Gender-Aff irming Penile

I n v e r s i o n Va g i n o p l a s t y
Ali Salim, MDa,*, Melissa Poh, MDb

KEYWORDS
 Vaginoplasty  Neovagina  Penile inversion  Plastic surgery  Transgender  Gender dysphoria
 Gender affirmation  Trans woman

KEY POINTS
 Gender-affirming vaginoplasty stems from use of skin grafts in the early 1900s. The most common
form of reconstruction today is based on pedicled penile inversion flaps.
 A multidisciplinary approach to evaluation and preoperative work-up following World Professional
Association for Transgender Health standards of care and thorough informed consent are neces-
sary to reduce risks and optimize outcomes.
 The penile inversion approach consists of development and lining of a neovaginal space, shortening
of the urethra, construction of a neoclitoris, and local skin rearrangement to define the vulva and
introitus.
 Postoperative care protocols, including strict adherence to a dilation schedule, are critical to a suc-
cessful reconstruction and maintenance of adequate neovaginal depth.
 Despite complications, high patient satisfaction and reduction in dysphoria have been documented
after vaginoplasty.

INTRODUCTION
In recent years, greater acceptance of transgender
individuals in society and the inclusion of medical
coverage for gender-affirmation surgeries (GASs)
has led to an increasing number of patients
seeking male-to-female vaginoplasty. Since the
first descriptions of neovaginal reconstruction for
gender affirmation were described in the early to
mid-1900s, various techniques and revisions
have been introduced. This article provides a brief
historical perspective, defines the goals of surgical
treatment within a multidisciplinary approach
adhering to World Professional Association for
Transgender Health (WPATH) standards, and fo-
cuses on issues related to the most common
method for primary neovaginal reconstruction:
HISTORY
Surgical techniques for vaginoplasty are often
divided into categories based on the type of donor
tissue used to create the neovaginal canal. The
donor sites include (1) genital (scrotal) and
nongenital skin grafts, (2) pedicled penoscrotal
and nongenital local skin flaps, and (3) pedicled
bowel segments.1
The first case of a vaginoplasty in a trans woman
was reported by Abraham in 19312 and involved the
use of a skin graft placed inside-out over a form to
line the neovaginal canal in a patient who had prior
orchiectomy and penectomy. For several decades,
surgeons continued to perform vaginoplasties using
split-thickness skin grafts to line the neovagina, likely
due to donor site availability, simplicity of grafts, and
potential for non–hair-bearing reconstruction.3 To
plasticsurgery.theclinics.com

the penile inversion vaginoplasty (PIV).

Disclosure Statement: No disclosures.

a
Department of Plastic Surgery, Kaiser Permanente Medical Center, 1635 Divisadero Street, 6th Floor, San
Francisco, CA 94115, USA; b Department of Plastic Surgery, Kaiser Permanente Medical Center, 6041 Cadillac
Avenue Suite 156, Los Angeles, CA 90034, USA
* Corresponding author.
E-mail address: ali.x.salim@kp.org

