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complication rates, both studies highlight the role of penile prosthesis implantation in achieving satisfactory
sexual function for transmen following neophalloplasty. Longer-term studies with larger cohorts are needed
to fully elucidate the long-term outcomes of ZSI 475 FtM implantation.

Evaluation of patient satisfaction is limited by the lack of validated questionnaires designed specifically for
this population. In this study, we used the IIEF, a commonly used questionnaire for evaluating sexual
satisfaction. While informative, the IIEF may not fully capture the nuances of the transgender experience.
Since this study was initiated, the GENDER-Q - a trans-specific series of patient-reported outcome
measures (PROMs) has been developed and could provide a more comprehensive assessment in future
studies . Most previous studies (66%) have reported results based on non-validated questionnaires [16,17,30] . In
[29]
our cohort, a median IIEF score of 21.1 was recorded, which is consistent with normal erectile function.
Additional analyses and longer-term follow-up are needed to obtain more information about satisfaction
and long-term complications following this complex reconstructive procedure.

Limitations of this study include its retrospective design, small sample size, absence of a standardized,
validated questionnaire, and lack of a control group, which restricts comparative analyses. Long-term
outcomes remain to be determined.

Overall, penile prostheses specifically designed for transmen in our cohort appeared to have enabled
favorable surgical outcomes and high patient satisfaction. MLD free flap neophalloplasty provided adequate
neophallus volume and sufficient blood supply for safe penile prosthesis implantation. The most significant
complication observed was penile implant fracture. Long-term studies are needed for further analysis.

DECLARATIONS
Acknowledgements
All figures were created by Professor Miroslav Djordjevic and his team at the Belgrade Center for Urogenital
Reconstructive Surgery.

Authors’ contributions
Contributed substantially to the conception and design of the study and performed data analysis and
interpretation: Djordjevic ML, Bencic M, Yepes C
Provided administrative, technical, and data acquisition support: Bizic M, Pusica S, Stojanovic B
Drafted the work and substantively revised it, contributed substantially to the conception and design of the
study: Stojanovic B, Bizic M, Djordjevic ML

Availability of data and materials
All the data and materials used in our study are available from the corresponding author upon reasonable
request.

Financial support and sponsorship
None.

Conflicts of interest
Djordjevic ML is an Editorial Board member of Plastic and Aesthetic Research and a Guest Editor of the
Special Issue “The Clinical Complexities and Ingenious Solutions within Gender-Affirming Surgery.”
Bencic M and Stojanovic B are Guest Editors of the same Special Issue. Djordjevic ML, Bencic M and
Stojanovic B were not involved in any aspect of the editorial process for this manuscript, including reviewer
selection, manuscript handling, or decision making. The other authors declared that there are no conflicts of