Skin Graft Vaginoplasty (FTSG / STSG Canal Augmentation)
Skin graft vaginoplasty uses a full-thickness (FTSG) or split-thickness (STSG) skin graft to augment or replace penile skin as neovaginal canal lining when there is insufficient genital skin to achieve adequate depth during penile inversion vaginoplasty (PIV).[1][2][3] It is the most common adjunct to PIV — required in 85.7% of the 15-year Ghent series (n = 384) to reach the 14 cm depth target[4] — and also serves as a standalone revision technique after failed primary vaginoplasty (van der Sluis 2016 perineal FTSG: 81% success, 12.5 cm depth, 19% rectal perforation).[5]
This is the dedicated atlas page. For the host operation, see Penile Inversion Vaginoplasty. For the principal alternatives when donor tissue is insufficient, see Peritoneal Pull-Through Vaginoplasty and Intestinal Vaginoplasty. For stenosis-management context, see Neovaginal Stenosis Management.
Indications
Skin-graft augmentation is indicated when penile skin alone cannot provide adequate neovaginal depth. Risk factors for insufficient genital skin:[4][6]
- Prior circumcision — the most common reason for needing supplemental graft.[4]
- Prior orchiectomy — 3× greater odds of needing extragenital skin graft (Sineath 2022).[6]
- Stretched penile skin length < 10 cm.[6]
- Pubertal suppression — early hormone-blockade-driven genital hypoplasia.[1]
- Lichen sclerosus or other conditions affecting genital-skin quality.[1]
Decision threshold: the option to add a graft is typically offered when penile skin length falls between 7 and 12 cm.[7] In the Ghent 15-year series, 85.7% required FTSG to reach 14 cm.[4]
Graft Types and Donor Sites
| Graft type | Donor site | Notes |
|---|---|---|
| Full-thickness skin graft (FTSG) — most commonly used | Scrotal skin (preferred — hairless after electrolysis, readily available); abdominal / lower-abdomen / groin | Scrotal FTSG: hairless canal, no vaginal-wall-prolapse risk[4][8] |
| Split-thickness skin graft (STSG) | Thigh, buttock | More common in modified Abbe–McIndoe technique for vaginal agenesis; also applicable in transgender vaginoplasty[9][10] |
| Extragenital FTSG | Flank, iliac crest, thigh | When scrotal skin is unavailable / insufficient[1][11] |
Preoperative electrolysis of the donor site (especially scrotum) is essential to prevent intravaginal hair growth.[12]
Surgical Technique
- Donor-site harvest — scrotal-skin FTSG most common; epilation completed ≥ 6 weeks preoperatively.
- Graft preparation — defat (FTSG); fenestrate as needed.
- Anastomosis to inverted penile skin tube — graft sutured to the distal end of the inverted penile skin tube, extending the canal lining.
- Inversion into the canal — composite tube (penile skin + graft) inverted into the dissected rectoprostatic space.
- Stent / mold placed to maintain canal during initial healing.[2][13]
Outcomes
| Outcome | Skin-graft vaginoplasty | Comparator |
|---|---|---|
| Intraoperative neovaginal depth | ~13.8 cm (with or without graft) | — |
| 1-year depth | ~11.5 cm (15% decline, mostly in first 3 wk) | — |
| Revision FTSG depth | 12.5 ± 2.8 cm | Intestinal revision 15.9 ± 1.4 cm (p < 0.01)[5] |
| Penetrative intercourse (Ghent 15-yr) | 97.2% | — |
| Orgasm (Ghent 15-yr) | 83.4% | — |
| Aesthetic / functional satisfaction | No significant difference with vs without graft (Buncamper 2017) | — |
Anchors: Buncamper 2017[7], Opsomer Ghent 15-yr[4], van der Sluis 2016 revision comparison[5].
Complications
Across a Salibian 2021 systematic review of 1,622 patients receiving skin grafts as adjuncts to PIV:[3]
| Complication | Incidence | Notes |
|---|---|---|
| Neovaginal stenosis | 1.2–12% | Most common; dilation intensification or revision |
| Neovaginal necrosis (partial / complete) | 0–22.8% | Significant concern unique to grafted tissue[3] |
| Lubrication satisfaction | Low | Skin-lined canals do not self-lubricate[3][12] |
| Rectal perforation — primary | 1.6% | Ghent series[4] |
| Rectal perforation — revision FTSG | 19% | vs 10% for intestinal revision[5] |
| Donor-site morbidity | Minimal | Scarring possible[3] |
| Late revision surgery | 37.1% | Diabetes the only independent risk factor (Ghent)[4] |
Graft vs No Graft — The Buncamper 2017 Controversy
Prospective Amsterdam study (n = 100; 32 with vs 68 without additional FTSG):[7]
- No significant difference in neovaginal shrinkage, aesthetic outcome, sexual function, or genital self-image.
- The addition of a skin graft does not worsen outcomes through contraction or insensitivity.
