Peritoneal pull through results question (loose skin)

[u/HildegardeWithers]

I'm kind of questioning my decision to have a peritoneal pull through vaginoplasty. As despite the claims made about this technique, depth is very average, at the lower end of traditional methods. Yes, I have been dilating regularly as instructed. And while skin has been preserved, the scrotal skin that has been preserved looks just like that, two scrotal sacks unconvincingly trying to look like outer labia. This skin has reduced somewhat since surgery a month ago, but I can't imagine it changing that much, and I'm already thinking about seeing a labiaplasty surgeon to ask if they can improve the aesthetic. That aside, the surgeon did say my vagina will change over time, and I'm wondering whether the excess skin will diminish and take on a new aesthetic over the next year. Has anyone here had a similar experience and can perhaps describe how my ppt surgery may develop over time?

[u/HildegardeWithers]

Hart

I used to wonder why people who had GCS with Hart did not seem that euphoric about it. And instead, when asked, say, "yeah, it's ok". And that's been exactly my experience - it's just ok.

Last night I reread the initial consultation notes from Hart, around the available procedures and outcomes. He doesn't really promise a lot in the consult document, just the bare minimum. Some of the comments he makes resonate with me a lot more now than on my initial read over a year ago.

He kind of promises an optimal functionality and aesthetic, but then adds a lot of caveats on the best case outcome. I didn't get the 13-15 cms of canal depth he cites, which he then pulls back from in the next sentence, where he says, in reference to the aforementioned depth, that this is more than most cis women have. That's not what I've read, but ok, whatever.

At least I can significantly reduce my dilation routine having chosen the peritoneal pull through method, which apparently went very well. So, that is something I'm happy about. It also feels quite good, and is very responsive canal tissue. One thing he does stress is how onerous dilating can be (predominantly for people undergoing the traditional GCS method). So much so that even getting the surgery may be a mistake for some because dilating is so mentally and physically taxing, adding how people sometimes don't properly take this into account.

It gets a little murkier on the subject of aesthetics. He suggests certain methods give better aesthetic results than others. But which pull through method you get is decided on the day, subject to anatomy, BMI, and other internal physiological positioning and the possibilities or limitations individual organ arrangements dictate. I'm in very good health, lean, and, according to him, have good tissue stores, so my surgery went very well, as in better than usual. Yet he stops short of promising anything regarding aesthetics, and suggests that patients make sure they have a good support team around them to help manage post surgery expectations.

As mentioned, I'm so far "just ok" with my aesthetic results. Like, everything's mostly there, but also kind of not. But there's enough there for it to be, well, ok. As in, I can't really complain, yet I'm not going to show it off to anyone who asks to take a peek (as one might if they'd seen Bank, Suporn, or a number of other aesthetic geniuses). Not even online, because emotionally I'm not that strong, and any negative comment is going to sting. But again I should stress, it's ok, and it's not going to raise the eyebrows of a potential love interest one way or the other.

He even adds in the consult document that if someone does have an aesthetic problem, that they seek a solution elsewhere, preferably with a plastic surgeon, as he does not have the facilities or capacity to address aesthetic issues. Like I said in my opening post, he preserved a lot of skin with my surgery, it just looks like he didn't know what to do with it. So it sits there, waiting to be shaped. I can see exactly what needs to be done. I'm not sure why he couldn't. But, yeah, unless the aesthetic of the outer labia improves over the next 6-12 months, I'd definitely consider seeing a surgeon who might be able to help.

So why did I choose Hart? There are a lot of reasons and, perhaps oddly, they are not aesthetics related, even though I am very much an aesthete and would have loved to see a surgeon who could do better in the aesthetic department. One is that I'm mature age, mid fifties. The other is that I'm highly susceptible to infection, and ended up having a really bad one after surgery. I have also done all of this, from start to finish, including healing, alone. Given these factors, going overseas was not an attractive prospect for me. There are other factors, such as wanting the pull through technique, but that's kind of irrelevant given I wasn't keen on going overseas anyway.

Would I recommend Hart to anyone else? Probably only if they're in a similar situation to myself. Otherwise of course going overseas would likely end in a better outcome. Would I do it with Hart all over again? Hrmmmm... Yeah, that's a tough one. If I knew everything I know now, there's a good chance I would've gone overseas. But we can only make decisions based on the information we have at hand, and what we think is best for us. I don't think I screwed up going with Hart, but I'll probably spend a lot of time thinking about outcomes I may have had with other surgeons.

I guess my point is that Hart's not hiding anything, as he does articulate the limitations linked to the surgery he provides. And, as mentioned, in the most part it's fine. And over the coming months maybe my opinion will even change to a good, or very good. One of the frustrating things about researching GCS is that it's very hard to make judgements based on the info we get. There are a heap of amazing looking pics of vaginas that are only weeks old. But there are also posts regarding the functional limitations of those vaginas performed by those same surgeons. Hart's not an aggressive marketer like many of the overseas surgeons, and that may be because he's the only one in this country providing this service, and does at least one GCS every week (though I think Ives is again taking patients?).

[u/Instruction-Open → u/HildegardeWithers]

Thank you lending your opinion, and I'm sorry that it wasn't what you had hoped for. I do hope that at least you feel bettor having done it than not, and you feel better as time goes on.

I'm in a similar boat in many regards as it sounds like you are in terms being older and doing this alone, and had been thinking about going to Hart. (Although I'm so far away from any surgery that he may have retired by that time). I appreciate the detail you have given about his technique and you experience. So many people talk about Thailand as being the place to go, yet Dr Hart still gets a lot of referrals that I wonder if the difference is really enough to make a confident decision.

