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scrotal skin graft still yields a neovagina of suboptimal depth. Additional donor tissues such as extragenital
skin, biologic grafts, and peritoneum can further augment the canal.

Extragenital skin grafts can be harvested from multiple sites such as the lower abdomen, groin, buttocks,
and thigh. Non-hair-bearing skin is preferred to avoid later neovaginal hair growth, which can be
cumbersome to address. While both split-thickness and full-thickness grafts are feasible, the latter are
generally favored due to the lower risk of secondary contracture and subsequent neovaginal stenosis.
Despite their utility, extragenital skin grafts incur the morbidity of additional donor sites and may result in
bothersome surgical scars.

Peritoneum
The use of peritoneum to augment the neovaginal canal was first described by Davydov in 1969 for the
vaginal reconstruction of patients with Mayer-Rokitansky-Küster-Hauser syndrome . The technique has
[14]
since been adapted for laparoscopic and robotic approaches; the latter represents a major contemporary
technique for both primary and revision gender-affirming vaginoplasty [15,16] .

In the robotic Davydov peritoneal flap vaginoplasty, flaps of peritoneum are mobilized anteriorly from the
posterior surface of the bladder and posteriorly from the anterolateral surface of the rectum. The inferior
aspects of the flaps are sewn directly to the edge of the inverted penile tube, whereas the apices of the flaps
are sewn together; the rectovesical pouch is thus incorporated as the neovaginal apex and excluded from the
remaining peritoneal cavity. An alternative approach described in the context of revision vaginoplasty is the
tubularized urachus-peritoneal hinge flap, which mobilizes a single inferiorly based flap of peritoneum
spanning the bladder to the umbilicus . This can be folded posteriorly to form a “cap” of canal apex or a
[17]
nearly completely peritoneum-lined vaginal canal.

Utilizing peritoneal tissue yields a well-vascularized, hairless neovaginal apex, supplements canal depth, and
obviates the need for extragenital skin grafting in most cases. Peritoneum is a semi-permeable, secretory
membrane that may contribute to passive neovaginal canal lubrication. Despite this theoretical benefit, a
recent systematic review suggested that neither skin, peritoneum, nor colon yields functional neovaginal
[18]
lubrication and that lubricating potential should not factor into the choice of tissue for neovaginal lining .
Peritoneum produces a basal fluid rate unresponsive to sexual stimulation; patients may find such fluid
more akin to near-constant discharge than to true erogenous lubrication.

The role of peritoneal flaps in primary and revision vaginoplasties is debated. A disadvantage of primary
peritoneal flap vaginoplasty is the addition of an intra-abdominal component to an otherwise perineal
dissection, thereby introducing the risks associated with abdominopelvic surgery. Moreover, primary
peritoneal flap vaginoplasty may complicate the use of peritoneum during revision vaginoplasty, severely
limiting donor tissue options and potentially necessitating intestinal vaginoplasty, which carries additional
morbidity . In a recent study of 17 high-volume surgeons who perform at least 40 gender-affirming
[19]
vaginoplasties per year, five surgeons in the cohort reported using peritoneal flaps or grafts, while only one
surgeon utilized peritoneal flaps in more than 50% of cases .
[7]
Local grafts and flaps
Additional tissue to augment the neovaginal canal can be gained from local tissue flaps and grafts. Several
authors report using tunica vaginalis grafts as adjuncts to scrotal skin for lining the neovaginal canal,
although supporting data are sparse [20,21] . The tunica vaginalis, embryologically derived from the abdominal
peritoneum, envelops the testis as it descends through the inguinal canal. In patients without prior