Dr. Satterwhite and Dr. Safir recently co-hosted an Instagram Live to discuss traditional and robotic vaginoplasty, the right candidate for each approach, and things to know about each procedure.
Check out the on-demand recording below to learn more!
For more information about each procedural approach, visit our vaginoplasty and robotic vaginoplasty pages.
Dr. Satterwhite:
Hi there, Dr. Safir. So, good afternoon, good evening, good morning—I guess depending on where people happen to be located. It would be a pleasure and honor if there were people all over the world who are watching this. But again, thank you for taking the time to hang out with us for the next half hour.
This is an Instagram Live with myself, Dr. Satterwhite, and Dr. Michael Safir. We’re both part of Align Surgical, and today’s title is “Traditional or Robotic Vaginoplasty: Finding the Right Fit for You.”
I just wanted to start off with introductions. My name is Dr. Satterwhite. I’m the founder of Align Surgical Associates. We’re a private practice based in California—we have an office in San Francisco and an office in Los Angeles. We serve exclusively the transgender, the gender-diverse, and the gender-creative patient population.
We take care of our patients from head to toe, so we’re here for you to serve all of your needs. My training was at Stanford in plastic surgery. I had a year of craniofacial fellowship training as well. We have six surgeons currently in our practice, and it’s an absolute pleasure and honor to have Dr. Michael Safir as a member of my team. His background is astounding. I’ll have him talk more about himself.
Dr. Safir:
My name is Michael Safir. I’m a reconstructive urologist with Align, and I have been performing surgery for the transgender, non-binary, gender-diverse patient population for about six years.
My specialization—I do only bottom surgery. My background is I trained in reconstructive urology at UCLA and UCSF, and like I said, have been performing only bottom surgery for the last six years.
I’m really excited to see what feedback and comments we get. What we’ve done is we’ve disabled the comment function just to stay on point—that’s worked out for us really well in the past. But feel free to ask questions using the question function, and we’ll leave some time at the end to go through your questions.
Dr. Satterwhite:
You’re much too humble, Dr. Safir, for saying that you just perform bottom surgery, because that operation in and of itself encompasses so many steps. It’s like 10 operations all in one. You’ve got an amazing background, a very unique set of skills that very few people in this country—and very few people in this world—have. Both vaginoplasty as well as phalloplasty. You’ve had years of training upon training to get where you are.
I think it’s important for all of us to understand what vaginoplasty is. Vaginoplasty is one of many different types of gender-affirming procedures that we do, and it’s a procedure requested by trans women and gender-diverse individuals.
What this operation entails is basically using current genitalia—sorry, well, in one aspect, you can use your current genitalia, but in the more traditional sense, it’s using the genitalia that you currently have—so penis and scrotum—to produce and create a vagina.
That includes creating all the external components: the vulva, the clitoris, the labia minora, and the labia majora, and then using tissue to create the vaginal canal itself.
Most surgeons are doing what’s called a penile inversion vaginoplasty, where they take the tissue that you have and invert it—turn that inside out—to create the vaginal canal. Additional skin grafts can be needed if that’s the case.
Once again, a vaginoplasty can be, for some patients, the initial operation that they start off with. For others, it might come later down the line—they might start off with facial surgery, breast surgery, and then move on to a vaginoplasty.
Was there anything else that you wanted to add regarding vaginoplasty, Dr. Safir?
Dr. Safir:
No, just to say, years ago vaginoplasty meant one thing and phalloplasty meant one thing. What we’ve tried to do is customize—or tailor—our operations based on what a patient’s surgical goals are.
So, just when you’re telling your surgeon what you want, explain what your goals are, and don’t feel like you can’t make your individual desires known. It’s important to us that we give you the operation that’s right for you.
Dr. Satterwhite:
I think that’s so important—understanding that for us, as surgeons, it’s important to be on the same page with you in terms of your goals and wishes. We never want to be the ones telling you what the “right” thing is for you.
