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Preto et al. Plast Aesthet Res. 2025;12:28 https://dx.doi.org/10.20517/2347-9264.2025.26 Page 3 of 17

The primary objectives of the study were to analyze and report surgical and functional outcomes following
GAS. Demographic characteristics, surgical outcomes, and intra- and postoperative complications were
collected from clinical patient records and operative notes. Postoperative complications were evaluated and
[14]
classified for severity according to the Clavien-Dindo classification (within 90 days after surgery) . Surgical
revision rate within 12 months following the primary surgical procedure was also evaluated.

Functional outcomes as perceived by the transgender women were assessed through the administration of
validated questionnaires.

Operated Male-to-Female Sexual Function Index (oMtFSFI) consists of 18 questions: 4 assess genital self-
perception, 10 assess sexual satisfaction, and 4 assess vaginal pain. The overall oMtFSFI score is categorized
[15]
as follows: normal 18-36; mild-moderate 37-49; borderline 50-55; critical > 55 .

Female Sexual Function Index (FSFI - not specifically intended for transgender women) consists of 19
questions assessing six domains: sexual desire, arousal, lubrication, orgasm, satisfaction with intimacy, and
dyspareunia. Each domain is scored from 0 to 6 after applying domain-specific correction factors, with
higher scores indicating better sexual function. The final FSFI score is obtained by summing the six domain
scores, with a maximum total of 36. In cisgender women, a score below 26.55 is considered indicative of
sexual dysfunction [Table 1] [16,17] .

Female Genital Self-Image Scale (FGSIS - not specifically intended for transgender women) is composed of
seven items that evaluate women’s feelings and beliefs about their genitalia using a 4-point response scale
(strongly agree, agree, disagree, strongly disagree). The scores for each item were summed for a total score
[18]
ranging from 7 to 28, with higher scores indicating a more positive genital self-image .

The questionnaires were administered to every patient via email or during a follow-up consultation in a
clinical setting at 3, 6, and 12 months after GAS.

Patients with incomplete data or follow-up were excluded from the study.

Surgical technique
All patients received penoscrotal vaginoplasty carried out by two consultant urologists with specific training
in andrology surgery and genital reconstructive surgery.

All patients received standard antibiotic prophylaxis with 2 g of intravenous cefazolin at induction, followed
by a repeat dose after 4 h of surgery. At that time, a single dose of intravenous amikacin (1 g) was also
administered. Thromboembolic prophylaxis was performed using low-molecular-weight heparin (LMWH),
typically initiated on postoperative day 2 or 3, depending on individual bleeding risk. This approach reflects
the generally low thromboembolic risk profile of our patient population, who were predominantly young
and otherwise healthy.

The vaginoplasty included penectomy, bilateral orchiectomy, vulvoplasty, and creation of the vaginal canal,
aiming to achieve an aesthetically pleasing and functional genital complex. The surgical procedure was
carried out under general anesthesia with the patient in the lithotomy position, with legs placed on calf
stirrups to provide adequate exposure of the perineum and external genitalia.