- It also does not clearly improve aesthetic results by preserving more penile skin for vulvar construction.
- This contradicts both sides of the longstanding debate — argues against doctrinaire stances either for or against routine graft use.[7]
Skin Graft vs Alternative Revision Techniques
van der Sluis 2016 head-to-head revision comparison (n = 53):[5]
| Outcome | Perineal FTSG revision (n = 32) | Laparoscopic intestinal revision (n = 21) |
|---|---|---|
| Success | 81% | 91% |
| Depth | 12.5 ± 2.8 cm | 15.9 ± 1.4 cm (p < 0.01) |
| OR time | 131 ± 35 min | 191 ± 45 min |
| Rectal perforation | 19% | 10% |
FTSG revision is shortest OR time but has lower success, less depth, and highest rectal-perforation rate. For revision technique selection see the Neovaginal Stenosis Management page (Step 3 framework: peritoneal-flap first-line, sigmoid for complete obliteration, FTSG when shortest OR is the priority).
Postoperative Care
- Lifelong vaginal dilation — up to 3× daily initially, tapering over months. Failure to dilate → stenosis and depth loss.[12]
- External lubricant always required — the skin-lined canal does not self-lubricate.[12]
- Pelvic-floor PT for persistent pain or dilation difficulty.[12]
See the PIV page dilation-protocol table for the full schedule and the Neovaginal Stenosis Management page for the PFPT framework (Jiang OHSU pre + post 28% vs 86%, FLOWER RCT no-routine-benefit signal, Shamamian dilation-difficulty predictors).
Evidence Limitations
- Salibian 2021 SR of 1,622 graft-augmented PIV patients is the largest aggregate; component series are heterogeneous in graft technique, donor site, and outcome definitions.[3]
- Buncamper 2017 (n = 100) is the only direct graft-vs-no-graft comparison and found no significant difference in outcomes.[7]
- van der Sluis 2016 (n = 53) is the only head-to-head FTSG-vs-intestinal revision comparison.[5]
- No standardised outcome definitions for "neovaginal necrosis" — wide 0–22.8% range reflects definitional heterogeneity.[3]
- Long-term outcomes beyond 5 yr poorly characterised across most graft series.[3]
References
1. Bene NC, Ferrin PC, Xu J, et al. Tissue options for construction of the neovaginal canal in gender-affirming vaginoplasty. J Clin Med. 2024;13(10):2760. doi:10.3390/jcm13102760
2. van der Sluis WB, Schäfer T, Nijhuis THJ, Bouman MB. Genital gender-affirming surgery for transgender women. Best Pract Res Clin Obstet Gynaecol. 2023;86:102297. doi:10.1016/j.bpobgyn.2022.102297
3. Salibian AA, Schechter LS, Kuzon WM, et al. Vaginal canal reconstruction in penile inversion vaginoplasty with flaps, peritoneum, or skin grafts: where is the evidence? Plast Reconstr Surg. 2021;147(4):634e–643e. doi:10.1097/PRS.0000000000007779
4. Opsomer D, Vyncke T, Mertens D, et al. Fifteen-year experience with the Ghent technique of penile inversion vaginoplasty. Plast Reconstr Surg. 2021;148(3):416e–424e. doi:10.1097/PRS.0000000000008300
5. van der Sluis WB, Bouman MB, Buncamper ME, Mullender MG, Meijerink WJ. Revision vaginoplasty: a comparison of surgical outcomes of laparoscopic intestinal versus perineal full-thickness skin graft vaginoplasty. Plast Reconstr Surg. 2016;138(4):793–800. doi:10.1097/PRS.0000000000002598
6. Sineath RC, Butler C, Dy GW, Dugi D. Genital hypoplasia in gender-affirming vaginoplasty: prior orchiectomy, penile length, and other factors to guide surgical planning. J Urol. 2022;208(6):1276–1287. doi:10.1097/JU.0000000000002900
7. Buncamper ME, van der Sluis WB, de Vries M, et al. Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft? Plast Reconstr Surg. 2017;139(3):649e–656e. doi:10.1097/PRS.0000000000003108
8. Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet. 2016;388(10042):401–411. doi:10.1016/S0140-6736(16)00682-6
9. Committee on Adolescent Health Care. ACOG Committee Opinion No. 728: Müllerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 2018;131(1):e35–e42. doi:10.1097/AOG.0000000000002458
10. Linder BJ, Gebhart JB. McIndoe neovagina creation for the management of vaginal agenesis. Int Urogynecol J. 2021;32(2):453–455. doi:10.1007/s00192-020-04425-y
11. Morley GW, DeLancey JO. Full-thickness skin graft vaginoplasty for treatment of the stenotic or foreshortened vagina. Obstet Gynecol. 1991;77(3):485–489.
12. Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75–e88. doi:10.1097/AOG.0000000000004294
13. Ferrando CA. Updates on feminizing genital affirmation surgery (vaginoplasty) techniques. Neurourol Urodyn. 2023;42(5):931–938. doi:10.1002/nau.25088