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The History of Gender-Affirming Vaginoplasty Technique

Open AccessPublished:April 21, 2022DOI:https://doi.org/10.1016/j.urology.2022.03.032

      SOCIOPOLITICAL BACKGROUND

      Evidence of gender variance is present throughout all societies of human history, dating back to the earliest cultures of which we have anthropologic record.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      The phenomenon first came to the attention of modern medicine around the turn of the twentieth century, where it was described as a psychiatric illness by Richard von Krafft-Ebing and other early sexologists.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      With the primordial classification of the condition as a form of delusional disorder, all means of psychotherapy were attempted to convince patients to abandon the belief they were trapped in the wrong sex body and to accept their assigned gender.
      • Pauly IB.
      The current status of the change of sex operation.
      Such attempts were widely and consistently ineffective to convert the adult transgender/non-binary (TGNB) patient or to relieve their suffering, which was regularly severe enough to drive patients to genital amputation or suicide.
      • Pauly IB.
      The current status of the change of sex operation.
      ,
      • James SE
      • Herman JL
      • Rankin S
      • Keisling M
      • Mottet L
      • Anafi M.
      The Report of the 2015 U.S. Transgender Survey.
      Therapeutic benefit was first achieved using the affirmative treatment pathway, originally pioneered in Magnus Hirschfeld's Institute of Sexual Research in 1919 in Berlin, until it was sacked and its library burned by the Nazi party in 1933.
      • Stryker S.
      Transgender History.
      The endocrinologist Harry Benjamin successfully championed comprehensive transgender healthcare beginning in the early 1950s in San Francisco.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      His affirmative treatment pathway supported patients’ case-by-case need for social transition, need for the newly available cross-sex hormones, and even the need to refer patients for gender-affirmation surgery where appropriate.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      During this time there were scarce surgeons offering gender-affirming vaginoplasty (GAV): for example the American trained Plastic surgeon Fernando Ortiz Monasterio of Mexico,
      • Cairns T
      • de Villiers W.
      Vaginoplasty.
      ,

      Gallegos E. Fernando Ortiz Monasterio, cirujano plastico: el uico limite es la imaginacion. La Jornada (Mexico City). Published online 1997:12.

      the British Urologist Peter Philip,
      • King D
      • Ekins R.
      Pioneers of transgendering: John Randell, 1918-1982.
      the American Urologist Elmer Belt,
      • Stryker S.
      Transgender History.
      ,
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      and most notably the French Gynecologist Dr. Georges Burou.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      So few were willing to risk performing the operation due to fear of patient regret and retribution, professional shame and legal consequence.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      It was well understood that any surgeon who performed GAV might be charged with criminal mayhem, the purposeful maiming of a patient.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      The Danish-American trans woman Christine Jorgensen, who had become famous for undergoing a gender-affirming surgery in 1952, used her growing influence to create “as much good publicity as possible for the sake of all those to whom I am a representation of themselves.”
      • Stryker S.
      Transgender History.
      ,
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      She fit into the role of the classic American female.
      • Stryker S.
      Transgender History.
      She presented herself with poise and because of her the stereotype of the transgender person as a mentally ill, sexual-deviant began to fade.
      • Stryker S.
      Transgender History.
      She became Benjamin's patient as he used her spotlight to further his mission to facilitate greater access to transgender medical and surgical care.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      By the early 1960s, in part due to referrals by Christian Hamburger and Christine Jorgensen, Benjamin had become the mecca for TGNB patients seeking hormonal and surgical care.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      He referred patients to Burou and the few other known surgeons.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      As he toured the country giving lectures on transgender medicine, his network of potential surgeons grew.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      Despite this, his ability to connect his patients to surgeons was still lacking.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      By 1964, only 31 of his patients had received GAV.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      Transgender medicine was a taboo fringe science and little progress occurred in the field until 1963, when Benjamin met his most significant patient since Christine Jorgensen.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      Reed Erikson was an American transman and millionaire philanthropist.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      He founded and personally financed the Erickson Educational Foundation (EEF) in 1964; the first international transgender healthcare network.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      The EEF supported Benjamin's mission to link transgender patients to capable providers, and it directly funded almost every aspect of research and applied science related to transgender care in the 1960s and 1970s.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      The 1970′s were a time of expansion for genital gender-affirmation surgery.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Stryker S.
      Transgender History.
      The opening of the Johns Hopkins Gender Identity Clinic (GIC) in 1966 was closely followed by the establishment of GICs in the United States at The University of Minnesota, The University of Washington Seattle, Stanford, University of California Los Angeles, University of Texas Galveston and Northwestern.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      -
      • Pauly IB.
      The current status of the change of sex operation.
      ,
      • Huang TT.
      Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.
      GICs were also founded in the Netherlands and Charing Cross Hospital in London.
      • King D
      • Ekins R.
      Pioneers of transgendering: John Randell, 1918-1982.
      ,
      • Freundt I.
      Colocolpopoiesis: The Use Of Sigmoid Colon In The Treatment Of Conditions Associated With Absence Of The Vagina.
      The unquestionable reputation of these combined institutions removed the previous dread of retribution from the minds of potential GAV surgeons.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      With new patient selection protocols, the risk of post-operative regret was decreasing.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      Surgeons no longer had cause to fear criminal mayhem charges as the operation was now part of legitimate medical science.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      The positive public image of trans woman Christine Jorgensen, Harry Benjamin's growing provider network, coupled with the arrival of the first high-volume provider since Burou, together marked the beginning of the renaissance in transgender surgical care.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      Stanley Biber, a rural community general surgeon, first performed GAV in 1969 on a Benjamin patient utilizing operative reports he'd requested from Hopkins.
      • Bradley-Springer L.
      Interview with marci bowers, MD.
      In the small town of Trinidad, Colorado, from 1969 to 2003, Biber would perform an estimated 4000 GAV operations, including complex revision work.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Bradley-Springer L.
      Interview with marci bowers, MD.
      ,
      • Laub DR
      • Laub Jr., DR
      • S Biber
      Vaginoplasty for gender confirmation.
      In 1977 the American psychologist-sexologist Paul A. Walker reorganized the foundation and the EEF became known as the Janus Information Facility (JIF).

      Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/history

      In 1979, Walker and an elected committee of 6 others renamed and expanded the JIF into the Harry Benjamin International Gender Dysphoria Association (HBIGDA).

      Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/history

      This committee published the first Standards of Care (SOC) for transgender health.

      Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/history

      The SOC set forth by the HBIGDA provided a practical set of guidelines to help determine who was a candidate for GAV.
      • Stryker S.
      Transgender History.
      ,

      Walker PA. Memo to: persons interested in the harry benjamin international gender dysphoria association. Published online 1979. https://www.wpath.org/about/history

      In 2007, the HBIGDA was renamed the World Professional Association for Transgender Health (WPATH) and their published guidelines are still considered the standard of care in transgender medicine.
      • Stryker S.
      Transgender History.
      Opponents of the affirmative treatment pathway for TGNB patients argued that these irreversible, morbid treatments did not truly help patients. They held the archaic position that TGNB patients suffered from a form of delusional disorder and that all aspects of the affirmative treatment pathway, most notably surgery, were inappropriate in the treatment of a purely psychiatric illness. The poster child of this influential opposition movement was Paul R. McHugh. In 1979, wielding his position as the chair of Psychiatry at Johns Hopkins Hospital, he successfully closed the Hopkins GIC. This resulted in a confused, hostile atmosphere for transgender healthcare in the United States and accordingly the growth of the field plateaued and was effectively stifled for at least 3 decades.,
      • Terris-Feldman A
      • Chen A
      • Poudrier G
      • Garcia M
      How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.
      Expert transgender healthcare providers, who saw patients benefit from gender-affirmative social transition, hormones and surgery debated the opposition camp, asking the critical question: “what meaningful alternative help have you been able to offer the transsexual patient?”
      • Edgerton MT.
      The role of surgery in the treatment of transsexualism.
      Eventually, the answer from the opposition to this question became apparent, they had no meaningful alternative to the affirmative treatment pathway. Gradually, the influence of the opposition waned and the hostile environment lifted. In 2017, Hopkins moved beyond the anti-transgender views of McHugh and reopened the GIC. This occurred within the context of a larger phenomenon, a long overdue expansion of gender-affirming healthcare providers and surgeons.,
      • Terris-Feldman A
      • Chen A
      • Poudrier G
      • Garcia M
      How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.
      Recent United States and Dutch data show that TGNB persons compose an estimated 0.4%-1.1% of the population.
      • Meerwijk EL
      • Sevelius JM.
      Transgender population size in the United States: a meta-regression of population based probability samples.
      12% of American trans women have undergone GAV and an additional 54% desire GAV.
      • James SE
      • Herman JL
      • Rankin S
      • Keisling M
      • Mottet L
      • Anafi M.
      The Report of the 2015 U.S. Transgender Survey.
      Of those seeking insurance coverage for GAV, 55% are denied and 21% were covered, but had no GAV surgeons available in their network.
      • James SE
      • Herman JL
      • Rankin S
      • Keisling M
      • Mottet L
      • Anafi M.
      The Report of the 2015 U.S. Transgender Survey.
      As the demand for GAV continues to rise, so will the need for qualified GAV providers.
      • Terris-Feldman A
      • Chen A
      • Poudrier G
      • Garcia M
      How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.
      In this new era of gender-affirming surgery, where a growing number of urologic, plastic, gynecologic and general surgeons are becoming specialty trained in gender-affirmation surgery, the fascinating history of GAV is more important than ever.
      • Terris-Feldman A
      • Chen A
      • Poudrier G
      • Garcia M
      How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.
      The traditional history that persists to this day has left behind several significant events and persons.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      ,
      • Goldwyn R.
      History of attempts to form a vagina.
      We present an updated, overview of the history of GAV technique based on rigorous re-review of the primary literature, historical research and historical discovery.
      • Zilavy A.
      Figure 2.
      • Zilavy A.
      • Zilavy A.
      • Zilavy A.
      • Zilavy A.
      • Zilavy A.
      Figure 1.
      Figure 1
      Figure 1Timeline of select major events in GAV history. Gender-affirming vaginoplasty (GAV), split thickness skin graft (STSG), bowel substitution vaginoplasty (BSV), penile inversion vaginoplasty (PIV), gender identity clinic (GIC), dorsal neurovascular pedicled glansplasty (DNVPG), robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV).
      Figure 2
      Figure 2
      • Zilavy A.
      Figure 2.
      Peritoneal flaps are mobilized, pulled down to be anastomosed to the skin of the distal canal, and the peritoneal apices are coapted.

