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From the standard guidelines for clinical practice, the patient must have met the criteria for SRS, as follows:
1. Be of legal age in the patient’s nation. In Thailand, the father/mother or legal custodian may
give consent for patients under the age of 18.
2. 12 months of continuous hormonal therapy.
3. 12 months of successful continuous full time real-life experience.
4. No medical impediments.
5. Medical letters of recommendation required for SRS: one from mental health professional psychotherapist; the second letter should be from a psychiatrist or a Ph.D. clinical psychologist.
In accordance to The Standards of Care for Gender Identity Disorders, Sixth Version, 2 letters from mental health professionals who specialize in Psychology, Psychiatry, Social work, Counseling, or Nursing are generally required for genital surgery.
Any of the following are the recommended minimal credentials for special competence with the GIDs:
- A master degree or equivalent in a clinical behavioral science field.
- Specialized training and competence in the assessment of the Sexual disorder (DSM-IV/ICD-10).
- Documented supervised training and competent in psychotherapy.
- Continuing education in the treatment of GID (Attendance at a professional meeting, workshops, seminar, or participating in research related to GID).
The surgeon will consider each client individually to see who is a good candidate for genital surgery (including SRS).
Dr. Kamol's standards for performing sex reassignment surgery from male to female
1. Highest safety during the operation process.
2. Functionality of neo-vagina as close as possible to natural sensation.
3. External appearance as close as possible to a natural look, with less noticeable scaring.
4. Less post operative pain, without using epidural morphine. Drug administration is used for the patient's recovery after surgery.
5. Less time of recovery. Patient can recover quickly and return to normal life.
6. Excellent post operative care by our nursing team. After the surgery, our nursing team will do your cleaning and dilation until you depart to your country. We also provide excellent care, and extend our sincere friendship to you. This (we feel) will help our patients both physically and mentally towards a speedy recovery until patient departs to their country. We also provide excellent care, and make patient to feel our sincere friendship. This (we feel) will help our patients both physically and mentally towards a speedy recovery.
Dr. Kamol offers:
1. Penile skin inversion is the most popular procedure for vaginal construction. The skin of the penis is inverted to create a vagina. The glans with its nerve supply is used to create the clitoris, thereby maintaining normal sexual sensation. The scrotal skin is used to form a full-thickness graft to give extra depth to the neo-vagina.
2. Split-thickness/full-thickness skin graft procedure is performed by some clinics and achieves patient satisfaction. Patient attests to its advantages when the procedure is performed with great attention to details. However, donor site scaring and the shrinkage associated with the skin graft procedure are obvious disadvantages.
3. The sigmoid colon vaginoplasty has been used for decades in Eastern Europe to treat vaginal atresia. Currently, the procedure is used in primary or secondary vaginoplasty. A section of the recto-sigmoid colon is used to form the neo-vagina. The colon serves as a self lubricating neo-vagina. Generally, the low transverse scar is made to resemble a hysterectomy scar.
Dr. Kamol has developed and improved a technique of conventional penile inversion skin to his own unique technique.
Dr. Kamol's SRS unique procedures
1. Most surgeries are under general anesthesia. However, a patient can choose to have epidural anesthesia.
2. Preventing pulmonary embolism from deep vein thrombosis. The risk is very low in healthy people without a family history of deep vein thrombosis (DVT). However, we routinely prevent DVT during surgery by intermittent leg compression technique. The patient is able to move in bed during hospitalization.
Intermittent Compression Sleeves
3. Since there is a small risk of embolism from blood clot in healthy person, Dr. Kamol does not give a prophylactic anticoagulation agent before surgery, which can cause negative effects. Doctor will consider giving anticoagulation medicine only for patients who have experienced a history of embolism.
4. Operation is performed in the lithotomy position. During the long hours of the operation, there'll be padding supporting patient's legs in order to prevent numbness after surgery due to compression on the sensory nerves.
5. Keeping warm during the long operating period: Patients under general anesthesia in cool air tend to have low body temperature. When the operation is over, many patients may get cold and shiver, and some encounter delayed recovery from anesthesia. To prevent this we regularly keep our patients warm under a non-electrical contact warmer machine.
Warmer Machine
6. Operation will be performed in one stage procedure, consisting of vaginoplasty, outer labioplasty, inner labioplasty, urethroplasty, and neoclitoroplasty. Of course, if minor correction is needed after surgery in our clinic, there will be no charge for this correction.
Step-by-Step SRS Male to Female Penile Skin Inversion Procedure
7. Narrow pedical flap technique: Dr. Kamol uses his own technique to create narrow, curving scars from upper to lower outer labia, and to look as close as possible to a natural appearance. This technique requires a highly experienced surgeon.
8. Thin pedical flap sensate clitoris technique: Dr. Kamol makes the neo-clitoris by keeping sensory nerves as close as possible. Doctor also keeps neurovascular pedicle as small as possible without having excess fascia, which produces a natural look.
