[–]Veinscrawler[
S] 1 point 54 minutes ago*
All tissues of "male" genetalia are direct homologues to tissues of "female" genetalia. Penile prepuce (foreskin) to clitoral hood, penile glans to clitoral glans, penile corpora cavernosa erectile tissue to clitoral cavernosa, penile urethral mucosa to vulvar vestibular mucosa, ventral penile skin to labia minora, scrotal skin to labia majora. This is because all these structures develop from the same parts of genital tubercle we all share in common as fetuses up until sexual differentation starts at 9 weeks of gestation. Usually by 12 weeks the external genetalia have developed, as either a vulva or penis and scrotum, and differentation continues from there. Our genitals differentiate even moreso during puberty. However, because these structures developed from the same basic tissues, they continue to have relatively similar aesthetics and functioning. It is mostly the positioning and size of various structures that differs.
What this means is that, at least in terms of external genetalia, those parts of "male" anatomy should be used to create the corresponding parts of "female" anatomy during feminizing surgery, and it should be roughly possible to mimic those homologous structures almost perfectly with minimal disruption of nerves and functioning.
However, that is not what most surgeons are doing. Feminizing genitals traditionally prioritize the amputation of the penis and scrotum over using those tissues in fully homologous ways that prioritize nerve preservation. This is partly because penile inversion vaginoplasty has been the standard for a long time, which means some of the penile skin and scrotal skin is being sacrified purely to make the vaginal canal for want of a better substitute for natal vaginal lining. But it goes deeper that that, because even surgeons who are performing forms of vaginoplasty that use only internal tissue for lining (colon, peritoneal, jejunum) are not utilizing the all of those fully available genital tissues in homologous structuring with preservation of nerves and functioning. They give various reasons for doing so.
For instance, it is customary among most surgeons to cut the scrotal skin both medially along the raphe and laterally along the "sides" of the scrotum, creating two flaps of scrotal skin which must be pulled posteriorly, removing so-called "dog ears" of scrotal skin and usually involving excision of a significant amount of groin skin as well.
However, doing this severs many more of the blood vessels and nerves in the scrotum, causing loss of erogenous sensation and sexual function. This also removes a pre-existing naturally smooth transition from groin skin to scrotal/labial skin, and creates the tell-tale lateral scars of on many trans femmes post-op labia majora. If the scrotal skin were instead only cut medially and folded inward, with any true excess cut off only medially instead of laterally, this disruption of blood vessels, nerves, and natural aesthetics can be largely avoided, preserving both function and natal labial aesthetics. And even for vaginoplasties that utilize a scrotal graft, the graft can come from the medial scrotal skin.
There are several surgeons who do ot this way, or at least a variation of it - Dr. Min Jun at Jun Surgical and Dr. Rachel Bluebond-Langner at NYU Langone, to name a couple - and some surgeons have even published papers on this - Dr. Worapon Ratanalert at Yanhee Hospital, for instance, who specifically hides the medial scars of the labia majora in the interlabial sulcus
https://pmc.ncbi.nlm.nih.gov/articles/PMC11984771/. Some surgeons still do some additional excision of perineal skin at the posterior part of the vulva in order to pull the scrotal skin more posteriorly, which is more disruptive, but the scars there can at least be hidden in the perineal groin crease. Overall, these methods produce much more natural-looking and functional labia majora than the more traditional method of cutting the scrotal skin and groin skin laterally.
However, both Dr. Min Jun and Dr. Bluebond-Langner use a different surgical shortcut for clitoroplasty, making horseshoe-shaped glans clitorises using only the coronal part of the glans penis (though I believe Min Jun may be moving away from this practice - not sure about BBL). This is done to ensure the the preservation of the coronal blood vessels and nerves, but it causes the visible clitoris to have an unnatural shape and flatness. This is just one of three different clitoroplasty methods that American surgeons and many others use - there really is no standard, and surgeon who says otherwise is lying.
However, it is not necessary to simply discard the other glans tissue, which can be kept at least partially attached and shaped along with the coronal part into a more natural-looking clitoral glans. Supposedly, one reason this is not done is because there is a higher chance of the clitoris partially necrotizing if more glans tissue is kept. Yet, strangely, that has not kept many other surgeons from doing it, often very successfully.
Dr Bank at Suporn Clinic does it exceptionally well, creating clitorises that in many cases look almost identical to natal ones. Dr. Bank also incorporates the remaining glans tissue that he does not use for the clitoris into the additional "Chonburi organ" for increased preservation of erogenous sensation (as the glans tissue contains highly sensate nerves). The Chonburi organ isn't really anatomically accurate to natal vulvas, but it shows again that it is possible to prioritize preservation of erogenous sensation without sacrificing aesthetics. And if he were simply to do without the Chonburi part, the clitoris would still be very accurate and functional. Howver, Dr. Bank does cuts off scrotal skin laterally and uses most of the scrotal skin as a vaginoplasty graft, though he does a better job with the scars than some do.