      VAGINOPLASTY TECHNIQUE

      Random Skin Flaps and Pedicled Fasciocutaneous Flaps

      Descriptions of surgical interventions to restore form and function for vaginal obstruction or non-functioning vagina, be it from imperforate hymen, vaginal septum, vaginal hypoplasia or vaginal agenesis, date back to Greek antiquity.
      • Goldwyn R.
      History of attempts to form a vagina.
      Incision of the obstruction or sharp dissection for creation of a canal in the pre-aseptic era generally resulted in injury to the urethra, bladder or rectum with fistula or entry into the peritoneal cavity and death from infection.
      • Goldwyn R.
      History of attempts to form a vagina.
      Even with improved safety in canal dissection due to increased surgical prowess and adoption of aseptic technique, simple perineal rectovesical canal dissection for creation of a neovagina proved insufficient.
      • Goldwyn R.
      History of attempts to form a vagina.
      It was observed that without maintenance the cavity uniformly stenosed or obliterated.
      • Goldwyn R.
      History of attempts to form a vagina.
      Therefore, indwelling neovaginal molds with progressive dilation and epithelialization over a period of months following dissection were attempted in cis-women, but these too with dissatisfying results; stenosis, incomplete epithelialization and excessive granulation tissue.
      • Goldwyn R.
      History of attempts to form a vagina.
      In 1872, C.L. Heppner was the first to line the newly dissected neovaginal cavity of a cisgender woman with random skin flaps.
      • Kroemer P.
      Die plastische neubildung der scheide bei par tiellem und totalem defekt.
      The distal canal was lined with advancement flaps from the rectovesical septum and the proximal canal was lined with thigh flaps.
      • Kroemer P.
      Die plastische neubildung der scheide bei par tiellem und totalem defekt.
      Random skin flaps from labia, perineum and buttock donor sites have also been described.
      • Goldwyn R.
      History of attempts to form a vagina.
      ,
      • Kroemer P.
      Die plastische neubildung der scheide bei par tiellem und totalem defekt.
      The early days of random skin flap surgery were guided by primitive knowledge.
      • Hashimoto I
      • Abe Y
      • Ishida S
      • et al.
      Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.
      It was understood that a random connection between the flap and the body must be maintained for blood supply.
      • Hashimoto I
      • Abe Y
      • Ishida S
      • et al.
      Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.
      Surgeons realized that random skin flaps of large size or irregular shape tended to suffer ischemic loss, so rigid flap length-to-width ratios were followed.
      • Hashimoto I
      • Abe Y
      • Ishida S
      • et al.
      Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.
      Knowledge began to accumulate regarding methods for increased skin flap survival, for example the observation that the intact skin of musculocutaneous flaps had excellent survival.
      • Ponten B.
      The fasciocutaneous flap: its use in soft tissue defects of the lower leg.
      Through insights derived from such observations, modern skin flap surgery developed.
      • Hashimoto I
      • Abe Y
      • Ishida S
      • et al.
      Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.
      Ponten popularized the pedicled fasciocutaneous flap (PFCF) in 1981, a culmination of decades of combined experience in the plastic surgery community that described principles for creation of well vascularized skin flaps.
      • Hashimoto I
      • Abe Y
      • Ishida S
      • et al.
      Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.
      ,
      • Ponten B.
      The fasciocutaneous flap: its use in soft tissue defects of the lower leg.
      These principles included dissection of appropriately thick flaps composed of cutis, subcutaneous tissue and fascia.
      • Ponten B.
      The fasciocutaneous flap: its use in soft tissue defects of the lower leg.
      Greater understanding of skin vascular pedicle anatomy and preservation of the subcutaneous and fascial vascular network increased PFCF survival.
      • Hashimoto I
      • Abe Y
      • Ishida S
      • et al.
      Development of skin flaps for reconstructive surgery: random pattern flap to perforator flap.
      ,
      • Ponten B.
      The fasciocutaneous flap: its use in soft tissue defects of the lower leg.
      Cairns and De Villiers first demonstrated random skin flaps for revision of stenotic neovagina in the transgender population as early as 1977 using random medial thigh flaps.
      • Cairns T
      • de Villiers W.
      Vaginoplasty.
      Ted Huang described use of inguinopudendal PFCFs based on superficial branches of the internal pudendal artery.
      • Huang TT.
      Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.
      He demonstrated successful outcomes in 109 primary GAV cases from 1978 to 1992.
      • Huang TT.
      Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.
      Mukai et al reported 15 cases of GAV utilizing inguinopudendal flap from 2010 to 2016, noting the continued feasibility of the technique.
      • Mukai Y
      • Watanabe T
      • Sugimoto M
      • Kimata Y
      • Namba Y.
      Vaginoplasty with a pudendal-groin flap in male-to-female transsexuals.
      Though effective, donor site scarring and morbidity of PFCF is significant.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      These flaps lack self-lubrication and can be bulky, resulting in dry neovaginal vaults of lesser dimensions.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      Because of this, non-genital skin flaps are generally currently reserved for atypical cases of salvage GAV where other salvage methods are not possible.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.

