Sex Change (SRS)

Sex change surgery/sex reassignment surgery refers to the administration of surgery to change the sex appearance according to one’s sex identity. There are two kinds of surgery.

BCOSS doctors have developed a sex change technique called the Bcoss technique with the following details that make the outstanding result not just the cosmetic appearance, but also better functional result.

  1. Dorsal Neurovascular Glans Penis Preputial Flap
  2. Secondary Sexual Sensated Organ
  3. Single stage with complex of scrotal-penile flap and scrotal skin graft that can make promisable depth of neovagina and full length of vagina can create by all scrotal skin graft
  4. Long posterior scrotal skin flap is designed to give thick sensated posterior wall of vagina. When compare between graft and flap on rectal wall, scrotal flap produce soft sensation and more elastic than skin graft during sexual arousal period. The scrotal flap can give more width and length of neovagina during sexual intercourse period while retract to be narrow and shallow during normal period (the same as female vagina) Moreover, the posterior sensated scrotal flap can facilitated orgasm though its own sensation that was preserved and by transmit the sensation to anterior rectum wall that is the organ that involve orgasm complex
  5. Clitoris From glans penis with intact sensory nerves and vessels
  6. Vestibule of Vagina between the Labia Minora and urethral flap to look similar to female vestibule from glans penis with intact sensory nerves and vessels.
  7. Narrow neurovascular flap to create narrow hood of critoris and to look as close as genital female
  8. Thin pedical flap sensate clitoris technique: The Doctor 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. Clistoroplasty, uses the top skin of the glans penis
  10. Sensate inner labioplasty. The penile skin that surrounds glans penis looks similar to skin of inner labia, but thinner and more flaccid.

We use 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. The doctor uses two types of skin to create inner labia look more natural. The outer part is from scrotal skin, and inner part is from prepuces, which can sense just like neo-clitoris.

G spot of neovagina is combination of sensated labia minora, critoris, remnant of urethral flap between dissection.  The cavity will be created just beneath the capsule of prostate gland that will lie over the penile skin. During dilation of neovagina you can feel sensated prostatic capsule. This complex of sensated 5 organ can create sensitive neovagina.

Long urethral flap technique: The doctor 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.

The labia minora which are anterior enough to cover the clitoris, uretha, and vaginal cavity (as in genetic women).

Labia minora which can be stretched manually (as in genetic women).

Pink or red colour of the inner surface of labia minora (as in genetic women).

Complete anatomic homology between the reconstructed neovagina and the natal female genitalia.

The fenulum which extends below the clitoris and which is continued to both sides of the labia minora (as in genetic women).

The advantage of Bcoss Technique

  1. One stage procedure.
  2. A more aesthetically pleasing and natural looking vagina.
  3. Less skin hanging below the urethral opening from too large size inner labia.
  4. Enhanced vaginal depth approximately 5-7 inches.
  5. Less recovery time; 2-3 weeks after surgery.
  6. More elastic vaginal wall with sensate G-spot at posterior and anterior vaginal wall.

Criteria of patients that suitable for Bcoss technique

  1. age <60 years
  2. penis is longer than 5 cm
  3. has enough scrotal skin to raise scrotal flap

Nowadays the techniques of MTF surgery that has been done are

  1. Penile skin inversion
  2. Penile  skin inversion with scrotal skin graft
  3. Penile skin inversion with donor skin grafts from the abdomen, waist, thighs, buttocks
  4. rectosigmoid colonvaginoplasty (primary)
  5. rectosigmoid colonvaginoplasty (secondary)
  6. delayed scrotal skin graft

Bcoss technique is the development of the second technique that add the width of vagina with scrotal flap and add the depth with all renant of scrotal skin graft

