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Vulvoplasty: Assessing an Alternative to Vaginoplasty

Vulvoplasty - Zero Depth VaginoplastyVulvoplasty is a male-to-female gender affirming procedure that removes the penis, scrotum and testicles, creates the labia and clitoris, and re-positions the urethral opening. Unlike Vaginoplasty, Vulvoplasty does not include the creation of the vaginal canal, though in most cases, a vaginal introitus dimple can be constructed (ie, Shallow Depth Vaginoplasty.) The surgery is shorter and risks to adjacent structures such as the rectum are decreased. (Salim, et al.)

Vulvoplasty is a suitable surgical solution for patients who:

  • Are not interested in receiving penetrative vaginal sex;
  • Have concerns about age and recovery;
  • Do not want to or are unable to commit to the lifelong regimen of dilation associated with Vaginoplasty;
  • Identify as non-binary and feel that Vulvoplasty is more affirming of their gender;
  • Have higher risk factors due to:
      - Previous radical prostatectomy, pelvic radiation, major rectal injury;
      - Congestive heart failure;
      - Multiple mental health conditions or limited ability for self-care.
  • Have concerns about timing, for example impending loss of health insurance (Vulvoplasty can often be scheduled sooner than Vaginoplasty), hair removal requirements (no pre-operative hair removal required with Vulvoplasty.)
  • Lack insurance and are paying out-of-pocket for surgery. (Vulvoplasty costs less than Vaginoplasty.)

For these patients, Vulvoplasty is appropriate and should be offered by the surgeon as an option.

While more studies are needed, Vulvoplasty has been associated with a high rate of satisfaction. A 2018 study reported that 93% of respondents were satisfied with their surgery and with their decision to pursue Vulvoplasty. (Jiang, et al.) In cases where a patient later desires Vaginoplasty, a Vulvoplasty can be converted to full depth Vaginoplasty, using skin grafts or a section of sigmoid colon.


What's in a Name? Vulvoplasty and Zero Depth Vaginoplasty

Vulvoplasty is known by many other names, most notably: Zero Depth Vaginoplasty, Shallow Depth Vaginoplasty, and Limit Depth Vaginoplasty; Cosmetic Vaginoplasty; No Cavity SRS and Partial SRS.

Both providers and patients can agree that the choice of terminology used by surgeons in reference to patients is extremely important, and should be gender affirming as well as culturally sensitive. However, not all surgeons agree on the terminology for Vulvoplasty:

"Gender-affirming vulvoplasty" is the authors preferred term to describe gender-affirming surgery that creates the vulva (including the clitoris, labia majora and labia minora, and female urethral position) without creation of a vaginal canal. We prefer "vulvoplasty" over other terms in common use, such as "zero depth" or "cosmetic" vaginoplasty, as it more accurately reflects the anatomic intent of a surgery for which the goal is to form a vulva without creating a vagina." (Jiang, et al.)

"Various terms exist for vaginoplasty without creation of a vaginal canal, including partial vaginoplasty and vulvaplasty. These are technical, anatomic terms that are not part of lay language. The author believes that the use of such terms is purely academic and for patients, creates a false dichotomy. Such terms suggest that a patient is not undergoing creation of a "real vagina," which itself can create dysphoria for patients.
"While the term 'zero-depth vaginoplasty' is technically an accurate term for a neovagina without a true canal, the author has moved away from this term and instead now uses 'shallow depth vaginoplasty.' The decision to adopt the term 'shallow-depth' was based on feedback from a small subset of patients who found 'shallow depth' to be a more normalizing term than 'zero depth.'" (Garcia, et al.)


Case Report: Patient Living for Nearly 50 Years as Trans Woman Undergoes Successful Vulvoplasty Surgery In Minnesota

A trans woman who transitioned nearly 50 years ago sought out Gender Confirmation Surgery with goals of removing male genitalia, being able to urinate while sitting and having a sensate clitoris. Three months after healing completely, this patient was happy with results of a sensate neoclitoris and feminine-appearing vulva.


The Growing Trend of Vulvoplasty

While Vaginoplasty is performed much more frequently, Vulvoplasty has become more popular in recent years, with as many as 10% of patients requesting it. (Jiang, et al.) Some surgeons believe that Vulvoplasty should be offered as an option to all patients:

"The author believes that shallow-depth vaginoplasty should always be offered to patients during discussion of surgical options and planning. Doing so helps ensure that patients are provided with a review of all surgical options. A thorough approach such as this is patient centered and affords patients who may not feel the need to have a vaginal canal, or want to expend effort and assume the risks of maintaining a canal, to opt out if they wish. This approach also likely engenders greater mutual respect between patient and surgeon." (Garcia, et al.)

Some surgeons offer Vulvoplasty specifically to patients who have greater risk factors:

"At our institution, we offer vulvoplasty to patients who are at high risk for complications due to social or medical co-morbidities. For those patients, vulvoplasty is a lower-risk alternative. Additionally, despite having no contra-indication to vaginal canal reconstruction, some patients present requesting vulvoplasty." (Jiang, et al.)

It is much more common however for patients to not be offered Vulvoplasty at all in consultation with surgeons. A recent study reported that 86% of patients surveyed had not been offered Vulvoplasty. (Garcia, et al.)

In 15 years of performing MTF Vaginoplasty, Dr. Marci Bowers says that patient requests for Vulvoplasty are "rare" and that she has only completed three in more than 1800 MTF surgeries. "To be fair, this number may be limited by consumers who were previously unaware of [zero depth vaginoplasty]—we did not talk about this as an option unless specifically asked." Furthermore, Dr. Bowers believes:

"A troubling trend of late is that inexperienced surgeons, lacking confidence in their own abilities to perform the difficult and risky portions of the procedure, use fear of complications (and their own inadequacy?) to convince patients to undergo [zero depth vaginoplasty] rather than traditional vaginoplasty. Recently—in a public statement—one surgeon declared that more than 30% of his patients chose [zero depth vaginoplasty]! Absurd! If your surgeon suggests [zero depth vaginoplasty], 'buyer, beware!' Surgeons, lacking confidence, may speak of complications—as they should—but, when the centerpiece of their interaction is framed by a discussion of complications, seek care elsewhere."

When it comes to bottom surgery, decision making is critical. Vulvoplasty is a valid alternative to Vaginoplasty that deserves discussion between patients and surgeons. While it does not include the creation of a vaginal canal, Vulvoplasty results in aesthetically pleasing female genitalia which is entirely gender affirming for some patients. Vulvoplasty is also a good solution for patients with higher risk factors. There is no "one-size-fits-all" way to medically transition and Vulvoplasty is simply another option worthy of consideration for those seeking gender affirming lower surgery.

Dr. Wittenberg is an experienced surgeon in San Francisco who works exclusively with trans patients, offering Male-to-Female Gender Reassignment Surgery.

Surgeons who offer Vulvoplasty:

References:

Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women.
Jiang D, Witten J, Berli J, Dugi D. J Sex Med. 2018 Jun;15(6):902-906. doi: 10.1016/j.jsxm.2018.03.085. Epub 2018 Apr 26.

Sexual Function After Shallow and Full-Depth Vaginoplasty: Challenges, Clinical Findings, and Treatment Strategies — Urologic Perspectives
Maurice M.Garcia, Clinics in Plastic Surgery, Volume 45, Issue 3, July 2018, Pages 437-446.

Gender-Affirming Penile Inversion Vaginoplasty.
Salim A, Poh M. Clinics in Plastic Surgery, Volume 45, Issue 3, July 2018, Pages 343-350.

Last updated: 02/06/24