9. Sensate clitoroplasty: Dr. Kamol uses the top skin of the glans penis, with all nerves and blood vessels uncut.
10. Sensate inner labioplasty: Dr. Kamol uses the skin of the glans and prepuce, with all nerves and blood vessels uncut. The penile skin that surrounds glans penis looks similar to skin of inner labia, but is thinner, and more flaccid. This cannot be used for the whole inner labia. Dr. Kamol uses two types of skin to create inner labia look more natural. The outer part is from scrotal skin, and inner part is from penile skin, which can sense just like neo-clitoris.
11. Natural G-spot technique: Dr. Kamol locates the vaginal cavity between the urinary bladder and rectum, making neo-vaginal wall as close to lower part of prostate gland as possible (under the prostate gland area, and positioned within 2 inches of neo-vaginal entrance). This position can be compared with one of sensation spots in women.
12. Template-scrapping skin graft technique: Dr. Kamol makes very thin scrotal skin graft and removes hair follicles as much as possible to prevent the regrowth of hair at skin graft area. In some cases a few hairs may be found after surgery, indicating that hair in penile skin flap still exists at the outer part. Normally, we cannot remove hair follicles in skin flap area during an operation, because this would cause blood circulation to the flap to discontinue. Using a vaginal stent for skin graft provides high possibility of good results and also designates a better width of inner neo-vagina. This method enables less shrinkage of skin graft in long term.
13. Long urethral flap technique: Dr. Kamol uses middle area of the outside, and above the urethral opening to create a urethral mucosa, which is smooth, lubricated, varnish, and in pinkish color close to natural appearance. Only a highly professional surgeon will be able to perform this technique.
14. Orchiectomy: Dr. Kamol performs orchiectomy in every operation of SRS, in order to prevent production of male hormones. With this surgery, patient will need less on female hormones after surgery. Keeping the scrotum increases a risk of having cancers.
15. Depth of neo-vagina will be 5-6 inches on average for a western male. However, in some cases, immediate results after surgery could be up to 7-8 inches. Long term results are different depending on many factors such as dilation and wound care.
Depth of neo-vagina from penile skin inversion without skin graft depends on length of penile skin when having an erection or being stretched out under normal conditions. For example, with same length, shorter person will have a deeper vagina. It also depends on other factors such as circumcision, or amount of penile skin. Dr. Kamol uses all of penile skin for vaginal wall and inner labia.
16. More erectile tissue removal: Dr.Kamol removes the erectile tissue around urethral opening as much as possible, to prevent a high position of the urethral meatus and meat ball phenomenon.
17. Patient will need to stay at hospital for 4 nights after having SRS without skin graft, and for 6 nights after having SRS with scrotal skin graft. Patient can walk comfortably after taking off pads and catheter on last day in hospital.
The advantage of SRS: Dr.Kamol’s technique
1. One stage procedure.
2. More sensory tissue preserved and used to form the female external genitalia.
3. A more aesthetically pleasing and natural looking vagina.
4. Less skin hanging below the urethral opening from too large size inner labia.
5. Enhanced vaginal depth approximately 5-7 inches.
6. Less conspicuous scar.
7. More fullness of mons pubic.
8. Less recovery time; 2-3 weeks after surgery.
On the clinical consultation, you will be interviewed to see if you are a good candidate for SRS and evaluate for your fitness for surgery. The quantity and quality of penile and scrotal skin will be examined to evaluate the vaginal depth.
Expectation after surgery
Pain:
After you recover from the anesthesia you may feel pain but it is minimal and usually lasts for the first day and will gradually subside. You will receive IV fluid and some potent antibiotics.
Catheter and Tube drains:
Tube drains and the urinary catheter will be left in place for 4-6 days. After the catheter is removed, you will be able to urinate by yourself while sitting.
Food:
Upon waking up you will be able to have drinks and soft meal in the first few days and you will start regular meals after you are able to have bowel movement.
Vaginal stent:
The vaginal stent will be left in place for 6 days. After it is removed, the neo-vagina will need to be douched at least two times a day in order to keep it clean and free from infection.
Hospitalization:
The post operative period will require a 6 day stay in the hospital. After the vaginal packing is removed you will be able to walk and leave the hospital. You will also require an additional 7-14 days to recuperate and be ready for travel. You are recommended to stay at a hotel close by our clinic and taken care of by our nursing team until you leave Thailand.
Vaginal dilation:
After the vaginal stent is removed from the neo-vagina, it is then necessary to start to gently dilate the neo-vagina two times a day, for the first month. For about one hour each time with an adequate amount of lubricant jelly. The need to dilate becomes less frequent over time, particularly when you regularly engage in sexual intercourse.
Intercourse:
After the 8th week post op, you should be able to engage in neo-vaginal intercourse. The neo-vagina will need some form of lubrication. In general, patients may have sexual intercourse after they successfully dilate the neo-vagina to the last size of the vaginal dilators.
Return to female hormones:
Patients can resume taking oral female hormones in 3-4 weeks after surgery but the need for female hormones is less than prior to surgery.
Medical certificate:
You will receive documents certify you have successfully undergone sex reassignment surgery.
