SURGEON'S CORNER

The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for

Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty
Tim H. J. Nijhuis, MD, PhD,1,2,3 Müjde Özer, MD,1,2 Wouter B. van der Sluis, MD, PhD,1,2
Muhammed Al-Tamini, MD,1,2 Ali Salim, MD,4 Philip Thomas, MB, BS, FRCS(Urol),5
James Bellringer, MB, FRCS(Urol), FECSM,6 and Mark-Bram Bouman, MD, PhD, FECSM1,2

ABSTRACT

Background: Penile inversion vaginoplasty is a commonly performed genital gender-affirming procedure in

transgender women. The creation of an adequate functional neovaginal depth in cases of too little usable penile
skin is a challenge. The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an easy adjunctive
technique and may serve as a tool in the surgical armamentarium of the gender surgeon.
Aim: To describe the use, dissection, design subtypes, and surgical outcomes of the BPES-flap in vaginoplasty.
Methods: Perioperative considerations and different flap design subtypes were described to illustrate the possible
uses of the BPES-flap in vaginoplasty. A retrospective chart study was performed on the use of this flap in 3
centers (blinded for review purposes).
Outcomes: The main outcome measures are description of surgical technique, flap design possibilities, and
postoperative complications.
Results: A total of 42 transgender women were included (median age: 28 years (range 18e66), mean body mass
index: 24.5 ± 3.5). The mean penile length and width preoperatively were 9 ± 3.1 and 2.9 ± 0.2 cm, respectively.
With a mean follow up of 13 ± 10 months, total flap necrosis occurred in one case (2.4%). Partial flap necrosis
occurred also in one. Neovaginal reconstruction was successful in all patients with a mean vaginal depth of
13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial prolapse of the neovaginal top occurred in 3 patients (7%).
Clinical Implications: The BPES-flap is a useful addition to the arsenal of surgeons performing feminizing
genital reconstructive surgery.
Strengths & Limitations: Strenghts comprise (1) the description of the surgical technique with clear images,
(2) completeness of data, and (3) that data are from a multicenter study. A weakness is the retrospective nature
with limited follow-up time.
Conclusion: The BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial
perineal arteries. It may be used for neovaginal depth creation during vaginoplasty and may be quicker to
perform than full-thickness skin grafting. Nijhuis THJ, Özer M, van der Sluis WB, et al. The Bilateral
Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile
Inversion Vaginoplasty. J Sex Med 2020;17:1033e1040.
Copyright
2020, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Transgender; Gender Dysphoria; Vaginoplasty; Scrotal Flap

4
Received November 25, 2019. Accepted February 25, 2020. Department of Plastic and Reconstructive Surgery, Kaiser Permanente,
1
Department of Plastic, Reconstructive and Hand Surgery, Amsterdam San Francisco, CA, USA;
5
University Medical Center, Location VUMC, Amsterdam, the Netherlands; Department of Urology, Nuffield Health Brighton Hospital, Brighton,
2
Center of Expertise on Gender Dysphoria, Amsterdam University Medical United Kingdom;
6
Center, Location VUMC, Amsterdam, the Netherlands; Deparment of Gender Surgery, Parkside Hospital, London, United Kingdom
3
Department of Plastic, Reconstructive and Hand Surgery, Amphia Hospi- Copyright ª 2020, International Society for Sexual Medicine. Published by
tal, Breda, the Netherlands; Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jsxm.2020.02.024