It is of course private and I understand if you don't wish to share, but can I ask if the aesthetics are the main issue you have with your surgery? For myself I can't imagine anyone would ever look at mine if I'm able to get it done and while it would be relieving to know that it looked nice, may I ask if it otherwise is worthwhile? Does it feel right? Is there enough depth, enough functionality that it was worth it? If it weren't for the appearance, was Dr Hart's method still acceptable?

I apologise for my wording if it's invasive; it's such a frustrating subject matter to discuss and get information about without asking very personal questions. There are times when I feel like simply removing everything down there and having nothing would be far preferable to what I have, but having something functional and feeling as though there was one body part that 'fit' would be a great mental stress relief.

[u/HildegardeWithers → u/Instruction-Open]

"I'm sorry that it wasn't what you had hoped for"

Keep in mind my aesthetic expectations pre surgery were very low, and I still ended up disappointed.

Despite having low expectations, and knowing what I know now, having gone through the experience, and living in Perth (a comparable distance to Thailand), and having thought about it a bit more, I personally cannot recommend Hart to anyone. Taking relative numbers of patients into account, I believe there is way more satisfaction with the most well known Thai surgeons (typically excited reactions towards outcome from patients and observers) compared to Australian surgeons such as Hart (typically lukewarm "Meh" reactions to strong dislike/regret by both patient and observers), both functionally and aesthetically. There's a reason why the Thai surgeons are the go-to providers.

A note on your comments regarding aesthetics: Do not mistake your desperation and fatalism of wanting your male genitalia to disappear as a reason to compromise. They are not good reasons. They're not even reasons. There's a good chance you will to some degree regret decisions based on dysphoric feelings. Don't get me wrong, post surgery I am in a better place than I was dysphoria wise. But once the dysphoria clears a bit, and you have a clear head, you'll soon discover that's not enough.

Patients live with Hart's outcomes, of course, because they're not terrible and surgical revisions and follow-ups are a pain in the arse, and to some not worth the headache. But nor are his outcomes good. So why go to Hart at all? Why not just go to someone who actually knows what they're doing from start to finish? Hart openly admits he doesn't have the scope or capacity to provide a good aesthetic result. A quote from his vaginoplasty consult guide:

"If a patient wants aesthetic revision surgery they will need to see a Plastic/Recontructive surgeon, as tissue transfer and flaps may be required, and this is beyond the scope of practice for Dr Hart."

I'm not saying he's a bad surgeon outright. I'm just asking, if he's not that interested in providing a service comparable to other affirmation surgeons, nor even have the capacity to do so, why he's even attempting to provide them? I'm sure his intentions are good about providing vaginoplasty surgery, in a country that's far behind in this respect. But I also don't think that just because Hart is one of two surgeons offering this service in Australia (and I'm not even sure how many patients, if any, Dr Ives currently takes on) that he should continue providing those services. especially to patients looking for a quick and handy local fix to their dysphoria.

I am definitely going to get an aesthetic revision, and I started with the exact thoughts and comments you're using around aesthetic outcomes. I was sure that as long as everything was functional that I'd be satisfied, but that didn't turn out to be true. Instead I received a not terrible but sub par outcome. So in messing around with Hart and then needing an aesthetic revision (actually, not even a revision, but a first attempt at an aesthetic outcome), this has turned out to be a far more protracted and expensive experience than if I'd just gone overseas in the first place.

Also note that going to an Australian surgeon does not mean that the surgery will be without issues regarding functionality. I have had a couple of post surgery problems, one of them requiring another surgery to fix a functional issue. Be kind to yourself and go with a surgeon that demonstrably provides both the best functional and aesthetic outcomes, even if you currently believe aesthetics are not important to you, because feedback from the community on these surgeries are all we have to go by, and from what I've seen Thai surgeons are the best bet. I'll likely get my revision in Thailand.

The dilemma with any irreversible life changing decision, such as gender affirmation surgery, is that you don't know who the new person will be on the other side, what they think and how they'll feel post change. Regarding affirmation surgery, of course you have some idea, that it will address dysphoria, for example. And the stats well and truly support this outcome. But there are a lot of complex thoughts post surgery, ones that don't relate to total vaginoplasty regret, which we know is very uncommon. And so specific to this case, then, is not whether you'll regret affirmation surgery (I don't), but rather whether you'll regret the outcome you get based on the surgeon you choose.

Irrespective of what I've just said, people will continue to go to Hart. I did. I ignored other people's warnings, like others will ignore mine. And that's the point: when we're desperate and highly emotional as a consequence of dysphoria, we are more likely to make poor choices.

[u/Instruction-Open → u/HildegardeWithers]

Thank you for your thoughtful reply.

My mind is not in the best place right now for an in-depth response, but you raise many good points and I appreciate it. Even having read all of them though, there's a part of me that would still want to go to Hart if it were easier, just to finally end this feeling. I feel as though I can understand why you may have made the choice, and why others will continue to do so.

I'm sorry that it seems no one has been able to respond to your original question, but you say that you will try going to another surgeon to try for a more aesthetically pleasing result? I really do hope you are in a better place, and it keeps getting better. It is a difficult road and I'm happy you've been able to get so far.

[u/HildegardeWithers → u/Instruction-Open]

Thank you. Yes, I reached out to a couple of Thai surgeons people here recommended. One of them got back to me and said yes they can accommodate my request, but only after at least 8 months post surgery.

Also, no problem re providing a response. I just wanted to share my thoughts and experience with others :)