Full-Length Peritoneal Flap Vaginoplasty: A Feasible Approach for Hairless Neovaginal Reconstruction in Gender-Affirming Surgery

Summary:

The authors present a technique for neovaginal reconstruction in gender-affirming vaginoplasty using an anteriorly based peritoneal turnover flap to create a full-length lining throughout the depth of the neovaginal canal. Between 2024 and 2025, 10 patients successfully underwent the procedure without major complications. At the 3-month follow-up, 80% of patients maintained neovaginal depth comparable to the immediate postoperative measurement. Internal neovaginal examination demonstrated that the neovaginal lining exhibited a mucosal surface, high elasticity, and self-lubrication. The potential impact of peritoneal flap harvesting on the urinary bladder was evaluated using the Incontinence Questionnaire–Male Lower Urinary Tract Symptoms. This technique may represent a feasible approach for achieving hairless neovaginal reconstruction in gender-affirming surgery, particularly for patients with scrotal skin deficiency or extensive genital hair.

Standard robotic peritoneal vaginoplasty typically involves a hybrid approach, with peritoneum lining the apex and the distal segment reconstructed using inverted penile or scrotal skin.^1–4 Although outcomes are favorable, concerns persist regarding hair-bearing skin within the neovaginal lining. Some transgender women prefer a fully hairless neovagina, as residual hair may cause discomfort and hygiene issues. Postoperative hair removal is generally ineffective.

To address this, we developed a technique using a full-length, vascularized peritoneal flap from apex to introitus, eliminating the need for skin bridging. This may benefit patients with limited genital skin or those seeking a hairless neovagina without intestinal vaginoplasty.

Patients were evaluated according to the World Professional Association for Transgender Health Standards of Care.⁵ This approach was offered to those with inadequate genital skin who declined alternatives such as colovaginoplasty or external grafts, and to those seeking a mucosal-surfaced neovagina. Previous abdominal surgery is a contraindication, as peritoneal integrity may be compromised by adhesions or scarring. All patients were counseled regarding risks, including herniation, apex perforation, and adhesions, along with preventive strategies.

All patients underwent nonpenile inversion vaginoplasty comprising canal dissection, orchiectomy, urethroplasty, clitoroplasty, and labial reconstruction. Peritoneal harvest was performed laparoscopically during the intermediate stage. After placing the patient in a 30-degree Trendelenburg position, a 20×20-cm flap was harvested from the anterior abdominal wall, extending from the bladder dome to the umbilicus and 10 cm laterally. Bilateral ureters were identified to avoid injury. Flap dimensions were individualized based on the circumference of a 3.5-cm diameter, 15-cm long vaginal dilator. The flap exceeded the canal length to allow turnover (Fig. 1, above, left). (See Video 1 [online], which demonstrates the peritoneal flap design.) In selected areas, transversalis fascia was included to enhance thickness, and muscle fibers were avoided to minimize risk of intercostal nerve injury. (See Video 2 [online], which demonstrates the peritoneal flap harvest.)

Fig. 1.

Stepwise illustration of the full-length peritoneal flap vaginoplasty. (Above, left) Peritoneal flap outline and laparoscopic port placement. (Above, right) Peritoneal flap tubularization. (Below) Peritoneal flap delivery into the neovaginal canal in a turnover manner. Illustration created by Dr. Pobpan. Copyright © 2025 Pea Pobpan, MD. All rights reserved.

Video 1. This video demonstrates the peritoneal flap design.

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Video 2. This video demonstrates the peritoneal flap harvest.

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The flap was tubularized laterally to laterally. The midline was suspended to the abdominal wall to assist tubularization (Fig. 1, above, right). (See Video 3 [online], which demonstrates peritoneal flap tubularization.) The bladder was mobilized and the distal flap was sutured to the bladder serosa, creating a closed neovaginal pouch, which was delivered through a rectovesical incision and anchored distally to the introitus using labia minora flaps derived from penile skin (Fig. 1, below). (See Video 4 [online], which demonstrates peritoneal flap delivery into the neovaginal canal.) Capillary bleeding at the distal edge confirmed perfusion. A bioresorbable antiadhesion barrier was applied to the abdominal surface.

Video 3. This video demonstrates peritoneal flap tubularization.

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Video 4. This video demonstrates peritoneal flap delivery into the neovaginal canal.

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Ten patients underwent this procedure from 2024 through 2025. The mean age was 27.5 years, and the mean body mass index was 23.05 kg/m². One patient required partial scrotal grafting due to limited flap reach. The average operative time was 9 hours and 2 minutes. The mean immediate neovaginal depth was 5.5 inches. (See Table, Supplemental Digital Content 1, which shows demographic data, clinical characteristics, and surgical details of patients undergoing full-length peritoneal flap vaginoplasty, http://links.lww.com/PRS/I308.)

After the surgery, patients performed dilation twice daily using custom acrylic dilators for 1 year. They were instructed to limit insertion depth to the surgeon-specified length, maintain positioning, and avoid sitting on the dilator to prevent apex perforation. Penetrative intercourse was permitted after 3 months.

