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Page 4 of 13 Ramirez et al. Plast Aesthet Res. 2025;12:16 https://dx.doi.org/10.20517/2347-9264.2025.10

sexual function. The form also asks patients to rate the significance of various surgical goals that may be
included in gender-affirming surgery. Gender fluidity can manifest in a multitude of ways and impact
patient goals. For example, one may encounter an individual who does not want to rely on exogenous
hormones and therefore wants to maintain their native sex hormone-producing organ (i.e., testes or ovary).
Other individuals may desire anatomy that allows them to maintain the ability to have penetrative sex with
their penis while experiencing penetrative vaginal sex. Many individuals may not be interested in
penetrative sex or prefer not to engage in any kind of sex at all and, therefore, do not want to pursue a
surgery that has certain risks or requires too much maintenance. Similarly, aesthetics may be important to
some, while others may consider the functional component more of a priority.

A key component of intake is assessing readiness for surgery. In addition to physical health, lifestyle factors
can equally impact recovery and the surgical outcome. Ensuring the patient has a support system and safe
recovery location is vital. A study on quality of life after gender-affirming care found higher reported scores
on quality of life in the immediate postoperative period after GAS in those with a greater network of social
support . Emotional responses to these types of altering surgeries can vary, and therefore, it is critical for
[17]
there to be support in place to help one navigate any potential difficulties. Understandably, not everyone has
access to a direct support system, and having a member of the team dedicated to directing patients to
available local resources is an important need. An effective way of addressing this is by applying a
multidisciplinary approach. The World Professional Association for Transgender Health (WPATH)
Standard of Care (SOC) Version 8 emphasizes the utility of a multidisciplinary approach, particularly when
[18]
it comes to more “customizable” GAS . Oregon Health Science University discusses its use of a
multidisciplinary approach for GAS, particularly for less commonly sought procedures, and reports that this
[19]
approach fosters a more inclusive and informed environment . This institution’s approach for those
seeking GAS is also to provide a multidisciplinary experience. Every patient seeking surgery meets with a
social worker to identify any additional needs prior to surgery (e.g., mental health services, finances,
housing, etc.). If deemed appropriate, patients are discussed at our monthly disciplinary meeting, which
includes primary care, social work, and mental health services. It is then determined if additional resources,
help, or workup are required prior to proceeding with surgery. We have found that this has led to a more
comprehensive and supportive care plan before surgery and allows for patients and providers to make an
informed, safe, and appropriate shared decision regarding surgical treatment.

Risks and benefits
Effective counseling includes a discussion of the risks, benefits, and alternatives, all summarized in Table 1.
When discussing the risks and benefits of these specific surgeries, it is crucial to acknowledge the limited
outcome data available for many of these surgeries, given their infrequent occurrences. Our discussion of
pros and cons is based on our limited experience with these specific cases, as well as the outcomes of related
cases observed in cancer, trauma, and reconstructive surgeries.

Scrotectomy is the removal of the scrotal skin. This surgery can be performed concurrently with an
orchiectomy or subsequently. A scrotectomy allows for a flatter appearance of the perineum, and often
excises dysphoric anatomy, while preserving a functional penis for sexual and urinary purposes. Surgical
risks are often low, but may include wound separation and, in rare occurrences, urethral injury if the
[20]
dissection is carried too deep . Orchiectomy can result in erectile dysfunction, while removal of excessive
scrotal tissue can result in an acquired buried penis, which may be aesthetically and functionally
[21]
unpleasant . The surgeon should highlight that a scrotectomy can preclude patients from seeking a
successful vulvoplasty or vaginoplasty in the future, as the tissue preserved for labial construction and
vaginal lining would have been discarded. It is ill-advised to perform this surgery in folks who are unsure or
may be considering future vulvar or canal reconstruction.