Scrotal skin graft vaginoplasty is a form of gender-affirming genital surgery in which scrotal skin is used to help create part of the lining of a neovaginal canal. It is most commonly performed as a variation of penile inversion vaginoplasty, particularly when penile skin alone may not provide enough tissue to achieve the desired vaginal dimensions.
The procedure is therefore more accurately described as:
Penile inversion vaginoplasty with a full-thickness scrotal skin graft.
The penile skin usually forms the entrance and part of the vaginal lining, while the prepared scrotal skin graft extends the lining toward the deeper portion of the canal. Penile inversion remains one of the most widely used approaches to gender-affirming vaginoplasty, and scrotal skin is the most common local source of additional graft tissue.
This article provides general educational information. The exact surgical method, tissue arrangement, recovery protocol, and expected results may differ between surgeons and patients.
What Is a Scrotal Skin Graft?
A scrotal skin graft is a section of skin surgically removed from the scrotum and prepared for use as vaginal lining.
Unlike a skin flap, which remains attached to its original blood supply, a graft is completely separated from the donor area. It must establish a new blood supply after being placed against healthy tissue inside the surgically created vaginal canal.
The graft is normally harvested as a full-thickness skin graft, meaning that the epidermis and dermis are preserved while excess fat, connective tissue, and visible hair follicles are carefully removed.
After preparation, the graft may be joined to the penile skin and shaped into a tube around a surgical stent or dilator. This combined skin lining is then positioned within the newly created vaginal space.
Why Is Scrotal Skin Used?
Penile skin is often preferred for part of the neovaginal lining because it is generally flexible, relatively hair-free, and remains attached to its blood supply during penile inversion.
However, the amount of penile skin available varies significantly between patients. Factors affecting tissue availability may include:
- Natural penile and scrotal dimensions
- Circumcision
- Previous orchiectomy
- Previous genital surgery
- Scarring or tissue damage
- Puberty suppression
- Individual anatomy
- The depth and width that can be safely created within the pelvis
Many patients do not have enough penile skin to line the entire vaginal canal. Scrotal skin can provide additional surface area without requiring a separate graft from the abdomen, groin, hip, or thigh.
A previous orchiectomy may reduce the amount of scrotal skin available at the time of vaginoplasty. One study found that patients with a prior orchiectomy had approximately three times greater odds of requiring an additional extragenital skin graft, although individual circumstances vary.
What Are the Main Goals of the Procedure?
Scrotal skin graft vaginoplasty may be designed to create:
- A vaginal canal with appropriate depth and width
- A feminine-appearing vulva
- Labia majora and labia minora
- A sensate clitoris
- A shortened and repositioned urethral opening
- A vaginal entrance suitable for dilation
- The possibility of receptive vaginal intercourse
- Genital anatomy that more closely reflects the patient’s gender identity
The surgeon must balance vaginal depth, width, tissue viability, sensation, urinary function, wound healing, and external appearance.
No surgeon can guarantee an exact vaginal depth, appearance, sensation level, orgasmic function, or sexual outcome. Results depend on anatomy, surgical technique, healing, complications, dilation, scar formation, and long-term follow-up.
Who May Be Considered for Scrotal Skin Graft Vaginoplasty?
The procedure may be considered for a patient who:
- Desires a vulva and a vaginal canal
- Has insufficient penile skin for the planned canal dimensions
- Has adequate healthy scrotal skin available
- Understands the need for long-term dilation
- Can participate in postoperative wound care and follow-up
- Has completed the required medical and surgical assessments
- Has realistic expectations regarding depth, lubrication, sensation, recovery, and possible revision surgery
- Is medically suitable for major surgery and anesthesia
Patient selection should be individualized and performed according to current professional standards and the requirements of the treating surgical team. WPATH describes gender-affirming healthcare as an interdisciplinary and evolving field in which assessment and treatment planning should be tailored to the individual.
Preoperative Assessment
Before recommending a scrotal skin graft, the surgeon may evaluate:
Genital tissue availability
The surgeon examines the length, width, elasticity, health, and hair distribution of the penile and scrotal skin.
Measurements can help estimate whether penile skin alone will be adequate or whether a scrotal or extragenital graft may be required. However, final decisions may sometimes be made during surgery after the vaginal canal has been safely dissected.
Previous procedures
Previous circumcision, orchiectomy, genital surgery, radiation, trauma, injectable materials, or infection may influence tissue quality and availability.