Clin Plastic Surg 45 (2018) 343–350

https://doi.org/10.1016/j.cps.2018.04.001
0094-1298/18/Ó 2018 Elsevier Inc. All rights reserved.
344 Salim & Poh
reduce the contracture related to split-thickness
grafts, full-thickness skin grafts were also used. In
1956, Paul Fogh-Andersen, a Danish plastic sur-
geon, was first to report harvest and inset of penile
skin as a full-thickness graft to line the neovagina.4
Graft contracture, notable scars outside of the peri-
neum, and early stenosis of the neovaginal introitus,
however, led to the use of other tissue options. One
year later, Gillies and colleagues5 published their
technique of pedicled penile skin to reconstruct the
neovaginal canal in trans women. Independently,
Burou in Casablanca developed a similar technique
and performed his first pedicled penile skin inversion
for gender-affirming vaginoplasty in 1956, and he
continued this practice into the 1980s.6
The implementation of the pedicled penile flap
meant improved vascularity and thickness of tis-
sue placed over the rectum, less contracture,
and typically hairless skin. Several modifications
have been made over the years, which include
the addition of a small posteriorly based perineal
skin or scrotal flap to lessen introital stenosis, or
use of both pedicled penile flap and posteriorly
or laterally based scrotal flaps. Other local pedi-
cled skin flaps from the medial thigh and inguinal
and pudendal regions have also been described
but have not been adopted as first-line surgical
options due to notable scars and often thicker tis-
sue which can narrow the neovaginal canal.7
Reconstruction of a neovagina using a bowel
segment has been well described in the oncology
literature. More recently, this technique has been
applied in the setting of primary or secondary vag-
inoplasty for trans women.8 The advantages of
bowel vaginoplasty are reliable length, texture,
and natural lubrication. The disadvantages are
the addition of abdominal surgery and the poten-
tial for odor, excessive mucus discharge, and
introital stenosis.9 Because the number of young
transgender women seeking vaginoplasty who
lack sufficient penile and scrotal tissue due to early
hormone treatment is growing, bowel vaginoplasty
as a primary method may become more popular.10
Other options for reconstructing a neovagina are
emerging and include the use of peritoneum,
buccal mucosa, amnion grafts, or decellularized
tissue. To date, most surgeons prefer the use of
inverted pedicled penile skin flaps with the addi-
tion of either scrotal flaps, scrotal skin grafts, or
nongenital skin grafts to accomplish a fully lined
neovaginal canal.
GOALS OF RECONSTRUCTION
The goals of a vaginoplasty follow one of the gen-
eral tenets of plastic surgery—reconstructing like
with like. As described by Karim and colleagues,1
the gender surgeon should strive to create a func-
tional and aesthetically acceptable perineum that
appears as feminine as possible with minimization
of scars and desensitization. In terms of function,
the patient should be able to urinate in the sitting
position without obstruction and achieve sexual
satisfaction. Sexual stimulation may arise from
either the neoclitoris (prior penile glans) or from
penetrative intercourse secondary to prostate stim-
ulation. Given the cis female vagina is hairless and
elastic, the tissue used to line the neovaginal canal
should have similar characteristics. Accordingly,
preoperative hair removal of the donor site skin is
important. Furthermore, the neovagina should be
similar in length to the average cis female vagina,
at 9.6 cm (range 6.5–12.5 cm).11 The reconstructed
length is limited by a patient’s anatomy. The neova-
ginal space is developed along Denonvilliers fascia
and should not extend past the peritoneal reflection
and enter into the abdominal cavity. To yield a nat-
ural appearance, the labia majora are created from
their embryologic equivalent, the scrotum. Lastly,
given that the PIV is completed through the use of
skin flaps, the neovagina is not self-lubricating.
The only established means of achieving a self-
lubricating vagina is bowel-based reconstruction.
PREOPERATIVE PLANNING
The key to success for performing GAS is to
develop a multidisciplinary team that consists of a
combination of reconstructive surgeons (eg, plastic
surgeons, urologic surgeons, urogynecologists, and
colorectal surgeons), endocrinologists, internists,
case managers, physical therapists, social workers,
and mental health specialists so that all aspects of a
patient can be adequately addressed according to
WPATH standards of care. In addition to use of
the WPATH guidelines and a multidisciplinary
team during both the diagnostic and treatment
phases of care, it is critical for the responsible sur-
geon(s) to provide informed consent for the pro-
posed procedure. This includes a thorough review
of options, risks, and possible complications.
Body mass index and medical comorbidities are
addressed preoperatively to reduce anesthesia
and surgical complications. Even in surgical candi-
dates with no physical comorbidities, the pres-
ence of severe mental health issues outside the
diagnosis of gender dysphoria will likely compli-
cate compliance with the recovery plan, both in
the short term and long term. In the authors’ prac-
tices, patients have multiple discussions with the
surgical team to provide ample opportunity for
informed consent prior to surgery, and they are
also provided with didactic teaching and exposure
to patient panels.
 Gender-Affirming Penile Inversion Vaginoplasty 345

