Sex reassignment surgery for male-to-female transgender women involves reshaping the male genitals into a form with the appearance of and, as far as possible, the function of female genitalia. Prior to any surgeries, trans women usually undergo hormone replacement therapy and depending on the age at which HRT begins, facial hair removal. Other surgeries undergone by trans women may include facial feminization surgery, breast augmentation, and various other procedures.
When changing anatomical sex from male to female, the testicles are removed and the skin of foreskin and penis is usually inverted, as a flap preserving blood and nerve supplies (a technique pioneered by Sir Harold Gillies in 1951) to form a fully sensitive vagina (vaginoplasty). A clitoris fully supplied with nerve endings (innervated) can be formed from part of the glens of the penis. If the patient has been circumcised (removal of the foreskin), or if the surgeon's technique uses more skin in the formation of the labia minora, the pubic hair follicles are removed from some of the scrotal tissue, which is then incorporated by the surgeon within the vagina. Other scrotal tissue forms the labia majora.
In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from skin grafts from the thighs or hips, or a section of colon may be grafted in (colovaginoplasty). These linings may not provide the same sensate qualities as results from the penile inversion method, but the vaginal opening is identical, and the degree of sensation is approximately the same as that of most biological women so pleasure should not be less.
The aesthetic, sensational, and functional results of vaginoplasty vary greatly. Surgeons vary considerably in their techniques and skills, patients' skin varies in elasticity and healing ability (which is especially affected by smoking), any previous surgery in the area can impact results, and surgery can be complicated by problems such as infections, blood loss, or nerve damage. However, in the best cases, when recovery from surgery is complete, it is often very difficult for anyone, including gynecologists [dubious - discuss], to detect that someone has undergone vaginoplasty.