Vulvoplasty

Minimal-depth vulvoplasty is a surgery that creates the vulva. The vulva is the external genitalia, including the clitoris, labia minora and labia majora.

We recommend minimal-depth vaginoplasty for several reasons, including for people who:

• Do not wish to have penetrative vaginal sex
• Do not want to or are unable to receive hair removal
• Do not want to do routine vaginal dilations
• Want to reduce the risk of complications like fistulas and bowel injuries

Your surgeon will answer your questions about surgery and provide you more information about the risks associated with vaginoplasty during your consultation.

How do I prepare for vulvoplasty while I am waiting for a consultation?

While you wait for your consultation, there are several things you might need to do to prepare for vulvoplasty.

Orchiectomy

Orchiectomy is a surgery that removes both testes. An orchiectomy is necessary to perform vulvoplasty. You can undergo an orchiectomy while you are waiting for vulvoplasty, or undergo an orchiectomy at the same time as vulvoplasty.

Nicotine cessation

We require you to abstain from nicotine consumption, including tobacco and e-nicotine products, for at least 6 weeks prior to surgery and 6 weeks after surgery. This is because nicotine constricts the blood vessels and decreases blood flow to body tissues. Nicotine users may have a higher risk of complications, including delayed healing of wounds and skin graft failure.

Some patients may choose to work with their primary care provider and the Koop Tobacco Treatment Center at Dartmouth Hitchcock Medical Center to receive support in quitting nicotine products to help them prepare for surgery.

Diabetes management

For individuals who are diabetic or are at-risk for diabetes, it is important to have A1C levels checked and confirmed before you have surgery. We ask that you have an A1C of 7% or lower prior to surgery. Having uncontrolled blood glucose levels can lead to higher rates of infection and there are risks associated with poor healing of the surgical site.

Body mass index (BMI)

We recognize that bodies come in all sorts of shapes and sizes and that weight is not the ultimate deciding factor for overall health. Generally speaking, a BMI of 35 or less is desirable for optimal surgical recovery. Having a BMI above 35 can lead to higher rates of complications, specifically with regard to blood clotting and tissue healing.

Some patients may choose to work with their primary care provider and the Weight and Wellness Program to address weight and related conditions to help them prepare for surgery. However, each person is unique and BMI is not always a reliable indicator of overall health.

Mental health letters of support

Patients will need two letters of support from two separate mental health providers. In 2022, the World Professional Association for Transgender Health (WPATH) released the 8th version of their Standards of Care document, which recommends only one mental health letter is needed before gender-affirming genital surgery. However, many insurance companies still use the older SOC-7 guidelines and require two letters before they will cover surgery for the treatment of gender dysphoria.

Letters must meet the requirements of the specific insurance carrier as well as the criteria listed below. It is important for patients to contact their insurance provider to confirm what their requirements are for coverage.

• One of the letters needs to come from a mental health provider who the patient has an established and ongoing relationship with. This provider is usually a therapist or psychiatrist who the patient has regular appointments with.
• The second letter can come from a mental health provider who has screened the patient for eligibility and surgical readiness but that the patient does not continue to see on a regular basis.

Please note: One of the letters needs to come from a mental health provider who holds an MD, PhD, or PsyD degree. The other letter needs to come from a mental health provider who holds a Master's degree or higher.