That’s why it’s nice to know we have the peritoneal pull-through vaginoplasty and other different types of operations available, depending on your goals and wishes—depending on your tolerance for certain risks or complications.
And this goes in line with a question we have here—so Glenn, who I know well—Glenn, welcome! Glenn does a wonderful job taking care of our patients pre- and postoperatively with scar management, lymphatic treatment. Thank you so much for all the care you provide to our patients.
Glenn is asking a really insightful question: When do you recommend electrolysis when someone is planning on vaginoplasty?
Dr. Satterwhite:
This is a perfect segue into who would be a good candidate for the peritoneal pull-through versus the traditional penile inversion vaginoplasty.
If you have a patient who just cannot move forward with electrolysis—for example, they’ve had a history of sexual trauma, which is very unfortunate—they may have post-traumatic stress disorder (PTSD), or they may not have access to hair removal. In that case, the scrotum and the scrotal tissue may not be accessible.
Then, a peritoneal pull-through vaginoplasty may potentially be a good option for that patient, because the perianal tissue doesn’t have hair on it. You don’t have to do hair removal beforehand.
But for someone who is going to move forward with a penile inversion—or really, for any type of vaginoplasty in general, getting back to your question, Glenn—you want to start the hair removal process as soon as possible. Because once again, hair removal is permanent. Once you’ve had it done, it’s done—and you never have to worry about it again.
So if you know it’s going to be part of your journey, then move forward with that. That’s one reason why someone may pursue peritoneal pull-through versus a penile inversion vaginoplasty. But there are a whole host of other reasons why one might be more advantageous to you.
Dr. Safir:
Yeah. On the hair removal part—and also maybe some aspects of who may be a good candidate for robotic versus traditional—well, you know, whenever there’s a choice in surgery, we know that no operation is perfect for every patient. And that’s true for all aspects of reconstructive surgery.
I think the conversation that starts with what you’re looking for is really important. In certain aspects, like you said—whether or not patients are able to do electrolysis or laser hair removal—it’s really important for us to know.
I think the overwhelming majority of patients who have not had bottom surgery and are looking for a sizable canal and external anatomy that looks right for them, as it is now, the majority of patients are pretty well served with penile inversion vaginoplasty.
That said, I think it’s good to visit programs that actively perform both types of operations. Because if all we’re doing is one operation, and there are no alternatives, then it’s going to seem like that’s the right operation for everyone.
So I think it’s important to start by talking about what you’re looking for and speaking with your surgeon about the advantages of either.
Dr. Safir:
For a first-time patient—Thomas, what do you think about the patient who comes in and says, “I want to have good depth. Everyone’s talking about robotic surgery. What should I do?”
Dr. Satterwhite:
Right, and I think—as you were stating—it’s important that you, as a patient, should be as informed as possible and really know about each of the operations. Because you might have friends or family members who’ve gotten a certain type of operation and they did super well, and then you’re like, “Oh my gosh, I want that same operation!”
But you really have to have a full understanding of all the different options that are out there.
Dr. Safir:
As you were saying, Dr. Satterwhite, the penile inversion vaginoplasty is still the number one operation that we like to do for patients.
So, if you have an adequate amount of genital tissue and you’ve done hair removal, I think the penile inversion vaginoplasty—where you use your current tissue, the penile shaft skin, and also the scrotal skin—is going to be a good way to go to get good depth. And patients do quite well.
My thoughts have always been—our thoughts in our practice have been—that the robotic peritoneal vaginoplasty or the pull-through vaginoplasty, and we can talk more about the technicalities of that one, but once again, that’s using lining from the inside of the abdomen to create the vaginal canal, which has become more popular.
I often feel it would be best for patients who’ve had a prior penile inversion vaginoplasty and that’s failed in some way—where it’s developed what’s called stenosis or closure, which can happen if dilation hasn’t gone well or other complications. Then you can use the robotic peritoneal pull-through vaginoplasty as a way of salvaging or creating a reconstruction of the vagina.