Insurance and Legal issues:
Insurance carriers may specifically exclude transsexual treatment as they do aesthetic surgery. Legal name change and birth certificate amendments are accomplished according to the laws of the particular state or country.
Dilation and Surgery wound care:
Dilating is the most important thing you must do to ensure the success of your surgery. If you do not dilate responsibly, this can result in the shortening of depth and vaginal stenosis, including partial to total collapse because of scar contracture especially in Colon Vaginoplasty. Failure to properly dilate in the early stages can result in patients experiencing excessive vaginal pain in later times. You will be instructed on proper and gentle dilation technique after the vaginal packing is removed. Dilation may be uncomfortable and even painful in the first weeks, but is essential for developing maximum depth and ensuring post operative functionality of the neo-vagina.
Preparation for neo-vaginal dilation:
1. Urination or having a bowel movement prior to dilation can make dilation more comfortable.
2. Gather all of your materials together. You will need dilators, lubricant jelly, waterproof pad or towel, saline and Betadine solutions, cotton sticks, gloves, and syringe.
3. Wash your hands thoroughly with antibacterial soap before starting.
4. Place your pad or towel on the bed, lie down and get comfortable.
5. Place your feet about the width of your hips apart and bend your knees at about 45 degree angle. Move you knees apart only enough to get your have between them.
6. A good practice is to place a small pillow under your back to allow the lower back and butt muscles to relax.
7. Clean your vagina with saline or part Betadine with saline until it’s clear.
8. Apply antibacterial ointment to the wound for the first 3 weeks and use the KY jelly after 3 weeks.
Insertion the dilator
1. Before starting, relax the muscles and flex them.
2. Starting by inserting your Index finger. Always wear a glove. Insert the finger in, and then try to squeeze your finger with the vaginal muscles.
3. A condom is placed over the dilator, apply KY-jelly and insert slowly and keep it in for about 1-2 hours, finally clean as previously directed and apply the antibiotics ointment over the stitching and any area of fresh wound.
4. Start with the smallest dilator and progress to the larger diameter provided.
5. Do not skip dilation even if it is painful. Failure to do it may result in partial or total collapse.
6. Rinse out the lubricant after dilation and apply an antibiotic ointment or Betadine solution until the wound is completely healed.
7. One month after SRS operation you will be required to start applying Premarin cream to your neo-vagina. Apply two times a day to soften your neo-vagina. This generally lasts around six months.
Timetable
DAY 1
At the airport:
We will pick you up at the airport and take you to your hotel, or to meet Dr. Kamol for clinical consultation.
At the hospital:
You will be asked to fill out some consent forms. Blood tests, electrocardiography (EKG), and chest x-rays will be taken. In some cases, you may need a psychiatric evaluation and the psychiatric fee will be excluded from surgery price.
DAY 2
Preparation for surgery:
You will have your genital area shaved, be given an enema (colon cleansing), and start on an IV fluid. No food and drink 8 hours before the operation. The anesthesiologist may meet you at your room or at the operating theatre before starting surgery.
The operation time:
The operation takes 4-5 hours for penile skin inversion technique, and 5-6 hours for penile skin inversion plus scrotal skin graft.
DAY 3-5
Early post operative period:
Stay in bed. You will feel sleepy from the effects of anesthesia and antibiotics. You will be able to have soft meal. The urine catheter might irritate you and feel the need to urinate. You will be able to move in bed. The surgical wound will be examined and cleaned daily.
DAY 6 – 8
For penile skin inversion procedure:
The vaginal packing will be removed on Day 4. You can walk and urinate by yourself, learn to take care of your neo-vagina and to be a new you.
For penile skin inversion with scrotal skin graft procedure:
You must stay in bed for 6 days after surgery to assure the skin graft taking well. The vaginal packing will be removed on Day 6, and neo-vagina will be cleaned with normal saline with antibiotic solution. External genitalia will be applied with antibiotic ointment.
Stitches off:
Some stitches will be removed from outer labia at day 6 after surgery to reduce scar formation.
After checking the results, you may leave the hospital and check in to your hotel.
DAY 8 – 14
Post operative recovery:
Staying at your hotel and starting neo-vaginal dilation. You are recommended to walk not more than 1-2 hours to prevent slow speed of the wound healing. Our staff will assist you in cleansing and starting neo-vaginal dilation.
Day 15
Final check up:
You will receive a final post operative check up and additional necessary medications. You will also receive medical certificates that authenticate the surgery and recommends that you receive a legal change of gender.
DAY 16
In case that you have a normal healing and do not have other complications, you will be able to depart to your country. However, we recommend you stay in Thailand for 3 weeks after surgery, to make sure the surgical wound is fully healed.
Surgical fee and Service
Surgical fee includes:
- Doctor fee
- Post operative care
- Surgical and anesthetic fee
- Pre and post surgical consultation
- Post op medical supplies including SRS dilators
- Medical certificate
- No doctor fee for post op correction
Concierge services:
- Hotel reservation
- Transportation (Airport-Hotel-Hospital)
- Tourist information
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