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Billings et al. Plast Aesthet Res. 2025;12:27 https://dx.doi.org/10.20517/2347-9264.2025.52 Page 7 of 18

to 75% of transfeminine patients pursue this option [3,4,9,49,59] . The most common surgical method for breast
augmentation in this population involves the use of breast implants. However, there is no standardized or
validated approach for selecting implants or determining the placement plane in transfeminine patients.
[59]
Surgeons generally rely on adapted techniques and tools designed for cisgender patients .

The complication rates for breast augmentation in transfeminine patients are low and comparable to those
seen in cisgender populations. These complications include symmastia, capsular contracture, altered nipple
sensation, implant leakage and migration, hematoma/seroma, and infection [66,72] . Because there is less
manipulation of the NAC compared to masculinizing chest surgery, the risk of sensory loss is significantly
lower. However, patients should still be counseled about this potential risk and its possible impact on sexual
[59]
health. Other sensory changes to the chest may also occur after augmentation .

As with masculinizing chest surgery, there is substantial evidence showing improved QOL, psychosocial
functioning, and sexual health following feminizing breast augmentation. One study, for example, reported
more than double the scores for sexual well-being on the BREAST-Q survey after the procedure [6,7,18,73,74] .

Vaginoplasty/vulvoplasty
Feminizing genital surgeries, including vaginoplasty and vulvoplasty (collectively referred to as
vulvovaginoplasty), have been studied extensively, particularly in the context of sexual health. Unlike other
forms of GAS, these procedures typically involve a combination of penectomy, reshaping and relocating the
glans to create a sensate clitoris, aesthetic vulva creation, and vaginal formation. However, some individuals
seeking feminizing genitoplasty are not interested in vaginal penetration and may choose techniques that do
not include the creation of a vagina. These options also avoid the lifelong need for vaginal dilation that
follows vaginal vault construction.

Several surgical techniques fall under the umbrella of vaginoplasty. The most commonly reported technique
is penile inversion vaginoplasty, which uses penile, scrotal, and perineal skin to line the cavity of the
neovagina [4,30,75,76] . Other methods involve tissue from donor sites, such as bowel or peritoneal flaps, which
can offer additional benefits, including natural lubrication and varied tissue texture [4,77] . Selection of the
technique depends on multiple factors, including the surgeon’s expertise and the patient’s anatomy and
embodiment goals, much like gender-affirming chest surgery.

The sexual health benefits of gender-affirming vaginoplasty are well documented. Numerous studies have
shown significant improvements in sexual function and satisfaction. These improvements are correlated
with factors such as vaginal depth and width, pain levels, ease of orgasm, absence of surgical complications,
clitoral sensation, vulvar appearance (especially the ability to “pass” as a cisgender female), and natural
lubrication when flaps other than penile skin are used to line the vaginal canal [30,77-79] . Notably, reviews
emphasize that “objective” measures of genital sensation (e.g., devices using electrical current or vibration to
assess sensitivity thresholds) have no correlation with patients’ self-reported experiences of orgasm, pain,
erogenous or tactile sensation, or overall sexual satisfaction.

Achieving orgasm post-vaginoplasty varies across studies, but reviews consistently report that ~80% of
patients achieve satisfactory frequency and intensity of orgasm [30,77-79] . This rate is comparable to that of
cisgender women, though data are limited [80,81] . Rates of dyspareunia (pain during intercourse) vary between
25%-75%, and this should be addressed during patient counseling. Importantly, transgender women post-
vaginoplasty report similar scores on the Female Genital Self-Image Scale (FGSIS) as cisgender women,
indicating high levels of body congruence, self-confidence, and sexual satisfaction with genital
appearance .
[79]