At 3-month follow-up, 8 patients maintained a depth equivalent to the immediate postoperative measurement, 1 showed mild reduction, and 1 developed canal closure after cessation of dilation. Depth was assessed by dilator markings at the introitus at maximal insertion without force. Width was measured from the largest comfortably inserted dilator. (See Figure, Supplemental Digital Content 2, which shows a set of custom-made acrylic vaginal dilators used for postoperative depth and width assessment. The dilators are marked with depth indicators in 1-inch increments ranging from 3 to 6 inches. Diameters of the small, medium, and large dilators are 26 mm, 28 mm, and 32 mm, respectively, http://links.lww.com/PRS/I309.) Colposcopic examination showed a mucosal-like lining with pink coloration, good elasticity, and mild serous secretions (Fig. 2). (See Video 5 [online], which demonstrates colposcopic examination of the neovagina at 3 months following full-length peritoneal flap vaginoplasty.)

Fig. 2.

External vulvar appearance at 3 months postoperatively.

Video 5. This video demonstrates colposcopic examination of the neovagina at 3 months following full-length peritoneal flap vaginoplasty.

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Postoperative lower urinary tract symptoms were assessed using the Incontinence Questionnaire–Male Lower Urinary Tract Symptoms in 6 patients. Symptom severity was mild (mean 9.83 of 52), and bother was moderate (mean 22.83 of 130). Subdomain severity scores were 4.5 of 20 (voiding), 5.7 of 30 (storage), and 1.0 of 10 (postmicturition), with corresponding bother scores of 11.3 of 50, 9.5 of 60, and 5.7 of 20.⁶

DISCUSSION

This technique provides continuous peritoneal lining from apex to introitus, eliminating the need for interposed skin bridging, which may be particularly beneficial for patients with insufficient or hirsute genital skin.^7–9 Suwajo et al.¹⁰ introduced a full-length pedicled peritoneal flap, but its reliance on the deep inferior epigastric artery makes it technically demanding and limited to specialized centers.

Other vascularized peritoneal flap techniques have been well described, including the tubularized urachus–peritoneal hinge flap, the single pedicled flap, and the robotic tubularized approach.^1–3 These represent important innovations; our method differs in flap design and application. We describe a laparoscopically harvested anterior-based turnover flap originating at the bladder dome that reaches the introitus without skin interposition. This avoids posterior or mesenteric pedicles and may offer advantages in selected patients. To offset turnover-related length loss, the flap is harvested longer than the intended canal and calibrated intraoperatively. By contrast, Jun et al.⁴ used peritoneal flaps only to augment the apex in penile inversion vaginoplasty.

Before adopting the current technique, we used free peritoneal grafts for full-length neovaginal reconstruction. Despite adequate vascular beds, the graft take was inferior to skin grafts, with a higher rate of canal stenosis, prompting a shift toward a vascularized flap approach.

Capillary bleeding at the distal edge supports preserved perfusion. We hypothesize perfusion through urachal branches, as described by Smith et al.¹ Although perfusion imaging was not performed, future studies will include intraoperative assessment. All canals remained accessible and functional, except one with complete dilation cessation. No cases of introital narrowing or blind pouch were observed.

Nonarousal secretions were expected; however, most patients did not require sanitary pads beyond the first month, as volume was minimal and retained within the canal. Lubrication was advised during intercourse due to the penile-skin origin of the labia minora.

The male International Consultation on Incontinence Questionnaire module was used due to prostate retention and male-pattern voiding. Lower urinary tract symptoms assessment was limited by the absence of baseline data. Symptoms were generally mild, but perceived bother varied among patients. Without preoperative comparison, causal relationships cannot be established. Longitudinal studies incorporating baseline evaluation are recommended.

Potential risks include intraabdominal adhesions, intercostal nerve injury, and limited feasibility of secondary peritoneal-based vaginoplasty. Dissection remained superficial to the muscle plane, typically sparing the T7–T12 intercostal nerves.¹¹ No patient experienced abdominal wall weakness or sensory changes. In one patient who later underwent unrelated abdominal surgery, minimal adhesions and near-complete peritoneal regeneration were observed at the donor site, although this is anecdotal. (See Figure, Supplemental Digital Content 3, which shows an intraoperative view taken 1 year after full-length peritoneal free graft vaginoplasty during an unrelated abdominal surgery. Minimal intra-abdominal adhesions were observed and easily lysed with sharp dissection. The peritoneal surface at the donor site showed near-complete regeneration, suggesting favorable healing characteristics and low long-term morbidity at the harvest site, http://links.lww.com/PRS/I310.) In revision cases, bowel-based vaginoplasty is recommended as the preferred backup option.

The short follow-up is a limitation. Although colposcopy at 3 months showed a soft, elastic, hairless lining, long-term remodeling remains uncertain. Future studies will assess morphologic changes, lubrication, and sexual function to validate long-term viability.

DISCLOSURE

The authors declare they have no conflicts of interest to report.

Supplementary Material

prs-157-0566-s006.pdf ^{(75.9KB, pdf)}

prs-157-0566-s007.pdf ^{(6.1MB, pdf)}

prs-157-0566-s008.pdf ^{(6MB, pdf)}