Abstract
Background:
Aesthetic refinement of labia minora reconstruction remains a challenge with the traditional penile inversion vaginoplasty, which may result in inadequately defined labia minora, a gaping introitus, or redundant labial folds. This study described a refinement based on nonpenile inversion vaginoplasty (NPIV) to address these limitations.
Methods:
The NPIV technique uses preputial and penile skin exclusively for external labial reconstruction. Labial aesthetic outcomes were assessed using either standardized photographs or patient-submitted images via telemedicine, graded with a 4-point aesthetic scoring system. Patient satisfaction was evaluated using a customized patient-reported outcome measure with Likert-scale scoring (1–5). Clinical outcomes and complication profiles were also analyzed.
Results:
Between July 2023 and March 2025, 74 patients underwent primary vaginoplasty using the NPIV technique. Of these, 72 (97.3%) completed a 1-month follow-up. Mid- to long-term data were available in 42 (56.8%) patients, comprising 15 with standardized photographs and 27 with self-taken photographs. Most aesthetic ratings were excellent or good (80.9%). Patient-reported outcome measures data were available in 40 patients, with mean scores of 4.5 for appearance, 4.3 for symmetry, and 4.6 for overall satisfaction. The most frequent complication was introital wound dehiscence with minor labial necrosis (25.7%), followed by significant labia minora necrosis (12.2%), which occurred more often in circumcised patients (30.0% versus 5.6%, P = 0.014).
Conclusions:
The NPIV technique offers a predictable and reproducible approach for labia minora reconstruction with improved labial contour and definition. Clinical and patient-reported outcomes demonstrate high satisfaction and favorable aesthetic results.
Takeaways
Question: Can labia minora construction in gender-affirming vaginoplasty be refined to achieve improved aesthetic outcomes?
Findings: In this prospective study of 74 patients, the nonpenile inversion vaginoplasty achieved well-contoured and aesthetically favorable labia minora in most cases, with high ratings from both aesthetic evaluations and patient-reported satisfaction.
Meaning: The nonpenile inversion vaginoplasty offers a predictable and reproducible approach to gender-affirming vulvar reconstruction, ensuring reliable labia minora definition.
INTRODUCTION
Gender-affirming vaginoplasty aims to create both functional and aesthetically natural female genital anatomy, with penile inversion remaining the most widely practiced and accepted standard technique.1–5 Although the method generally yields satisfactory outcomes, limitations persist in the reconstruction of the labia minora.6,7 Common concerns include inadequate definition, with the labia minora terminating at or proximal to the urethral meatus and appearing separated from the neovaginal introitus (Fig. 1). Additional issues include excessively wide labial apposition resulting in a gaping introitus and redundant folds or excess labial definition.
Fig. 1.
Comparison of vulvar configuration between penile inversion and NPIV techniques.
From a reconstructive standpoint, the labia minora functions as a transitional element among the labia majora, the anterior column of the clitoral complex, and the vaginal introitus. Adequate anterior projection of the labia minora is critical to achieving an aesthetically pleasing vulvar appearance. A key limitation of the penile inversion technique is that the penile skin tube must be inverted to create the neovaginal canal, which limits the ability to control the labia minora definition at the introitus. Consequently, a gaping introitus, defined as a visible neovaginal opening without coverage by labial tissue, is commonly encountered in such cases. In addition, redundant skin folds at the introitus, often resulting from prolapse of the penile tube, are not infrequently observed.
To address these limitations, this study presented a refinement technique based on a nonpenile inversion vaginoplasty (NPIV) approach. The key concept involves separating the penile skin flap into discrete components and placing them in a manner distinct from the penile inversion technique, positioning the penile shaft skin anteriorly, followed by the preputial flap, and finally the neovaginal lining. This configuration creates an anteriorly projecting labial contour that conceals the canal entrance and allows more precise shaping of the labia minora independent of inversion-related tension. The objective of this study was to provide a detailed description of the surgical technique and to evaluate its clinical outcomes in a prospective series of primary vaginoplasty patients, including labial aesthetic results, patient-reported satisfaction, and complication profiles.
