensory nerves of the patient to transform the male sexual organ into a female sexual organ that is perfect in the following ways:

1. Transform the sexual organ to that which is most similar to the female sexual organ.
2. The surgery will enable the patient to have as deep a vagina as his skin would permit.
3. All sexual sensory nerves would remain intact in the female clitoris so as to have normal sexual sensations in this area.
4. Plastic surgery must be undertaken to hide the wound so that there is the least chance of it being visible.

Sex Reassignment Surgery Techniques

1. General anesthesia is applied to the patient by an anesthesiologist.
2. A new vagina is formed between the anus and the urinary tract, approximately 6-7 inches deep.
3. The skin covering the penis is used to line the vagina wall, and a new vagina is consequently created, just like that of a woman.
4. The core of the penis is removed, and the sexual sensory nerves are kept for use in creating the clitoris.
5. The male urinary tract is shortened and shaped so that urine can flow out in the same manner as other women. If the surgery has not been properly undertaken, urine may shoot up when urinating in sitting position.
6. The exterior parts such as the Major Labia, Minor Labia, urinary tract, and clitoris are reconstructed to look beautiful and perfect as a female sexual organ which can still experience sexual sensations as before.

Sex Reassignment Surgery can be categorized into 3 methods in accordance with the construction procedures of the new vagina and the new clitoris as follows:

1. SRS 1 (Penile Skin Inversion)

This surgery involves inverting the skin of the penis to create and beautify the vagina. This is a widely popular method.
The advantage is that this method is relatively simple, not complicated. For experienced and specialized surgeons, this technique of sex reassignment surgery lasts about 4 hours.
The disadvantage is that it is not suitable for men with penises shorter than 4 inches because this will result in a vagina that is not deep enough (in general, the vagina depth is equivalent to the length of the skin covering the penis minus one inch (this includes skin required to construct the Minor Labia).

**This technique requires the patient be hospitalized for 4 nights.

2. SRS 2 (Non Skin Inversion with Scrotal Skin Graft)

This technique involves using the skin covering the penis to construct the vagina, as well as the skin covering the scrotal. This results in a sufficiently deep and functional vagina as required by the patient. If after the scrotal skin graft, the vagina depth is still not satisfactory to the patient and then the plastic surgeon will consider using skin graft from other areas such as the upper limbs, the stomach to further increase the depth of the vagina.

The advantage is that this technique helps patients with short penises, and enables them to possess the desired deep vagina.
The disadvantage is that the surgery is difficult and complex, and surgery time will be longer. For this technique, experienced and specialized plastic surgeons in sex reassignment surgery will take about 6 hours to complete.

**Hospital admission for 6 nights.

3. SRS 3 (The Sigmoid Colon Vaginoplasty)

This technique is used in the case where patients have short penises, or to assist patients whose vaginas have become obstructed. This can also be used in patients who have never undergone sex reassignment surgery. The vagina which is part of the colon will have good lubricant.

Advantages
1. This technique helps patients who have previously undergone sex reassignment surgery, whose vaginas have become obstructed, and are unable to perform sexual intercourse.
2. It also helps patients with very short penises. In this regard, the surgeon will have already decided that the surgery types SRS 1 and SRS 2 cannot be performed.
3. The vagina has a natural lubricant.
4. It is possible to determine the depth of the newly constructed vagina.
Disadvantages
1. A scar of approximately 7 cm long will be visible above the left side of the pubis.
2. The surgery is difficult to complete, with preparation procedures required such as cutting off parts of the colon, and the colon must be thoroughly cleansed (by an enema) 1 day prior to the surgery.
3. The patient may experience dyspepsia/indigestion symptoms 2-3 days after the surgery.

SRS I
(Penile skin inversion: Dr. Kamol's Technique)

Post Operative Care
The patient must be hospitalized for at least 4-6 days. In order to look after the wound whilst recovering at the hospital, the patient must take the following actions:

1. During the first 2 days after surgery, the patient must stop taking food that has fiber content, beverages such as fruit juice, milk, and yogurt as these will trigger waste excretion. It may lead to contamination of the wound by the feces.
2. 1-2 days after the surgery, the patient should lie on his back, with hips raised and legs slightly apart as this will help reduce swelling.
3. On the third day after the surgery, the patient may lie on her side.
4. On the 4th day after the surgery, the surgeon will remove the draining tube, open and clean the wound. The urine drainage/enema tube will also be removed. Patients who have undergone surgery SRS 1 may return home, and come back in 7 days to remove stitches. For patients who have undergone surgery SRS 2 (using skin graft from other parts of the body to add to the depth of the vagina) or SRS 3 (using cotton wool to reconstruct the vagina), the surgeon will not remove the urine drainage/enema tube, and the patient must remain in bed until Day 6.
5. Patients who have undergone surgery SRS 3 must refrain from drinking water or taking any food until she has broken wind from the body first. Thereafter, she may sip a small amount of water, or take soft food. If the food is taken too quickly, indigestion or dyspepsia symptoms may be found. Therefore, the patient of SRS 3 must strictly abide by the recommendations of the doctors and nurses.
6. On the 6th day, patients of SRS 2 or SRS 3 surgery will have their urine drainage/enema tube removed. The wound will then be cleaned, and the patient may return home.
7. Patients of SRS 1, SRS 2, and SRS 3 must come back for removal of stitches, and dilation of the vagina using the Dilator which is available at the clinic. In order for the patient to maintain the width and depth of the vagina, the patient should dilate the vagina at least twice a day, for about half an hour each time.
8. The patient must clean the wound, as well as dilate the vagina at least twice a day until the external wound and that in the vagina are fully healed.
9. The patient must refrain from sexual intercourse for at least 2 months.
10. The patient must ensure that she keeps her appointment with the doctor once a week for a period of one month, in order for the results of the surgery to be perfect and naturally beautiful.

Picture of the Surgery
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