• NijhuisTim H JTHJDepartment of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUMC, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUMC, Amsterdam, Müjde Özer, Wouter B van der Sluis, Muhammed Al-Tamini, Ali Salim, Philip Thomas, James Bellringer, and Mark-Bram Bouman.
• Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUMC, Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUMC, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amphia Hospital, Breda, the Netherlands. Electronic address: t.h.j.nijhuis@gmail.com.
• J Sex Med. 2020 May 1; 17 (5): 1033-1040.

BackgroundPenile inversion vaginoplasty is a commonly performed genital gender-affirming procedure in transgender women. The creation of an adequate functional neovaginal depth in cases of too little usable penile skin is a challenge. The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an easy adjunctive technique and may serve as a tool in the surgical armamentarium of the gender surgeon.AimTo describe the use, dissection, design subtypes, and surgical outcomes of the BPES-flap in vaginoplasty.MethodsPerioperative considerations and different flap design subtypes were described to illustrate the possible uses of the BPES-flap in vaginoplasty. A retrospective chart study was performed on the use of this flap in 3 centers (blinded for review purposes).OutcomesThe main outcome measures are description of surgical technique, flap design possibilities, and postoperative complications.ResultsA total of 42 transgender women were included (median age: 28 years (range 18-66), mean body mass index: 24.5 ± 3.5). The mean penile length and width preoperatively were 9 ± 3.1 and 2.9 ± 0.2 cm, respectively. With a mean follow up of 13 ± 10 months, total flap necrosis occurred in one case (2.4%). Partial flap necrosis occurred also in one. Neovaginal reconstruction was successful in all patients with a mean vaginal depth of 13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial prolapse of the neovaginal top occurred in 3 patients (7%).Clinical ImplicationsThe BPES-flap is a useful addition to the arsenal of surgeons performing feminizing genital reconstructive surgery.Strengths & LimitationsStrenghts comprise (1) the description of the surgical technique with clear images, (2) completeness of data, and (3) that data are from a multicenter study. A weakness is the retrospective nature with limited follow-up time.ConclusionThe BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial perineal arteries. It may be used for neovaginal depth creation during vaginoplasty and may be quicker to perform than full-thickness skin grafting. Nijhuis THJ, Özer M, van der Sluis WB, et al. The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty. J Sex Med 2020;17:1033-1040.Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

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