METHODS
This study included 74 transgender women who underwent primary gender-affirming vaginoplasty using the NPIV technique. All procedures were performed by the author at a single institution. The NPIV technique was applied in combination with the scar concealment method previously described.8 Approval for the clinical evaluation and the use of data was obtained from the institutional ethics committee. Written informed consent was obtained from all patients whose photographs are included in this study.
Patient Selection
All patients were identified as transgender women or individuals assigned male at birth and met all criteria outlined in the World Professional Association for Transgender Health Standards of Care.9,10 Eligibility criteria required patients to be between 18 and 60 years of age with a body mass index (BMI) of 35 kg/m² or lower. Individuals with significant medical or psychiatric comorbidities that could interfere with major surgery were excluded. Active patients who smoked were counseled to discontinue smoking and to abstain from all nicotine-containing products for at least 2 months before and after surgery. Patients must have realistic expectations for surgical outcomes and be able to comply with postoperative neovaginal care and dilation protocols.
Preoperative assessment focused on penile length and circumcision history. Penile length was evaluated by manually extending the shaft toward the perineum to determine whether it reached beyond the perineoscrotal junction, the future site of the neovaginal introitus. Adequate penile skin was defined as no prior circumcision with sufficient shaft length extending past the junction. In circumcised patients, the extent of residual foreskin was categorized based on its ability to partially or fully cover the glans. Patients with short penile length and extensive circumcision were selected for the modified NPIV technique and counseled preoperatively regarding increased risk of tension-related complications and the potential need for revision surgery (Fig. 2). (See table, Supplemental Digital Content 1, which displays the NPIV patient stratification based on preoperative genital characteristics. This table details the decision-making process illustrated in Fig. 2, outlining technical considerations and surgical modifications based on penile length and residual foreskin availability, https://links.lww.com/PRSGO/E545.)
Fig. 2.
Decision-making in the NPIV technique.
Surgical Technique
The key concept of the NPIV technique is the exclusion of penile skin inversion into the neovaginal canal. Instead, preputial and shaft skin are used entirely for double-layer labia minora reconstruction. (See Video 1 [online], which displays the operative steps of NPIV with scar concealment.)
Video 1. This intraoperative video presents the step-by-step surgical technique of non-penile inversion vaginoplasty (NPIV). The procedure features key refinements, including the use of preputial and shaft skin to create double-layer labia minora without inversion into the neovaginal canal. Scar concealment is achieved by quilting the penoscrotal flap to the corpus cavernosal crus, forming a natural-appearing interlabial sulcus. The technique is designed to enhance aesthetic outcomes and improve labial contour and definition. English narration is provided to guide viewers through each stage of the operation.
With the patient in lithotomy position, a hexagonal posterior perineal flap was designed from the ischial tuberosity to the perineoscrotal junction, approximately 2–3 fingerbreadths in width. Following incision, the posterior flap was mobilized with its subcutaneous vascular plexus. Standard neovaginal dissection, bilateral orchidectomy, and urethroplasty were then performed.
The penile skin was divided circumferentially into proximal shaft and distal preputial segment by aligning the incision with the inferior edge of the posterior flap. The shaft skin, with preserved dartos fascia, served as the outer labial layer, whereas the preputial skin, maintaining its vascularity from Buck fascia, formed the inner labial layer (Fig. 3).
Fig. 3.
Design and dissection of the penile skin flap for labia minora reconstruction in the NPIV. A, Penile incision marking aligned with the inferior edge of the posterior perineal flap, delineating the separation between the shaft and the preputial skin. B, The penile shaft flap with attached dartos fascia, demonstrating the course of the superficial external pudendal artery within the fascia, confirming an axial pattern blood supply. The preputial flap preserves its vascularity via the Buck fascia. C, Completed dissection showing separation of the shaft flap from the preputial flap while maintaining vascular integrity.
