A Vaginoplasty, also called MTF Bottom Surgery or Gender Affirmation surgery, is a surgical procedure where the male genitalia is reconstructed into aesthetically beautiful female genitalia including a clitoris, labia, urethra and possible vaginal vault. As an innovative cosmetic surgeon, Dr. Stiller continues to evolve his techniques, focusing on giving the most natural looking outcomes. The emotional benefits our patients feel after bottom surgery is truly amazing and inspiring as we see the newfound comfort they have with their bodies.
Dr. Stiller has trained extensively in multiple vaginoplasty techniques and is the only surgeon in Washington state devoted solely to MTF Bottom surgery. He has been performing vaginoplasties for the past 5 years and is trained in Zero Depth Vaginoplasties, Penile Inversion Vaginoplasties, and Colovaginoplasties. He has performed over 1,000 vaginoplasties, averaging 5 procedures a week, making him extremely sought after for MTF bottom surgery. Not only does Dr. Stiller have an immense amount of technical expertise and attention to detail, his bedside manner is unmatched. You will feel calm the moment you sit down for your consultation with his warm and compassionate nature. You will leave your consultation full of confidence knowing you are supported and in excellent hands.
The Colovaginoplasty procedure consists of creating a neo-vagina using the ascending colon (right side) after the Zero Depth Vaginoplasty has been performed. The procedure is done in a two-stage approach by reconstructing the male genitalia to give physical sensation, pleasure and urinary functionality first and then dissecting the right side of the colon to become the vaginal canal 6-9 months later. Full functionality regarding urinating, lubrication and sexual intercourse can be expected when transfeminine surgeries are performed by experienced board-certified surgeons such as Dr. Stiller. He has spent years perfecting his craft with the utmost goal of giving his patients the most natural looking outcome.
Many gender surgeons believe the Colovaginoplasty is a last resort procedure most commonly due to the lack of experience and knowledge regarding the technique. However, Dr. Stiller believes this is a great first option for patients depending on their own personal goals. Dr. Stiller performs 2-3 Colovaginoplasties a week, making him one of the most sought out gender surgeons to perform this technique. Due to his extensive background in general surgery, Dr. Stiller is the surgeon for every portion of the procedure, specifically regarding the colectomy and anastomosis. His extensive skillset and experience in laparoscopic surgery makes him on of the best gender surgeons to perform a Colovaginoplasty.
The Colovaginoplasty is performed after you have already underwent your Zero Depth Vaginoplasty where your clitoral hood, clitoris, urethra and labia were created. After your vulva has healed and your authorization has been approved it is time for the Colovaginoplasty. The Colovaginoplasty itself takes up to 3 hours, is done laparoscopically and you will have 5 small incisions on your abdomen. Through this procedure, Dr. Stiller carefully and meticulously dissects the ascending (right) colon from its surrounding tissues. The right colon is then separated from the transverse colon and the ileum (last portion of the small intestine). The transverse colon and ileum are then reconnected to keep the normal flow of the digestive system. If not already gone, the appendix is also removed to prevent any future confusion as its normal anatomical position comes off the right colon.
The vaginal canal is then created, between the bladder and rectum, and your right colon is brought through your new canal. It's important to note your right colon remains attached to its blood supply at all times and is closed at the posterior aspect. Once the right colon is pulled through your vaginal canal, if needed, any excess colonic tissue is removed. The edges of the colonic tissue are then sutured to the vaginal entrance. The final result is an anatomically congruent, aesthetically appealing, and functionally intact vagina. The prostate gland is left intact to assimilate the sensation of the G-spot during vaginal intercourse. This surgery is not intended for candidates who have a history of Ulcerative Colitis, Crohn’s Disease, or Colon Cancer.
Patients usually spend 2-4 nights at Deaconess Hospital after a Colovaginoplasty. After surgery, you will only have a catheter and vaginal packing- much different from your first stage surgery. The catheter is most commonly removed after 1 day. You will be on a liquid diet initially and slowly advance your diet as your bowels begin to normalize. Once you are able to have a bowel movement, you will be discharged.
You will again stay in Spokane for 2 weeks so Dr. Stiller and Riley can monitor your progress. At 1 week, your daily dilation schedule will begin after your vaginal packing is removed. Your anatomy will also be reviewed to make sure you are comfortable and confident going home.
The next follow up will be in another week to monitor your progress and you may return home after this appointment (if traveling out of town). The recovery process can look very different for every patient and you can find most of your recovery questions under our FAQs. However, the most common questions patients have are regarding diet, exercise, work and sex.
