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To describe our technique for performing gender affirming graft only vaginoplasty. In graft only vaginoplasty, penile skin is used only for the external genitals, and the entire vaginal canal is created from a full thickness skin graft. The inner scrotum is excised and used as a skin graft to line the vaginal canal. The outer scrotum is left in place then moved medially to form the labia majora. The penile skin and Dartos fascia are incised dorsally and ventrally then advanced to the posterior perineum to become the labia minora. The glans clitoris is constructed from a W-shaped dorsally-based portion of the glans penis, and the clitoral hood is constructed from the distal 2–3 cm of penile shaft skin. The posterior wall of the introitus is formed from a posterior perineal flap. The patient presented here is a 26-year-old transgender woman with marked and sustained gender incongruence. She is circumcised, has typical penile length, scrotal contents are normal, and all hair has been removed on the scrotum and perineum. She underwent graft only vaginoplasty, as shown in the accompanying video. Gender affirming graft only vaginoplasty allows for construction of the vaginal canal from a full thickness skin graft, and construction of external genitals from penile and scrotal skin. Advantages of this approach include availability of more tissue for construction of the external genitals and an external skin to graft anastomosis. The procedure is modified slightly when the patient has a small scrotum, short penis, or is uncircumcised. [ABSTRACT FROM AUTHOR]