J Sex Med 2020;17:1033e1040 1033

1034 Nijhuis et al

INTRODUCTION
Penile inversion vaginoplasty is a commonly performed genital
gender-affirming procedure in transgender women.1,2 The crea-
tion of an adequate functional neovaginal depth in cases of too
little available penile skin is challenging. Etiologies include bio-
logical variation, penile hypoplasia due to circumcision, genital
(auto)mutilation, and/or the use of hormonal puberty blockers
(although quite frequently, there is combined penoscrotal hy-
poplasia in these cases). In patients with a long perineum,
inversion of the penile skin flap is difficult, and length of the
native penile skin flap cannot be used fully for neovaginal lining
as the first centimeters are necessary for the fold.
The addition of full-thickness skin grafts (FTGs) at the neo-
vaginal top, for example, taken from the surplus of the scrotal
skin, to the inverted penile skin may help to achieve an adequate Figure 1. Schematic overview of the arterial perfusion in the
neovaginal depth. However, this procedure is time consuming genital area. Figure 1 is available in color online at www.jsm.
because of the need for meticulous graft defatting and removal of jsexmed.org.
hair follicles. Furthermore, the interface between the vascularized
penile skin and the non-vascularized FTG can be a possible area Preoperative Preparation
of dehiscence or scar contracture.3 In addition, the non- The (variation of) surgical steps of the penile inversion vag-
vascularized FTG will have some tendency to contract. inoplasty and the standards of care have been previously dis-
Another option for patients with insufficient penoscrotal skin is cussed extensively.1e3 When performing scrotal flap surgery,
performing intestinal vaginoplasty, with concomitant risks of preoperative permanent hair removal of the scrotal skin by laser
intra-abdominal bowel surgery.4,5 or electrolysis is mandatory. Excess neovaginal hair growth may
The bilateral pedicled epilated scrotal flap (BPES-flap) can be have a (preventable) negative impact on neovaginal hygiene.
used as an adjunctive technique and may serve as a solution for Before surgery, patients are seen by a pelvic floor physical
the aforementioned disadvantages of non-vascularized FTGs therapist as parts of a pelvic floor physical therapy program
when used as an adjunct to the inverted penile skin flap. The specifically aimed at transgender women, to facilitate easy
BPES-flap is a vascularized scrotal flap that can be raised on the postoperative dilatation.
bilateral inferior superficial perineal arteries.6,7 The subfascial
dissection also allows the surgeon good access to the bulbo-
Intraoperative Considerations
spongiosus muscle and the levator ani complex, facilitating the
dissection of the vaginal cavity. The BPES-flap has been previ- Anatomy
ously described mainly in urological literature for anterior ure- There are several key anatomical units that need to be iden-
thral reconstruction.8 This study describes the technique of the tified while harvesting this flap. Transversely, several layers
BPES-flap dissection and its inset in the inverted penile skin flap should be identified: skin, dartos fascia, cremaster muscle
in 42 patients. (including the external spermatic fascia), and bulbospongious
muscle. Appreciating these individual layers is important for the
dissection of the BPES-flap because the flap is raised in a sub-
Indications for Procedure fascial plane including the dartos fascia.
The first step is to define an adequate depth of the neovagina. In
The vascularization is supplied by the superficial perineal artery
a study by Schimpf et al,9 an average vaginal length of 9.1 cm was
that arises from the internal pudendal artery (see Figure 1). After
found in non-transgender women. Djordjevic and Stanojevic10
crossing the superficial transverse perineal muscle, the perineal ar-
described an average neovaginal depth of 11.6 cm after gender-
tery runs between the bulbosponiosus and ischiocavernous mus-
affirming surgery in transgender women. We believe that a neo-
cles. The most distal branches supply the skin and dartos tunica in
vaginal depth of 12 cm and an intravaginal diameter of 3.5 cm
a cross-over pattern supplied by the bilateral vascularization.
should allow for adequate neovaginal penetrative intercourse after
vaginoplasty. Accordingly, in penile inversion vaginoplasty, the The dimensions of the BPES-flap are limited by the peri-
planned inverted penile skin flap should at least be 12 cm long, neoscrotal fold caudally and distally and the proximal limitation
plus the distance of the perineum, to fully line the neovaginal is the base of the penis (where the scrotum ends). Maximal lateral
cavity. If there is shortness of skin to adequately line the neovaginal extension of the flap is determined by the need for scrotal skin to
cavity, a FTG or our proposed BPES-flap can be used. create the labia majora.

