The Optional Second
Stage of SRS

By Becky Allison, MD

(Graphic shows an actual Meltzer/Schrang post-op result at four weeks)

So, you will be so glad when you finally have your SRS, because that will be the last surgical procedure you will need - right?

Not for most of us. The majority of surgeons performing male to female sex reassignment surgery use a technique which requires a second, lesser procedure to be performed some months after the initial operation. This second procedure is called "labiaplasty". Here is why it is necessary:

During SRS the former scrotal skin is used to create the labia. The blood supply to this skin is not damaged as long as the front margin of the tissue is left in place. This requires the new labia to be left more or less parallel to each other, with the new clitoris left exposed between the front ends of the labia. Later, after the tissue has healed and the blood supply is stabilized, it is safe to bring the labia together over the clitoris and create a normal appearance. At least three months is necessary for safe results.

In my case, I have waited over a year after SRS before scheduling labiaplasty, primarily for financial reasons. I had SRS with a physician back East and was pleased with the results, but since I live in the West now I decide to contact Dr. Toby Meltzer at the Oregon Health Sciences University. My friends who have been to Dr. Meltzer have all been very pleased, and I had met him at Southern Comfort Convention and was very impressed with his presentation.

At the same time, I want to have malar (cheekbone) implants done. Prior to my transition I had feminizing facial surgery on my nose, eyelids, chin, and tracheal shave. This was the only other facial procedure I desired.

I write to Dr. Meltzer with my request, and he replies promptly with instructions on making an appointment. In my case, he will see me in his office one afternoon and do the surgery the next day. I find Dr. Meltzer and his office personnel to be very supportive and helpful. My office visit is scheduled for a Monday, with surgery on Tuesday.

I decide to take advantage of the weekend prior to my visit and tour the Portland area. My friend, Dr. Anne Lawrence, has given me good advice on where to stay and what to do. Between her advice and the Portland Guidebook, which I have found in my local bookstore, I am able to make good plans.

I schedule a flight to arrive in Portland on Saturday afternoon, staying for five nights, and returning home on Thursday. I rent a car (this is optional of course; you can get an airport shuttle to the hotel) and reserve a room at the Days Inn City Center. This is a relatively inexpensive business travelers' hotel which is located very close to the Oregon Health Sciences University. It has modem-compatible phones and local calls are 45 cents each. There is a restaurant in the hotel with room service (very important post op!) and decent food. When I made my reservation, I tell them I am an OHSU patient. They will give a generous discount for persons who are having outpatient surgery.

I spend the weekend sightseeing in the Portland area and relaxing. Late Monday afternoon I leave the Days Inn and drive south on Fifth Street, making several turns to arrive on Sam Jackson Park Road. A map of the downtown streets is available when you rent a car, and is essential for driving to the hospital. OHSU sits on the tallest hill inside the Portland city limits, with lovely views eastward across the Willamette Valley. I park in the basement garage of the Physicians Pavilion and find Dr. Meltzer's office on the fourth floor.

After I obtain a clinic patient card and fill out the usual forms, the nurse takes me back into his consultation room. Luckily, I have brought one of my new purchases from Powell's Books, because the doctor is running behind schedule. I understand; that happens in my practice too. So I wait my turn. When Toby arrives, we share small talk and the usual "do you know so-and-so" of mutual acquaintances. Then we get to business.

The procedures will be done under local anesthesia, so the risk to my health is minimal. He analyzes my facial bone structure, agrees the malar implants are a good idea, decides what size to use. We discuss technique. The labiaplasty is a very straightforward procedure - I hate to use the word "simple" but it is. Instead of a double-Z incision, he uses an inverted "Y" that only leaves a small midline scar, easily hidden in pubic hair. I sign the consent forms and am given my preoperative instruction (light breakfast, then nothing to eat). I buy a box of Maxi Pads. And of course, I pay for the procedures (they take plastic!).

On Tuesday morning I make two choices I shouldn't have made. First, even though I'm told I can have breakfast, I just have a Coke. I don't want a full stomach for surgery. Second, I drive myself to the Physicians' Pavilion and leave the car in the garage.

I check in. And I wait, and wait. Still with my book, fortunately. Finally I meet the anesthetist and the procedures are again explained to me. I disrobe and put on my hospital gown, and EMLA cream (topical anesthetic) is applied to the labia with an occlusive dressing. This feels a little messy, sitting around for an hour with ointment and cellophane on my vulva! Finally we are ready. I walk into the operating suite and lie down on the table. I am shaved and scrubbed, and attempts begin to start an intravenous line. By now it is 1:00 P.M., and that early morning Coke is long gone. So are my veins. I should have drunk more fluids! Finally an IV is established, and I receive an antibiotic and a mild sedative (Versed). The anesthetist and circulating nurse are wonderful, staying with me, talking and joking.

Toby does the malar implants first. Injection of the local anesthetic in the area between the gum and lip is mildly uncomfortable, but not bad. The main pain is when he undermines the periosteum, or tissue overlying the cheekbone, for placement of the implant. There are lots of nerve endings in the periosteum! The anesthetist gives me a small dose of morphine. I'm very relaxed. Toby closes the incisions in the cheeks with absorbable sutures. This part of my surgery has taken slightly more than one hour.

