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Preto et al. Plast Aesthet Res. 2025;12:28 https://dx.doi.org/10.20517/2347-9264.2025.26 Page 13 of 17

However, by 6 months, the percentage of patients in the normal range increased to 50%, with a
corresponding decline in those reporting critical dysfunction. At 12 months, the trend was even more
pronounced, with 63.3% of patients reaching normal function and no cases in the borderline or critical
categories.

The steady increase in normal scores, coupled with the significant reduction in severe dysfunction, suggests
that sexual function continues to improve well beyond the immediate postoperative period. These findings
highlight the importance of long-term follow-up and postoperative support, as patients may require time to
adapt physically and psychologically to their new anatomy. The persistence of mild-to-moderate
dysfunction in a subset of patients (36.7% at 12 months) indicates that, while most individuals achieve
satisfactory outcomes, some may require additional interventions to optimize function Additionally, while
the oMtFSFI provides a more appropriate assessment tool for transgender women, further research is
needed to refine its scoring thresholds and ensure that it accurately captures the nuances of sexual health in
this population. Indeed, functional outcomes using this specific validated tool are not frequently reported in
the literature.

It is debatable whether a questionnaire designed for cisgender women can reliably assess female genital self-
image or sexual function in the AMAB transgender population. In our study, we used two additional
questionnaires to better investigate sexual function and genital self-image in our patients, as no other tools
specifically designed for AMAB patients are currently available.

Regarding the FSFI questionnaire, there are inherent limitations when applied to transgender women,
particularly concerning the established cutoff for sexual dysfunction (score of 26.55). Given the anatomical
and physiological differences in neovaginal function, as well as potential disparities in sensory perception
and lubrication, the direct application of this threshold to our cohort may not be entirely appropriate. In
our cohort, 22 patients (73.3%) reported being sexually active at 12 months. Among them, the median FSFI
score at 12 months postoperatively was 24.8 (IQR: 22.2-27.1), slightly higher than the overall cohort median
score of 22.2 (IQR 20-25.7). Comparable outcomes are reported in the literature (e.g., FSFI score of 16.9 and
23.7 in the series by Buncamper et al. and 26.67 in the series by Monteiro et al. [2,6,29] ). This supports the
notion that sexual activity is associated with better FSFI scores and may help explain differences across
studies.

Additionally, no significant differences in FSFI scores were observed between patients who underwent
vaginal cavity expansion using a skin graft. Furthermore, the FSFI score appeared only marginally related to
the functionality of the neovagina and was not correlated with the grade given for overall satisfaction (P =
0.13) .
[6]
These low scores may be explained by the fact that the FSFI is not specifically designed for transgender
patients and does not adequately assess the unique aspects of sexual functionality in individuals with
reconstructed genitalia. It is worth noting that the domain of the questionnaire assessing satisfaction
consistently had the highest scores at all follow-up time points (at 3, 6, and 12 months). Similarly, in the
literature, the most difficult domain in the FSFI appears to be lubrication. Since the neovagina does not
contain mucous tissue and, therefore, cannot produce fluids, lubrication issues are an expected limitation of
this surgery [6,29] . Despite this limitation, the progressive improvement observed across all FSFI domains over
time suggests a significant enhancement in sexual function postoperatively, potentially nearing normative
values established for cisgender women, indicating substantial recovery and adaptation. Indeed,
Monteiro et al. report that overall, all patients had a dysfunctional FSFI score, with a mean of 21.58.