General health
The surgical team may assess:
- Cardiovascular and respiratory health
- Diabetes and blood-sugar control
- Blood pressure
- Body mass index
- Blood-clot risk
- Bleeding disorders
- Medication use
- Nicotine use
- Previous anesthesia problems
- Wound-healing history
- Mental-health and social support needs
Ability to complete aftercare
A patient must understand that creating the canal is only one part of the process. Maintaining it requires regular dilation, hygiene, follow-up examinations, and prompt reporting of complications.
Is Hair Removal Necessary?
Hair management is especially important when scrotal skin will be placed inside the vaginal canal because scrotal skin commonly contains hair follicles.
Intravaginal hair may contribute to:
- Persistent hair growth inside the canal
- Unpleasant odor
- Discharge
- Folliculitis
- Discomfort during dilation
- Pain during penetrative intercourse
- Accumulation of hair and skin debris
- Difficulty treating the hair after surgery
Preoperative laser hair removal or electrolysis may be recommended for the exact skin area expected to form the vaginal lining. The surgeon should provide a clear diagram because hair removal from the wrong area may be ineffective or unnecessary.
Some surgeons remove or destroy visible follicles during surgery by thinning the graft, scraping the underside, or using electrocautery. However, dormant follicles may not always be visible during the operation, and overly aggressive thinning can potentially affect graft quality. Practices therefore differ among surgical teams.
Patients should follow their own surgeon’s hair-removal protocol rather than arranging treatment without confirming the required area.
How Is Scrotal Skin Graft Vaginoplasty Performed?
The following is a general overview. Individual surgeons may perform the operation differently.
1. Anesthesia and surgical preparation
The operation is normally performed under general anesthesia. Preventive measures may be used to reduce infection and blood-clot risks.
2. Orchiectomy
The testicles are removed while the surgeon preserves the scrotal tissue required for construction of the vulva and possible vaginal grafting.
3. Creation of the vaginal space
A vaginal canal space is carefully created within the pelvis, generally between the rectum posteriorly and the urethra, prostate, and bladder structures anteriorly.
This is one of the most technically sensitive parts of the operation because injury to the rectum, urethra, bladder, nerves, or surrounding blood vessels can cause serious complications.
4. Penile disassembly and tissue preservation
The penile skin is separated from the internal erectile structures while important tissues are preserved for genital reconstruction.
The penile skin may later be inverted to form the vaginal entrance and part of the canal lining.
5. Clitoroplasty
A portion of the glans penis is reshaped to form the clitoris. The surgeon attempts to preserve its neurovascular supply to support sensation and sexual function.
The final level of sensation varies. Temporary numbness, altered sensation, hypersensitivity, or changes in orgasmic response may occur during healing.
6. Urethral reconstruction
The urethra is shortened and repositioned to create a feminine urinary opening.
Early swelling may temporarily affect urination. Longer-term concerns can include urinary spraying, dribbling, recurrent urinary infections, narrowing of the urethral opening, or abnormal connections known as fistulas.
7. Harvesting the scrotal skin graft
The required portion of scrotal skin is removed while enough appropriate tissue is preserved for construction of the labia majora.
The graft is carefully prepared by:
- Removing attached fat and connective tissue
- Thinning the graft to an appropriate level
- Identifying and treating hair follicles
- Shaping the graft according to the planned canal dimensions
- Checking the tissue for damage or excessive thickness
8. Formation of the vaginal lining
The scrotal graft is connected to the penile skin. The tissues may be wrapped and sutured around a vaginal stent or large dilator to form a skin tube.
The skin surface is positioned toward the inside of the neovagina, while the graft’s deeper surface is placed against the vascular tissue of the newly created canal so that it can establish a blood supply.
9. Placement of the lining
The combined penile-skin and scrotal-graft lining is placed into the vaginal space and secured.
Close contact between the graft and the recipient tissue is important. Bleeding, fluid collection, movement, infection, excessive pressure, or poor tissue contact may interfere with graft healing.
10. Vulvar construction
Scrotal and penile tissues are reshaped to create structures such as:
- Labia majora
- Labia minora
- Clitoral hood
- Urethral opening
- Vaginal entrance
- Perineal contour
11. Packing, stent, drains, and catheter
A vaginal stent or packing is commonly placed to support the new lining during early healing. A urinary catheter and surgical drains may also be used.
Removal timing varies according to the surgeon’s technique and the patient’s condition.
What Are the Potential Advantages?
Additional vaginal lining
The primary advantage is that scrotal skin can extend the available penile skin and help line a deeper or wider canal.
Use of local tissue
The graft is obtained from the same operative area. This may avoid a separate donor-site scar on the abdomen, groin, thigh, or hip.
