Neo-Vagina Monologue 5

Skin Graft vs. Colon Transfer

If you have decided to undergo Genital Repurposing Surgery, one of the decisions you need to make is whether to use the colon transfer method or penile inversion. I wrote this essay to clarify my own thoughts for my own decision on this matter. If you are not a serious GRS candidate, there is no reason for you to be reading this!

This is not an un-biased essay. I have pretty much made up my mind to go with a penile inversion. But I will try to be as objective as I can.

Update, 2/2007: I had my penile inverstion on February 17, 2003. I'm adding some notes to this essay to update you about how it turned out, in regards to this issue. At this point, I'm glad I didn't choose the colon transfer method. The main reason is probably that I'm not actually having much sex, and most of the advantages of the colon-transfer method are sex-related.

This essay is not a primer on how the surgeries work. There is plenty of material available on line about the penile inversion method. It is a little harder to dig up much about the colon transfer method. Here is a detailed description of one form of the colon transfer procedure: Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients? Interestingly, construction of a vaginal canal from colon or skin graft is NOT exclusively for GRS patients. Women occasionally lose their vaginal canal from cancer and it can be reconstructed by one of these methods. Also women are sometimes born without a vagina due to a rare birth defect (or intersex condition, if you prefer).

Basically most of the exterior work is the same for either procedure. The penectomy, the vaginoplasy, the labiaplasty can all be done the same way. Surgeons have slight variations in how they do these parts of the GRS procedure. The difference is what material is used to construct the interior of the neo-vagina. In the standard penile inversion, available penile skin is used, and it is extended (unless you were "blessed" with a humongously long penis) with a skin graft. Typically the scrotal skin is used. Some surgeons prefer to use a skin graft from the abdomen or the thigh or buttocks, either thin or full-thickness. In the colon transfer method, the surgeon goes in to you abdomen and cuts out a 20 cm piece of your large intestine; the remaining intestine is stapled back together, and the 20 cm piece is used as the neo-vaginal canal. The 20 cm piece of colon maintains an intact blood supply throughout the procedure, so it has a high likelihood of being viable. The abdominal surgery can be done open, with a big bikini scar, like a hysterectomy. Or it can be done laproscopically, where instruments are inserted through small holes to leave less scarring. I was told that the risk of infection is no greater for the open vs. laproscopic procedure; the main advantage of the laproscopic procedure is reduced of scarring.

So what are the advantages and disadvantages of a colon transfer versus a skin graft? One of the first things that comes up is that the colon transfer procedure will be more expensive, because basically a complete second operation requiring a specialized surgeon is involved. (Plastic surgeons cannot do the abdominal surgery, and abdominal or gynecological surgeon is needed.) Roughly--very roughly, as GRS costs vary all over the map (literally, i.e., the geographic map)--you can expect a colon transfer procedure to run you twice as much as a penile inversion. For my own analysis, I prefer to put the cost issue aside until last. First I want to analyze the options based strictly on the non-financial merits. Then, if colon transfer wins, I can decide if I want to spend the money. In any case, the cost is on the order of buying a car. You can get a decent used car (as low as $5 or $6 thousand), or new Lexus (as high as $40 thousand), and be in the range of possible GRS options.

Here are the considerations I can think of that are affected by a colon transfer versus a skin graft:
1. Lubrication
2. Vaginal depth
3. Dilation
4. Hair growth
6. Durability
7. Risk/success likelihood of procedure

1. Lubrication

Colon type neo-vaginas are self-lubricating. Some say actually too much, that they have a persistent drip problem, but that seems to not be the case these days. Dr. Kunaporn mentioned that he saw excessive drip problems when he used a section of the small intestine, but the procedure now is to use the large intestine and he reports no problem there.

Clearly the advantage goes to the colon transfer in this category. However skin graft neo-vaginas have been reported to be somewhat self-lubricating as well. And of course many people, especially older women, rely on artificial lubrication for comfortable sex. It seems to me this might be an important consideration for a young person who has a long and active sex life ahead of them. I am not now nor do I expect to become sex machine. So I am sure I can live with the lubricative properties of a skin graft, as thousands of transsexual women before me have.

Update, 2/2007: I do get a little natural lubrication, but I need extra to have comfortable sex. However, it hasn't been much of an issue, because I'm not finding many guys who want to have sex with me.

2. Vaginal depth

Vaginal depth is not controlled by the graft, but by your internal plumbing. How far can your vaginal cavity extend before it bumps into, oh I don't know, what would it be, your prostate? your bowels? Anyway, either GRS method should be able to provide the same vaginal depth. However, the skin graft has a greater tendency to shrink or heal up, reducing depth and width. The colon is already the shape it wants to be, so this isn't an issue. So this one again goes to the colon, but it's really an issue of dilation.