The neoclitoral pedicle was dissected with preservation of Buck fascia and the dorsal tunica albuginea. Bleeding at the corporal stump was controlled using a running horizontal mattress suture on the way in, followed by a continuous over-and-over suture on the return. The raw surface of the pedicle was then sealed with fibrin glue to promote hemostasis. Neoclitoral reconstruction followed the Watanyusakul technique.11 The preputial skin was divided along the midline and rotated inferiorly to form the inner layer of the labia minora.
The posterior perineal flap was inverted and anchored to the sacrospinous ligament to support the neovaginal floor.12 The preputial skin was inset to the posterior flap to create a continuous vulvar frame, and the neovaginal lining was sutured to the inner preputial skin (Fig. 4).
Fig. 4.
Neoclitoral pedicle dissection and inner labial inset. A, Dissection of the neoclitoral pedicle with preservation of Buck fascia and the dorsal portion of the tunica albuginea, which retained vascular supply from the dorsal penile arteries. The corpus cavernosum and ventral tunica albuginea were excised. B, Application of fibrin glue to the raw surface of the neoclitoral pedicle to promote hemostasis and reduce postoperative bleeding. C, Incision markings for neoclitoral reconstruction following the Watanyusakul technique. D, Formation of the continuous inner vulvar frame from the preputial skin flaps. E, Inset of the preputial flaps into the posterior perineal flap, completing the inner labial lining and establishing continuity of the vulvar frame.
The penile shaft skin, forming the outer layer of the labia minora, was dorsally divided to the clitoral level, maintaining a flap width-to-length ratio of approximately 1:4 to ensure adequate vascularity. The inset points at the introitus were identified to achieve tension-free closure. Excess scrotal skin was excised in full thickness along the superolateral aspect, and the wound was closed medially, followed by scar concealment within the interlabial sulcus (Fig. 5). Redundant penile skin may be trimmed as needed to minimize bulk and prevent unwanted folding. Final labial symmetry was assessed intraoperatively. Interlabial sulcus reconstruction was performed with 4 interrupted 3-point fixation stitches placed from superior to inferior along each side of the sulcus, using 3-0 long-lasting monofilament absorbable sutures. Each stitch incorporated both penile and scrotal skin, anchored securely to the underlying corpus cavernosal crus, and exited through the opposing skin flap with knots externalized.
Fig. 5.
Outer labial inset, interlabial sulcus reconstruction, and scar concealment. A, The penile shaft flap was dorsally divided to the clitoral level, and the inset points at the introitus were identified to achieve a tension-free closure. B, The interlabial sulcus marking line was drawn and served as the medial incision for trimming the scrotal flap. Although the penile shaft flap received robust axial blood supply, the flap width-to-length ratio was maintained at approximately 1:4 to ensure adequate perfusion. C, Incision markings for scrotal flap excision along the superolateral aspect. D, After wound closure, the scrotal flaps were sutured to the penile flaps to form the interlabial sulci. E, Scar concealment was performed by quilting the interlabial sulci down to the crura of the corpus cavernosum. F, The final result showed a tension-free labial inset with symmetry and no redundant folds.
In cases of limited penile length or postcircumcision scarring, the technique was modified accordingly. (See Video 2 [online], which displays the modified nonpenile inversion technique for circumcised patients with inadequate penile length.)
Video 2. This video demonstrates the modified non-penile inversion vaginoplasty technique for patients with inadequate penile length or extensive circumcision. The penile shaft and preputial skin were combined to form the inner layer of the labia minora. Medial scrotal skin was advanced to reconstruct the outer labial layer. To preserve flap vascularity, interlabial sulcus scar concealment was omitted, and lateral trimming of excess scrotal tissue was performed instead. This approach allows for tailored reconstruction in challenging anatomical scenarios while minimizing the risk of flap necrosis.
The penile shaft and preputial skin were combined to form the inner labial layer, whereas medial scrotal skin was advanced to create the outer layer. In this approach, scar concealment at the interlabial sulcus was omitted; instead, scrotal skin was excised in full thickness, and the wound was closed laterally to preserve the vascular supply of the scrotal flap.