J Sex Med 2020;17:1033e1040

Scrotal Flap Application in Vaginoplasty
Figure 2. Illustration of the fasciocutaneous rectangular flap,
designed for neovaginal depth creation. Figure 2 is available in color
online at www.jsm.jsexmed.org.
Surgical Planning
The BPES-flap is versatile and can be designed and imple-
mented in several ways:
- When the inverted penile skin flap is of sufficient width but
insufficient length, a fasciocutaneous rectangular flap is
designed for neovaginal depth creation. The vascular pedicle of
the dorsally based flap is de-epithelialized. The vascular pedicle
length and the rectangular dimensions can be calculated as
shown below (See Prime Example and Figure 2).
- When the inverted penile skin flap is of sufficient length but is
too narrow, an axial fasciocutaneous flap can be designed. The
inverted penile skin flap is incised longitudinally, and the axial
flap is interposed to create more neovaginal width (see
Figure 3). This approach was described earlier in various
penoscrotal vaginoplasty techniques.7,11 The BPES-flap forms
Figure 3. Illustration of the fasciocutaneous longitudinally shaped
flap, designed for extra neovaginal width. Figure 3 is available in
color online at www.jsm.jsexmed.org.
J Sex Med 2020;17:1033e1040
1035
Figure 4. Illustration of the fasciocutaneous T-shaped flap,
designed for extra neovaginal width and depth. Figure 4 is available
in color online at www.jsm.jsexmed.org.
the posterior, and the incised inverted penile skin flap is used
for the lateral and anterior vaginal wall.
- When the inverted penile skin flap is of both insufficient
length and width, a combination of the aforementioned 2
techniques can be used. An axial T-shaped flap is designed. No
de-epithelialization is performed. The base of the T is inter-
posed in the longitudinally incised penile skin flap, and the
rectangular top of the flap is used for neovaginal depth creation
(see Figure 4).
Prime Example
Scrotal flap length: In this example, the penile skin flap length
is 8 cm (frenar band to the base when retracting the
penisemeasuring ventral stretched penile skin) and has a width
of 3.5 cm. The perineal length is 2 cm. The available penile skin
to line the neovaginal cavity is 8 cm minus the length of the
perineal length of 2 cm. Hence, to achieve 12 cm of lined
neovaginal depth, an additional 6 cm of neovaginal lining has to
be acquired. A scrotal flap of 6 cm long needs to be harvested.
Scrotal flap width: Using the mathematical formula for
calculating circumference (2 p r), the width of the scrotal flap
needs to be approximately 11 cm to achieve a diameter of
approximately 3.5 cm.
Determining the Flap Pedicle Length
In this case, the scrotal flap will be used as an extension of the
inverted penile skin flap. For example, if 6 cm of penile skin is
available for neovaginal lining, the scrotal flap is set in after 6 cm.
The minimal pedicle length is 6 cm. The scrotal flap is drawn
6 cm cranially from the planned introitus, with a caudal to
cranial height of 8 cm (see Figure 5). The 6-cm base of the flap
will be de-epithelialized. When the widest part of the scrotum
lies more anteriorly, a longer vascular pedicle can be created so
that enough scrotal tissue can be incorporated in the flap.
1036
Figure 5. Operative photographic recording of the rectangular
shaped design for neovaginal depth creation. Figure 5 is available in
color online at www.jsm.jsexmed.org.
In summary, the following algorithm could help in calculating
the required extra length:
1. Define the desired neovaginal depth and diameter.
2. Measure the penile length and perineal length.
3. Calculate the width of the BPES-flap: 2 p r (r is the radius; in
this case, half of the desired vaginal diameter).
4. Define the pedicle length: penile length subtracted by the
perineal length.
5. Define the caudal starting point of the BPES-flap: pedicle
length measured from the introitus.
6. Draw the BPES-flap dimensions with the scrotal skin
stretched.
Scrotal Flap Dissection
The scrotal flap is harvested in a subfascial plane (subdartos
fascia), leaving the cremaster muscle and external spermatic
fascia intact. The raised flap now includes only the skin and
Figure 6. Operative photographic recording of the raised BPES-
flap. BPES-flap ¼ bilateral pedicled epilated scrotal flap. Figure 6
is available in color online at www.jsm.jsexmed.org.
Nijhuis et al
Figure 7. Illustration of the inset of the vascularized rectangular
flap, to create more neovaginal depth. Figure 7 is available in color
online at www.jsm.jsexmed.org.
the dartos fascia (see Figure 6). The scrotal flap can be
transposed through the penile skin and sutured to it in an
interdigitating fashion to form the eventual top of the neo-
vagina. This is best peformed before inverting the penile skin
into the cavity, to facilitate easy suturing. The scrotal flap will
form the most distal part of the neovaginal canal, and the de-
epithelialized base of the scrotal flap will be placed posterior
to the penile inverted skin. A modification of this scrotal flap
is the T-flap. This modification uses in fact a rectangular
perineal flap in conjunction with the scrotal flap on the same
pedicle to create more width of the neovaginal canal. The
penile skin is incised, and the scrotal skin is maintained in
the midline (1e2 cm in width) and sutured to the penile skin
to enlarge the diameter (see Figure 7).
Postoperative Management and Follow-Up
At the end of the surgical procedure, a neovaginal tampon (ie,
double condom filled with gauzes) is positioned in the neovaginal
canal and will remain in place for 5 days. The current practice of
5-day postoperative packing is based on our experience with
“regular” penile inversion vaginoplasty procedures with or
without skin grafting. There is no flap monitoring because we
believe that a flap with such a robust pedicle does not require
monitoring by visual inspection. At the fifth postoperative day,
the tampon is removed, together with the transurethral urinary
catheter. When there are no postoperative problems, patients
start dilating (twice a day) and rinsing the neovagina. At 3 weeks,
6 weeks, 3 months, 6 months, 1 year, and 2 year after the sur-
gery, they are regularly seen at the outpatient clinic for scheduled
follow-up appointments.
Outcomes
A total of 42 patients were included (median age: 28 years
[range 18e66], mean body mass index: 24.5 ± 3.5) using data
of 3 gender affirmation centers (blinded for review purposes).
J Sex Med 2020;17:1033e1040
 Table 1. Patient demographics and outcomes
J Sex Med 2020;17:1033e1040

