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Page 6 of 13 Ramirez et al. Plast Aesthet Res. 2025;12:16 https://dx.doi.org/10.20517/2347-9264.2025.10

Nullification
Nullification, to our knowledge, has not been well described in the literature. The surgery involves the
removal of any binary-associated externalized genitalia and the creation of a more neutral appearance,
resulting in a smooth transition from the abdomen to the groin. In those assigned males at birth, one must
decide to preserve the neurovascular bundle of the penis to attempt to maintain sexual sensation. The
approach in which nerve endings (i.e., glans) are managed (buried vs. left exposed) can also influence
outcomes. For example, buried glans may be a nidus for infection if not de-epithelialized appropriately, or
lead to discomfort, decreased, or dull sensation, while exposed glans will require consideration of placement
[30]
to avoid irritation, dulled sensation, or bother . Careful consideration of how the neurovascular bundle is
managed is crucial to mitigate any undesired sexual or chronic pain complications. Aesthetic considerations
include midline versus lateral placement of the incisions. A midline incision may offer an easier closure but
will leave a central scar. A lateral incision may distribute tension differently, potentially minimizing scar
appearance, but risks asymmetric alignment. Further, a penectomy will eliminate the patient’s ability to
engage in penetrative sex with limited alternatives for reversal or future genitalia reconstruction.

Finally, it is pivotal to emphasize the irreversible nature of these procedures. While various studies report
the prevalence of regret after GAS is < 1%, with only 8% of these being medical, effective counseling ensures
patients make informed decisions [31,32] . It is imperative that the patient and surgeon are aligned in the
surgical goals and understanding of their surgical options before proceeding with surgery.

SURGICAL TECHNIQUE
Given the limited literature discussing these less frequently requested options, we choose to describe our
surgical approach to these techniques, based on the author’s experience. There are many considerations
when choosing to embark on these options, and as was previously mentioned, it is important to review
these considerations in detail. It should be noted that these are simply suggested approaches, as there are
limited outcome-based data to indicate that one approach is superior to another.

Scrotectomy
Figure 1 illustrates the approach to scrotectomy. Scrotectomy has been more commonly done in the setting
[20]
of trauma or lymphedema . Given that testicles are absent or removed simultaneously, and there is usually
minimal edema in this patient population, the suggested surgical approach to scrotectomy is to make an
elliptical incision around the scrotum such that the maximum amount of skin can be excised without
putting too much tension on the wound once re-approximated [Figure 1A]. The elliptical incision helps to
[33]
minimize “dog ears” . The skin and underlying subcutaneous tissue are removed, and the bilateral
orchiectomy is performed. Only enough subcutaneous tissue and fat need to be removed to flatten the
surface to the level of the adjacent perineum while avoiding over-dissecting and exposing the corpus
spongiosum. The wound is then re-approximated at the midline in several layers to avoid any dead space
and to help redistribute the tension off the wound [Figure 1B]. The scrotal skin is often fused with the penile
shaft skin, and one should be mindful to avoid chasing the dog ear up the shaft and inadvertently removing
too much penile shaft skin. This can be most effectively prevented by placing the penis on stretch, which
can also reduce the risk of creating a closure that is too tight and minimize the downward tethering of the
penis.

PSV
Figure 2 illustrates our suggested approach to PSV. Given that limited scrotal skin and no penile skin can be
recruited for vaginal canal coverage, we suggest approaching a PSV in a similar fashion to the robotic