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orchiectomy, it can be harvested and used as a supplemental graft to avoid the morbidity of an extragenital
harvest site or peritoneal flaps. In the only published description of its routine use, the authors report
incorporating tunica vaginalis grafts in 51.6% of patients undergoing primary gender-affirming
[22]
vaginoplasty . Another option is incorporating the spatulated urethra as a portion of the neovaginal canal,
which can yield additional width, lubrication, and sensation [23,24] . Some authors have also posited
repurposing the scrotal skin as a pedicled flap to form the posterior neovaginal canal and apex, rather than
early harvest and thinning for use as a FTSG [25,26] .

Allografts, xenografts, and tissue engineering
A promising option for neovaginal canal augmentation is the use of xenografts and allografts. These provide
additional possibilities for canal coverage while eschewing the morbidity and requisite hair removal of a
donor site, though the associated costs and dearth of long-term outcomes remain points of concern.

Rodriguez et al. (2020) first described the use of Nile tilapia fish skin in lieu of scrotal skin grafts during
gender-affirming vaginoplasty. Nile tilapia skin is a viable option to scaffold epithelialization of the
neovaginal canal due to its non-infectious microbiota, structural similarity to human skin, and good in vivo
[27]
bio-resorption . Similar to scrotal skin grafts, the biologic is tubularized and sutured to the inverted penile
skin flap to form the neovaginal apex. Microscopic analysis of biopsied vaginal canal tissue at 180 days
demonstrates hyperplastic stratified squamous epithelium with underlying fibrous connective tissue, much
like a natal vaginal canal . Other authors have described similar techniques for primary gender-affirming
[27]
vaginoplasty utilizing decellularized ovine foregut extracellular matrix (Myriad; Aroa Biosurgery, San Diego,
CA) in conjunction with peritoneum .
[28]

AlloDerm (LifeCell, Branchburg, NJ) is an acellular allograft consisting of the basement membrane and
collagen scaffolding from human cadaveric skin. It has been described for use in cisgender vaginal
reconstruction and, more recently, for revision vaginoplasty in combination with peritoneal flaps . In such
[29]
cases, Alloderm is sutured distally to the remnant neovaginal canal and proximally to newly mobilized
peritoneal flaps, thereby “mending the gap” between the remnant canal and peritoneal cavity. After 3-6
weeks, the nonimmunogenic, acellular graft is epithelialized. One major drawback is the estimated cost of
$30/cm , which may restrict its use to complex revision cases.
2

Another allograft option for neovaginal reconstruction is dehydrated human amnion/chorion membrane,
commercially available as AmnioFix/EpiFix (MiMedx Group Inc., Marietta, GA). Amnion has long been
utilized for complex burn and wound care due to its availability, cost-effectiveness, and low morbidity; in
recent years, various authors have expanded its use for cisgender vaginoplasty in cases of Mayer-
Rokitansky-Kuster-Hauser syndrome [30,31] . Amniotic membrane is favorable due to its immunologic
properties, antifibroblastic activity, and propensity to epithelialize without hair growth or bothersome
discharge . However, additional study in the context of gender-affirming surgery is needed.
[32]
A nascent but encouraging realm is the use of tissue-engineered biomaterials in neovaginal
reconstruction [33,34] . Tissue engineering carries the theoretical benefits of reproducibility, eschewing the need
for a donor, and the ability to tailor specific growth factors to optimize the characteristics of the neovaginal
mucosa.

Intestine
Intestinal vaginoplasty utilizes a pedicled flap of ileum, jejunum, or colon for the neovaginal canal and has
historically served as the primary alternative to penile inversion vaginoplasty. Advantages include a robust,