No bowel resection
Unlike intestinal vaginoplasty, this technique does not require removal of a section of colon or small intestine.
It therefore avoids bowel anastomosis and several gastrointestinal risks specifically associated with intestinal surgery.
No laparoscopic abdominal component
A traditional open penile-inversion procedure with a scrotal graft may avoid the abdominal access required for laparoscopic or robotic peritoneal vaginoplasty.
Familiar and established approach
Penile inversion with scrotal grafting is a commonly described modification of penile inversion vaginoplasty and is performed by surgical teams in multiple countries.
What Are the Limitations?
The graft does not have its own blood supply
A free skin graft must develop a new blood supply after placement. Partial or complete graft loss can occur if healing is disrupted.
Possibility of contraction
Skin grafts can contract during healing. This may contribute to reduced vaginal width, reduced depth, or stenosis, particularly when dilation is difficult or inconsistent.
Regular dilation may help oppose the natural tendency of scar and graft tissue to contract.
Reduced sensation in the graft
A free scrotal graft is not expected to retain the same direct sensation as vascularized penile skin. Sexual sensation is generally expected to depend more heavily on the reconstructed clitoris, tissues around the vaginal entrance, surrounding nerves, and other erogenous structures.
Hair-related concerns
Hair may grow inside the canal if follicles remain active.
Limited natural lubrication
A skin-lined neovagina does not contain the same mucosal lining as a natal vagina. External water-based lubricant is commonly needed for dilation and penetrative sexual activity.
Available evidence does not show that any current neovaginal lining reliably reproduces lubrication equivalent to a natal vagina.
Dilation is required
Long-term dilation is an essential commitment for patients receiving a full-depth vaginal canal.
Possible staged revision
Some patients later undergo labiaplasty, scar revision, urethral revision, correction of asymmetry, clitoral-hood revision, or treatment of vaginal narrowing. The possibility of revision does not necessarily mean the primary operation failed; swelling, scar maturation, anatomy, and tissue healing can influence the final appearance.
Expected Vaginal Depth and Width
There is no universal guaranteed depth for scrotal skin graft vaginoplasty.
The achievable dimensions depend on:
- Pelvic anatomy
- Available penile and scrotal skin
- The depth that can be safely dissected
- Graft dimensions and healing
- Scar contraction
- Dilation adherence
- Infection or wound complications
- The surgeon’s technique
Published studies report varying vaginal depths because surgical methods, patient anatomy, measurement techniques, follow-up periods, and dilation protocols differ significantly. Patients should therefore avoid comparing one published number with an individual surgical guarantee.
Maintaining usable width is also important. A canal that is deep but too narrow may still make dilation, examination, or penetrative intercourse difficult.
Hospital Stay and Early Recovery
The length of hospitalization varies according to the surgical center, technique, patient health, and postoperative progress.
During the early recovery period, patients may experience:
- Swelling
- Bruising
- Temporary numbness
- Pain or pressure
- Light bleeding or discharge
- Difficulty sitting comfortably
- Temporary changes in urination
- Fatigue
- Reduced mobility
- Anxiety about wound appearance
- Emotional adjustment
The early appearance should not be considered the final result. Swelling can temporarily make the labia look uneven, enlarged, or irregular. Tissue shape and scars continue to change as healing progresses.
Patients should not remove packing, dressings, drains, or catheters unless instructed by their surgical team.
Vaginal Dilation
Dilation is one of the most important parts of recovery after full-depth vaginoplasty.
Its purpose is to:
- Maintain vaginal depth
- Maintain vaginal width
- Reduce narrowing caused by scar contraction
- Help the patient gradually adapt to insertion
- Allow the surgical team to evaluate canal healing
Dilation normally begins after the surgeon removes the vaginal packing or stent and confirms that it is safe to proceed.
Schedules differ significantly between surgical teams. A patient may initially need to dilate several times per day before gradually reducing the frequency over the following months. Some level of maintenance dilation may remain necessary long term, especially when penetrative activity is infrequent.
The patient should follow the exact instructions provided by the treating surgeon. Severe pain, sudden resistance, heavy bleeding, loss of depth, inability to insert the usual dilator, or a feeling that the canal is closing should be reported promptly.
Dilation should never be forced through severe resistance because this may injure healing tissues or create a false passage.
Hygiene and Long-Term Care
A skin-lined neovagina behaves differently from a vagina lined with natural vaginal mucosa.