      Grafts

      Robert Abbe described the first case of split thickness skin graft (STSG) vaginoplasty in 1898 for a cisgender woman with vaginal agenesis.
      • Abbe R
      New method of creating a vagina in a case of congenital absence.
      STSG harvested from the thighs was left over a mold in the neovaginal canal.
      • Abbe R
      New method of creating a vagina in a case of congenital absence.
      Archibald Hector McIndoe became the namesake of the modern Abbe-McIndoe STSG vaginoplasty which McIndoe popularized in 1938 in cisgender women.
      • Freundt I.
      Colocolpopoiesis: The Use Of Sigmoid Colon In The Treatment Of Conditions Associated With Absence Of The Vagina.
      Unlike the more technically demanding PFCF, STSG vaginoplasty was accessible to more surgeons.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      Lifelong dilation is still necessary to prevent stenosis and there is still appreciable morbidity associated with donor sites.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      Various other grafts have been used effectively: meshed and full thickness skin grafts, peritoneum, minced and grafted buccal mucosa graft, and even in vitro tissue-engineered vaginal mucosa.
      • Raya-Rivera AM
      • Esquiliano D
      • Fierro-Pastrana R
      • et al.
      Tissue-engineered autologous vaginal organs in patients: a pilot cohort study.
      The first operation for creation of a neovagina in a TGNB patient occurred in Magnus Hirschfeld's Institute of Sexual Research in Berlin.
      • Stryker S.
      Transgender History.
      In 1931, Erwin Gohrbandt performed STSG GAV on Dora Richter.
      • Stryker S.
      Transgender History.
      ,
      • Abraham F.
      Genital reassignment on two male transvestites (genitalumwandlungen an zwei mannlichen transvestiten).
      For the following 3 decades, GAV would occur rarely, generally in secrecy, and by the hands of virtuoso surgeons who tended to dabble in a few cases before deserting the practice.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      The Danish Surgeon Eling Dahl-Iverson performed a penectomy and cosmetic vulvoplasty in 1952 on 24 year old Danish-American Christine Jorgensen following an orchiectomy in Denmark the year prior.
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      She had received preoperative hormonal therapy from Danish endocrinologist Christian Hamburger.
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      On December 1, 1952 Jorgensen made the United States and even world headlines as a model of a sensational case of gender-affirmation surgery.
      • Stryker S.
      Transgender History.
      ,
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      In light of the publicity, the Danish government refused to perform castration or other gender-affirming surgery on foreign nationals.
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      Despite this, Hamburger, an advocate for transgender care, received 645 letters from patients all over the world desperate for care he could not legally provide.
      • Stryker S.
      Transgender History.
      ,
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      In 1956 the Danish surgeon Poul Fogh-Andersen reported a case of one foreigner who had come to Denmark seeking gender-affirmation surgery and when denied, he attempted to castrate himself; forcing the surgeons to complete the orchiectomy.
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      At the insistence of the patient, Fogh-Andersen agreed to perform penectomy and vaginoplasty using full thickness penile skin graft.
      • Fogh-Andersen P.
      Transvestism and trans-sexualism; surgical treatment in a case of auto-castration.
      Fogh-Andersen's innovative use of the penile skin to line the neovaginal canal had the great benefit of no graft donor site morbidity.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.

