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Ramirez et al. Plast Aesthet Res. 2025;12:16 https://dx.doi.org/10.20517/2347-9264.2025.10 Page 11 of 13

approached by either incising the midline or lateralizing the incisions. When lateralizing the incisions, the
perineal body is palpated, a perineal flap is marked, and the wound is incised 1 cm from the groin crease
[Figure 3A]. The dissection is continued through the dartos to perform the orchiectomy. A circumcising
incision is made adjacent to the corona and the penile skin is separated from the skin tube. [Figure 3B].
Surgical considerations for nullification include whether to preserve nerves or not. If nerves are not
preserved, the penis can be excised en bloc [Figure 3(i)]. If preserving nerves, then the penis can be
deconstructed by opening the corpora, removing the spongy tissue, and keeping the nerves intact along the
tunica [Figure 3(ii)]. The urethra is then shortened and spatulated to the point where the urethral opening is
in line with the external sphincter. When preserving nerves, the glans can either be de-epithelialized and
[36]
buried or can be matured to the surface of the wound . The penile skin tube is then advanced down
towards the shortened urethra and re-approximated to the superior lateral urethra. The scrotal skin flaps are
then advanced down towards the lateral edges to close the wound and the excess skin is excised
[Figure 3D]. If a midline approach is taken, then the scrotum and penis are incised in the midline
[Figure 4], and the orchiectomy, penectomy, and urethrostomy are performed in a similar fashion. The
wound is re-approximated in the midline [Figure 4].

POSTOPERATIVE CARE
In the author’s practice, patients undergoing scrotectomy and nullification can be safely managed on an
outpatient basis. Scrotectomy patients typically have a single incision closed with absorbable sutures and
skin glue. They are advised that the incision can take 4-6 weeks to fully heal. Nullification patients receive
similar guidance but are discharged with a catheter in place for 72 h due to the urethrostomy. If a surgical
drain is placed, it is kept until the output remains low (~less than 25 cc per day). Our postoperative
management of PSV patients follows the same protocol as for primary vaginoplasty: inpatient bedrest for 5
days, vaginal packing, and dilation post packing removal. The expected healing time for PSV is 6-8 weeks.

CONCLUSION
Building a safe and inclusive environment enables patients to articulate their goals for surgery. Open
conversations are vital for aligning surgical plans with patient needs and goals, as well as setting realistic
expectations for aesthetic and functional outcomes. By addressing feasibility, comfort, and safety, surgeons
can guide patients toward procedures that best align with their identities and goals. These efforts contribute
to the holistic success of GAS, particularly for non-binary individuals seeking less common options.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception, literature review, and manuscript content: Ramirez ML,
Butler C
Contributed to the illustrations and figures: Wangamez M, Huynh R.

Availability of data and materials
All data relevant to the study are included in the article or uploaded as Supplementary Materials.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.