Neovaginal Lining
Neovaginal lining options included scrotal skin grafts, sigmoid colon, peritoneal flap, and zero-depth vulvoplasty. Technique selection was based on patient preference following counseling on each method’s advantages and limitations. Scrotal grafting was standard for patients with sufficient skin, colon or peritoneum was used to provide the mucosal lining, and the zero-depth technique was performed for neovulvar reconstruction only.
Postoperative Protocol and Follow-up
The surgical site was covered with gauze, and a urinary catheter and 2 closed-suction drains were placed. Oral intake resumed on postoperative day 1, except in sigmoid vaginoplasty cases, which followed a stepwise diet. Patients remained on bed rest with standard deep venous thrombosis prophylaxis for 3 days, followed by mobilization on day 4. On day 7, dressings and neovaginal packing were removed. Hospital discharge was carried out the following day after individualized instruction in neovaginal care and dilation by a trained nurse. Progressive dilation was initiated using 6 dilator sizes (diameters: 17, 20, 22, 25, 27, and 30 mm), with weekly stepwise increases to minimize stress on the labial inset.
Follow-up included weekly visits during the first month, with international patients remaining in Thailand for at least 1 month. Subsequent visits were scheduled every 3 months during the first year and annually thereafter, or as clinically indicated. For patients unable to return in person, follow-up was conducted via telemedicine, which included patient-reported outcome measures (PROMs) and submission of self-taken vulvar photographs.
Outcome Measurements
Follow-up assessments included neovulvar examination, photographic documentation, neovaginal depth, complication profiles, labia minora aesthetic evaluation, and patient-reported satisfaction. Labial aesthetic outcome was assessed using standardized postoperative photographs taken 3 months or later for in-person follow-up patients. For those evaluated via telemedicine, patients submitted self-taken vulvar photographs under guidance for framing and lighting. All images were reviewed by the primary surgeon using a 4-grade aesthetic scoring system (excellent, good, fair, and poor), focusing on the clarity of labial edges, symmetry, and natural appearance.
Patient satisfaction was assessed through telemedicine follow-up using customized PROMs. Patients were contacted beginning at 6 months postoperatively. The questionnaire included Likert-scale ratings (1–5) for aesthetic appearance, symmetry, and overall satisfaction. (See table, Supplemental Digital Content 2, which displays the customized patient-reported outcome measure used to assess postoperative aesthetic satisfaction following NPIV. The questionnaire includes Likert-scale items [1–5] evaluating labial appearance, symmetry, and overall satisfaction, https://links.lww.com/PRSGO/E546.)
Associations between complications (wound dehiscence and labia minora necrosis) and potential risk factors—including circumcision status, smoking, and BMI—were analyzed using the Fisher exact test for categorical variables. For BMI, optimal cutoff values predictive of each complication were determined via receiver operating characteristic curve analysis. The Youden J statistic was applied to select the threshold, and corresponding area under the curve (AUC) values with 95% confidence intervals (CIs) were reported. A P value of less than 0.05 was considered statistically significant.
RESULTS
Between July 2023 and March 2025, 74 patients underwent primary vaginoplasty using the NPIV technique. The mean age was 30.3 ± 10.1 years, and the mean BMI was 22.9 ± 3.9 kg/m². Twenty patients (27.0%) were circumcised, and 54 (73.0%) were not. The majority were Asian (n = 64), followed by Australian (n = 4), European (n = 3), American (n = 2), and New Zealander (n = 1). Neovaginal lining was constructed using scrotal skin grafts (n = 37), peritoneal flaps (n = 24), sigmoid colon (n = 10), or a zero-depth technique (n = 3). A scrotal flap was used for the outer labial layer in 6 patients (8.1%) with limited penile length or prior circumcision.
Aesthetic assessment was performed in 42 patients (56.8%), comprising 15 (20.3%) with standardized photographs and 27 (36.5%) who provided vulvar photographs via telemedicine. Overall, 4 cases (9.5%) were rated as excellent, 30 (71.4%) as good, and 8 (19.1%) as fair; no cases were rated as poor. PROMs data were obtained from 40 patients (54.1%), with mean scores of 4.5 for aesthetic appearance, 4.3 for symmetry, and 4.6 for overall satisfaction (Fig. 6).
