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Scrotoplasty

Scrotoplasty is a gender-affirming surgical procedure that creates or reconstructs a scrotum, typically using tissue from the labia majora. While testicular implants are commonly placed in a later stage, alternatives like fat grafting or the use of local tissue are increasingly being used to achieve natural volume and shape.

Hoebeke’s Technique

Hoebeke’s Technique, often called V-Y Scrotoplasty within the transmasc community and referred to as Ghent-style scrotoplasty by surgeons, is the most widely used surgical method for creating a scrotum as part of gender-affirming bottom surgery. It was developed by Professor Piet Hoebeke and his team at Ghent University Hospital in Belgium, and was published in the seminal 2009 article “Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty.”

What is V-Y Scrotoplasty?

This technique uses the labia majora, which are embryologically homologous to the scrotum, to form a natural-looking scrotum. Surgeons make a V-shaped incision on each side, then rotate and fold the tissue inward to form a single sac. The closure forms a Y shape, which is where the name “V-Y advancement” comes from.

How it Works

  • Labial flaps are carefully dissected, rotated inward, and bent on themselves to create two halves of the scrotum.
  • These flaps are sutured together at the midline and anchored in a forward position, so the new scrotum sits in front of the legs.
  • The dorsal skin of the clitoris is used to help shape the front of the scrotum, contributing to a more natural wrinkled appearance.

Key Differences Between Hoebeke and Belgrade Scrotoplasty Techniques

Hoebeke’s technique and the Belgrade method are two different approaches to creating a scrotum during Metoidioplasty, and they differ in several important ways. Both use the labia majora, but Hoebeke’s method follows a more standardized design with V-Y advancement. In comparison, the Belgrade approach uses the labia to form a scrotum as well, but the exact flap technique isn’t as clearly defined in published materials. It does, however, position the scrotum in front of the thighs, just like Hoebeke’s, rather than letting it sit between the legs as some older techniques did.

The Belgrade method creates a bifid scrotum using a midline union of the labia majora, often resulting in a more visibly separated appearance. While this maintains a natural division consistent with cis male anatomy, some patients may find the result more distinctly “split” than expected.

View a photo of the appearance of the scrotum immediately following Belgrade Metoidioplasty surgery. Note: This is a graphic operating room photo.

Another difference between the two techniques is when testicular implants are placed. In Hoebeke’s Technique implant placement is delayed until a second stage. Delaying placement of implants allows the scrotal tissue to heal and expand first, which can lower the risk of complications like implant extrusion and make it easier to place larger implants. In contrast, implants are inserted during the initial surgery in the Belgrade method, which is designed to be a complete, one-stage genital reconstruction.

Feature Hoebeke’s Technique (V-Y Scrotoplasty) Belgrade Method
Implant Placement Delayed to a second stage (after healing or expansion) During initial surgery (single-stage)
Scrotum Design V-Y incisions; flaps rotated and folded inward Uses labial flaps; technique less standardized
Use of Clitoral Skin Included to create wrinkled, natural appearance Sometimes used, but not clearly documented
Scrotum Positioning In front of the thighs In front of the thighs
Sensation Preservation Specifically emphasized and designed to preserve feeling Intended, but less described in detail
Ideal For Patients preferring staged, customizable outcomes Patients wanting a complete single-stage surgery

Hoebeke’s staged technique may offer more control over aesthetics and sizing, especially for patients with more body fat or tighter tissue, while the Belgrade method offers a faster, single-stage option for those who want everything done at once.

Note: Simply placing testicular implants into the labia majora without any rearrangement of tissue does not constitute scrotoplasty. In such cases, no new scrotum is surgically constructed—only the prosthetic implants are placed into existing tissue. True scrotoplasty involves reshaping or repositioning the labial tissue to create a unified scrotal sac, typically with improved forward positioning and aesthetic appearance.

Risks & Complications

As with any surgery, complications can occur with the most common being wound separation. However, scrotoplasty is generally considered a low risk procedure. Major complications are rare.

Hoebeke’s V-Y Scrotoplasty is considered the gold standard for scrotal creation in gender-affirming surgery. Its balance of cosmetic, sensory, and functional outcomes makes it the most commonly performed scrotoplasty method today. Many surgeons have introduced their own refinements to the technique to better suit individual patient anatomy and goals.

View 3D renderings of Hoebeke's Technique »

 

Relevant Journal Articles

  1. Sengezer M, Sadove RC. Scrotal construction by expansion of labia majora in biological female transsexuals. Ann Plast Surg. 1993 Oct;31(4):372-6. doi: 10.1097/00000637-199310000-00016. PMID: 8239440.
  2. Hage JJ, Bouman FG, Bloem JJ. Constructing a scrotum in female-to-male transsexuals. Plast Reconstr Surg. 1993 Apr;91(5):914-21. doi: 10.1097/00006534-199304001-00029. PMID: 8460195.
  3. Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, De Cuypere G, Monstrey S. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast Reconstr Surg. 2009 Jun;123(6):1710-1718. doi: 10.1097/PRS.0b013e3181a659fe. PMID: 19483569.
  4. Miller TJ, Chen ML, Lin WC, Safa B, Watt AJ. Labia Majora Flap Scrotoplasty and Perineal Reconstruction in Phalloplasty Patients: Technique and Outcomes. Plast Reconstr Surg Glob Open. 2019 Sep 10;7(8 Suppl ):82-83. doi: 10.1097/01.GOX.0000584684.31625.6c. PMCID: PMC6750540.
  5. Pigot GL, Al-Tamimi M, van der Sluis WB, Ronkes B, Mullender MG, Bouman MB. Scrotal Reconstruction in Transgender Men Undergoing Genital Gender Affirming Surgery Without Urethral Lengthening: A Stepwise Approach. Urology. 2020 Dec;146:303. doi: 10.1016/j.urology.2020.09.017. Epub 2020 Sep 24. PMID: 32980404.
  6. Miller TJ, Lin WC, Safa B, Watt AJ, Chen ML. Transgender Scrotoplasty and Perineal Reconstruction With Labia Majora Flaps: Technique and Outcomes From 147 Consecutive Cases. Ann Plast Surg. 2021 Sep 1;87(3):324-330. doi: 10.1097/SAP.0000000000002602. PMID: 34397521.

Last updated: 05/31/25


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