      Penile Inversion

      The first described penile fasciocutaneous flap inversion vaginoplasty was performed by J. Riddle Goffe for an intersex woman with vaginal hypoplasia in 1903.
      • Goffe J.R.A
      A Pseudohermaphrodite, in Which the female characteristics pre-dominated; operation for removal of the penis and the utilization of the skin covering it for formation of a vaginal canal.
      He utilized the skin covering the enlarged clitoris as a pedicled flap to line the neovagina.
      • Goffe J.R.A
      A Pseudohermaphrodite, in Which the female characteristics pre-dominated; operation for removal of the penis and the utilization of the skin covering it for formation of a vaginal canal.
      Goffe demonstrated not only that genital skin could be utilized, thereby preventing donor site morbidity, but that the neurovascular pedicle could be preserved in the process.
      • Goffe J.R.A
      A Pseudohermaphrodite, in Which the female characteristics pre-dominated; operation for removal of the penis and the utilization of the skin covering it for formation of a vaginal canal.
      Sir Harold Delf Gillies and David Ralph Millard devised and performed the first anteriorly pedicled fasciocutaneous tabularized penile inversion flap to line a neovagina in 1952 on trans woman Roberta Cowell.
      • Gillies H
      • Millard RD.
      The Principles and Art of Plastic Surgery.
      ,

      Kennedy P.The First Man-Made Man: The Story of Two Sex Changes, One Love Affar, and a Twentieth-Century Medical Revolution. Bloomsbury, USA; 2007.

      In 1956, Georges Burou independently developed anteriorly pedicled penile inversion vaginoplasty (PIV) in transgender women, and first performed the operation in Casablanca, Morocco.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      In purposeful secrecy, Burou performed at least 800 PIV operations.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      Trans women who learned of his clinic would travel from all over the world to pursue his care.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      For several decades, he was the only provider consistently offering GAV.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      He stripped the penile skin free of the glans, corpus spongiosum and corpora cavernosa, which were transected at the level of the pubis.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      The penile skin tube was closed distally, inverted, and used to line the neovaginal cavity.
      • Hage JJ
      • Karim RB
      • Laub DR.
      On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca.
      The Johns Hopkins Gender Identity Clinic publicly opened in 1966 with funding from the EEF.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      Hopkins Gynecologist, Howard W. Jones Jr., independently discovered PIV for the third time in history in 1968.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      ,
      • Edgerton MT
      • Bull J.
      Surgical construction of the vagina and labia in male transsexuals.
      Jones utilized a combination of anterior penile and posterior scrotal PFCFs.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      The anterior penile flap was opened along the ventrum, converting the native tubular architecture to a rectangle.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      A posterior scrotal flap was developed.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      The apices of the anterior and posterior flaps were anastomosed.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      This combined anterior and posterior flap complex was then inverted into the neovaginal canal.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      Milton T. Edgerton described the modified Hopkins method in 1970 in which posteriorly based pedicled tabularized PIV was performed with preservation of the scrotum which was utilized in a delayed, second stage operation for labiovulvoplasty.
      • Edgerton MT
      • Bull J.
      Surgical construction of the vagina and labia in male transsexuals.
      Gillies and Burou's effective single stage method of anteriorly pedicled PIV with scrotal flaps used for labiovulvoplasty ultimately became the basis of the modern PIV.
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      The renaissance in transgender medicine, which began in the late sixties and early seventies, was fully realized with the advent of prolific providers.
      • Green R
      • Money J.
      Transsexualism and Sex Reassignment.
      Preecha Tiewtranon first performed PIV in 1975 and his work led to Thailand's emergence as a major GAV destination.
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      The global modernization of PIV is reflected in the evolving operative technique of his group over the course of 3000 cases from 1975 to 2013.
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      Use of full thickness scrotal skin graft anastomosed to the open end of pedicled inverted penile fasciocutaneous flap to augment the proximal canal and apex became commonplace to create neovaginas of adequate dimension, generally defined as 12.5 cm in depth, 3.5 cm diameter.
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      Clear advantages of forming at least the introitus and distal canal with a neurovascularly PFCF made total skin graft vaginoplasty obsolete for primary colpopoiesis in GAV.
      • Edgerton MT
      • Bull J.
      Surgical construction of the vagina and labia in male transsexuals.
      PIV features decreases stenosis as compared to skin grafting, though lifelong dilation is still required to prevent stenosis and loss of depth.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      With over 60 years of experience, multiple large case series demonstrating the safety and efficacy of the modern PIV, it continues to be known in numerous circles as the ‘Gold Standard’ in GAV.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.