Fig. 6.
Postoperative results following NPIV. A, Three months postoperatively, showing well-defined labia minora framing the introitus with good symmetry. B, Two months postoperatively, with well-contoured labia minora and mild redundancy of anterior vulvar commissure skin. C, Eleven months postoperatively, demonstrating balanced labial contour with minor residual folds. D, One year postoperatively following surgery using the modified NPIV technique.
The most common complication was wound dehiscence at the introitus, observed in 19 patients (25.7%). Management varies depending on severity. Minor dehiscence, often with limited distal labial necrosis, was treated conservatively. (See figure, Supplemental Digital Content 3, which displays the postoperative view of a patient with introital wound dehiscence with minor labial necrosis managed conservatively, https://links.lww.com/PRSGO/E547.) Extensive dehiscence with significant labia minora necrosis occurred in 9 (12.2%) patients, most often involving the inferior portion with limited perfusion, and these cases were managed with delayed local flap reconstruction after inflammation subsided (3–6 mo). (See figure, Supplemental Digital Content 4, which displays the postoperative view of a patient with significant labia minora necrosis, predominantly involving the inferior portion, https://links.lww.com/PRSGO/E548.)
Risk factor analysis revealed that circumcised patients had a significantly higher incidence of labia minora necrosis compared with uncircumcised patients (30.0% versus 5.6%; Fisher exact test, P = 0.014). Receiver operating characteristic analysis for BMI demonstrated that a BMI greater than 22.1 kg/m² was associated with wound dehiscence (AUC = 0.603; 95% CI, 0.465–0.741), whereas a BMI greater than 28.2 kg/m² was associated with labia minora necrosis (AUC = 0.657; 95% CI, 0.482–0.833), although the latter did not reach statistical significance (P = 0.086). Smoking status showed no significant association with either complication (all P > 0.05 by the Fisher exact test). Other adverse events, including labia majora necrosis, canal stenosis, and rectal or urethral injury, were infrequent. (See table, Supplemental Digital Content 5, which displays the postoperative complications in 74 patients undergoing NPIV, stratified by circumcision status, https://links.lww.com/PRSGO/E549.)
DISCUSSION
Although technical refinements in vulvar reconstruction have been described in the literature,13 few have specifically addressed the challenge of constructing clearly defined labia minora with sufficient length to frame the neovaginal introitus. The present technique, based on a nonpenile inversion approach, was developed to enhance labial contour, symmetry, and introital aesthetics. By separating and reassembling the penile flap into discrete components, this method enables intentional flap planning and precise inset.
In this study, labial aesthetic outcomes were encouraging. Among 42 patients assessed for labial aesthetics, comprising 15 evaluated through standardized photographs and 27 via self-taken photographs, the majority achieved clearly defined and symmetrical labia minora. PROMs data from 40 patients further supported high levels of satisfaction. These findings suggest favorable aesthetic viability of the NPIV technique. However, as the number of patients completing long-term follow-up remains limited, future studies with broader datasets and longitudinal PROM analysis will be valuable to confirm these results.
This technique is best suited for patients with adequate penile skin. The most frequent complications were introital wound dehiscence with minor labial necrosis (25.7%) and significant labia minora necrosis (12.2%). Significant necrosis was defined as tissue loss involving more than one-third of the labial length. This complication occurred significantly more often among circumcised patients (30.0% versus 5.6%, P = 0.014), likely reflecting reduced penile tissue availability and decreased pliability from scar adhesions. Both conditions commonly resulted in some shortening of the labia minora, with the degree of loss proportional to the extent of necrosis. In cases of significant labial loss, marked shortening or asymmetry was observed, necessitating delayed local flap reconstruction.