You will be on a low fiber diet for 6 weeks after surgery. Patients usually return to light exercise when they feel comfortable however no heavy lifting, greater than 20 pounds, for 4 weeks after surgery. You may return to work once cleared by medical staff, most commonly around 4 weeks. No submerging in water or vaginal sexual intercourse until cleared by medical staff, most commonly 3 months.
You will be provided with detailed post-operative instructions upon completion of your procedure. If at any time you should have any questions or concerns after surgery, please contact our practice immediately.
You will receive your dilators from MultiCare Deaconess Hospital the day of your surgery and you will bring these to your 1 week post-op appointment. You will have four dilators that go up in size, purple, blue, green and orange. After all dressings are removed, we will go over your new anatomy and dilate, yay! It's important to remember, your vaginal canal was created in a space that was not originally there or lined with your own tissue and unfortunately your body will try to heal itself by closing the entrance to the space. Therefore, dilations are important to keep the vaginal canal open.
Initially, dilations can be painful but improve as swelling goes down and healing continues. After a few months, dilations become much easier and become a simple easy routine. And don't be afraid to ask questions! There are no silly or uncomfortable questions you could ask. Dr. Stiller and Riley are there to best support you and make sure you are comfortable and confident.
When it comes to dilating, patients should dilate 3 times a day for 30 minutes each session for about 6 months. You will douche with water after your first and last dilation of the day. Initially, dilating at home can be difficult compared to first dilating in the office. It's important to get multiple pillows to prop yourself up on, a mirror to familiarize yourself and water-base lubricant. Staying calm and attempting to relax your pelvic muscles will help dilations go much smoother. The goal is to get to the orange dilator by 3 months. However, the dilation process is different for everyone, some may get there sooner than 3 months or later than 3 months so try not to stress. Around 6 months, the frequency of dilations can decrease depending on personal preference of depth and width however it is a lifelong commitment.
The prior authorization process can take 8-10 weeks. Our office will be notified when surgery is approved. Once we receive the approval you will be placed on a calling list to schedule surgery. This process can take an additional 1-2 weeks.
After surgery, you will need to stay 2 weeks in Spokane.
Stiller Aesthetics requires all surgical patients are accompanied by a caregiver during their stay. Specifically, for vaginoplasties, we only require a caregiver the first week of your stay.
Patients are responsible for all lodging and transportation. Patient may choose hotels or Airbnbs for their stay. Please refer to our list of hotel recommendations for places to stay.
Stiller Aesthetics does not provide any type of lodging, transportation, or home health.
We recommend that you call the customer service phone number on the back of your insurance card to discuss your specific plan benefits with an insurance representative. We are happy to provide you with billing codes if needed.
You should expect to receive bills from Stiller Aesthetics, the hospital, anesthesia, and pathology if applicable.
Your authorization has been submitted specifically to the transgender health department of the Washington State Health Care Authority. Authorizations for transgender care are NOT processed through subplans of Washington Medicaid such as Molina, United Healthcare, etc.
Washington Medicaid has specific requirements for letters of support from other providers. Please refer to the forms for the letter requirements. Our authorizations specialist will follow up with this request and send the additional information to your insurance company.
Due to insurance purposes, these procedures need to be performed separately. However, if you are traveling out of town, we will try to coordinate both surgeries to occur during your 2 week stay.
If you are taking oral hormone supplements or injectables, you will need to stop estrogen AND progesterone 3 weeks prior to surgery and 3 weeks after your surgery.
If you are on hormonal patches or pellet therapy, you DO NOT need to stop your hormones. These do not increase your risk of blood clots compared to oral hormone therapy.
Penile inversion and Zero-depth procedure averages around 2.5-3 hours. Colovaginoplasty Stage 2 averages around 3 hours.
Penile inversion and Zero-depth vaginoplasties are usually discharged the same day. You may stay 1 night in the hospital if you are in too much discomfort.
Stage 2 Colovaginoplasties usually spend 2-3 nights in the hospital.
We try for a minimal narcotic pain regimen which involves a spinal and general anesthetic or just general anesthesia. You will meet with the anesthesiologist the day of your surgery to ask any further questions you may have.
Unfortunately, scars are inevitable in any procedure. It can take 1 year for scars to fully heal and resemble a thin white line.
Zero-Depth Vaginoplasty & Penile Inversion Vaginoplasty: 2 scars along each labia majora, 2small scars on the mons pubis for the drains. Stage 2 Colovaginoplasty: In addition to the scars listed above, you will also have 5 small incisions, about ¼” in length, on your abdomen.
You can use any kind of scar care such as vitamin e oil, bio-oil, Moderna, etc. This is best to start around the 3–4-week mark after the incisions have healed and all the skin glue has come off.