Scrotal Flap Application in Vaginoplasty

History of Relevant Penile Neovaginal Clinical follow-up
Case # Age BMI smoking? surgical history length (cm) Scrotal flap size (cm) depth (cm) Postoperative complications (months)

1 18 18 - - 11 10  4 15 - 11
2 27 23 Yes - 9 8  12 15 Neovaginal hypergranulation, for 9
which conservative treatment
3 27 29 - Circumcision 8 6  20 11 Introital wound dehiscence 12
4 25 20 - Circumcision 9 79 15 Intraoperative urethral injury, 12
oversewn without
postoperative consequences.
5 38 26 Yes Bilateral open 14 89 14 þ3m Minor neovaginal prolapse, 10
inguinal hernia for which surgical excision of
correction some skin without
consequences for neovaginal
depth
6 24 24 - - 13 57 12 - 13
7 20 21 - - 9 4  22 11 - 15
8 57 25 Yes - 10 17  4 11 þ1m Partial neovaginal prolapse, 15
for which conservative
treatment
9 24 21 - - 12 76 13 - 16
10 26 29 - - 14 85 13 þ1d Postoperative bleeding, for 14
which re-exploration under
general anesthesia
11 39 26 Yes - 15 8  5 13 - 15
12 38 26 - - 11 8  5 14 - 17
13 40 24 - - 12 6  9 14 - 15
14 20 23 Yes - 12 5  12 14 - 17
15 33 20 - - 12 7.5  9 15 - 30
16 22 26 - - 11 8  8 14 þ1w Total flap necrosis, for 30
which debridement
17 18 24 - - 11 88 14 Hypergranulation, for which 29
topical application of silver
nitrate
18 28 24 Yes Circumcision 9 98 13 - 28
19 23 19 - - 12 87 15 - 35
20 26 22 - - 11 88 13 þ1w Partial flap necrosis, for 20
which debridement and at a
later stage new full-thickness
skin grafting.
21 20 19 - - 11 10  10 14 - 24
(continued)