  • atient must be at least age 18 years of age. Patients will require permission from parents if under 20 years old.
  • Patients must be diagnosed with at least one of the following disorders: gender identity disorder, gender dysphoria, or associated conditions.
  • Patients must have undergone at least one year of antiandrogens and/or female hormones.
  • Patients are required to have lived full-time in the cross-gender role for at least 1 year (supported by Identification Documents).
  • Patients must have approval from a psychiatrist (MD), psychiatric social worker (PhD), or clinical psychologist (PhD).
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  1. One letter recommend the S.R.S. from; either i. Therapist ii. Psychiatrist iii. Endocrinologist or General Practitioner
  2. Discontinue hormone treatment at least 14 days prior to surgery. Hormones should be halted to reduce the risk of thrombosis (blood clots). Oral tablets should be halted two weeks prior to surgery and injectables should be halted four weeks prior to surgery. Oral antiandrogens can be halted three days before surgery (four weeks if injectables).
  3. Have your private doctor performed preoperative physical check up within three months prior to SRS. Patients must also be confirmed by a private physician to be free from serious medical diseases and must pass the following blood tests and e-mail the results;
    • CBC, HIV Electrolytes, FBS, Creatinine Urinalysis
    • Alkaline Phosphatase, Chest X-ray
    • SGOT LDH EKG
  4. Reduced smoking, No aspirin and ibuprofen (Advil etc.) and Vitamin. E.
  5. G.R.S. date; should send the Fax, email. For appointment one month prior to surgery date and itinerary.
  6. HIV + can be done but will cost 30% extra due to the necessity of using disposable instrument.
  7. Must stop taking aspirins three weeks prior to the surgery.
  8. It is best to stop alcohol consumption one week prior to the surgery.
  9. On the day before operation the bowel will  be prepared and cleaned.
  10. The period of your total stay should be discussed before scheduling your flight. Please arrange your flight to arrive Bangkok before your surgery 2-3 days.
  11. Any female hormones, including spironolactone must be stopped prior to surgery, 2 weeks for oral tablets and 4 weeks for injection, to prevent the risk of thrombosis (blood clot in the vessels).
  12. Aspirin and Vitamin E must also be halted 2 weeks before surgery as they interfere with normal blood clothing.
  13. No need for any particular vaccination except for those who come from or through the countries where there are reported cases of Yellow Fever.
  14. Please do not carry any unnecessary drugs or personal belongings in your baggage. For clothing -Thin cotton is the best.
  15. Foreign visitors may bring unlimited amount of Thai or foreign currencies.
  16. For travelers leaving Thailand, the maximum amount permitted to take out without prior authorization is 50,000 Baht per person.

The operation can be arranged once you have all the required papers ready. Just inform us of your convenient date at least one month in advance prior to arrival, either by click here to contact us via e-mail at consult@bcoss.com, or by faxing us at (66)02-895-6576, or by calling us at(66) 02-895-6565