      Intestinal Substitution

      W.F. Sneguireff performed the first primitive bowel substitution vaginoplasty (BSV) in 1892 in cis women using pedicled terminal rectum and anus, pulling down the proximal rectum to perform anorectoplasty.
      • Freundt I.
      Colocolpopoiesis: The Use Of Sigmoid Colon In The Treatment Of Conditions Associated With Absence Of The Vagina.
      ,
      • Kroemer P.
      Die plastische neubildung der scheide bei par tiellem und totalem defekt.
      James Fairchild Baldwin first described a pedicled ileal neovagina in 1904 and performed the operation in 1907 in cis women.
      • Freundt I.
      Colocolpopoiesis: The Use Of Sigmoid Colon In The Treatment Of Conditions Associated With Absence Of The Vagina.
      ,
      • Kroemer P.
      Die plastische neubildung der scheide bei par tiellem und totalem defekt.
      By 1911, both Schubert and Albrecht described successful methods for rectosigmoid vaginoplasty in cases of vaginal hypoplasia/aplasia.
      • Freundt I.
      Colocolpopoiesis: The Use Of Sigmoid Colon In The Treatment Of Conditions Associated With Absence Of The Vagina.
      ,
      • Kroemer P.
      Die plastische neubildung der scheide bei par tiellem und totalem defekt.
      Building on these effective operations in the cisgender population, bowel substitution was then able to be translated into the transgender population.
      • de Savitsch E.
      Homosexuality, Transvestism and Change of Sex.
      Charles Wolf of Switzerland successfully performed rectosigmoid vaginoplasty on Arlette-Irene Leber in 1942, modelled on Schubert's method, the first case of bowel substitution GAV.
      • de Savitsch E.
      Homosexuality, Transvestism and Change of Sex.
      In 1978, Colin Markland of the University of Minnesota published his success utilizing colon BSV in 9 trans women with neovaginal stenosis following PIV.
      • Markland C
      • Hastings D.
      Vaginal reconstruction using bowel segments in male-to-female trasnssexual patients.
      In the combined abdominoperineal procedure, an isolated ileal or colonic flap is obtained, primary bowel anastomosis is performed, and the pedicled bowel flap is pulled through for enterocutaneous anastomosis.
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      Rectosigmoid colon, right colon, ileum and several pouch modifications utilizing ileum have all been demonstrated.
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      ,
      • Garcia MM
      • Shen W
      • Zhu R
      • et al.
      Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes.
      In search of a GAV method with utility in cases of limited genital skin or in cases of revision vaginoplasty, the Stanford Plastic Surgeon Dr. Donald R. Laub expanded and modernized the bowel substitution GAV.
      • Laub DR
      • Laub Jr., DR
      • S Biber
      Vaginoplasty for gender confirmation.
      ,
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • Kirby J
      • Laub DR
      • VanMaasdam J.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to female gender reassignment surgery.
      He published his long term follow up data in 2015 of 83 patients who had received open sigmoid vaginoplasty in his hands from 1978 to 2000; 13 as secondary operations and 70 as primary operations.
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • Kirby J
      • Laub DR
      • VanMaasdam J.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to female gender reassignment surgery.
      He demonstrated safety and efficacy of the method which had previously been dismissed as unacceptably risky.
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • Kirby J
      • Laub DR
      • VanMaasdam J.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to female gender reassignment surgery.
      His findings were corroborated by a 2014 Dutch Retrospective review of 686 patients who underwent rectosigmoid vaginoplasty and 169 patients who underwent ileal vaginoplasty from 1996 to 2013 for any indication; including cis-female patients with primary vaginal agenesis from any cause, cis-females with acquired conditions like trauma or gynecologic malignancy, and vaginoplasty for gender-affirmation.
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      With 1.3-12 year follow up, no cases of anastomotic leak, diversion colitis or colonic neoplasm were reported.
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      Advantages of ileum include minimal tendency for malodor and prolapse.
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      Diversion colitis and potential for colonic neoplasm development are not concerns with ileum.
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      Advantages of BSV include adequate neovaginal dimensions, preserved sensation, self-lubrication, hairless tissue, and minimal tendency for neovaginal stenosis with only temporary dilation requirement.
      • Laub DR
      • Laub Jr., DR
      • S Biber
      Vaginoplasty for gender confirmation.
      ,
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      ,
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • Kirby J
      • Laub DR
      • VanMaasdam J.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to female gender reassignment surgery.
      Disadvantages of BSV include intestinal surgery with potential accompanying donor site morbidity such as ileus, increased length of postoperative hospitalization, introital stenosis, and bothersome neovaginal secretions.
      • Laub DR
      • Laub Jr., DR
      • S Biber
      Vaginoplasty for gender confirmation.
      ,
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      ,
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • Kirby J
      • Laub DR
      • VanMaasdam J.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to female gender reassignment surgery.
      Though BSV has been demonstrated as a primary GAV method and there are some that advocate for its use as a primary method which should be offered to all patients, the strongest justification for BSV is refractory neovaginal stenosis.
      • Laub DR
      • Laub Jr., DR
      • S Biber
      Vaginoplasty for gender confirmation.
      ,
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      ,
      • Bouman MB
      • van Zeijl MCT
      • Buncamper ME
      • Meijerink WJHJ
      • van Bodegraven AA
      • Mullender MG.
      Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.
      ,
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • Kirby J
      • Laub DR
      • VanMaasdam J.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to female gender reassignment surgery.
      However, a new GAV technique has emerged with similar utility in primary cases where genital skin is limited and in revision cases for refractory stenosis.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      ,
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      Due to the decreased donor site morbidity of this new method, the limited indications for BSV may become even fewer.