1037
 1038
Table 1. Continued
History of Relevant Penile Neovaginal Clinical follow-up
Case # Age BMI smoking? surgical history length (cm) Scrotal flap size (cm) depth (cm) Postoperative complications (months)
22 26 22 - - 10 9  10 14 Hypergranulation, for which 44
topical application of silver
nitrate
23 38 27 Yes - 7 7 14 Granulation tissue 3
24 26 26 - - 8 7 13 Granulation 2
25 28 24 - - 6 6.5 12.5 Some prolapse 8
26 27 24 - - 5 6 11 - 8
27 42 26 - - 4 6 10 Granulation and pain 3
28 55 23 Yes - 4 6 10 - 2
29 35 27 - - 5 6 11 Granulation 2
30 46 25 - - 6 8 14 - 2
31 44 27 - - 6 7 13 Granulation 2
32 32 28 - - 8 6 15 - 4
33 25 22 - - 7 6 13 - 2
34 66 24 - - 6 7 13 - 3
35 60 32 - - 1 7.5 8.5 - 3
36 55 24 - Bilateral 6 6.5 12.5 - 4
orchidectomy
37 18 19 - - 7 6  7 12 Scar revision 12
38 46 23 - - 9 6  8 13 - 12
39 54 32 - - 11 7  8 12 - 9
40 36 34 - - 8 8  8 11 Excision of excess tissue 8
41 27 26 - - 10 7  7 14 - 8
42 48 25 - - 8 7  7 10 - 7
BMI ¼ body mass index.
J Sex Med 2020;17:1033e1040

