Introduction

I had a virtual consultation for vaginoplasty (SRS) with Dr McGinn at the Papillon Center in New Hope, PA last March. I took notes for my future reference and to share my perspective with the community, wound up moving shortly thereafter, and forgot about the whole sharing thing. Surgery is much more prominently on my mind now that my SRS is coming up in May, and I went back to compile my notes into something sensical to share.

In July 2022 I booked an in-person consult scheduled for July 2023. I got a call in March 2023 informing me that a slot was available for a virtual consult and was asked if I was interested. Avoiding the need for another cross-country trip was nice, so I took the opportunity.

We went well over the allotted hour (sorry whoever was after me!) discussing all the aspects listed below. I’ve made an effort to boil this down to what I think will be most useful to strangers on the internet while maintaining accuracy of what was discussed. Any mistakes are mine and the notes are not exhaustive.

I’ve learned a bit more since my consult that’s relevant to what we discussed, and I’ve updated my notes where I can accordingly. This includes some personal thoughts/opinions, which are strictly my own, and while based on the best information I can find, you should take these with a grain of salt because I’m not a doctor.

Background

I want to make a more detailed post at some point on how I decided to pursue SRS. It wasn’t an easy process. There was a tension between the clear desire I experienced to feel this part of my body in harmony with my femininity, but I also never felt what I imagined bottom dysphoria “should” feel like. I felt a bit of detachment and vague disgust at my factory original genitals, but never something so powerful that I felt like I needed this to survive. For me bottom dysphoria mostly manifested in my genitals making me feel invalid, stopping me from seeing myself as a woman (at least the way I strongly desire to see myself as a woman).

I chose Dr McGinn to consult with because time and again I saw her patients reporting good experiences about post-operative support from her office and sensation/function. Going into the process of committing to SRS, these were the most important priorities for me. I wanted to make sure I’d get the best possible support after surgery, and that I had the best chance of keeping the pleasure and intimacy I enjoy now, but in a new feminine way after.

There were also some nonrational aspects of the decision to go with Dr McGinn, as is typical of big life decisions. I read up on her background and CV and was delighted to find that she started out in the aeromedical world, more or less adjacent to work I’ve done in the space industry in the past. I personally know a patient who had an excellent experience with her and gave her recommendation. I also just felt more comfortable with a woman working on this part of my body, and doubly more comfortable with someone trans. The intersection of that Venn diagram is a very, very small set.

I also set up a consultation with the gender affirming surgery team at OHSU, since they’re the most local option for me. After approximately a year of waiting I canceled that consult when I realized that I really wasn’t interested in going to a different surgeon.

Hair Removal/General Preparation

-At the time I booked my consult the Papillon Center sent me a diagram of what to remove. We verified I was clearing the correct area. I was about a week out from my last electrolysis session, so I don’t think she was able to get a good view of how my progress was coming along.

-Not necessary in her opinion to wait a year. Follicle scraping/cauterizing can be done.

--[My opinion/thoughts]: I was concerned about relying on the follicle scraping/cauterizing process because of the way hair cycles work. You can only reliably see the hairs that are currently in anagen, right? My electrologist pointed out that follicles can be seen and removed from the back side of skin during grafting, which enlightened me about what can be done, at least to skin that’s removed and grafted during surgery.

--[My opinion/thoughts]: I’ve chosen to be more conservative about hair removal. I started electrolysis in August 2022 and will have a total of about 84 hours done between then and my last session this April. The downside of hair in the vagina that’s extremely difficult to remove is concerning enough to me that I’m putting more work than may be strictly necessary into killing this problem.

-I’ve been taking Viagra about once a week since summer 2022 as part of my effort to avoid atrophy. It seems to have worked ok as Dr McGinn had no concerns about atrophy based on the photos I sent. I haven’t measured closely, but I don’t think there’s been much or any change since the time of my consult.

-I had several moles in the surgical area that I wound up getting removed at my dermatologist’s recommendation to avoid any possibility of them becoming malignant after becoming part of my vagina (doesn’t sound great)

Hormones

-Estrogen ok. No difference in blood clot risk for different delivery methods.

-Evidence from other surgeons in 2010s indicated that additional clot risk of being on E just prior to surgery is minimal

-Recommend no progesterone 6 weeks before, 6 months after surgery. Currently no good evidence on what risk profile of progesterone is.

Anatomy/Structure/Technique

-Outer 1-2 inches of vagina are made from penis skin

-Deeper section of the vagina made from scrotal/skin graft. Doesn’t make lubrication. You’ll probably need to apply lube for penetration.

-Inner surface of labia is made from urethra tissue. This makes them pink, means they get the same lubrication supply (from glands of Littre) that cis labia/outer vagina get.

-Urethra makes the “correct” (cis-homologous) type of lubrication at the correct time. Results in vagina behaving like a cis vagina.

