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Page 14 of 17 Preto et al. Plast Aesthet Res. 2025;12:28 https://dx.doi.org/10.20517/2347-9264.2025.26

However, when analyzing only the sexually active population, the mean score was 26.67, indicating
[2]
adequate sexual function. In this cohort, the satisfaction domain also had the highest score .
Regarding the questionnaire assessing genital self-image (FGSIS), the score at 12 months in our population
was 24 (range: 21-26), comparable to other series, such as 22.6 in the series by Buncamper et al. and 21.8 in
another series by the same group [6,29] . Furthermore, we found an interesting comparison with the scores of
[18]
cisgender women in a representative sample of the U.S. population (21.3) . The results obtained from the
FGSIS suggest that the participants were generally positive about their genital self-image. Unfortunately, no
data are available for such a comparison in the Italian population.

The progressive improvement in FGSIS scores over time suggests that as the postoperative period advances,
patients tend to develop a more positive perception of their neogenitalia, reflecting increasing satisfaction
and adaptation to their surgical outcomes. This trend aligns with previous findings in GAS, where initial
concerns about appearance and functionality tend to decrease as patients become more accustomed to their
[43]
bodies and experience improved quality of life. In this context, recent survey data demonstrated that
transgender women who had undergone vaginoplasty reported significantly higher FGSIS scores compared
with those awaiting surgery (79.4% ± 17.1% vs. 50.6% ± 15.1%, P < 0.0001). Interestingly, in the postoperative
cohort, no correlation was found between FGSIS scores and sexual health outcomes, suggesting that genital
self-image and sexual function may evolve independently. This supports the notion that sexual health in
transgender women is a multifactorial construct, requiring multidimensional and population-specific
assessment tools .
[43]

Considering the positive findings observed at least 12 months after surgery, multivariate analyses were
carried out to identify factors potentially associated with overall patient satisfaction. However, no clear
preoperative or intraoperative predictors of adverse satisfaction outcomes emerged in our cohort.
Interestingly, although not statistically significant, a trend was observed toward better sexual function
(oMtFSFI scores) in patients who were active smokers and lower satisfaction in patients over 35 years old.
These findings may reflect unmeasured psychosocial or behavioral factors not captured in our dataset, and
highlight the importance of integrating broader health and lifestyle variables in future prospective studies.
Further studies with larger sample sizes are needed to better define risk factors and optimize patient
selection and perioperative management.

Furthermore, these data reinforce the importance of long-term follow-up in assessing functional outcomes
beyond the early postoperative phase and underline the value of patient education in GAS. A
multidisciplinary approach remains essential to ensure both surgical success and long-term functional well-
being. Moreover, there is a pressing need for transgender-specific tools to evaluate sexual function and
patient satisfaction, given the limitations of instruments designed for cisgender populations, to better
capture the unique aspects of neovaginal physiology and patient-reported satisfaction.

A primary limitation of this study, shared with other reports on similar populations, is the low post-surgical
adherence to research protocols, resulting in small sample sizes and underpowered analyses [44,45] . Additional
limitations include the retrospective, single-center design, short follow-up, and patient attrition. The lack of
standardized protocols for assessing complications and outcomes further limits the generalizability of
findings. Identifying the most effective vaginoplasty technique for AMAB patients remains challenging
because of heterogeneity in surgical approaches, patient populations, and outcome measures. Future
prospective, multicenter studies with standardized surgical techniques, longer follow-up, and validated
instruments - such as the recently developed GENDER-Q , specifically designed to assess patient-reported
[46]