And then if that fails, you can move on to a colon procedure. But that doesn’t mean you always have to follow that particular pathway. There are some patients who state, “Lubrication is important. Self-lubrication is important for me,” so they would be a good candidate for the colon operation—because the colon does produce natural lubrication.
That’s oftentimes a misconception—folks think that the peritoneal pull-through vaginoplasty creates lubrication. Anecdotally, some people state that’s the case, but in reality, the general consensus is that is not the case. It’s really only the colon procedure.
Dr. Satterwhite:
I think it’s important for patients—as you said, Dr. Safir—to speak with surgeons who offer all of these. Currently, in our practice, we do offer the penile inversion, and now we’re fortunate to be able to offer the penile pull-through vaginoplasty.
We can offer you all the different risks and benefits of these options and make sure that they line up with your particular goals and wishes.
And that kind of goes with another question here—someone said they had bilateral hernia surgery as a child. What is recommended for someone who has had previous abdominal surgery. Very good question.
So once again, that goes in line with whether or not you would be a good candidate for a peritoneal pull-through vaginoplasty. If you’ve had significant abdominal surgery—inside your abdomen—there might be a lot of scar tissue, and you may not be a good candidate for having the robotic perianal pull-through vaginoplasty.
That’s a very good point. Just letting your surgeons or doctors know your full medical and surgical history is a really important part of the evaluation process.
Dr. Safir:
Yeah. What I’d say about hernia surgery in particular is—a lot of surgeons, when they do laparoscopic hernia repairs, will use mesh. And that mesh goes in an area that may make it difficult to use peritoneum during the surgery.
So, the specifics of what you know about your past surgery are important.
The other thing I think is important to know is that I’d say almost 90% of the operation—penile inversion vaginoplasty versus robotic peritoneal surgery—it’s the same.
All the work we do on the outside, in developing the opening and starting the reconstruction of the vagina near the opening—that’s really the same. So, while these operations have important differences, they share more in common than they differ.
I was talking with someone in Los Angeles about surgery and they had said, “The doctors who offer penile inversion vaginoplasty are offering an operation that’s dated or from a different era.”
But really, like you were saying—it’s the most common operation performed now. And to have the versatility to offer both operations—especially in complex or redo cases—and for the surgeons to have the freedom to decide between them, that’s important.
Otherwise, we risk getting pigeonholed into doing an operation that might not be right for the individual patient.
Dr. Satterwhite:
Yeah, that is so true. It has to be a two-way discussion between the surgeon and the patient—even a multi-person discussion with the surgeon, the primary care doctor, family members.
But then, just to really clarify—so, Dr. Safir, who is a good candidate for robotic vaginoplasty? Who would be a good candidate for the peritoneal pull-through robotic vaginoplasty as an initial operation?
Dr. Safir:
Yeah, you know, I think in some cases, patients who’ve been on puberty blockers and haven’t developed anatomy that would be sufficient to create even a good portion of the canal—maybe that’s a good option.
Also, like we were talking about before, patients who’ve had a penile inversion vaginoplasty and lost some of their canal—I think patients like that, we can salvage some of the canal and then add to it with the peritoneum.
So, failed or previous penile inversion vaginoplasty that’s resulted in some loss of depth.
And there are some patients—it’s not necessarily that the initial operation went wrong. Some patients stop dilating or something happens that interrupts the ongoing process necessary to maintain the canal. Something happens during recovery, and they need something else done.
You know, I think if you also have a patient who says, “Look, I want to have as much depth as possible,” someone who says that and only wants an operation that will give them as much depth as possible—a patient like that might be best served with peritoneal surgery.
Although we’d certainly have a conversation and say that I think penile inversion vaginoplasty could likely offer them what they want, too.
Dr. Satterwhite:
So then, Dr. Safir—if you had a patient who did have adequate genital tissue, right? They hadn’t been on blockers, and you tell them, “Hey, I still think you would be a good candidate for the penile inversion vaginoplasty,” but they really, really, really want the peritoneal pull-through vaginoplasty—what would you tell them?
