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Page 6 of 18 Billings et al. Plast Aesthet Res. 2025;12:27 https://dx.doi.org/10.20517/2347-9264.2025.52

SEXUAL HEALTH IMPACTS OF COMMON TYPES OF GAS
Many commonly performed GASs can affect sexual health, both positively and negatively. These include
masculinizing chest surgery, feminizing breast augmentation, vaginoplasty, vulvoplasty, phalloplasty, and
metoidioplasty (see Table 1 for an overview) [59-62] . Other procedures, such as facial feminization or
masculinization surgery, may also enhance sexual well-being indirectly through improvements in body
image and sexual self-esteem. This review, however, focuses on surgeries with more direct effects on sexual
anatomy and function.

Masculinizing chest surgery
There are numerous surgical techniques for masculinizing chest surgery, including double incision with free
nipple graft (the most common technique), inferior pedicled mammaplasty, semicircular, transareolar,
concentric circular, and extended concentric circular approaches. A full description of each technique is
[63]
beyond the scope of this review . The selection of technique depends on surgeon training, patient
preferences, and breast characteristics . When patients are appropriately selected, there is no strong
[64]
evidence suggesting significant differences in sexual health outcomes or subjective satisfaction between
techniques, provided surgical complications do not occur . Complications vary by technique but are
[65]
generally uncommon, including hematoma, seroma, and, more rarely, nipple necrosis or abscess
[66]
formation .
A critical factor influencing both healing and sexual function is the management of the nipple-areolar
complex (NAC). Surgeons may leave the NAC largely in place, remove it completely, or modify and
reposition it to enhance the masculinized appearance. These decisions are guided by both surgical technique
and patient preference. Some individuals may choose to forgo nipples altogether due to concerns about
graft healing or aesthetic considerations. Others may prioritize nipple preservation due to its role in sex
stimulation and may require more intensive counseling regarding potential surgical effects. Importantly,
most individuals undergoing chest masculinization report extreme discomfort with others seeing or
touching their unaltered chest . Thus, the key consideration may not be whether patients can retain nipple
[67]
sensation but whether they can engage in sexual activity involving their chest.

Data on NAC sensory preservation are variable. Small-scale studies report rates of NAC sensation loss
ranging from 19.7% to 53.3% in theoretically nipple-sparing procedures (inferior pedicled mammaplasty,
semicircular, transareolar, and concentric circular) and from 56.6% to 100% in nipple-grafting procedures
(double incision and extended concentric circular) [68-70] . This variability underscores the importance of
counseling patients about the risk of sensation loss, which has been linked to reduced sexual arousal and
self-esteem in some cases .
[71]
Despite these differences in sensation outcomes, masculinizing chest surgery generally has strong positive
effects on sexual health and overall well-being. An international systematic review (n = 1,052) by
Bustos et al. reported a pooled patient satisfaction rate of 92%, with improvements in QOL, reduced gender
dysphoria and depression, and increased sexual confidence . Although many studies included in the
[65]
review had mean follow-up times of less than one year, some included follow-up periods of up to six years,
all demonstrating sustained improvements in these outcomes. Additional studies have reported extremely
low regret rates and significant gains in QOL, sexual satisfaction, and psychosocial functioning [6,7,18] .

Feminizing breast augmentation
While some transfeminine patients may achieve satisfactory breast development through hormonal therapy
alone, many opt for surgical breast augmentation to meet their embodiment goals. Studies estimate that up