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Dr. Chettawut’s Non-Penile Inversion Technique

Dr. Chettawut’s non-penile inversion technique is well known as a top option for gender affirmation surgery, particularly among transgender women worldwide. This method produces the best aesthetic appearance of the vulva, commonly the priority of patients’ desire.

The non-penile inversion technique is more adaptable and flexible than the obsolete penile inversion technique. In the traditional penile inversion technique, most penile skin is inverted inside the vagina to serve as the lining. The penile skin is also used to create the inner labia, so it must be stretched. This is a drawback, as using one material for different parts compromises the aesthetic result of the external genitalia. With the non-penile inversion technique, the penile skin is no longer inverted into the vagina, which is more beneficial as it can be freely managed. It can be maximized, pulled, and stretched adequately to achieve a vertically oriented vulva. The approach includes careful placement of skin and tissue to mimic the contours and features typical of female genitalia, contributing anatomically correct surgical outcomes in a single-step procedure.

Why is the aesthetic appearance of the external genitalia so crucial following gender affirmation surgery?

The aesthetic appearance of the external genitalia is a critical component of successful gender affirmation surgery. Achieving a natural and feminine appearance helps patients feel more aligned with their affirmed gender identity, promoting self-confidence, body positivity, and overall emotional well-being. Aesthetic considerations also support smoother social integration and a stronger sense of self-assurance in daily life.

Dr. Chettawut’s non-penile inversion technique allows for the creation of vulval aesthetics that closely resemble those of a cisgender woman. This method carefully considers anatomical alignment, sensory function, and visual harmony to achieve outcomes that meet both aesthetic and functional goals.

Clitoris

This is the vulva’s most sensitive, or erogenous, zone. The clitoris is placed underneath the clitoral hood and designed to bend anteriorly away from the pubis, as is the natural alignment in a biological woman. The clitoris is made from the most sensitive part of the glans penis that transmits erotic sensation from the innervation of the dorsal nerve of the clitoris.

Inner Labia

The inner labia, also known as the labia minora, are a pair of small, delicate, and elongated folds of skin located within the outer labia (labia majora) of the female genitalia. They are on either side of the vaginal opening and enclose the clitoral hood and clitoris. The appearance of the inner labia can vary widely from person to person, and there is a natural diversity in size, shape, color, and texture. The length and size of the inner labia can vary depending on the condition of the foreskin, which is different between circumcised and uncircumcised patients.

Dr. Chettawut uses a part of the foreskin (prepuce) for the inner side, which is labeled A, and the penile skin for the outer side, which is labeled C, to form the lip-like appearance of the inner labia. The constructed inner labia have a lot of sensory nerve endings, which contribute to sexual pleasure. The coloration of the inner labia can be light pink for those who have originally pink penile foreskin (prepuce).

Outer Labia

The outer labia, or labia majora, are the two folds protecting the urethral and vaginal opening. This is usually fleshy and has fat tissue underneath. This part is made of the skin from the scrotum.   

Urethral Opening

The urethral opening is positioned just above the vaginal opening, allowing the usual urination pattern. The total removal of surrounding spongy tissue called corpus spongiosum is an essential step during urethral opening reconstruction to prevent the engorgement of the tissue under the urethra during sexual arousal.

The bulging under the urethral opening from either the remnant corpus spongiosum or the fold of inverted penile skin (from the traditional penile inversion technique) compromises the aesthetic look of the vulva. It may cause a narrowing of the vaginal opening.

Vaginal Opening

The vaginal introitus (vaginal entrance) is the entrance to the vagina, encompassing the distal end of the penile skin flap, which is labeled C as the bilateral side wall, and the perineal skin flap, which is labeled D as the floor of the vaginal entrance.

Dr. Chettawut emphasizes that the form of the reconstructed vaginal opening must have a vertical orientation, similar to the shape of a cis female’s vaginal opening.

Posterior Fourchette

The posterior fourchette is a small fold of skin where the labia minora converge at the back of the vaginal opening. Its appearance may vary from person to person. Dr. Chettawut’s innovative non-penile inversion technique plays an important role in creating a neovagina with a naturally formed posterior fourchette in the one-step construction of primary gender affirming surgery, which depends on the individual patient’s skin conditions.