Step 1: Designing the Vaginal Opening and Creating the Tunnel

Dr. Chettasak begins by designing the vaginal opening, with careful incorporation of the perineal skin to form the floor of the new vaginal entrance. This approach enhances the natural appearance and structure of the vaginal introitus.

Next, a tunnel is meticulously created to follow the anatomical pathway of a natal female. This tunnel runs just beneath the urethra and behind the bladder, extending toward the posterior pelvic cavity, where it will later be connected to the abdominal cavity. This prepared space will receive the sigmoid colon segment during the next surgical phase.

Step 2: Bilateral Orchidectomies

Both testicles are surgically removed in a procedure known as bilateral orchidectomy. During this step, the entire spermatic cord is also carefully excised, with the cut made as close as possible to the external ring of the inguinal canal. This technique helps create a smoother contour in the groin area and reduces the risk of palpable remnants.

Importantly, the scrotal skin is preserved in optimal condition, as it will be used in the later stages to construct the outer labia (labia majora), ensuring a natural and feminine aesthetic outcome.

Step 3 : Clitoris and Clitoral Hood Reconstruction

The clitoris is reconstructed from the dorsal part of the glans penis, using a precise dissection technique to maintain maximum sensory function. Dr. Chettasak meticulously preserves the clitoral neurovascular pedicle, ensuring the branches of the pudendal nerve remain intact to support long-term erogenous sensation.

To provide an aesthetically natural appearance, the clitoral hood is created using a portion of the prepuce skin, mimicking the protective fold of tissue found in natal female anatomy. This step not only enhances the appearance but also helps reduce direct friction on the clitoris, contributing to postoperative comfort and sexual function.

Step 4: Penectomy and Urethral Reconstruction with Penile Skin Preservation

The penis is removed through a careful penectomy, during which the entire corpus spongiosum—the spongy tissue surrounding the urethra—is also completely excised to prevent residual erectile tissue and improve surgical precision.

At the same time, the urethra is shortened and repositioned to align with typical female anatomy. A new urethral opening is reconstructed just above the introitus (vaginal entrance) to mimic the natural female location.

Throughout this step, Dr. Chettasak Tulayaphanich ensures that the penile and prepuce skin are preserved in optimal condition. These tissues will be used in the following step to create the inner labia and a natural-looking vaginal opening as part of Dr. Chettasak’s signature NPI technique.

Step 5: Inner Labia, Vaginal Opening, and Posterior Fourchette Reconstruction

Using the preserved penile and prepuce skin, Dr. Chettasak Tulayaphanich carefully reconstructs the inner labia and sculpts a natural-looking vaginal opening with a delicate V-contour. This approach ensures a feminine and realistic appearance.

A key part of this step is the precise creation of the posterior fourchette—the natural joining point at the lower end of the vaginal opening—using the inner folds of preserved skin. This detail enhances both the aesthetic and anatomical authenticity of the vagina.

This reconstruction method is the signature feature of Dr. Chettasak’s Non-Penile Inversion (NPI) technique, which is globally recognized for delivering superior cosmetic and sensory outcomes in gender-affirming surgery.

Step 6: Outer Labia Reconstruction

The outer labia are reconstructed using the preserved scrotal skin, completing the external genital reconstruction phase.

Colon Harvesting and Integration Phase

Step 7: Colon Segment Selection and Preparation

Dr. Chettasak’s colorectal surgery partner performs this phase through minimally invasive laparoscopic surgery. An 8-inch segment of sigmoid colon is selected and fully separated from the original digestive tract. Both ends are cut, but the blood supply is carefully preserved. The colon segment is then rotated and moved down to the pelvic area, ready for placement into the vaginal tunnel.

Step 8: Digestive Tract Restoration

The remaining colon is securely reconnected to ensure that digestive function remains completely normal after the procedure.

Step 9: Creating the Vaginal Vault

One end of the harvested colon segment is carefully closed to form the deepest portion of the neovagina, also known as the vaginal vault. This closure helps define the internal endpoint of the vaginal canal and ensures a smooth, rounded base that mimics natural female anatomy.

The prepared colon segment is now ready to be positioned into the vaginal tunnel in the next step.

Step 10: Securing the Colon Segment at the Vaginal Opening

To complete the vaginal formation, the open end of the colon is carefully secured to the vaginal opening. Prior to this, a surgical window is created near the cul-de-sac area to connect the vaginal tunnel (created in Step 1) with the abdominal cavity, allowing smooth passage of the colon segment into its final position.

Once the colon segment is guided through this tunnel, the open end is meticulously sutured to the deep portion of the vaginal introitus. This precise integration ensures that the colon lining is not visible from the outside, maintaining a natural aesthetic while providing a fully functional neovagina with self-lubricating capability.

Step 11: Secure the Colon Flap in Place

Once the new vaginal lining is in position, Dr. Chettasak’s colorectal surgery partner also fixes the upper part of the colon flap to the side of the abdominal wall.
This helps keep it stable and prevents the colon from sliding or moving downward into the vaginal canal — which could cause a bulge or prolapse later on.

Step 12: Initial Healing Support

Gauze packing is placed inside the new vaginal canal for 5 days to keep the canal expanded during the critical early healing period.