The local anesthesia for the labiaplasty was more than a little painful, but very brief. Then the area is numb. I have another injection of Versed, and all I feel is the sutures being pulled through. There is very little bleeding and - for now - no pain.

Afterward I am fully awake. I dress, remembering the Maxi Pad. I get prescriptions for antibiotics (Velosef) and pain pills (Vicodin). Dr. Melter's nurse gives me my instructions: ice packs as much as tolerated to prevent swelling. Take ibuprofen for anti-inflammatory effect. Rest with head elevated. Eat soft food for the next two days. Resume dilating in five days. Oh, and don't drive until tomorrow. What? Oh, well. The office secretary calls a taxi to return me to the Days Inn.

Back at the hotel I'm not hungry. I try to sip water through a straw, but sipping is hard when your upper lip is numb. I wrap my legs around an ice bag, put another on my face, take two Vicodin and go to sleep. Later I awaken feeling hungry. I call Room Service and persuade them to bring me an omelet, even though we are past breakfast menu hours. The night passes with further doses of medication and no other problems.

On Wednesday I awaken feeling better and check the results in the mirror. The labiaplasty looks really, really good, even on day one. Everything is now in its right place. I am quite impressed. My face is more swollen, especially the upper lip. I look like I lost a fight. But I can tell the malar implants are going to be a big improvement. By afternoon I'm feeling well enough to retrieve the car and go out for a milk shake. (Bummer - no Dairy Queen in downtown, they are all in the burbs.)
Thursday is my day to return home. I have enough time to stop by for a postoperative check, where Dr. Meltzer is pleased with the results. The airline flight is not too uncomfortable, but a doughnut pillow would probably have been a good idea. I have the weekend to recuperate at home, and by the next week I'm back at work full speed.

I never had a single problem from the labiaplasty. I'm amazed at how easily it went. My cheeks remained swollen for another twenty days or so, gradually improving. It has been a very positive experience, and I'm sure if the need for more cosmetic surgery ever occurs, I will feel very comfortable returning to Dr. Meltzer.

Labiaplasty FAQ

Labiaplasty, or "Z-plasty" as it is sometimes called, is a surgical operation performed on male to female transsexual persons; it is a secondary procedure, performed at least three months after sex reassignment surgery (SRS).

Why is labiaplasty performed?

Most surgeons who perform SRS create the external labia from scrotal tissue. To create labia which meet in the front, it is necessary to undermine the scrotal tissue and bring both sides to the midline. If this is done at the time of SRS, there is danger of the tissue losing its blood supply. Therefore the new labia are allowed to heal and develop a safe blood supply before a second operation is done to bring them together.

Do all SRS surgeons perform labiaplasty?

A minority of surgeons perform a one stage procedure in which the labia are brought together in the midline at the time of SRS. Some persons are very satisfied with this procedure, but others feel it does not produce as normal a postoperative appearance as the two stage procedure. There is some risk of harming the blood supply to the tissue by doing labiaplasty at the time of SRS; but of course there is also the risk of a second operation when labiaplasty is done later. This risk, however, is very small.

Is labiaplasty painful?

The patient is given preoperative medication including antibiotics and sedatives. Some surgeons use a topical anesthetic (EMLA cream) on the labial area for at least an hour before the procedure. An intravenous line is started so more medicine can be given. Then local anesthetic (lidocaine) is injected around the area. There is some brief pain with the lidocaine injection, but this resolves quickly.

What is done at labiaplasty?

Different techniques are used by individual surgeons. One technique uses a double "Z" incision to create long strips of tissue which are then reversed at the base of the incision to bring together two strips which had been parallel. Another technique, which leaves only a small midline scar, produces an incision like an inverted "Y". At the same time, if a band of tissue has been left across the area between the urethra and clitoris, this band is divided to expose the inner labia. The end result may be indistinguishable from any female external genitalia.

What is the cost of labiaplasty?

Costs vary from one physician to another. Average costs range from $1000.00 to $3000.00. Some surgeons charge more if the patient's SRS was performed by a different doctor. When considering cost, consider also the cost of air fare from your home to the surgical site. A savings of a few hundred dollars can disappear quickly if an expensive airline ticket is required.

Am I admitted to a hospital?

Labiaplasty is an outpatient surgical procedure. After the procedure you will remain in the office for perhaps an hour. A light dressing will be applied to the incision and you will be given instructions for wound care. You will not require a bladder catheter. Prescriptions will be given for antibiotics and pain medication. Do not expect to drive home or to your hotel; make other arrangements for transportation after surgery.

When can I resume normal activity?

You will probably be asked to avoid sitting in a bathtub for up to ten days. This helps prevent the spread of infection and helps your incisions to heal. You may shower the day after the procedure. You will probably be allowed to resume dilating - and sex - in five to seven days. Driving is permitted the day after the procedure.

Is labiaplasty absolutely necessary?

Many women choose not to have labiaplasty after SRS. It is not necessary for normal sexual function, although some say it has improved their sensitivity and responsiveness. Perhaps the most common reason for labiaplasty is a desire to have the anatomical appearance of a normal female.

Return To Home Page

1996 Anne A. Lawrence and Becky Allison; e-mail:

Return to Surgical Page Return to Top of Page
Return to Main Menu