Dr. Safir:
Yeah. Well, what I’ve been talking with patients about is to really explore their path to surgery. Sometimes it’s as simple as, “My friend had a peritoneal operation and it went great, and that’s what I want.”
And the power and value of having someone you care about doing well with surgery—that’s not to be discounted. It’s really important.
But I would just explain to the patient—like we do for all of our operations—these are complicated operations. We try not to make a big deal out of them, but they are really complicated. There are a lot of steps, and some of them are perilous.
There may be complications or problems with healing. For example, with intraabdominal surgery using a robot, there can be injury to the bowel, injury to the bladder, bleeding, injury to major blood vessels. Those things are relatively uncommon, but I think with a lot of the press that peritoneal or robotic peritoneal surgery is getting, it doesn’t talk about some of the complications that would be extraordinarily rare to encounter with a simpler penile inversion vaginoplasty.
Dr. Satterwhite:
Yeah—what do you think, Thomas? How do you talk with patients?
Because obviously they’re coming in—maybe someone they know had surgery, maybe you did their friend’s surgery, or maybe their friend lives across the country and had robotic surgery.
You know, how do you counsel them?
Dr. Safir:
It’d be the same thing you did. So, once again, addressing their goals and wishes.
Letting them know that if you pursue the peritoneal pull-through vaginoplasty and that vagina closes off for whatever reason—we can’t go back and do another.
You cannot do another peritoneal pull-through vaginoplasty at that point. You have to move on to a colon. Right? And so then that kind of, I suppose, burns that bridge.
But once again, that goes along with why someone who has adequate genital tissue might still move forward with the robotic peritoneal pull-through.
And you brought up one of the potential advantages—because there are some studies that show with the robotic procedure, you can actually get a little bit more depth. Not a huge amount—maybe one or two centimeters or so—and there’s still more research being done.
But that seems to be, as far as I can tell, the biggest advantage: just a little bit more depth.
Because you still don’t generate any lubrication, and you still have to dilate.
That’s a question Glenn brought up—vaginal dilation or pelvic therapy between the two different types of operations. You still have to dilate. It’s not a self-sustaining vagina. You still have to continue doing lifelong dilation.
Dr. Safir:
Yeah, agreed. You know, one thing I’d say also is: as surgeons, we’re concerned about everything and worried really about nothing—or at least we try to be that way.
And it should be said that we love these operations. We think they’re awesome. They really make a difference for our patients. And we have incredible optimism for the future—with the addition of other operations.
It should also be said that the peritoneal addition to surgery is not the only advance that’s been made in the last four or five years. There have been really important changes in the way penile inversion vaginoplasty has been done that have catapulted it to continue being the number one operation.
Even though we talk about complications and differences and concerns—what we really have are awesome operations and awesome relationships with our patients that give us the opportunity to step into their lives and make important changes.
So while we’re talking about differences—“Do I do this one? That one?”—what we really have is an opportunity to discuss it. And that opportunity is one of incredible optimism for the future.
Dr. Satterwhite:
You’re so right. I think that the best way for any patient to come in is—once again—going to a center like ours that offers multiple options.
Then just let us know what your goals and wishes are. We can break down what each of these operations entails in terms of:
- What the pre-operative preparation is,
- What happens during the operation,
- What the potential risks could be, and
- What the postoperative recovery regimen is.
And then you can decide—among all the things we’ve provided—what would be the best route.
That’s the best way to go, because yeah, you hear a lot, you see a lot on the internet, a lot on social media—and this applies to everything, not just vaginoplasty—so it’s hard to be able to know what’s going on. So that’s why spending time talking with us is going to help tremendously.
And this kind of goes along with a question someone asked here—it was about age.
This is from Jay. She was asking: “Does age complicate or present other concerns?”
So, on top of all the other concerns we’ve talked about, does age present additional challenges when exploring vaginoplasty? The oldest patient I’ve operated on was 78, and she did well.