Update, 2/2007: My vaginal depth sucks. I started out with 5 inches right after surgery, but it shrunk down to 4 inches within a few months, despite rigorous dilation. Since then, it's gone down to 3-1/2 or 3 inches. I can feel the back of my vagina with my long middle finger, just barely. My shrinkage may be worse than typical because my vaginal canal was made from a thin skin graft from my thigh rather than a thick graft from my abdomen (because I was so thin) or scrotal skin. However, I've also heard that vaginal shrinkage is a nasty little secret among post-ops. I heard from one girl who was going back for a colon transfer reconstruction five years after her original surgery, because she had substantial shrinkage and she said she has a very active tantric sex life. However, my depth is enough for satisfactory sex, although guys do notice that they are bottoming out.

3. Dilation

Dilation dilation dilation. 6 times a day, 30 to 45 minutes at a time, for at least 3 months. You know about that, don't you? If you don't, you better get familiar with it before you decide you're serious about GRS. Because you better be serious enough to be disciplined about your dilation. Here is a link where you can read about it: The Theory And Practice Of Dilation (This web site is also the best place to buy your stents.) In fact, you'd better read this article too while you're at it: Zen and the Art of Post-Operative Maintenance.

Dilation is required whether the neo-vaginal canal is formed of colon or skin graft. In both cases, it is necessary to keep the vaginal opening from constricting, and to train the muscle that the neo-vaginal is tunneled into. In the case of the skin graft, it is also necessary to keep the graft from closing up or shrinking, losing vaginal depth or width. Presumably the self-lubricating property of the colon makes dilating a little bit easier. And perhaps (?? I'm just guessing here) the colon is a little less painful because it is not trying to close up. Perhaps dilation frequency can be reduced a little more quickly with the colon transfer as well; again, this is just an unsubstantiated rumor.

Again, this issue favors colon transfer over skin graft, although only slightly in my mind.

Update, 2/2007: Dilation is a bother, but it's not that bad. Now I dilate once a week, though I could go for a couple weeks with no problem. I decided I would make up for my lack of depth by increasing my width, so I got some more stents that went beyond the 1.5 inch diameter of the standard set all the way up to 2 inches. (I got them from Duratek Plastics . It was a custom order. [Oops, they're gone, too. But you can get vaginal dilators on now!]) I named my second-to-largest stent Big Pussy, and my 2 incher Tony Soprano. But Tony is still a challenge, so I'm plateaued at Big Pussy.

4. Hair growth

You don't want hair growing inside your neo-vagina. The colon has no hair, so clearly this is not a problem with the colon transfer method. I'll bet your scrotum is quite hairy (no don't show me, just look yourself). So if the scrotal skin is used to construct the vaginal canal, something must be done about this hair. Some surgeons (Meltzer, Schrang) strongly recommend having electrolysis done in this area. Yikes! That gives me nightmares. In fact, I even wrote an essay about it: Balls! Besides the pain and expense, it also requires 4 to 6 months to do it right, so it has a serious impact on your GRS planning. However, some surgeons (Kunapron for one) ask that you do NOT have electrolysis performed, as they believe it damages the skin. They remove the hair follicles during the GRS procedure, either by plucking or burning or some other method. (I am astounded by the thought of a brilliant surgeon spending an hour or whatever it takes plucking follicles out of a donor skin, but Dr. Schrang told me he does it personally.) Apparently this works acceptably, but there seems that there should be an issue that not all the hair follicles are active at any one time, and it would be difficult to find the inactive ones. But I guess a few hairs aren't a problem, especially if they are thin fine hairs due to your hormone regime.

Some surgeons (Cholon) do not use the scrotal skin for the vaginal canal. Rather, they use a graft from the abdomen or thigh or buttocks. In my case I am fairly thin, so my abdomen is not a good donor site. A graft from my thigh or buttocks would be taken as a thin graft, using a tool essentially like a cheese slicer. This graft is so thin it does not carry any hair follicles, so the hair problem is solved. The thin graft will leave a large scar in the donor area, which heals up better or worse on any given individual. There is no way to predict how visible the scar will ultimately be. I have seen some picture where it is invisible, others where is it an obvious red area.

An abdominal graft may be taken full thickness. This has the advantage of being less prone to shrinkage. Also the donor site can be closed with a linear scar rather than the scar patch left by the thin graft. I am not sure what the situation is with hair follicles on the thick graft; but hopefully your abdomen is not very hairy!

Personally, it is worth a lot to me to avoid scrotal electrolysis. (I am told that even Meltzer, who is fairly insistent about it, does accept patients who have not had electrolysis.) I am attracted to the idea of a thin skin graft from by thigh or buttocks, and I am not alarmed by the possible scarring. I can see that the scarring might be a bigger issue for a younger person who would be spending lots of time in micro-skirts and bikinis!

