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

[29]
Surgical revision for urethral complications in some series can reach up to 20% . Our data align with
previously published data. However, the majority of revision procedures (approximately 43%) were
performed for aesthetic reasons. In our current series, aesthetic revision requests were not detailed, but they
only involved 4 patients out of 47 (8.5%). Recent prospective data from Mañero et al. highlight the
importance of systematically evaluating not only surgical outcomes, but also functional, aesthetic, and
sensory complications following transfeminine vaginoplasty. In their 2022 study, over 60% of patients
experienced at least one postoperative issue, including sexual dysfunction and altered genital sensitivity,
[35]
despite high overall satisfaction rates . In our cohort, a proportion of patients reported some degree of
sexual dysfunction at 12 months, most commonly related to reduced genital sensitivity or mild discomfort
during penetration. While these findings underscore the need for long-term follow-up and targeted
postoperative counseling, it is important to interpret them within a broader context. Although these scores
were actually higher than those reported in a sample of Italian cisgender female undergraduates in a 2018
study , it should be noted that comparisons across populations must be interpreted with caution.
[36]
Furthermore, Mañero et al., in another manuscript, emphasized the demand for aesthetic revision surgery in
transfeminine patients, reporting a revision rate of 22.9%, primarily for labia minora asymmetry, clitoral
hood irregularities, and introitus contour . Differences in patient expectations, surgical technique, follow-
[37]
up duration, and even legal or cultural factors may help explain this discrepancy.

The overall revision rate in our series, combining both aesthetic and complication-related revisions, was
[2]
27.6%, which is similar to previously published global revision rates around 27% .

Finally, a notable difference from other series is the absence of neovaginal prolapse in our cohort. While
previous studies have reported this complication in approximately 2% of cases [12,38,39] , those data primarily
derive from penile inversion techniques rather than penoscrotal flaps. Additionally, unlike historical
approaches, modern penoscrotal flap techniques no longer involve fixation to the prostatic capsule, which
was a common practice in the past.

Regarding the response rate to functional questionnaires during follow-up, we achieved a response rate of
63.8%. Similar studies addressing functional outcomes reported comparable response rates, which highlights
the challenges of following these patients over time and obtaining large sample sizes. This difficulty arises
because patients are often unreachable or non-compliant in completing the questionnaires during the long-
term postoperative period. Monstrey et al. reported similar challenges in contacting women after surgery, as
they could not be located . Reasons for not wanting to participate included “research fatigue” or “to be
[40]
done with being seen as a patient” and desire to move beyond the surgical aspect and return to everyday life.
However, it is possible that this has introduced a bias in the results .
[29]
As supported by other series, the overall results from the different questionnaires confirm that GAS leads to
high success rates, patient satisfaction, and an overall improvement in quality of life [10,41,42] .

Specifically, the oMtFSFI questionnaire, which was designed to assess sexual function in transgender
women, offers a more tailored evaluation of postoperative outcomes compared to generic tools designed for
cisgender populations. The progressive improvement in oMtFSFI scores observed over time suggests a clear
trend toward functional recovery and enhanced sexual well-being following vaginoplasty.

At 3 months, only 33.3% of patients achieved scores classified as normal, while a considerable proportion
still fell into the mild-to-moderate, borderline, or even critical ranges. This likely reflects the early
postoperative challenges, including ongoing healing, tissue adaptation, and psychological adjustments.