Preoperatively, patients must undergo perma-

nent hair removal in the areas used to create the
skin lining of the introitus (perineum, base of the
penis, and surrounding skin) and neovagina (cen-
tral portion of the scrotum and penile shaft). Laser
hair removal is often better tolerated, although it
works best on individuals with light skin and dark
hair and may not be permanent. Electrolysis is
widely accepted as a form of permanent hair
removal but cost and pain even with topical anes-
thetics are limiting factors. Consequently, hair
removal can be a long process, taking up to a
year, depending on individual factors, such as
amount of hair, color of hair, pain tolerance, and
the patient’s schedule. The presence of hair in
the neovagina can lead to persistent malodorous
discharge, pain with dilation, and/or granulation
tissue requiring in-office treatments. Although Fig. 1. With the patient placed in the lithotomy posi-
intraoperative scraping of a few residual hair folli- tion, reference lines are marked for the midline,
cles from the undersurface of the scrotal skin graft inguinal creases, and planned infraumbilical skin
is possible, this approach, when applied to the release. An inferiorly based perineal flap to form the
penile inversion flap, is time-consuming, leads to floor of the introitus and the scrotal skin for harvest
thinning of the tissue, and increases the risk of are marked. The shaft skin will be split prior to inset.
skin loss. It is, therefore, not recommended.
Patients are instructed to stop estrogen at least
2 weeks prior to surgery to reduce the risk of peri-
operative deep vein thrombosis and pulmonary
embolus. No additional risk is incurred with testos-
terone blockade. These medications are continued
to the day of surgery but stopped after the
orchiectomy. A preoperative bowel preparation is
completed 2 days prior to surgery. In the authors’
opinion, this helps reduce the risk of infection and
fistula in the setting of a recognized and repaired
intraoperative rectal injury. The bowel preparation
also lessens postoperative constipation and strain-
ing, which helps avoid the rare complication of neo-
vaginal prolapse with excessive Valsalva maneuver.
Cessation of nicotine containing products at least
3 months before and after surgery is mandatory to
reduce healing complications.

OVERVIEW OF SURGICAL TECHNIQUE

The most common technique for GAS in trans
women is PIV. This technique accomplishes
most of the reconstruction goals delineated previ-
ously in addition to an acceptable risk profile.12 In
this procedure, the neovagina canal is typically
lined with a superiorly based penile skin flap that
is turned inside-out and advanced into the newly
created vaginal canal. Often the amount of penile
skin is insufficient to line the entire canal so a
full-thickness scrotal skin graft is harvested or, in Fig. 2. The scrotal skin is harvested as a free graft,
rare cases in which a patient presents with a trimmed to appropriate length, and tubularized
pendulous scrotum, an inferiorly based scrotal over a form. With a pendulous scrotum, a pedicled
flap is used to supplement the penile inversion– scrotal flap is used (not shown).
346 Salim & Poh
based lining of the neovagina. The use of skin or
scrotal grafts does not necessarily lead to delayed
healing or clinically significant contraction.13 Other
variations of this technique exist, such as including
a strip of urethral tissue to line a portion of the neo-
vaginal canal.14
The authors use a superiorly based penile skin
flap supplemented with a scrotal apical cap graft
or flap as needed to line the neovaginal canal. The
patient is placed in the lithotomy position with pres-
sure points well-padded and protected, and mark-
ings are made (Fig. 1). The scrotal skin is
harvested as a graft or maintained as a pedicled
flap if pendulous; this skin is tubularized (Fig. 2).
The neovaginal space is carefully developed under
direct vision, with attention paid to avoid injury to
the rectum inferiorly, the bladder, urethra, and pros-
tate superiorly and the peritoneal reflection superi-
orly (Fig. 3). A small posteriorly based perineal flap
Fig. 3. The neovaginal space is carefully developed
under direct vision, with attention paid to avoid
injury to the rectum inferiorly, the bladder, urethra,
and prostate superiorly, and the peritoneal reflection
superiorly.
is created to help to decrease the risk of introital ste-
nosis. The neovaginal canal is dissected sharply
and/or bluntly by first dividing the central tendon
(perineal body) and then extending the dissection
deeper to separate the 2 layers of Denonvilliers fas-
cia. The initial dissection stays on the prostatic
capsule to avoid rectal injury. This dissection is per-
formed up to the level of the seminal vesicles and
until the peritoneal reflection is encountered. Manual
rectal examinations during the dissection can lessen
the risk or help identify a rectal injury, which is
repaired in layers with absorbable suture given
that an adequate bowel preparation was completed
preoperatively. Preservation of the bulbospongiosus
muscle is performed to buttress a rectal repair if
needed; otherwise, it can be discarded during the
penile component separation. Use of a dilator or
form in the rectum during the dissection is not rec-
ommended because it can spread out the rectal
wall, making full-thickness injury more likely.
Next, the component separation of the penis is
performed with degloving of the shaft, separation
and shortening of the urethra, and removal of the
corpus cavernosum from the overlying dorsal fascia
(Fig. 4). The dorsal neurovascular bundle to the
glans penis is preserved, and the glans is reduced
for shaping of the neoclitoris. The excision of the
corpus cavernosum must be completed proximally
to its base to avoid undesired bulging with sexual
arousal. An orchiectomy is performed taking care
to identify and spare the ilioinguinal nerves.
Fig. 4. Component separation of the penis is performed
with degloving of the shaft, separation and shortening
of the urethra, and removal of the corpus cavernosum
from the overlying dorsal fascia. The dorsal neurovascu-
lar bundle to the glans penis is preserved.
 Gender-Affirming Penile Inversion Vaginoplasty 347