-Outer surface of labia is penile skin. Nerves get cut, reconnect with thigh nerves. They’ll be numb for a while, then feel more like thigh tissue.

-Pudendal nerve becomes part of the clitoris. This gives the clitoris majority of erotic sensation (cis-like).

-6-7 inches of depth routine. Exact amount depends primarily on deep pelvic anatomy (go too deep and you risk a fistula).

-McGinn thinks they’ve settled on a good technique, takes the best aspects of last 20 years of iterative improvements

-Surgery takes around 2.5-3 hours

Complications

-Approximately as risky as a gallbladder removal or appendectomy

-Most common problem: 8% see depth/width loss, painful penetration. Main cause is problems with dilation.

-0.4% risk of blood clot

-0.4% risk of fistula. Often associated with Crohn’s Disease, ulcerative colitis. Requires colostomy to fix. After 6 months colostomy is reversed.

- Post-operative depression is common. Therapy, friends help.

- Type A people have the biggest problems, both with depression and dilation. They try to do too much too quickly after surgery.

-Urethral stricture? Never. [I have a less-than-rational concern about this one in particular and that felt reassuring to hear.]

Dilation

-Extremely important. Initial schedule is 4x daily, 30 minutes per session.

Pain and Numbness

-Anxiety is often worse than pain. Pain correlated with anxiety. Management of anxiety surrounding the surgery is the best way to minimize pain.

-Labia will initially be numb because nerves to the tissue are cut

-Regaining labial sensation is the norm, takes time (months), will feel different from how penile skin feels now

Comparison with Peritoneal Pull-Through

--[My opinion/thoughts]: I was particularly interested in this so we discussed penile inversion vs PPT a fair bit

-Same depth as PI. Limiting factor on depth is still internal pelvic anatomy.

-Generally better to use tissue local to surgical site if available. PPT doesn’t do this.

-Requires robot (expensive), not more cis-like, less known about long-term outcomes in transfeminine patients

-Peritoneum makes neutral pH fluid. Cis-like vaginal microbiome requires an acidic environment.

-Cap of peritoneum bleeds easily. Some evidence it may collapse over time.

-Same dilation requirements/schedule

-Lubrication isn’t erotic lubrication, it’s water. pH, fluid properties, timing of lubrication different from cis lubrication. [My thought: It does happen deeper though, which was the initial appeal for me.]

-Lubrication you can’t turn off can happen

-Abdominal tissue extraction adds complication risks/scars

--[My opinion/thoughts]: This was the biggest question in my head over whether I wanted to proceed with Dr McGinn or not, because I was interested in other information I’d found about PPT. I felt more assured after this conversation that I was going to get what I wanted out of PI.

Comparison with Cis Vaginas

-Cis vaginas are typically 3-4” deep, but stretchier

-Estrogen encourages glycogen sloughing in vagina (cis and trans). This enables lactobacillus to grow, creates vaginal flora.

--[My opinion/thoughts]: Dr McGinn made the comment of encouraging cis-like vagina flora to develop being like setting up an aquarium. I was amused at the thought of having a little aquarium of fun bacteria between my legs.

Logistics

-$115/night at Spring Hill (near hospital). Actual surgery happens at Capital Health in Pennington, New Jersey (~half hour from New Hope). Can get corporate rate on car rental.

-Travel to region no later than Sunday

-Bowel prep Monday

-Surgery happens on Tuesday

-Friday: Discharge from hospital with catheter/packing in

-Following Monday: Catheter/packing come out

-Typical New Hope stay typically Friday-Friday

--[My opinion/thoughts]: I’m planning on spending an extra day in New Hope since I’ll have a 6-hour flight back to the west coast ahead of me.

-If no direct flight home from PHL, fly out of EWR

-Ask for wheelchair at the airport, all the assistance you can get

-2% wind up changing their flight home because they’re not ready [My opinion/thought: Get travel insurance]

-Followups at 6 weeks and 6 months, should be in person, not virtual.

-Revisions typically at 6-month followup

Finance/Scheduling

--[Note this section is based on my subsequent experience with the Papillon Center rather than directly during the consult]

-Cost of surgery is $21,000. $3,500 deposit required to book a date. The remainder is split into two payments due 3 months and 1 month out from surgery.

-Papillon Center doesn’t accept insurance directly but works with insurance to get prior authorization, reimbursement

-Hospital/anesthesia fees total $6,200. This can be billed directly to insurance if prior authorization approved.

-Scheduling typically around 6 months out from surgery. I waited until November to get mine on the calendar to make sure hair removal was progressing the way I wanted it to go, and was able to get a date in May.

Conclusion

I feel confident moving forward with Dr McGinn and the Papillon Center for SRS. Her expertise and dedication to supporting the trans community was clear throughout the process.

At the end of last year I joined a small Discord server for McGinn patients having surgery this year. It’s been very helpful connecting with others about to go through the same experience I’ll be having in a few months. If you wind up making the same decision, feel free to DM me and I can send you more information on that.