The penile shaft flap used for the outer labial layer received its primary blood supply from the superficial external pudendal artery, which courses within the dartos fascia. The axial pattern blood supply provided robust and reliable perfusion, allowing for safe division and mobilization of the flap.14 However, flap vascularity remains subject to several patient-specific factors, such as smoking status, intrinsic vascular condition, and scarring from prior circumcision. To mitigate the risk of flap ischemia, it is recommended to maintain a flap width-to-length ratio no greater than 1:4. This ratio helps ensure adequate perfusion throughout the flap, particularly at the distal margin, and may reduce the likelihood of postoperative labial necrosis.
Although smoking is a well-established risk factor for wound healing complications, this association did not reach statistical significance in our series. This outcome is likely explained by the limited number of patients who reported active smoking, which reduced the statistical power to detect meaningful differences. In addition, preoperative nicotine levels were not measured, further restricting the reliability of smoking-related findings.
BMI demonstrated an association with dehiscence at an exploratory threshold; however, the AUC indicated poor discriminatory ability, and its predictive value for necrosis was similarly weak. The limited predictive strength of BMI for complications in our study is likely due to several factors, including the low number of patients who experienced these events, the small number of patients in higher BMI ranges within our cohort, and the absence of multivariable adjustment. Consequently, low event counts and a lack of statistical power limit the confidence with which an association can be inferred.
In our practice, quilting sutures for interlabial sulcus reconstruction were placed to incorporate both penile and scrotal skin flaps together at each stitch, rather than anchoring a single side. A 3-point fixation technique was used, with the knot positioned externally. Each stitch began at the skin edge (penile or scrotal), passed through the underlying corpus cavernosal crus, and exited on the opposing flap. The key principle was to ensure that both flaps were securely anchored to the corporal tissue without intervening subcutaneous fat, as fat interposition may compromise sulcus durability and predispose to scar creep. From our experience, anchoring both sides simultaneously provides greater long-term stability and reduces the risk of scar migration compared with the fixation of a single flap.
In cases where penile length is limited or postcircumcision scarring renders the remaining shaft skin insufficient for labial inset, we opted to advance the medial aspect of the scrotal skin to serve as the outer labial layer. In this setting, interlabial sulcus reconstruction involved only quilting sutures without additional scar concealment, as trimming and closing the wound medially could jeopardize the scrotal flap vascularity. Excess scrotal skin was excised, and wound closure was directed laterally to preserve the blood supply at the scrotal base.
Compared with the traditional penile inversion technique, the NPIV approach offers aesthetic advantages through greater control over labial flap contour and placement. Labia minora definition at the introitus becomes more consistent and reliable. Additionally, intraoperative flap trimming at the final stage of the procedure allows for refinement of symmetry and reduction of excess bulk, which are common reasons for secondary revision.15,16 A learning curve is anticipated, particularly in identifying optimal flap inset points and minimizing tension along closure lines. In addition, successful execution of the penile component separation requires both meticulous dissection and careful flap handling to preserve vascular integrity and prevent flap loss.
This study has some limitations. Follow-up duration was limited, particularly among patients with a short penile shaft requiring the modified NPIV technique; as all were international patients, extended monitoring was challenging. Furthermore, evaluation of risk factors for complications, such as smoking and high BMI, was constrained, as previously discussed. Additionally, all procedures were performed by a single surgeon using the NPIV technique, without direct comparison to other vaginoplasty methods or operators. Further studies with larger cohorts, longer follow-up, and multicenter participation are warranted to validate these findings and assess their generalizability.
CONCLUSIONS
The NPIV offers improved aesthetic control in labia minora reconstruction by enabling deliberate flap design and placement. This technique may serve as a reproducible option for vulvar aesthetic refinement in carefully selected primary vaginoplasty cases.
DISCLOSURE
The author has no financial interest to declare in relation to the content of this article.
ACKNOWLEDGMENT
The author is deeply indebted to Dr. Poonpissamai Suwajo for primary training in gender-affirming vaginoplasty, to Dr. Suporn Watanyusakul for laying the foundational principles of the nonpenile inversion technique, and to Dr. Sukit Worathamrong for his continued academic mentorship.
Supplementary Material
Footnotes
Published online 17 December 2025.
Disclosure statements are at the end of this article, following the correspondence information.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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