  • Inform us your age, height/weight, your known underlying diseases and also any unusual conditions that may have an impact on the procedure.
  • If your age is over 40, please send the report of your current lab test include complete blood count (CBC), anti HIV, kidney and liver function test, fasting blood sugar, chest x-ray and electrocardiogram (EKG). Also, you should consult the doctor who specializes in medicine that the lab is OK for major operation or not. If you find the serious medical problem, such as heart disease or hypertension, the operation should be postponed and you should be treated until the doctors allow to begin the operation.
  • Tell me the preferred time of your surgery, I try to adjust my schedule to accommodate you.
  • After the tentative arrangement has been made, kindly be advised that we require 10% non-refundable deposit, which can be transferred to my bank account.
  • e-mail scan, fax one piece of photo identification (e.g. drivers license, Passport, etc)
  • e-mail scan, fax of bank 10% wire transfers (please check at term and payment)
  • e-mail scan, fax copy of the flight reservation itinerary
  • original signed (hard-copy) documents of claimed diagnoses or referrals. We will collect your hard documents during consultation.
  • Once the applicant has been approved for Penile Skin Inversion (MtF) Surgery, the patient can then make the flight arrangement.
  • Must discontinue taking hormones three to four weeks prior to and one week after your surgery.
  • Please carry only essential belonging
  • If the patient arrives alone, it is essential to travel with light luggage (max. 25 kgs)
  • Avoid risking injury during the 4-6 week recovery period.
  • Bring your favorite book or musical CD with you so you can use during pos-top period in hospital and in hotel
  • Give your fiends or relatives the phone number of our office and hospital before you leave.
  • If you have more than 2 companies with you, you should make hotel reservation for them during the time you stay in the hospital.
  • Bring in the laptop if you have to work with them or in case that you want to use other language (not English or Thai)
  • Generally, in Bangkok, some hospitals have system of Wireless LAN, but if they do not have, there will be hi-speed internet service in hospital that you can uses by buying a card, or else outside the hospital, there are a lot of internet services in stores or in hotels. Anyway, the languages that are used in the desktop or laptop in Thailand are Thai and English. Even though you can encode to other language, you can just read the data, you cannot install the data or type other character that is not English or Thai because the keyboard has only 2 languages.
  • Prepare cash for your personnel to stay another 5 days after surgery. (If you would like to stay at hospital hotel room for additional night after surgery is US$ 62 per night excluded meal) about $20-40 (U.S.) per day for food expense.
  • Touring arrangements will be around $100 (U.S.) per day (optional)
  • The nurse will do complete enema to clean rectum.
  • Take very nice shower.
  • Preoperative intravenous fluid and sedation.
  • In operating room under general anesthesia.
  • Surgery takes about three hours
  • Surgical fee xxxx USD
  • Travel arrangements for 7 days will be at least around 100 USD per day
  • If you are HIV positive, then you are a risk to hospital personnel. For this reason you need to pay an extra 30% of the original charge.
  • Please present the supporting documents confirming the scheduled operation upon request. Please do not carry any unnecessary drugs or dangerous objects in your luggage. Appointment with Surgeon
  • The operation can be arranged once you have all the required papers ready. Just inform us of your earliest convenient date prior to arrival, either by to contact us via e-mail consult@bcoss.com, or by calling us at (66)02- 895-6576
  • Two letters are required from foreign patients. One letter must be from either a medical doctor or a psychologist that states the person is a candidate for SRS. The other letter may be from any doctor, showing proof of having been on hormones for at least one year.
  • The 90% balance of your package price should be prepared to pay in only cash (US Dollar or Euro or Australian Dollar cash), this is the most convenient way to settle your remaining fee at the clinic.
  • n case you don’t want to bring much money, you can transfer your full balance (exclude the bank service for wire transfer) to my bank account 2 weeks before departure.
  • We do not accept any cahier checks or money orders.
  • The 90% balance of your package price should be prepared to pay in only cash (US Dollar or Euro or Australian Dollar cash), this is the most convenient way to settle your remaining fee at the clinic.
  • The position is set in standard lithotomy. Before the operation starts, the silicone-made cushion is used to support the weight bearing area (back and buttock).
  • The perineal skin flap is designed in proper shape and size and will finally be joined with the inverted penile flap for vaginal opening reconsturction.
  • The vaginal opening and space are created below the urethra (urinary tube) and the prostate gland. After passing the prostate capsule at 4 inches depth, the plane become loose and the direction will be a downward slant to the recto-vescicle pouch. The depth of this newly created space normally 6-7 inches, or even more in some cases depends on the anatomy of individuals.
  • Bilateral orchidectomy (removal of testes and spermatic cord)
  • The inverted skin flap from the penis is used for the skin lining of neovagina. In this step, the scrotal skin graft will be routinely added for the additional depth.
  • The penis shaft is removed except some small parts of the gland penis and its sensory nerves and vessels for constructing the sensate clitoris.
  • The urethral opening is centrally located above introitus (vaginal opening) and the urethral mucosal set between the clitoris and urethral opening can simulate the pink wet vulva mucosa.
  • A portion of the glans (head of the penis), with its nerves and vessels, is converted into a clitoris. In so do, the clitoris will be functional in sensation as well as in appearance.
  • The excess erectile tissue around the urethra should be removed in order to avoid symptoms that stem from engorged erectile tissue during sexual arousal, that may result in the narrowing of the vaginal opening.
  • The inner labias are simulataneously made from the prepuce flaps (pink-colour skin attached to the gland penis), which are long enough to cover the neoclitoris, urethral and upper part of vaginal opening. However, thinner lip appearance of the inner labia can be done later at the labiaplasty stage.
  • A vaginal packing is placed inside the neovagina for 5 days.
  • Sensate Glans- Clitoris
  • Neourethra
  • Vulva Floor
  • Labia major and minor
  • Neovagina of 5-6 inches (Natural Vagina is 4.5 inches)

