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The first reports on gender-confirming surgery had been published in Germany in the 1920s, but it took some 30 years before sex reassignment surgery for transsexuals became generally known. Initially, such surgery was performed mostly in Europe and Casablanca. In 1956, the gynecologist Dr Georges Burou (1910-1987) independently developed the anteriorly pedicled penile skin flap inversion vaginoplasty in his Clinique du Parc in Casablanca. This technique was to become the gold standard of skin-lined vaginoplasty in transsexuals. During his life, he was to perform well over 800 vaginoplasties for transsexual patients from all over the world, but Burou always kept a low profile to be able to continue this controversial part of his work in Morocco. Because his work was pioneering and innovative, Georges Burou and his vaginoplasty are given a place in the recorded history of plastic surgery.

The surgical aim of genital reassignment surgery in male-to-female transsexuals is to create a perineogenital complex as feminine in appearance and function as possible. In this paper, we present a review of the various methods to line the neovagina in male-to-female transsexuals. These methods may be classified in five categories involving, respectively, application of nongenital skin grafts, penile skin grafts, penile skin flaps, nongenital skin flaps, and pedicled intestinal transplants. Based on this review and our extensive personal experience, we come to certain recommendations regarding the eligibility of these methods.

A simple method to ensure penile skin graft immobilization and easy accessibility is presented. The method uses a hollow cylinder made of plaster-cast material applied to the pubis around the penis, to which the long tails of the skin graft threads are fixed. The method is inexpensive, simple to use, and comfortable both for patients and for the nursing staff.

Penile skin inversion is the method of choice for vaginoplasty in male-to-female transsexuals. Rectosigmoid neocolpopoiesis should be considered only when penile skin inversion has become impossible or has not led to functional results. In this paper we describe our technique and the results of colocolpopoiesis in 7 male-to-female transsexuals.

A new procedure for repairing damage to the scrotum caused by Fournier's gangrene is dscribed. Complete and quick covering of the exposed testicles is important aesthetically and functionally. A distally based flap split in the middle is designed. Flap viability is ensured by an abundant blood supply and venous return. This one-stage procedure for reconstruction of the scrotum using a flap of penile skin has proved effective in selected cases.

Penile and scrotal skin avulsion, an uncommon but not rare event, occurs mainly in machine accidents. According to the authors' experience, reconstruction should be undertaken immediately; penile skin covering is made by free graft and the scrotum is reconstructed by flaps rotated from the thighs. A case is presented, with a ten-year follow-up, in which such reconstruction was performed.

A follow-up is presented for 67 male transsexuals who had surgery, along with detailed information for 55 patients. The operative technique used is first described by Stuteville, Pandya, and Arieffin 1971. The main principle of this technique is that the vagina is lined with inverted penile skin like a flap on an abdominal pedicle. All the erectile tissue is removed. In the follow-up, special attention was paid to the patients' reactions to the surgery and to the anatomical and functional results. There was only 1 patient who regretted having had the operation. All the others were well pleased and content that their external sexual organs at last fitted their body image. There were few complaints about the appearance, and only 4 patients needed further surgery to increase the size of the vagina. Some patients had a vagina that would be judged too small. They did not complain because the vagina was unimportant in their sexual activities.