Long-term care may include:
- Washing hands before wound care or dilation
- Keeping dilators clean
- Using only surgeon-approved lubricant
- Following the surgical team’s cleansing instructions
- Wiping from front to back
- Monitoring discharge, odor, bleeding, pain, and hair growth
- Attending scheduled examinations
- Reporting difficulty with urination
- Practicing safer sex
- Receiving sexually transmitted infection testing based on anatomy and sexual exposure
Patients should not use perfumes, harsh antiseptics, herbal preparations, vaginal medications, or strong cleansing solutions unless approved by a qualified clinician familiar with their surgical anatomy.
Persistent odor, unusual discharge, bleeding, pain, or difficulty dilating may be related to granulation tissue, retained debris, infection, hair, stenosis, or another condition that requires examination.
When Can Penetrative Sex Begin?
Penetrative sexual activity should begin only after the surgeon confirms that:
- Wounds have healed adequately
- The vaginal entrance is stable
- Dilation is progressing safely
- There is no active infection or significant granulation tissue
- There is no fistula, wound separation, or unresolved bleeding
The timing varies. Beginning too early may cause bleeding, wound separation, pain, graft injury, or loss of depth.
Even after healing, patients may need generous lubrication and gradual penetration. Persistent pain should not simply be endured. It may be related to scar tissue, pelvic-floor muscle spasm, narrowing, inadequate lubrication, granulation tissue, or another treatable condition.
Pelvic-floor physical therapy may be helpful for selected patients who experience muscle tension, pain, anxiety, or difficulty with dilation.
Sensation and Orgasm After Surgery
The clitoris is usually constructed from a portion of the glans penis while preserving its associated nerves and blood vessels.
Many patients retain erotic sensation and may be able to achieve orgasm, but the experience can change after surgery. Healing of the nerves may take months, and early sensations may include:
- Numbness
- Tingling
- Hypersensitivity
- Electric or shooting sensations
- Uneven sensation
- Discomfort with direct pressure
- Gradual return or change in erotic response
Orgasmic ability cannot be guaranteed. It may be influenced by nerve healing, preoperative sexual function, hormone therapy, pain, psychological comfort, medication use, relationship factors, and familiarity with the reconstructed anatomy.
The deeper scrotal graft itself may have limited sensation compared with tissues that remain attached to their nerves and blood supply.
Possible Complications
All vaginoplasty procedures carry risks. Complication rates vary by surgical method, surgeon experience, patient health, definitions used in research, and duration of follow-up.
Early complications may include:
- Bleeding
- Hematoma
- Infection
- Blood clots
- Anesthesia complications
- Wound separation
- Delayed healing
- Urinary retention
- Catheter-related problems
- Injury to the rectum, urethra, bladder, nerves, or blood vessels
- Partial skin loss
- Partial or complete graft loss
- Clitoral tissue compromise
- Severe swelling
- Fistula formation
Delayed complications may include:
- Vaginal stenosis
- Loss of vaginal width or depth
- Narrowing of the vaginal entrance
- Scar bands or vaginal webbing
- Granulation tissue
- Persistent bleeding or discharge
- Intravaginal hair
- Pain during dilation or sex
- Pelvic-floor muscle spasm
- Urinary spraying or dribbling
- Recurrent urinary tract infection
- Urethral or meatal narrowing
- Labial asymmetry
- Clitoral exposure or inadequate hooding
- Prolapse
- Persistent numbness or altered sensation
- Need for revision surgery
A systematic review pooling different vaginoplasty techniques reported overall rates of approximately 11% for stenosis or strictures, 4% for tissue necrosis, 3% for prolapse, and 1% for fistula. These pooled figures are not specific to scrotal skin graft vaginoplasty and should not be interpreted as an individual patient’s predicted risk.
Warning Signs Requiring Medical Attention
Patients should contact their surgical team urgently if they develop:
- Heavy or rapidly increasing bleeding
- Fever or chills
- Increasing redness, warmth, swelling, or foul-smelling drainage
- Severe or worsening pain
- Shortness of breath or chest pain
- New calf swelling or pain
- Inability to urinate
- Loss of urinary control that is new or severe
- Stool, intestinal gas, or urine passing through the vagina
- Sudden inability to insert the dilator
- Rapid loss of vaginal depth
- Black, grey, or foul-smelling tissue
- Opening of a major surgical wound
- Expulsion of a large amount of graft or vaginal lining
- Severe abdominal or pelvic pain
- Persistent vomiting or inability to drink fluids
Emergency symptoms should be evaluated immediately and should not wait for a routine appointment.
Scrotal Skin Graft Versus Other Vaginoplasty Techniques
Penile inversion without a graft
This may be possible when sufficient penile skin is available. It avoids dependence on a free graft but may not provide enough tissue in every patient.
