Vaginoplasty is a surgical procedure that reshapes existing genital tissue to create a vulva and, in most cases, a vaginal canal. The most common technique, called penile inversion, uses skin from the penis and scrotum as the primary building material. Other methods use tissue from the abdominal lining or a segment of the colon. The choice depends on the patient’s anatomy, the surgeon’s expertise, and how much donor tissue is available.
The Penile Inversion Technique
Penile inversion is the most widely performed approach. The surgery typically takes four to six hours and involves several coordinated steps, all done in a single operation. The core idea is straightforward: skin that once covered the penis is separated, turned inside out, and placed into a newly created canal between the bladder and rectum. But the full procedure involves far more than inversion alone.
First, the surgeon carefully separates the penile skin from the underlying tissue, preserving blood supply and a flap of dorsal skin that will later become the clitoral hood. The testes are removed, and erectile tissue from the shaft is excised. A small piece of the sensitive head of the penis is preserved on its nerve and blood supply, then repositioned and tucked beneath the pubic bone to form a clitoris. This nerve-sparing step is what makes orgasm possible after surgery. The goal is to remove all erectile tissue while keeping the nerve bundle that provides sensation to the new clitoris completely intact.
Next, the surgeon dissects a space between the rectum and the prostate to create the vaginal canal. The inverted penile skin is shaped into a tube, sometimes combined with a graft of scrotal skin to add length, and inserted into this canal. The urethra is shortened and repositioned. Finally, the outer anatomy is sculpted: labia minora are formed from urethral and dorsal skin flaps, and the overall appearance is refined to resemble typical vulvar anatomy.
Peritoneal Flap Vaginoplasty
Some patients don’t have enough penile or scrotal skin to create adequate vaginal depth with inversion alone. In these cases, surgeons can harvest tissue from the peritoneum, the thin membrane that lines the inside of the abdomen. Using a robotic laparoscopic approach, the surgeon raises flaps of this tissue and connects them to the penile or scrotal skin tube, extending the canal deeper into the body. The canal is widened to fit a standard surgical dilator, roughly 35 millimeters across.
This technique is also useful for revision surgeries when a prior vaginoplasty has scarred or shortened. Because the tissue comes from inside the body, there’s no visible donor site and less scarring compared to taking skin grafts from the thigh or abdomen.
Sigmoid Colon Vaginoplasty
A third option uses a short segment of the sigmoid colon, the lower portion of the large intestine. Surgeons typically recommend this for patients with a stretched penile length under about 4.5 inches (11.4 cm), where penile inversion alone wouldn’t provide enough tissue. It’s also commonly used as a revision procedure when a previous vaginoplasty has developed scarring or lost depth.
The colon lining has several distinct advantages. It naturally produces mucus, which provides self-lubrication. It looks and feels more similar to vaginal mucosa than skin grafts do. And unlike inverted skin, intestinal tissue is less prone to shrinking over time, which means less aggressive long-term dilation. That said, colon vaginoplasty is a more complex surgery because it involves abdominal work to harvest the intestinal segment. Compared to the small intestine, the sigmoid colon produces less excessive discharge and more closely matches the width of a vaginal canal without needing further adjustment.
Hair Removal Before Surgery
If you’re having a vaginoplasty with a vaginal canal, permanent hair removal on the donor skin is required before surgery. The skin that gets inverted or grafted into the canal will continue growing hair if it isn’t cleared beforehand. Johns Hopkins recommends starting electrolysis or laser hair removal as soon as possible, since full clearance can take up to 12 months. Your last session should be at least three weeks before your surgery date to allow the skin to heal.
Recovery and Dilation
Recovery from a full-depth vaginoplasty takes about eight weeks before most people can return to their normal routine. A shallow-depth procedure, which creates the external anatomy without a full canal, has a shorter recovery of around four weeks. Full healing and adjustment can take nine to 12 months.
In the first month, you’ll need to avoid lifting anything over 10 pounds. Gentle walking for 10 to 15 minutes a few times a day is encouraged early on, with activity increasing gradually based on your surgeon’s guidance. Driving is off-limits until you’re no longer taking prescription pain medication and can move your foot quickly between the pedals.
Dilation is the most demanding part of recovery. It involves inserting medical dilators into the vaginal canal on a strict schedule to prevent it from narrowing or losing depth. For the first year, you’ll dilate multiple times a day. After the first year, the frequency typically drops to about once a week. This is a lifelong commitment for patients who have penile inversion or peritoneal flap procedures. Skipping days and trying to make up for it later doesn’t work: the tissue will contract if it isn’t maintained on schedule. Patients who have sigmoid colon vaginoplasty still need to dilate for the first six to 12 months, primarily to prevent scarring at the connection point, but long-term dilation is generally less intensive.
Complications
A large retrospective study of 407 patients found that serious complications are uncommon. Vaginal stenosis, where the canal narrows enough to need surgical revision, occurred in 3.4% of patients. Fistulas, an abnormal connection between the vaginal canal and the rectum, developed in 0.5% of cases. Significant skin graft failure was rare, with vulvar skin necrosis reported in just 0.2% of patients. Minor complications like granulation tissue (excess healing tissue at wound sites) and temporary urinary issues are more common but typically resolve without additional surgery.
Sensation and Satisfaction
Because the clitoris is constructed from the most nerve-dense tissue of the original anatomy, most patients retain the ability to experience sexual sensation and orgasm. The quality of sensation tends to improve over time as nerves heal and the tissue settles into its new position, a process that can continue for a year or more after surgery.
Long-term satisfaction rates are high. A meta-analysis pooling data from 11 studies found that the prevalence of regret after vaginoplasty was approximately 2%. The physical results of the surgery, including appearance and function, are the strongest predictor of whether someone is satisfied, more so than any factor measured before the operation.