Another issue many surgeons seem to have is not making a clitoral hood that properly covers the glans clitoris anteriorly, often involving a clitoris that is placed relatively high on the pubic mound. Why they do this, I do not know. If anything there seems to be a focus among some surgeons on keeping the clitoris more exposed, which is just very strange and risks either hypersensitivity or desensitization from constant exposure. Many surgeons do not do it it this way, and I believe it has something to do with a difference in how the surgeons are placing the dorsal nerve bundle of the penis, which must stay attached to the glans, subsequently affecting the placement of the glans as well.
Most surgeons do at least follow the homologous route of using external penile skin for the external parts of the clitoral hood and labia minora and inner penile prepuce skin (foreskin) for the inner parts of the clitoral hood and labia minora. This is why circumcisions is in fact a serious detriment to vulvoplasty - you had your clitoral hood and a good chunk of your labia minora cut off. Some surgeons for that reason instead use scrotal skin for this part. Another reason maybbe because they are cutting off the penile skin entirely to use it as a vaginal graft. But this severs all the nerves in the penile skin, and costs the patient much of their natural aesthetic and functional difference between labia minora and labia majora (since said surgeons are still using other scrotalskin for the labia majora).
In fact, using any part of the penile skin for vaginoplasty (the canal) causes aesthetic shortcomings of the labia minora, such as the absence of a posterior fourchette or the labia minora not even reaching to enclosing the vaginal introitus, instead ending posterior to the urethral meatus and in some cases visibly diving into the vaginal introitus for the penile skin tube. It is one of the primary complaints many prospective patients have had about Dr. Min Jun's work, though he seems to have moved away from that practice. Dr. Bank is also known for making very accurate- looking and functional labia minora by using as much of the penile skin as possible for it, and he openly states that circumcision necessitates a subpar result.
Another issue that a lot of these surgeons have is that they do preserve a significant part pf the penile corpora cavernose to aerve as the clitoral corpora cavernosa. This robs the patient of clitoral erections (which are just as normal and healthy as penile erections) and has been shown to cause decreased sexual sensitivity and enjoyment in many patients. Dr. Bluebond-Langner, for instance, is known for achieving good function and sensation overall, but her apparent customary excision of the corpora cavernosa has caused sexual dysfunction and dissatisfaction in at least one patient who has posted on here.
Other surgeons, like Dr. Marci Bowers and I believe Dr. Bella Avanessian at Mount Sinai Hospital have recently been emphasizing the importance of preserving at least some of the corpora cavernosa for better sexual function, and many surgeons who do feminzing surgeries on intersex patients with clitoromegaly or pseudopenises are doing the same. Even a small bit of corpora cavernosa helps cushion the dorsal nerve bundle - the absence of this is one of the reasons I have chronic pain. I thought I was told that some would be kept or maybe that corpus spongiosum would somehow be used as a substitute, but that was apparently false.
Many surgeons refuse to preserve any corpora cavernosa because if misplaced it can cause painful swelling during erections, and because many trans women in the past requested it removed because I guess they didn't understand that clitoral erections are normal and it made them dysphoric (which is fair thing to request, but should not be the norm). But other surgeons' work proves it can be done without causing functional issues.
Really, what every surgeon should be doing is separating the two chambers of the corpora cavernosa to create the customary Y shape of clitoral corpora cavernosa and then largely burying them beneath the labia majora on either side of the vulva. Then they would function roughly identically to natal clitoral corpora cavernosa, contributing to vulvar swelling during arousal. But this is technically complex, and so nobody really does, as far as I know. But it's not because it's impossible - surgeons just haven't bothered to learn how to do it. In any case, not preserving any corpora cavernosa is an extremely common surgical practice that robs the patient of normal sexual function.
I could continue to go on about all of this, but I hope I've made my point. Effectively, there is no surgeon who is performing all of these aspects in the ideal way for preserving natal aesthetics and sexual function. And it's extremely frustrating, because when looking at the state of feminizing genital surgeries as a whole, it's clear that these different surgeons' best practices could very easily be combined to create a better standard for vulvoplasty (and I believe vaginoplasty would likewise have more of a focus on using internal tissues for canal lining, which we are seeing a significant rise of). But for whatever reason - money, ego, whatever - they aren't coordinating on that. And I think it's a real loss for all patients.
I would suggest that the biggest takeaway from this should be to avoid any surgeon who does not prioritize preserving as much of your natal genital tissue as reasonable possible. Because, regardless of what dysphoria says, your genitals are your genitals. You can change how they look, but you can not truly replace any part of them once lost. So make sure that you will not be losing parts of yourself future vulva in the process of getting one.
And personally, I would really recommend not doing penile inversion vaginoplasty, as it inherently compromises vulvar aesthetics. At worst, only use some scrotal skin for a canal graft, and only if you truly have a baggy excess.
I had very little scrotal skin, but the surgeon who operated on me insisted it was better to remove some of it anyway because apparently he doesn't understand how to make aesthetically and functionally accurate labia majora. I refused, but in the end he cut off nearly all of my scrotal skin, and now I have basically no labia majora at all as well as chronic pain in that area.