Penile inversion with scrotal skin graft
This adds local tissue to extend the vaginal lining. It avoids abdominal surgery but requires careful hair management, graft healing, and long-term dilation.
Extragenital skin graft
Skin may be obtained from the groin, lower abdomen, thigh, hip, or another area when genital skin is insufficient. This creates an additional donor-site scar and possible donor-site healing concerns.
Peritoneal vaginoplasty
Peritoneal tissue may be used to form or extend the vaginal apex, often through laparoscopic or robotic surgery. It may be considered when genital skin is limited or during revision, but it introduces abdominal and pelvic surgical risks.
Intestinal or sigmoid-colon vaginoplasty
A segment of intestine is used as vaginal lining. It can provide substantial depth but requires abdominal and bowel surgery and may cause ongoing mucus production, odor, prolapse, inflammation, or other intestinal complications. It is frequently considered for selected primary cases or complex revision surgery rather than automatically being the best option for every patient.
Zero-depth vulvoplasty
A feminine external vulva is created without a penetrable vaginal canal. It generally eliminates the need for vaginal dilation and internal hair removal but does not permit receptive vaginal penetration.
Frequently Asked Questions
Is the entire vagina made from scrotal skin?
Usually not. In a typical penile inversion procedure with scrotal grafting, penile skin forms part of the lining, while scrotal skin is used to provide additional length or surface area.
Does every patient need a scrotal graft?
No. Some patients have sufficient penile skin, while others may require scrotal skin, extragenital skin, peritoneum, or intestinal tissue. The decision is based on anatomy and the surgeon’s method.
Will hair grow inside the vagina?
It is possible if active follicles remain in skin used for the vaginal lining. Proper preoperative hair removal and careful intraoperative graft preparation can reduce the risk but may not eliminate it completely.
Does a scrotal skin graft self-lubricate?
Not in the same way as natural vaginal mucosa. External lubricant is generally required for dilation and penetrative sexual activity.
Is sensation preserved?
The surgeon attempts to preserve erotic sensation by constructing the clitoris from glans tissue attached to its nerves and blood vessels. Sensation in the free scrotal graft is more limited and unpredictable.
Is dilation required for life?
Frequent dilation is normally required during early recovery. The long-term schedule depends on the surgeon, healing, sexual activity, and whether the canal shows a tendency to narrow. Some maintenance dilation may remain necessary indefinitely.
Can the graft fail?
Yes. Partial graft loss may heal without major loss of function, but extensive graft failure can cause scarring, narrowing, or loss of the canal and may require revision surgery.
Can vaginal depth decrease?
Yes. Scar contraction, graft contraction, wound complications, or inadequate dilation can reduce depth or width. Early evaluation is important when a patient notices changes.
Can revision surgery be performed?
Revision options may include scar release, introitoplasty, additional skin grafting, peritoneal flap reconstruction, intestinal vaginoplasty, urethral revision, labiaplasty, or treatment of granulation tissue. The appropriate option depends on the specific problem and available tissue.
Questions to Ask During a Surgical Consultation
Patients considering this procedure may wish to ask:
- Do I have enough penile and scrotal skin for the planned technique?
- Will you use a scrotal graft routinely or only when needed?
- Which areas require permanent hair removal?
- How do you treat remaining hair follicles during surgery?
- What depth and width may be realistic for my anatomy?
- What happens if insufficient skin is found during surgery?
- What alternative tissue would you use?
- How often do your patients experience graft loss or stenosis?
- What is your postoperative dilation schedule?
- Who will teach and supervise my first dilation?
- How long must I remain near the surgical center?
- How are urgent complications managed after discharge?
- Is pelvic-floor physical therapy available?
- What revision procedures are sometimes needed?
- What follow-up is recommended after returning home?
Making an Informed Decision
Scrotal skin graft vaginoplasty can provide additional vaginal lining when penile skin alone is insufficient. Its main advantages are the use of local tissue, avoidance of bowel resection, and compatibility with a traditional penile-inversion approach.
However, the procedure also carries important considerations, including hair removal, graft healing, scar contraction, limited natural lubrication, long-term dilation, and the possibility of revision surgery.
There is no single vaginoplasty technique that is best for every patient. The appropriate method should be chosen after evaluating anatomy, medical history, previous surgery, tissue availability, personal goals, willingness to dilate, and the experience of the surgical team.
A comprehensive consultation with an experienced gender-affirming surgeon is essential before selecting scrotal skin graft vaginoplasty or any alternative technique.