Discomfort after the procedure is based upon the individual. We provide multiple modalities to minimize discomfort however some amount of pain is to be expected.
Typically, patient’s pain levels improve after the first week, after the drains/catheter/packing/bandages are removed, and narcotic pain medications are no longer needed. After this, patients’ discomfort is usually managed with Ibuprofen, Tylenol and Gabapentin. Around 1 month is when patients begin to feel more “normal”. As swelling begins to go down and nerve sensation returns, it is normal to feel twitches of pain as this represents nerve re-growth. This can last 6 months to a year.
Returning to work is based on a patient-by-patient basis. Generally, patients take off 4 weeks of work. You may return sooner as long as you are done taking narcotic pain medication. If your job involves heavy lifting and you received a Colovaginoplasty stage 2, we recommend 6 weeks. We can tailor doctor notes for you to accommodate whatever you need.
Icing 20 minutes on 20 minutes off for the first 2 weeks is best to really help with swelling. After that, icing 3-4 times a day (or more) until swelling resolves. Swelling can last up to 6 months. Do not put ice directly on skin. Frozen bags of peas or corn is sometimes more helpful as it can form to the area.
You may start masturbating after your 2-week appointment with your fingers or a vibrator (any toy works). You can stimulate the clitoris itself as well as 1 inch above the clitoris where the neurovascular bundle runs. Do not fret if you cannot orgasm right away! The nerves are growing, and it can take time (up to 1 year). Do not engage in any vaginal masturbation unless cleared by Dr. Stiller or Riley.
Re-starting your hormones can begin 3 weeks post-surgery. Make sure to discuss this with your prescribing physician as doses may change.
For the first week post-surgery, you may only sponge bathe. At your 1-week post op appointment, after the drains/catheter/bandages/dressings are removed, you may shower. For the first week, let the water run over the area (do not worry if soap washes over). Lightly pat the area dry. At 2 weeks, you may start to gently scrub the vulva with a fragrance-free body wash
Urinary spraying is common after your surgery due to swelling of the urethra. Also, welcome to womanhood! You will no longer pee in a straight line anymore. However, the spraying will improve greatly as swelling goes down.
Granulation tissue looks beefy red in color. This tissue is a part of the healing process however sometimes it will stay in this phase longer than it should. Do not worry, it is not harmful! Sometimes it may cause an odor or bleeding. If you are in the Spokane area, we can see you to cauterize the tissue with silver nitrate. However, many primary care physicians can take care of granulation tissue if you are out of town. You may always send a picture to the front desk if you are unsure.
With any procedure, we want you walking immediately after surgery. This will aid in the prevention of blood clots and help with bowel movement. You can start to do light exercises around 3-4 weeks, hiking, yoga, etc., if you feel comfortable. No lifting greater than 20 pounds for 4 weeks.
Majority of the discomfort after surgery will be abdominal from the laparoscope, rather than vaginal, however it is normal to have some vaginal discomfort as well. It can take 6 weeks-2months to recover from laparoscopic surgery involving discomfort, bloating and normalization of the bowels. It is normal to have increased gas and lose stools up to 6 months after surgery.
You will have 5 abdominal incisions about ¼” in length. One in each quadrant of the abdomen and one in the belly button. These usually fade to a thin white line.
As your surgery approaches, make sure you are drinking plenty of water (2 liters a day), increasing your vegetable and protein intake and staying away from processed foods.
The day before surgery you will be on an all-liquid diet. This includes water, nutritional shakes such as Boost and Ensure, Gatorade, water, Jell-O, coffee, and juices not containing pulp. If solid foods are consumed in the 24 hours prior to surgery, it will be unsafe to undergo anesthesia and the surgery will be postponed to a later date.
It is very normal to bleed after a Colovaginoplasty. It may seem scary but is good as this means the graft is getting good blood flow. Super absorbent maxi pads will help a lot! It is normal to bleed however if you have light headedness, dizziness or pass out please call our office.
There can potentially be an odor with the Colovaginoplasty. This likely will not last and usually resolves around 6 months due to colonic sloughing. If this does occur, increase hygiene and douching. Sometimes with an odor, this can be granulation tissue and cause yellow/green/brown discharge.
This is due to colonic sloughing and left-over stool from the bowel prep. Increasing the number of times you douche will help resolve this. You can expect yellow/brown discharge up to 6months after surgery.
Your vaginal canal is made from organ tissue (the colon) and that itself will never close. However, the first couple inches of the vaginal entrance can. Therefore, dilating is still so important with a Colovaginoplasty and is lifelong!
