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Page 2 of 13 Chao et al. Plast Aesthet Res. 2025;12:29 https://dx.doi.org/10.20517/2347-9264.2025.18

INTRODUCTION
Gender-affirmation surgery comprises a host of procedures that reshape patients’ physical characteristics to
reflect their gender identity. Feminizing gender-affirming procedures include breast augmentation, facial
and vocal feminization, and genital reconstruction via vulvoplasty or vaginoplasty. While historically a
minority of patients undergoing a transition proceeded to feminizing genital surgery, high satisfaction rates
and the increasing availability and coverage of gender-affirming care have facilitated patients’ interest and
[1]
access .
A critical aspect of gender-affirming vaginoplasty is the creation of a functional neovaginal canal suitable for
penetrative intercourse. The ideal neovagina is elastic, moist, and hairless; prior studies have suggested a
[2,3]
minimum depth of ≥ 10 cm and diameter of ≥ 3 cm . Neovaginal canal dissection is challenging due to the
deep perineal and pelvic anatomy, difficult exposure, and risk of injury to the adjacent urethra, bladder, and
[4]
rectum. Gender-affirming surgeons employ various techniques to surmount these concerns .
In this article, we briefly review the tissue options available for creation of the neovaginal canal and describe
our institutional practice for canal creation in primary and revision vaginoplasties. Other technical aspects
of gender-affirming vaginoplasty include creation of a sensate clitoris, an aesthetic vulva, and an
appropriately positioned feminine urethra with a downward-directed urinary stream. While equally
important for a “successful” feminizing vaginoplasty, these fall outside the purview of this article, which will
focus on neovaginal canal creation.

TISSUE OPTIONS FOR NEOVAGINAL CANAL CREATION
There are various donor tissues available to line the neovaginal canal during gender-affirming vaginoplasty.
Choice of donor tissue must consider factors such as sensation, hair-bearing status, risk of secondary
contracture, tissue availability, and donor site morbidity.

Skin
In 1957, Sir Harold Gillies pioneered early gender-affirming genital surgery via description of the penile
inversion vaginoplasty (PIV), wherein the penis is deconstructed and a cylindrical inverted penile skin flap
serves as the neovaginal canal . The technique was later refined and popularized by French gynecologist
[5]
[6]
Dr. Georges Burou . Despite modifications over the subsequent decades, PIV and its variations represent a
predominant technique for gender-affirming vaginoplasty.

The inverted penile skin flap is well-vascularized and sensate. However, most patients will have insufficient
neovaginal canal depth with penile skin alone. While the mean total penile length is 12.9 cm, penile skin
alone often falls short of the desired neovaginal depth of 12-14 cm because some length is lost traversing the
distance between the base of the penis and the future introitus; moreover, the proximal penile skin is
repurposed for vulvar definition . Many authors utilize full-thickness skin grafts (FTSGs) to line the
[7]
remaining mid- and proximal neovaginal canal; scrotal skin is an apt donor, as it would otherwise be
discarded. A notable disadvantage of its use is the need for preoperative laser or electrolysis hair removal,
which imposes an additional cost and time burden for patients . Hair removal can also be undertaken
[8,9]
intraoperatively via mechanical, adhesive, or electrocautery depilation [10-12] . However, there are no
comparative data to guide the choice of technique in the setting of gender-affirming vaginoplasty, and in
our experience, intraoperative depilation is both tedious and unreliable.

Some patients have deficient genital skin due to hormone suppression, prior orchiectomy or other genital
[13]
surgery, circumcision, or obesity . In such circumstances, the combination of a penile inversion flap and