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Page 8 of 18 Billings et al. Plast Aesthet Res. 2025;12:27 https://dx.doi.org/10.20517/2347-9264.2025.52

A critical area of counseling for potential vaginoplasty patients is the lifelong requirement for dilation if they
are not engaging in regular vaginal penetration, as well as douching. Many patients find these activities
unpleasant, and for some, this may lead to choosing vulvoplasty instead (sometimes called “zero-depth”
vaginoplasty) . Based on clinical experience, the senior author notes that survivors of sexual trauma may
[77]
face particular difficulties with dilation. Providers should assess whether patients who experience extreme
aversion to handling their genitals may struggle with postoperative dilation and hygiene. If concerns arise,
patients should engage in presurgical counseling with a knowledgeable therapist to help them manage
postoperative care. “Failure to dilate” and “non-adherence to dilation” are frequently cited as key drivers of
complications, highlighting the complexity of the procedure and the need for closer collaboration with
patients [76,77] . In addition to psychological therapy, pelvic floor physical therapy (PT) referrals may help
address both physical and emotional concerns before and after surgery (see The Role of Adjunctive Therapy
in Sexual Health After GAS below).

Regarding vulvoplasty, patient satisfaction, including overall QOL and sexual function, is generally high. In
one cross-sectional study, a 93% satisfaction rate was reported [77,82] . Over half of the patients who chose
vulvoplasty did so without any medical contraindications, highlighting that there are multiple reasons
people opt for this procedure. Vulvoplasty is not an inferior procedure to vaginoplasty, nor is it only for
those for whom vaginoplasty is medically contraindicated. It is simply a different option.

Phalloplasty/metoidioplasty
The goal of both phalloplasty and metoidioplasty is to create a more masculine genital appearance and
function, often including the ability to urinate while standing. For some individuals, this functional aspect is
[83]
a higher priority than sexual function . Metoidioplasty utilizes the hormonally enlarged clitoris as the body
of the phallus, resulting in what is functionally a micropenis. In contrast, phalloplasty creates a larger
phallus using a local or distant tissue flap. Both procedures typically involve creating a scrotum, and may
also include urethral lengthening and/or vaginectomy (removal of the vagina). Individuals wishing to use
their phallus for sexual penetration are generally advised that phalloplasty is the more appropriate
procedure, as the phallus length after metoidioplasty is usually insufficient for penetration [84,85] .

Gender-affirming phalloplasty is often a multi-staged procedure in which a tissue flap is used to create a
neophallus. The specific stages vary depending on the technique and the surgeon’s preference. Commonly
used flaps include the radial forearm (RFFF), anterolateral thigh (ATL), and abdominal flaps, though other
[86]
techniques are occasionally used (albeit less commonly due to higher risks of donor site morbidity) .

Both phalloplasty and metoidioplasty may be performed with or without urethral lengthening, depending
on whether standing urination is desired [75,86] . While standing urination is a key goal for many individuals
seeking masculinizing genitoplasty, it carries significant risks of complications. Indeed, most complications
requiring reoperation in both procedures are related to urethral reconstruction, some of which may be
acute. Therefore, individuals should consider the tradeoffs between optimizing function and minimizing
risks, based on the chosen surgeon and technique [87-90] . Urinary complications may also affect body image
and sexual self-esteem, although this has not been specifically studied.

The clitoris is typically either buried within the neophallus or positioned at its base to preserve erogenous
sensation. Additionally, some surgeons may incorporate one of the clitoral nerves into the neophallus flap
to improve sensation . Overall, most patients (94% in one systematic review) report full tactile sensation in
[86]