Dr Sanguan's GRS Technique

The following has been taken from an information document provided by PPSI.  In my situation I had a skin graft from the top of my thighs.

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Male to Female Gender Reassignment Surgery (MTF GRS) or Gender Confirmation Surgery aims to

create a functional vagina with an external appearance as close as possible to that of a genetic female,

together with the associated sensations and feelings. Dr. Sanguan achieves this via a two stage procedure, to ensure that the necessary scrotal skin graft for the vaginal tunnel are carried out after an

initial healing process of approximately 7 days. Until the second stage, the bleeding occurring from the

first stage surgery subside and stop completely and newly formed granulation tissue provides an

abundant blood supply , thus reducing the possibility of the skin graft failing.

STAGE 1

• The creation of a vaginal tunnel (Vaginoplasty)
• The removal of the penis (Penectomy)
• The removal of the testes (Orchidectomy)
• The construction of clitoris, clitoris hood, and labia minora (Labiaplasty).
• The construction of a new urethra opening (Urethroplasty)

Dr. Sanguan has improved MTF GRS techniques by using all of the sensitive skin from the corona ridge of Glans penis and prepuce skin cuff, with blood supply and nerves intact, to fashion the clitoris, clitoris hood and labia minora. By this process, the top of the glans becomes the neo-clitoris, and the underside forms the inner section of the labia minora – all preserved as one piece of skin. The color of the new labia minora will match that of the former prepuce skin. This new procedure significantly improves the external appearance of the new genitalia, as well as enhancing sensitivity.

STAGE 2 (after approx. 7 days)

• Scrotal skin graft is used for lining the new vaginal tunnel.

Although many GRS surgeons discard excess scrotal skin, Dr. Sanguan has found it to graft
successfully in the majority of cases, thus making additional skin grafts unnecessary. After the scrotal
skin is removed during the first stage of surgery, it is safely refrigerated at 4 degrees Celsius
(approximately 39 degrees Fahrenheit), where it will remain healthy for up to 2-3 weeks, far longer than necessary.

Before grafting, Dr. Sanguan carefully scrapes the scrotal tissue to remove hair follicles, thus preventing hair growth inside the vagina. This technique means patients do not require expensive and sometimes painful scrotal electrolysis prior to GRS.

The average vaginal depth will be 4-5 inches when grafted from the available penile and scrotal skin.  If, however, Dr. Sanguan concludes that the penile and scrotal skin is not sufficient to construct a
functional or sufficiently deep vagina, he will recommend a full thickness skin graft.  Excess or loose skin from the tummy, hip area or groin is added to the penile and scrotal skin. The  donor site for the graft will leave a linear or horizontal scar. This is the best, and least invasive, choice.

A new technique of Dr. Sanguan is Free Small Intestinal Jejunal Graft Vaginoplasty, moist vaginal
lining, more lubricated than scrotal skin but lesser than colon flap. Penile skin is used for Labiaplasty,
scrotal skin is used for construction of the vaginal opening only and not inside the canal, so there is no
hair growth inside neo-vaginal canal. With this technique, it can achieve 6 inches vaginal depth.
The process will be a delay graft approximately 3-6 days after the GRS. Dr. Sanguan always delay the graft procedure 3-6 days to ensure that there is no bleeding inside the neovaginal canal when he inserts the small intestinal Jejunal graft. If the insertion is done simultaneously during the GRS, there would be a risk of bleeding that will cause blood clot or hematoma between the neo-vaginal canal and Jejunal graft that can lead to graft necrosis or failure.

Dr. Sanguan will then pack the neo-vaginal canal with Polyurethane foam connecting to negative
pressure device (Vacuum assisted closure device) for 3 days, and if there is still some oozing of blood,
he will change the Polyurethane foam packing one more time and keep it for another 3 days, then it will
be ready for the graft. 

During the vaginal packing or delay period, the patient is allowed to walk, no need to be in bed all the time. After the second operation graft and neo-vaginal packing with Vaseline gauze, the patient must be restricted in bed. Then 3-4 days after graft is performed, it is now ready to remove the packing at bedside and start vaginal dilation immediately or the next day. The vaginal dilation will be carried on 3 times a day for 6 months to ensure that there is no vaginal stenosis. However, the patient can have vaginal sexual intercourse normally 2 months after surgery. 

After 6 months, the patient might dilate neo-vagina 2-3 times per week, not every day.