Catheter and Tube drains: 

Tube drains and the urinary catheter will be left in place for 5 days when you wake up you will feel tube drain and the urine catheter that will be left in place for 5 day.  You will feel like to urinate because of bladder irritation by the catheter.  Do not worry because the urine can gradually pass through the catheter.  On the 3rd day you will be easy to move around. We will start to train bladder by clamping urine catheter every 4 hours to keep bladder muscle tone and function normal to reduce the problem of urination. After the catheter is removed, you will be able to urinate by yourself while sitting.

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. IV morphine for pain alltime in the first day. On the 2nd day the pain will be much subside and oral analgesia can now relieve pain. But if it is still very painful, you can ask for intermittent morphine injection.

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. Do not have fruit, vegetable or fiber-rich food to avoid passing stool.

Anyway, if you have to pass the stool it can be done but you have to carefully clean the anal area because it is very close to the surgical wound. On the 3rd day, the day that we start bladder training, you can get up and walk around inside the room or sit in bedside sofa.

Vaginal stent: The vaginal packing will be left in place for 5 days. On the 5th day, vaginal packing, tube drain, and catheter will be removed in the same time in order to keep it clean and free from infection.

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.

After the packing removal, there might be some bleeding from vagina and urethral opening. We advise you to stretch your leg, close your knees together and stay still for 30 minutes, the bleeding will stop spontaneously. If it is not stopped, pressure compression by gauze can help to stop bleeding.
After packing removal the nurse will help you to go to the toilet to take the first shower and start to urinate. At the first time to void with all bladder power because it is swelling around the urethral opening. To pass the urine to this area you need more power than normal voiding.       If you can void, you can move to the nearby hotel. If you can not pass the urine you have to stay in the hospital and might need catheter retaining for another week.
If you already move to the hotel and have problems urinating, you should come back to the hospital or call our hotline number to give you advice and replace another catheter by our nurses.

If you can pass urine, you can leave the hospital. This is the checklist of stuff that we will provide to you to take to the hotel.

  1. Appointment card we will make  appointment on 7th day after operation or the 2nd day  after discharge from  the hospital for partial stitch off, exam the vaginal cavity and start  dilation. On this day please bring  a small dilator  and a piece of napkin with you to the clinic 10th day  after operation to    check the operation wound 14th day  for vaginal examination and total stitch off final check  on the day before you leave Bangkok
  2. Namecard of our staff and hospital in case of emergency problem of wound care or urination problem—do not hesitate to call us to help you, or in case you get loss during travel around you can call us
  3. Donut ring to sit on. It will make you more comfortable not to sit on surgical wounds.
  4. 2 sizes of dilator or mold
  5. 5 pack of condom
  6. Syringe ball for vaginal douches
  7. Post-op medication
  8. 1 bottle of betabine
  9. 1 mobile phone. We will provide you a registered mobile phone. This mobile phone have limited call out service (300 baht or 10$) but unlimited calling service. So we provide in case that you want to receive call from your friend or emergency situation to call our staffs. So do not use for international call. Anyway, if you want to extend your calling time you can buy the card at any 7-11 shop.
  10. 1 tube of syerile gel
  11. A  pack of bluepad

During the recovery period, after each dilation session: 

1.Wound Care the wound should be washed gently with Hibiscrub (pink colour) or with betadine solution  in the shower followed by douching while seated in the toilet:

  • Douche solution(proportion) = 5-10 ml (cc) of Betadine solution mixed with 1L of water or until the container is full.
  • Insert the douche to full depth, squeeze, and hold tightly the container.
  • While holding tightly the container, extract the douche
  • Keep the wound dry and apply Betadine solution with cotton balls and apply Kemicitine ointment with a cotton applicator. If there is some bleeding, press or apply pressure with a dry cotton ball to the site for 15 minutes. During the first weeks after surgery, feminine knapkins (tampons) should be changed several times per day due to normal vaginal bleeding during recovery.

