Herein, we aimed to demonstrate the potential utility of acellular cadaveric dermal allograft to compensate for substantial neovaginal tissue loss following gender affirming vaginoplasty with the penile skin inversion technique.

The patient is a 39-year-old transgender female who underwent penile skin inversion vaginoplasty which was complicated by bleeding that required reoperation in the early postoperative period. Her past medical history was remarkable with type 2 diabetes mellitus. Approximately two weeks following vaginoplasty, the scrotal skin graft and penile skin flap demonstrated near-total necrosis. She was readmitted for further evaluation and treatment. A staged management approach was planned and acellular cadaveric dermal allograft was chosen to repair the tissue defect as it provides a firm and elastic tissue support, it stimulates the natural healing process, and it serves as a scaffold upon which host cells can regenerate and differentiate.

As a first step, the neovaginal cavity was copiously irrigated and necrotic tissues were debrided. To prevent coaptation while healing, the cavity was packed with bacitracin-soaked gauze. After keeping the vagina packed for 5 days, we proceeded with the second step whereby the fibrotic skin edges were trimmed and the mucosal surface was refreshed with curettage to provide a well-vascularized surface for graft imbibition. Then, the acellular cadaveric dermal allograft was adapted and suture fixated along the neovaginal cavity. It was critical for the allograft to remain in contact with the wound bed for proper graft uptake. Therefore, we packed the neovagina with bacitracin-soaked gauze in order to apply circumferential pressure on the allograft along the entire length of the neovagina. Prior to discharge, we performed the first wound check. A minor detachment of the allograft was noted and securing sutures were placed before the cavity was re-packed. Follow-up in clinic after one week demonstrated good adhesion of the allograft to the cavity wall. The neovaginal packing was then replaced. Follow-up another week later demonstrated integration of the allograft but also some redundant material at the introitus that required minimal trimming. At this time point, vaginal self-dilatation protocol was initiated. Approximately two months following her presentation with substantial neovaginal tissue loss, the patient resumed vaginal intercourse. Throughout the course of corrective interventions, no complications or allograft-related side effects were encountered.

Near-total neovaginal tissue loss following penile skin inversion vaginoplasty can be salvaged by a staged approach to acellular cadaveric dermal allograft-based repair. This type of tissue substitution appears to be safe and is potentially effective with acceptable morphological and functional outcomes. Further research is warranted.