Nijhuis et al
Scrotal Flap Application in Vaginoplasty
The mean penile length and width preoperatively were 9 ± 3.1
and 2.9 ± 0.2 cm, respectively. With a mean follow up of
13 ± 10 months, total flap necrosis occurred in one patient
(2.4%) and partial flap necrosis in one (2.4%). Neovaginal
reconstruction was successful in all patients with a mean vaginal
depth of 13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial
prolapse of the top was observed in 3 patients (7%). For a
detailed overview on patient demographics and outcomes, see
Table 1.
DISCUSSION
This study advocates the usefulness of the BPES-flap as an
adjunct to the arsenal of the genital surgeon. It can be a powerful
adjunctive for creation of more neovaginal depth in a subset of
transgender women with relative insufficient amount of penile
skin and a surplus of scrotal skin.
Although, in literature, some other groups already promoted
the application of (similar) axial flaps in this region based on
varied pedicles, we have proven the usefulness in a clinical study
with 42 patients. For example, the group of Saint-Cyr showed in
their cadaver study the possibility of raising a flap on the external
pudental artery.12 And Angspatt et al13 stated the possibility of
raising a bilateral scrotal flap raised on the anterior scrotal artery.
However, this is also a study using only cadavers.
In this article, we described the surgical indications, tech-
nique, and preliminary clinical results of the BPES-flap in vag-
inoplasty surgery. Penile inversion vaginoplasty is considered the
gold standard for perineal feminization in transgender women.3
Creation of sufficient vaginal depth may be a challenge in pa-
tients with limited penile skin. In absence of sufficient penile
skin, surgeons may choose to perform scrotal vaginoplasty,
penile inversion vaginoplasty with use of additional FTGs, or
even perform peritoneal or intestinal vaginoplasty. For a specific
group of patients, those with penile skin shortage but sufficient
scrotal skin, use of the BPES-flap may have significant advan-
tages. In our opinion, one of the advantages is that a quick
harvest can be achieved and thus can result in a reduction of
operative time compared with the use of skin grafts. However,
intraoperative time recordings were not performed in this study.
This will be the subject of further research. This simple flap is an
ideal improvement for the group of patients who require extra
skin to create an anatomical neovaginal canal undergoing penile
inversion vaginoplasty.
An issue with the use of this flap for neovaginal lining is the
risk of prolapse, which in our data occurred partially in 3 of 42
patients (7%). These (partial) prolapses can be explained to some
extent: in one patient, there was a language barrier resulting in a
non-compliance regarding postoperative instructions; the other
patient reported straining due to constipation as she did not use
the standard postoperative prescribed laxative (Movicolon,
13.8gr sachet). Despite the fact that the prevalence of this
prolapse is low, a preventive action could be sacrospinous
J Sex Med 2020;17:1033e1040
1039
fixation of the flap or maintaining the position posterior using
the fibrin glue or barbed PDS as described by Stanojevic.14 That
being said, the authors of this publication do not fixate this flap.
During surgery, a packing is placed in the neovaginal cavity and
removed at day 5 after surgery. The current practice of 5-day
postoperative packing is based on our experience with “regular”
penile inversion vaginoplasty procedures with or without skin
grafting. A longer packing period or re-packing the neovaginal
cavity after 5 days may have a beneficial effect on the risk of
neovaginal prolapse.
When performing penile inversion vaginoplasty, the labia
majora are, by most surgeons, formed from redundant scrotal
skin. The use of the scrotal flap as described previously may yield
a relative shortage of scrotal skin as a consequence. It is therefore
a risk that has to be weighed: well-vascularized neovaginal depth
vs less prominent labia majora. It is a risk that can be discussed
preoperatively with the patient and could aid the surgeon in
choosing the right technique for the patient.
The use of a scrotal flap can answer some of the recon-
structive challenges faced in certain cases when performing
vaginoplasty surgery. Because it is an axial flap with reliable
blood supply, multiple different flap designs are possible. In
patients with insufficient penile skin length but sufficient
width, a rectangular design with de-epithelialized vascular
pedicle will suffice. In patients with sufficient penile skin
length but insufficient width, a longitudinal fasciocutaneous
flap can be interposed to create more width. A T-flap design
may be used in patients with both insufficient penile skin
length and width. Another benefit of using this flap and not
full-thickness skin grafting is the prevention of circular scar
contraction, which could result in loss of depth. In this study,
adequate postoperative neovaginal depths were measured after
the use of the BPES-flap in vaginoplasty. However, main-
taining depth with dilation is a dynamic process for at least
the first year, so long-term follow-up is mandatory to draw
generalizable conclusions on long-term neovaginal depth.
Strengths of this study are the concise description of the
surgical technique with clear images, completeness of data of the
included patients, and that it is part of a multicenter study. The
retrospective data collection on a small group of patients with
limited follow-up time is the weakness.
We recommend gender surgeons to incorporate this scrotal
flap in their surgical armamentarium, for the BPES-flap is a
powerful adjunctive for creation of more neovaginal depth in a
subset of transgender women with relatively insufficient amount
of penile skin and a normal to large scrotum.
Corresponding Author: Tim H.J. Nijhuis, MD, PhD,
Department of Plastic, Reconstructive and Hand Surgery,
Amsterdam University Medical Center, Location VUMC, De
Boelelaan 1117, Amsterdam 1081 HV, the Netherlands. Tel:
þ31-20-4443261; Fax: þ31-20-4440151; E-mail: t.h.j.nij-
huis@gmail.com
1040
Conflict of Interest: The authors report no conflicts of interest.
Funding: None of the authors have commercial associations or
financial disclosures that might pose or create a conflict of in-
terest with information presented in any submitted manuscript.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Tim H.J. Nijhuis; Wouter B. van der Sluis; Mark-Bram Bouman
(b) Acquisition of Data
Tim H.J. Nijhuis; Wouter B. van der Sluis; Ali Salim; Philip
Thomas; James Bellringer
(c) Analysis and Interpretation of Data
Tim H.J. Nijhuis; Wouter B. van der Sluis
Category 2
(a) Drafting the Article
Tim H.J. Nijhuis; Wouter B. van der Sluis
(b) Revising It for Intellectual Content
Tim H.J. Nijhuis; Müjde Özer; Wouter B. van der Sluis;
Muhammed Al-Tamini; Ali Salim; Philip Thomas; James Bell-
ringer; Mark-Bram Bouman
Category 3
(a) Final Approval of the Completed Article
Tim H.J. Nijhuis; Müjde Özer; Wouter B. van der Sluis;
Muhammed Al-Tamini; Ali Salim; Philip Thomas; James Bell-
ringer; Mark-Bram Bouman
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