Dilation after a Colovaginoplasty initially may take more time to get up to a larger dilator secondary to the colon that is swollen. Sometimes, it is more helpful starting dilations with your finger the first couple of weeks and progress to using your dilator. For the first 6 months, you will need to dilate 3 times daily for 30 minutes. After this, the frequency of dilations can decrease depending on personal preference of depth and width however it is a lifelong commitment. Once you reach the orange dilator, after discussing with Riley or Dr. Stiller, you can start to have vaginal intercourse if desired or adding toys to make dilations more fun.
We would like you to use the dilators given however, it is not required. If you find that silicone dilators (equivalent size to the ones you are given at the hospital) work better for you then that is completely fine! Anything that can make your dilating experience more comfortable, we support!
You will start with the dilator you were instructed to do so with on your 1st week post op. Once this becomes easier, you may increase the size. It is recommended to do 15 minutes with the smaller and 15 minutes with the next size until the next size becomes easy and so forth. Once you achieve your desired color, it is normal if you feel you must use the smaller dilators first to work up to that.
We recommend attempting to get to the orange dilator by 3 months. Don’t stress! Dilating is done to help you and shouldn’t be considered a chore. Some patients get to the orange dilator sooner than 3 months and some later than 3 months. Everyone is different.
First, make sure you are relaxed and comfortable! Tight pelvic muscles can cause resistance and make dilating difficult. If you are relaxed and still feel resistance, kegel 5 times (squeeze against the dilator as if you are trying to stop the flow of urine) and try to push further unless you are at the maximum depth of the dilator. It is important to always reach out to us if you are having difficulties, never just stop dilating. Patients often will see a pelvic floor therapist if they continue to have difficulty with dilations.
If you are having trouble dilating, always reach out to our office to discuss this with Dr. Stiller or Riley. Some options you have are using a vaginal plug or anal plug and keeping that in the vaginal canal for about an hour. We do not want this to take away dilations however if you find difficulty during the day to dilate this is a good option.
You want to use any water-soluble lube (example: Astroglide, KY jelly, Surgilube, etc.). Patients have found that Surgilube works best and is best to buy BEFORE your procedure as it is not in local drug stores. You can usually buy Surgilube on Amazon.
You will fill the douche you are given at your 1-week post op appointment with tap water (only water). You may use warm or cold water, whatever is comfortable for you. It is best to douche in the shower for easier clean up. Insert the end of the douche into your vaginal canal and squeeze the bulb a couple times, letting the water/discharge/potential blood, run out. Repeat as many times as it takes to empty the bulb. You will douche after your first and last dilation of the day. Clean the portion that you inserted into your vaginal canal with non-fragrance soap and water.
You may have to wear panty liners for the first 6 months after surgery. Luckily, this is a lower potential risk since Dr. Stiller uses the right side of the colon. However, it is normal, even for cis gendered females, to have random occurrences of discharge. After 6 months, the colonic bacteria changes to a vaginal bacterium, meaning discharge could happen randomly even years after your surgery and that is perfectly okay and normal! Again, welcome to the joys of womanhood!
Always discuss this with Dr. Stiller or Riley prior to doing so. Typically, patients may start to have vaginal intercourse once they have reached the orange dilator. You may have anal sex around 4-6 weeks post-surgery as long as you do not have any wounds. This allows the graft to heal and prevent any pressure from the rectum on your vaginal canal. Oral sex can occur as long as your incisions are healed, and you are comfortable doing so.
After your surgery, you will need to be on a low fiber diet for 6 weeks. Fiber is the part of fruits, vegetables and grains not digested by your body. This reduces the amount of undigested food moving through your bowels, so that your body makes a smaller amount of stool letting your bowels and vaginal graft heal.
Avoid these foods and products made with them:
▪ Nuts, seeds, dried fruit and coconut
▪ Whole grains, popcorn, wheat germ and bran
▪ Brown rice, wild rice, oatmeal, granola, shredded wheat, quinoa, bulgur and barley
▪ Dried beans, baked beans, lima beans, peas and lentils
▪ Chunky peanut butter
▪ Fruits and vegetables except those noted below
Choose these foods:
▪ Tender meat, fish and poultry, ham, bacon, shellfish, and lunch meat
▪ Eggs, tofu and creamy peanut butter
▪ Dairy products if tolerated▪ White rice and pasta
▪ Hot and cold cereals that have less than 2 grams of dietary fiber in a single serving, such as those made from rice
▪ Canned or well-cooked potatoes, carrots and green beans
▪ Plain tomato sauce▪ Vegetable and fruit juices▪ Bananas, melons, applesauce and canned peaches (no skin)
▪ Butter, margarine, oils and salad dressings without seeds