Advantage, colon. But the skin graft seems acceptable to me.

Update, 2/2007: I didn't do any scrotal electrolysis, and I had the skin graft from my thigh. I haven't had any trouble with hair inside my vagina, but my labia are a little bit hairy, which I guess is unlike a natrual vulva. It's not horribly noticeable, however.

6. Durability

How durable is the neo-vaginal canal when formed from colon material versus skin? One surgeon (who does not do the colon transfer) told me the skin graft was tougher, and the colon was subject to trauma during sex. Dr. Kunaporn does both procedures and he told me the colon is tougher. An American surgeon that does the colon procedure scoffed and said you're simply not going to damage the colon during sex. My guess is this is a wash.

Update, 2/2007: I only wish I was stress-testing my vagina! I did hear a story of a girl with a colon transfer whose large boyfriend shove it in and ripped her vaginal wall, but I can't swear it truly happened. 7. Risk/success likelihood of procedure

Finally, we need to consider the procedure itself. What is the likelihood of success? What are the risks involved? I am not qualified nor inclined to try to analyze these things in detail. But a few things are clear. GRS by either method is a mature medical procedure. If the candidate is properly screened (Harry Benjamin!) and carefully follows doctors orders, there is a high likelihood of success and an near zero risk of fatality. There is, however, a high likelihood of minor complications in every case. Enough stuff is being hacked and moved around, that not 100% of it takes the first time. That is one reason why they keep you in the hospital for 5 days.

In the case of the skin graft, there is some risk of morbidity of the graft itself. It is completely excised from the body and moved to its new home, where it has to pick up a new blood supply. A lot of the art of GRS is in doing the best job possible to make sure this skin graft is viable. If some or all of it fails to take, it can be repaired, however. It's not a one-shot deal.

With the colon transfer, it is highly likely that the colon will be viable, because it is never excised from the body. It always maintains a blood supply. It's simply been re-routed a bit internally.

But here's what seems in my mind to be the biggest deal. With the colon transfer, they open up your abdomen, cut apart your intestines, staple them back together, and re-route a section. This is pretty major stuff. It seems a shame to go cutting up a perfectly good, functioning intestine if you don't have to! The gravity of this procedure is further emphasized by the need for acute hospital care following the surgery, because you cannot take solid or liquid food until your bowel heals. This is part of what makes the surgery more expensive--with the skin graft, you can take food in a day or two, and so be moved to a less costly medical facility to continue your recovery.

I interview Dr. Kaplan in San Ramon, CA about colon transfer GRS surgery. Dr. Kaplan is a gynecological surgeon who has been fixing up women's internals for all sort of horrible problems like cancers and what-not for years. He is not shy about re-routing a person's abdominal plumbing, and I am confident of his ability to do it successfully. But I have to ask myself, "Why open up my abdomen if I don't have to?"

Update, 2/2007: What can I say? My surgery was a success.


In thinking about the colon transfer versus the skin graft, I find that all but one of the advantages go to the colon transfer, but only in ways that are of minor importance to me. The big disadvantage of the colon transfer, opening up my perfectly good abdomen to unnecessary surgery, outweighs all those advantages in my mind. Besides, hundreds or even thousands of transsexcual women are doing just fine with skin grafts, so I'm sure it can work out just fine for me too. My only apprehension is the odd chance that I will discover sex to be so wonderful with my new vagina, that it becomes a big new part of my life, and I regret not having the self-lubricating property of the colon. But you know what? I doubt that I will ever become anything like a sex machine. And if I do, well, that's a reward in itself, isn't it?

Update, 2/2007: "I doubt that I will ever become anything like a sex machine." Ha, that was prophetic! Not only are guys uninterested in having sex with me, but I've turned out asexual. I am not orgasmic; in fact, I do not feel any sexual arousal no matter where or how I am touched. It kins of sucks, but it gives me plenty of free time, and I still like to cuddle. I had planned to have a lot of sex to see if I could get my sex drive kick-started, but that plan didn't work because I couldn't find guys to have sex with. (I do have standards, after all.) Don't get me wrong—I'm still totally glad I had my surgery, and I'd do it again in a flash (thank god I don't have to do it again), but having no sex function is a disappointment. By the way, I know other girls who had surgery with the same doctor and they are orgasmic, so I don't think it's the doctor's fault. I think it's just the luck of the draw. A lot of cisgender women are inorgasmic, too.

One last note about the colon transfer. I've heard that penile inversion vaginas smell like natrual vaginas, and several guys (and girls) have told me I smell right. But I heard that colon-transfer vaginas smell different. Frankly, they kind of smell like ass, which makes sense when you think about it. I haven't been able to confirm that either personally for from anyone who's smelled one, but if it's true, then it's a big disadvantage to the colon transfer as far as I am concerned!

Lannie Rose

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