      Peritoneal Flaps

      In 1912, Walter Stoeckel described his use of peritoneal flaps for Colpopoiesis in a cis woman.
      • Stoeckel W.
      Zur operativen Herstellung einer künstlichen Vagina.
      Friedrich Schauta credited the Russian Gynecologist Dmitry Oskarovich Ott with discovery of the technique though S.N. Davydov became the namesake of the modern procedure after his case series in 1969 in cis women.
      • Kroemer P.
      Die plastische neubildung der scheide bei par tiellem und totalem defekt.
      ,
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      ,
      • Schauta F
      • Gersuny R.
      Report from obstetric gynecological society meeting in vienna march 8th, 1904. i. gersuny: eine operation bei angebornem defekte der scheide mit demonstration der pat.
      Lee C. Zhao and Rachel Bluebond-Langner first performed their novel robotic modification of the Davydov peritoneal flap vaginoplasty for GAV in 2017.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      They have since described 145 primary and 24 salvage cases of Robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV).
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      ,
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      The transabdominal portion of the case consists of creating a horizontal incision in the peritoneum of the rectovesical pouch.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      Denonvilliers’ fascia is incised and the prostatorectal space is developed until the retrograde perineal dissection is encountered.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      Well vascularized peritoneal flaps are mobilized from the posterior bladder and anterior rectum.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      A standard PIV is performed and the inverted penile skin forms the distal and mid canal.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      The anterior and posterior peritoneal flaps are anastomosed to the penile skin to form the distal canal.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      The peritoneal flaps are then coapted to form the vaginal apex and exclude the neovagina from the abdominal cavity.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      A full thickness scrotal skin graft was always utilized in early cases to form the mid canal where penile skin was insufficient.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      With technical advancement, larger peritoneal flaps could be harvested, in some cases obviating the need for supplemental scrotal skin graft augmentation.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      Although creation of a deep and wide neovaginal canal is easily performed by expert surgeons using standard penile inversion techniques, the authors suggest that an additional improvement of the peritoneal vaginoplasty technique is the ability to dissect the space robotically.
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      The robotic dissection is nearly identical to that of a robotic radical prostatectomy.
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      Familiarity and previous experience with robotic prostate surgery may allow more confident canal dissection in vaginoplasty, perhaps further minimizing the risk of bladder, urethra and rectal injury.
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      Because the peritoneum of the rectovesical pouch is used to form the vaginal apex, this technique may result in increased depth compared to standard PIV in which the dissection stops at the peritoneal reflection.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      ,
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      Donor site morbidity in Zhao and Bluebond-Langner's cohort was rare with no instances of peritonitis and only one case of small bowel herniation through a separation in the peritoneal flap which was treated with subsequent laparoscopic surgery.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      ,
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      Further research is required and the performance characteristics of this approach after widespread adoption is unknown.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      ,
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.
      RPGAV allows creation of hairless neovaginas with adequate dimension and may have decreased tendency for stenosis, though extended dilation is still required.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      Due to demonstrated safety and efficacy as both a primary and secondary GAV option, the RPGAV has already begun to disseminate to other centers.
      • Dy GW
      • Jun MS
      • Bluebond-Langner R
      • Zhao LC
      Outcomes of gender affirming peritoneal flap vaginoplasty using the da vinci single port vs xi robotic systems.
      ,
      • Dy GW
      • Blasdel G
      • Shakir NA
      • Bluebond-Langner R
      • Zhao LC
      Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis.