Depending on the amount of local tissue excess

and laxity, the mons and possibly the adjacent infe-
rior abdominal wall are elevated to facilitate a
tension-free advancement of the pedicled penile
skin flap. The penile skin flap is sewn to the scrotal
skin graft/flap over a form (Fig. 5). The neoclitoris is
designed by reduction and local rearrangement of
the glans, and the neurovascular bundle is gently
folded and tacked to the mons fascia to set the
neoclitoris in its desired position (Fig. 6). The
adductor longus tendons are palpated as a guide-
line to avoid placing the clitoris too high or low.
The skin is inverted and then rotated into the neova-
gina canal, which is tightly packed with a gauze-
filled condom, antibiotic-impregnated vaginal
gauze packing, or a silicone-based prosthesis
(Fig. 7). Internal suturing of the neovaginal lining is
not performed by the authors given the low risk of
neovaginal prolapse compared with that of inadver-
tent bowel injury or unwanted bleeding.
Both the neoclitoris and the shortened urethra
are delivered through the penile skin flap by
making an incision in the midline. The shortened
urethra is inset in a spatulated fashion around a Fig. 6. The neoclitoris is designed by reduction and
16F Foley catheter (Fig. 8). A dorsal extension local rearrangement of the glans, and the neurovascu-
lar bundle is gently folded and tacked to the mons fas-
cia to set the neoclitoris in its desired position.

of the urethra to approximate the urethral plate

between the neoclitoris and the urethral meatus
has been described but the difference in
pigmentation and desiccated mucosa can be

Fig. 7. The skin is inverted and then rotated into the

neovaginal canal, which is tightly packed with a
Fig. 5. The penile skin flap is sutured to the tubular- gauze-filled condom, antibiotic-impregnated gauze
ized scrotal skin graft prior to inset. packing, or a silicone-based prosthesis.
348 Salim & Poh
Fig. 8. The neoclitoris along with the shortened ure-
thra are delivered through the penile skin flap by
making an incision in the midline, and the shortened
urethra is inset in a spatulated fashion around a 16F
Foley catheter.
disconcerting to patients. The authors prefer to
preserve the glans tissue, which is trimmed and
shaped to provide a larger area of erogenous
sensation (Fig. 9).
Fig. 9. With the skin incisions closed with absorbable
suture, this final intraoperative view demonstrates
placement of drains, packing, and Foley catheter in
the shortened urethra.
The clitoral hood and labia minora are created
at the time of the vaginoplasty using the prepuce
skin but the size of the labia may be limited by
the location of the circumcision scar. The forma-
tion of the clitoral hood and labia minora can also
be deferred to a second surgery at least 3
months to 6 months postoperatively. This
approach may offer more labia minora projection
and length but does require a vertical scar
located superior to the neoclitoris for the turn-
over skin flap for clitoral hood reconstruction.
Plus, patients often express dissatisfaction with
a prominent and hypersensitive neoclitoris in
the months between the initial surgery and the
second stage. In patients who experience partial
loss of their neovagina, the lining can be scored
and skin or buccal mucosa grafts placed to
improve diameter of the canal.
Patients who are higher-risk surgical candidates
or do not desire penetrative neovaginal inter-
course may be offered a zero-depth vaginoplasty
(ZDV) (Fig. 10). The external appearance is the
same for both full-depth and zero-depth with the
only difference being ZDV patients do not undergo
a neovaginal canal dissection. Operative times
and risks to adjacent structures such as the
rectum are decreased. The ZDV may also be
preferred for patients who physically cannot or
choose not to dilate. In most cases, a vaginal
introitus dimple can be constructed by division of
the central tendon and inset of a small inferiorly
based perineal flap in conjunction with a shortened
pedicled penile flap. Because no neovaginal canal
Fig. 10. Example of zero-depth vaginoplasty at
approximately 6 months.
 Gender-Affirming Penile Inversion Vaginoplasty 349

exists, preoperatively hair removal of the shaft and

scrotum is not necessary to perform a ZDV.

