Male to female transsexuals frequently seek feminizing vaginoplasty for ''below the waist'' conformation, enhancement of sexual identity, and interactive sexual function. The author shares his experience with his first 250 primary surgical procedures. Included is a brief historical background, the patient selection process, some guidelines from the World Professional Association for Transgender Health (standards of care), preoperative evaluation and instructions, surgical technique, postoperative regimen, risk factors, results, complications and management. The patients all underwent feminizing vaginoplasty at the author's ambulatory surgical facility, which includes an overnight stay. The author's results suggest that feminizing vaginoplasty when performed vigilantly on a select group of patients is feasible.

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The evolving techniques of augmentation phalloplasty and penile autologous fat transplantation (AFT) are described, with historical correlation. Experience derived from 200 procedures is presented, relating to patient selection, informed consent, biophotography, intraoperative technique, skin transfer, and postoperative care. While total corporal length remains unchanged, an outward gain of 1 to 5 cm (average 3 cm) can be obtained. Success with simultaneous AFT has been variable, and touch-ups may be required. Complications include disappointment with “low-end” results, reabsorption of fat (zonal and complete), seen especially with smokers, emergence of fatty nodules minimized by more thorough undermining, and one case of mucosal shaft edema and hyperesthesia still in follow-up. In general, patients are pleased and thus there is encouragement to refine and continue in appropriately selected cases.

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