      VULVOPLASTY AND CLITOROPLASTY TECHNIQUE

      It had long been accepted that the primary outcomes for GAV were canal dimensions and minimization of complications.
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      Once these goals were regularly achieved in the hands of expert surgeons, attention gradually turned to the finer points of the operation.
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      The prolific Amsterdam group is often cited as influential in their formal announcement in the academic literature that aesthetic and function, patient focused outcomes, should be considered of principal focus as well.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      ,
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      ,
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      By the mid-1990s, following 2 decades of collaborative experience in the GAV surgical community, there were well described principles for creation of a more aesthetic and functional clitoris, urethral meatus, vaginal introitus, anterior and posterior commissure, and labia majora.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      ,
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      ,
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      Biber was the first major GAV provider to preserve the glans penis in any fashion.
      • Laub DR
      • Laub Jr., DR
      • S Biber
      Vaginoplasty for gender confirmation.
      During penectomy, the glans penis was transected free from the more proximal corpus spongiosum and left attached to the penile skin tube there at the apex and, once inverted, it formed a sensate neocervix.
      • Laub DR
      • Laub Jr., DR
      • S Biber
      Vaginoplasty for gender confirmation.
      Prior to Edgerton's description of this method in 1970 and Biber's adoption of the neocervixplasty, the glans penis was uniformly discarded during penectomy in all methods of GAV.
      • Edgerton MT
      • Bull J.
      Surgical construction of the vagina and labia in male transsexuals.
      ,
      • Brown J.
      Creation of a functional clitoris and aesthetically pleasing introitus in sex conversion.
      Similarly, clitoridectomy was the standard of care during feminizing genitoplasty for clitoromegaly in intersex patients.
      • Barinka L
      • Stavratjev M
      • Toman M.
      Plastic adjustment of female genitals in adrenogenital syndrome.
      In 1968, Barinka et al first described a successful method for functional preservation of the clitoris in intersex patients, which would prove important in the creation of a properly sized, sensate, orthotopically located clitoris during vaginoplasty.
      • Barinka L
      • Stavratjev M
      • Toman M.
      Plastic adjustment of female genitals in adrenogenital syndrome.
      They preserved the dorsolateral neurovascular pedicles of the enlarged clitoris, resected excessive corporal erectile tissue, and affixed the pedicled clitoral flap in a native female position.
      • Barinka L
      • Stavratjev M
      • Toman M.
      Plastic adjustment of female genitals in adrenogenital syndrome.
      John Brown published 65 cases of gender-affirming PIV utilizing dorsal neurovascular pedicled glansplasty (DNVPG) in 1976.
      • Brown J.
      Creation of a functional clitoris and aesthetically pleasing introitus in sex conversion.
      It should be noted that due to many documented instances of profoundly dangerous and negligent care, John Brown ultimately had his medical license revoked and was imprisoned for second-degree murder of a patient.
      • Ciotti P
      Why did he cut off that man's leg?.
      Alternative methods of functional or cosmetic clitoroplasty were attempted but all with inferior outcomes compared to DNVPG; these included free composite graft of glans, pedicled corpus spongiosum or urethral substitution flap, corporoplasty, ventrally based glans flap with intact corpus spongiosum pedicle, and even a purely aesthetic subcutaneously placed chin implant.
      • Hage JJ
      • Karim RB
      • Bloem JJAM
      • Suliman HM
      • Alphen M van.
      Sculpturing the neoclitoris in vaginoplasty for male-to-female transsexuals.
      Refined descriptions by Sava Perovic, Jan Eldh, and others led to DNVPG becoming standard for neoclitoroplasty in GAV around 1995.
      • Huang TT.
      Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals.
      ,
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      ,
      • Perovic S.
      Male to female surgery: a new contribution to operative technique.
      ,
      • Eldh J.
      Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
      Perovic also pioneered the augment pedicled urethral flap inlay for PIV.
      • Perovic S.
      Male to female surgery: a new contribution to operative technique.
      Extended excision or corporocleisis of the residual proximal corporal bodies, and spongiocleisis of the residual bulbar corpus spongiosum was adopted to prevent unsightly, painful, potentially obstructive engorgement of this erectile tissue.
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      ,
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      Spatulation urethroplasty to prevent meatal stenosis and create an appropriately oriented meatus for seated urination became standard.
      • Wangjiraniran B
      • Selvaggi G
      • Chokrungvaranont P
      • Jindarak S
      • Khobunsongserm S
      • Tiewtranon P.
      Male-to-female vaginoplasty: Preecha's surgical technique.
      ,
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      An innovative posterior triangular flap was described by the Amsterdam group to break the circular introitus and create a more natural and functional posterior commissure without dorsal introital webbing.
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      They also demonstrated secondary Z-plasties to narrow an unnaturally wide anterior commissure seen in cases where lateral dislocation had occurred during healing of the labia majora.
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      A secondary operation to create labia minora from the medial aspect of the labia majora was yet another innovation from the group.
      • Hage JJ
      • Goedkoop AY
      • Karim RB
      • Kanhai RCJ.
      Secondary corrections of the vulva in male-to-female transsexuals.
      Such modifications in primary construction and secondary revisions of the anterior and posterior commissures led to more aesthetic vulva.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.

      Discussion

      A growing number of urologic, plastic, gynecologic and general surgeons are becoming specialty trained in gender-affirmation surgery.
      • Terris-Feldman A
      • Chen A
      • Poudrier G
      • Garcia M
      How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.
      As we enter this new era of GAV, the fascinating history of its development is more important than ever.
      • Terris-Feldman A
      • Chen A
      • Poudrier G
      • Garcia M
      How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States?.
      Utilizing rigorous re-review of the primary literature, historical research and historical discovery we present an update to the traditional historical narrative which had left behind several significant events and persons.
      • Bizic M
      • Kojovic V
      • Duisin D
      • et al.
      An overview of neovaginal reconstruction options in male to female transsexuals.
      ,
      • Goldwyn R.
      History of attempts to form a vagina.

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        Figure 1.
        Timeline. 2021;