It’s more than just age—if you’re 50 and healthy, you’re going to do well.
Dr. Safir can say the same—we’ve had patients in their 20s with a lot of medical issues. They’ve had uncontrolled diabetes, they’re still smoking, or they’re using certain medications that can predispose them to bleeding. Those patients we worry about.
But a healthy 50-year-old? No. That’s a very good question though, Jay.
Because again, we want to take into account all these different factors: age, medical history, surgical history—as we work together to decide what the right operation is for you.
Dr. Safir:
Yeah. And someone else asked a very pertinent question:
Just kind of breaking it down—what is the difference between the two?
Dr. Satterwhite:
Yes! Dr. Safir—can you talk about that? I just realized we’ve been getting into a lot of technical aspects, but haven’t really broken that down clearly.
Dr. Safir:
Sure. So, what I would say is: the difference is in how the top of the vaginal canal is performed.
I scrubbed in on a lot of robotic surgeries, and that’s how I began to understand the operation.
The part of the vagina at the opening is identical. Above that part, we put some of the scrotal skin, which further adds depth to the canal.
The difference is sort of like the snow peak on the top of Mount Fuji. You’ve got this really tall mountain, and on top of it, you’ve tapped it with some additional real estate.
You get a little bit more width and length at the top. And you may have some additional anchoring ability, because the peritoneum is anchored in position—that helps keep the vagina up.
That’s the best way I can describe it. You can ignore the Mount Fuji thing—that was a little obscure.
Dr. Satterwhite:
No, it’s in my mind—it’s never going away. But yes, it’s the top—it’s the top of the canal.
So, with that being said—and thank you for breaking that down—what are the benefits? I know we touched on this, but in bullet point form, what are the benefits of the robotic vaginoplasty?
Dr. Safir:
I would say the benefits are:
- You can get a little bit of additional depth.
- It may be an option if your genitalia doesn’t lend itself to creating a decent canal.
- Patient preference is important—to get the operation you want and need. If it’s appropriate, we’ll give it to you.
- Taking advantage of new technology is always exciting.
As surgeons, we’re looking to expand our experience. But I think they’re very similar operations, and the best operation is the best operation in that surgeon’s hands. That’s what I’d say.
Dr. Satterwhite:
Yeah, I think there are more similarities than differences. And it goes back—because I think one of the misconceptions is lubrication.
That’s just not going to be the case.
Just to go back—because I know another question was submitted by the audience—about whether you need hair removal for robotic vaginoplasty.
In general, you still should, because there are going to be components used in the canal. But once again, if you can’t do hair removal, then we won’t be able to use the genital tissue—we’ll probably have to use more of the perianal tissue.
Just wanted to make sure I addressed those questions to whoever submitted them.
One thing I thought about quickly: for zero-depth and minimal-depth vaginoplasty or vulvoplasty, you don’t need robotic surgery. It doesn’t have a role—you wouldn’t use it.
So you don’t have to make that decision.
That’s a very good point, and it goes back to one’s particular goals and wishes. If hair removal is something you don’t want to move forward with, and you have no desire for a vaginal canal, as you said, then doing the minimal-depth or zero-depth is certainly a wonderful way to go.
And once again, it’s just important to talk with your surgeon. There are a variety of genital affirming procedures that can be performed, and we’ll help guide you through that process.
We’re coming to the half-hour mark—it goes by so quickly! Time flies when you’re having fun, doesn’t it?
I just wanted to thank everyone for being here. I know that you have a choice of doing so many other things today, and you chose to be here with myself and with Dr. Safir.
It’s a true pleasure and a true honor.
If you want to know more about vaginoplasty—about robotic peritoneal pull-through vaginoplasty, which we now offer—then go to our website:
www.alignsurgical.com
We are always here—reach out anytime. One of us is based in San Francisco and our beloved Dr. Safir is in Los Angeles. So we are here to serve all your needs.
Dr. Safir:
Thank you!
Dr. Satterwhite:
Thank you! Take care everyone.