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Billings et al. Plast Aesthet Res. 2025;12:27 https://dx.doi.org/10.20517/2347-9264.2025.52 Page 3 of 18

Table 1. Overview of common gender-affirming surgical procedures
% % %
Name Description
Had Wanted Unsure
[59,60]
Feminizing Breast augmentation/ Similar to breast augmentation in cisgender women but with unique anatomical considerations . Usually not pursued/recommended until 8 36 36
procedures “top surgery” breast development from hormone therapy has stabilized
*
Vaginoplasty/ Involves penectomy, urethral shortening, orchiectomy, creation of a clitoris using the neurovascular bundle of the glans, formation of the 9 42 27
“bottom surgery” vaginal vestibule and urethral opening, and construction of the labia. The vaginal canal is most often lined with penile-scrotal skin; other
techniques use peritoneal or colon flaps. Requires lifelong dilation and douching, which may be difficult for some patients
Vulvoplasty/ Similar to vaginoplasty but without creation of a vaginal canal; also termed “zero-depth vaginoplasty”. The absence of dilation/douching
“bottom surgery” requirements makes this option preferable for some women. It may also be chosen for other personal reasons
Orchiectomy Removal of the testes; may be performed alone for hormonal control or as part of vaginoplasty, depending on patient goals 11 42 25
Facial feminization A set of procedures designed to alter the facial and cranial appearance to a more feminine presentation. May include jaw contouring/reduction, 5 41 33
**
surgery/“FFS” brow and eyelid lifting, forehead and hairline contouring, rhinoplasty, and other procedures. Shown to significantly improve observer accuracy
in gender perception [61]
Tracheal shave Removal of a portion of the thyroid cartilage (the “Adam’s apple”) that develops during testosterone-dependent puberty. Also known as thyroid 3 28 36
chondrolaryngoplasty. May be performed alongside vocal cord surgery to raise the vocal pitch
Masculinizing Masculinizing chest Removal of most glandular breast tissue with modification of the nipple-areola complex, and sometimes chest contouring, to create a more 20 57 15
procedures surgery/ masculine appearance. Some non-binary individuals may prefer breast reduction rather than a full mastectomy. Patients may choose to forgo
“top surgery” nipple grafts. Some may later have nipples tattooed
Hysterectomy Typically includes bilateral salpingectomy to reduce cancer risk, may be performed with or without oophorectomy, depending on patient 6 51 28
preference. Prerequisite for any genital surgery involving vaginectomy
†
Metoidioplasty and Can be performed with or without urethral lengthening, depending on the desire for standing urination. Urethral lengthening usually requires 1/1 13/11 42/31
phalloplasty/ “bottom concurrent vaginectomy. Metoidioplasty uses the hormonally enlarged clitoris as the neophallus (similar to a micropenis). Phalloplasty uses a
surgery” local or distant flap (various techniques) placed over the anteriorly repositioned clitoris clitoris to create a larger neophallus, potentially more
suitable for penetration. Erectile implants are required for penetrative function and often require replacement; however, some patients pursue
alternative methods for achieving sufficient rigidity [62]
* † ** [18]
includes both vaginoplasty and vulvoplasty; metoidioplasty/phalloplasty; sexual function outcomes of FFS are not included in this review due to limited research . Population interest data are from the 2022
[9]
United States National Transgender Discrimination Survey, which included responses from 92,329 transgender individuals aged 16 years and older . FFS: Facial feminization surgery.

SEXUALITY IN TGD PATIENTS
Sexual orientation, sexual attraction, and sexual behavior are distinct constructs and should not be assumed to determine one another, nor should they be
presumed on the basis of gender modality - that is, whether a person identifies as cisgender or transgender.