After one month of 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 would generally take around six months.

Before being discharged from the hospital to your hotel, the nurse will teach you how to take care of your vagina and prescribe some more medications. The stiches will be removed after 7- 10 days. And you will be able to return home.

2. Dilation, During recovery in 3 rd day hotel, the patient must follow patient instructions, including: 

  • Dilating is the most important thing you can do to ensure the success of your surgery. If the patient does not dilate responsibly, this can result in the shortening of depth and width of the newly made vagina because of the scar contracture.
  • Failure to dilate properly can result in serious injury. You will be instructed to gently dilate into the right direction after the vaginal packing is removed.
  • Dilation can be painful for the first weeks, but is essential for developing maximum depth and ensuring post operative functioning of the neovagina.

 Insertion the dilator

  • Before starting, relax the muscles and Semiflex your knee.
  • A condom is placed over the dilator, apply KY-jelly and insert slowly and keep it in for about 15-30 minutes, finally clean as previously directed and apply the antibiotics ointment over the stitching and any area of fresh wound.
  • Start with the smallest dilator and progress to the larger diameter provided.
  • Do not skip dilation even if it is painful. Failure to do it may result in partial or total collapse.
  • Rinse out the lubricant after dilation and apply an antibiotic ointment or Betadine solution until the wound is completely healed.
  • 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.

Intercourse:

After the 4th week post operative, 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. Sex partners should wear condom and apply lubricant inside vaginal cavity during neovaginal intercourse in the 1st month to prevent trauma effect from inadequate lubricant. After 1 month intercourse can be done without condom but lubricant still has to be used.

Return to female hormones:

Patients can resume taking oral female hormones in 2 month 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. Patient can return to female hormones as before surgery after two months. You should consult your endocrinologist to re-adjust the dosage. A sudden change in hormone levels, for some individuals, may result in the fluctuation of emotion.

Side Effects

  • Unable to urinate, it can occur sometime after removing the urine catheter, due to the swollen stump at the opening of the shortened urethra which will need the urine catheter to be retained of a few more days, eventually you will be able to urine normally.
  • Bleeding; You may experience oozing blood around the gauze dressing the first day after surgery due to bleeding thru the stump of urethral opening, may require repacking or suturing.
  • Arrive in Bangkok Airport. Meet with BCOSS staff and be escorted to the Hospital.
  • Pre-surgery night in a private room in hotel
  • Appointment with our doctor for clinical interview/consultation.
  • Check medical documents.
  • Psychiatric tests (if necessary)
  • Admission to Hospital. You will be requested to sign hospital consent forms.
  • A nurse will come to clean and shave your genital area after you have showered. Afterwards, your perineum will be shaved before surgery. You will be given enema.

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.

  • 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. A nurse will come and bath you twice a day and change your bedding as often as necessary
  • The dressing gauze and the catheter will be removed. You can urinate take a shower and to be discharged back to hotel on the 5th day. Upon checking the results you may leave the hospital and check in to your chosen hotel. You can walk and urinate by yourself, learn to take care of your neo-vagina and to be a new you.
  • These should be rest at your hotel and relax on the bed on the 8th day.
  • Stitches off : Some stitches will be removed from outer labia at day 6 after surgery to reduce scar formation.
  • On the 7th day we will teach you how to dilate with a small dilation. The large dilation can be used on the 21st day post-op.
  • 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 the —– of the wound healing. Our staff will assist you in cleansing and starting neo-vaginal dilation.
  • If you were at your chosen hotel. Please return to the hospital where the doctor will remove sutures from the labia and do a final examination. You will receive a final postoperative recovery check up and some medications. You will also receive a medical certificate that authenticates the surgery and recommends that you receive a legal change of sex.
  • 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.
Information
AnesthesiaGeneral.
Surgery Length4-5 hours
Side Effects
Recovery PeriodBack to work: 2 to 4 weeks. More strenuous activity: 4 to 6 weeks.
Stay in Hospital4-5 days
Stay in Thailand14-16 days