(022) A NOVEL SURGICAL TECHNIQUE TO CREATE A NATURAL-APPEARING RECESSED VAGINAL INTROITUS WITH GENDER-AFFIRMING VULVOPLASTY (“SHALLOW-DEPTH VAGINOPLASTY”) UTILIZING A PEDICLED ADVANCEMENT FLAP
Authors: Sandhu S , Smith S , Stelmar J , Yuan N , Mallavarapu S , Garcia M 
Published: June 2024

Abstract

Introduction
Feminizing genital gender-affirming surgery options include vaginoplasty with neovaginal canal creation (“full-depth vaginoplasty”), or vaginoplasty without creation of a neovaginal canal, referred to as “vulvoplasty” or “shallow-depth vaginoplasty”. If a transgender woman does not require a vaginal canal for sexual intercourse, shallow-depth vaginoplasty is an excellent option for women as it does not carry the additional requirements of lifelong dilation and douching and lower risk of complications as compared to the full-depth vaginoplasty procedure. As with either of these procedures, achieving “normal appearing” feminine anatomy is critical for patients. Currently, techniques for shallow-depth vaginoplasty have relied on the use of a separate full thickness skin graft utilizing a portion of scrotal skin to delineate

Objective
1) To better understand decision-making factors when choosing to undergo shallow-depth vaginoplasty. 2) To describe a novel technique used to create a recessed vaginal introitus. 3) To evaluate patient perceptions of appearance as compared to cisgender vulvae.

Methods
Patients undergoing feminizing genital gender-affirming surgery between 04/2017-07/2022 were included in this study. Of the patients undergoing shallow-depth vaginoplasty, an anonymous electronic survey querying decision-making factors and overall post-operative satisfaction were undertaken. In addition, our novel technique is described.

Results
A total of 110 patients underwent feminizing genital gender-affirming surgery. Of these, 35 (32%) underwent shallow-depth vaginoplasty, whilst 75 (68%) underwent full-depth vaginoplasty. Priorities: Achieving an appearance which was “comparable to” cisgender vulvae was ranked second highest after “elimination of male genital anatomy” (Figure 1a). Technique: To achieve a recessed skin-lined introitus, gathering sutures were used to create a “dimple” from penile/scrotal skin, which is tethered to the tendon of the bulbospongiosus muscle, and the diffuse perineal body tissue behind the urethral bulb (Figure 1, b-d). Attractiveness: When comparing their vulva to cisgender women’s of similar age and weight, all 26 (100%) patients reported that their vulvas had “similar” or “somewhat similar” appearance to cisgender vulvae. 24/26 (92%) of patients found their vulvas to be either “similarly or more attractive”, and 2/26 (8%) found their vulvas to be “less attractive” as compared to cisgender vulvae.

Conclusions
Women option for shallow-depth vaginoplasty greatly consider the cosmetic appearance which must be indistinguishable from cisgender female anatomy, which appears to be offered by this surgical technique. In addition to this, this technique offers transgender women the opportunity to have external anatomy in line with their gender identity, and for women who are not interested in using a vaginal canal for sexual experiences (i.e. receptive vaginal intercourse), this option foregoes the added risks and commitment to lifelong dilation and douching which is required for women opting to undergo full-depth vaginoplasty.

Disclosure
No.