POSTOPERATIVE CARE
For PIV, hospitalization time lasts approximately
7 days in the authors’ practices. Brief or even
single-dose prophylactic subcutaneous anticoagu-
lation is administered as the patient is ambulating
by postoperative day 1 or day 2. After 2 days of
patient-controlled analgesia, the patient is quickly
weaned off to scheduled acetaminophen and
ibuprofen such that the majority of patients are dis-
charged on non-narcotic pain medications or a brief
course of narcotics. The neovaginal packing and
drain are removed on postoperative day 6. The Fo-
ley catheter can be removed the same day or next
day. Dilation teaching is performed at this time ac-
cording to a protocol, which has been extensively
reviewed with the patient preoperatively.
Once the packing is removed from the neova- Fig. 11. Example of full-depth vaginoplasty at approx-
gina, the patient must dilate several times a day imately 6 months. Small areas of superficial skin
with progressively larger dilators to maintain the breakdown at the introitus are common and treated
patency, length, and width of the canal. The dilation with silver nitrate and/or topical antibiotic ointment.
is most critical in the early postoperative period (at
least up to 1 year) and can lessen in frequency over vaginoplasty (1.2%–43%) was neovaginal steno-
time but is typically a lifelong commitment. Active sis. Rectal injury was encountered in 2% to 4.2%
participation by the patient is imperative to the of patients with the incidence of rectovaginal fis-
preservation of the full-depth vaginoplasty. tula at 1% (0.8%–17%). The incidence of neovagi-
Estrogen can be resumed after the patient dem- nal prolapse was 1% to 2%. Other reported
onstrates consistent postoperative ambulation or complications included urethral meatal stenosis
immediately after discharge home. The patient is (1%–6%), wound dehiscence (12%–33%), and
restarted on half of the preoperative estrogen
dose with instructions to follow-up with her endo-
crinologist for monitoring and adjustment. Testos-
terone blockers are not restarted because an
orchiectomy was performed. Outpatient postoper-
ative follow-up is continued on a regular basis with
consideration of a revision or second stage once
the patient is at least 3 months to 6 months post-
operatively. Patients are counseled that several
months are required for local swelling to diminish
and that small areas of skin breakdown, especially
with frequent dilation, are common and heal with
local care (Figs. 11 and 12).

OUTCOMES AND COMPLICATIONS

To date, most studies on gender-affirming vagino-
plasty have largely been based on small cohorts of
patients and variable measured endpoints. Hor-
bach and colleagues12 presented a detailed over-
view of published outcomes and found that the
majority of the studies were series of low to inter- Fig. 12. Example of full-depth vaginoplasty at approx-
mediate quality, with only 1 reporting on quality- imately 6 months. This patient was uncircumcised and
of-life improvement. The most frequently reported thus there was abundant tissue for sensate labia mi-
complication in both PIV (7%–12%) and bowel nora reconstruction.
350 Salim & Poh
bleeding (3.2%–10%), with the main source of
hemorrhage the corpus spongiosum surrounding
the urethra.
In terms of postoperative functional outcomes
after PIV, a mean percentage of 75% (33%–
87%) patients were having vaginal intercourse,
with orgasm achievable in 70% to 84%. These
findings were similar for bowel vaginoplasty.
A majority of patients were very satisfied with
the outward appearance (84%) and 89% would
recommend the procedure to other transgender
women.12,15
SUMMARY
PIV with adjunct scrotal/skin grafting as needed is
a reliable method for gender-affirming primary
neovaginal reconstruction. In the setting of a
multidisciplinary team approach, guidance by
the WPATH standards of care and proper
informed consent to help ensure compliance
with life-long dilation, this technique results in
high patient satisfaction despite known compli-
cations. As earlier hormone blockade begins to
have an impact on the availability of sufficient
penoscrotal donor tissue, the use of intestinal or
other novel sites for neovaginal lining will be
increasingly necessary.16
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