Gender-affirming surgery: Male to female

INTRODUCTION — Transgender women (feminine gender identity, assigned male sex at birth) may seek a variety of medical and surgical treatments to transition physically to their self-affirmed gender. Successful transitions typically require a scope of services, generally best provided by organizations with the capacity to provide a full spectrum of psychological, medical, and surgical care. Medical treatment often includes hormones to expose sex steroid-responsive target tissues to more estrogen and block androgen action. Commonly performed surgeries include facial feminization (craniomaxillofacial procedures), chest ("top") surgery (eg, breast augmentation), and genital ("bottom") surgery (eg, orchiectomy and vaginoplasty). Knowledge of these commonly performed procedures and the surgical techniques used will aid medical care providers in caring for transgender and gender-diverse patients before, during, and after the transition process, and may help in the assessment and management of complications related to these surgeries.

This topic will review surgeries that are commonly performed as part of feminizing transition. Other topics related to the care of transgender persons include:

●(See "Transgender men: Evaluation and management".)

●(See "Transgender women: Evaluation and management".)

●(See "Primary care of transgender individuals".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender-expansive individuals.

TERMINOLOGY — The language and terminology used to describe gender and sexuality is presented in the table and reviewed in detail separately (table 1):

●(See "Primary care of transgender individuals", section on 'Terminology'.)

ISSUES IN GENDER-AFFIRMING SURGERY

Overview of transition process — Gender dysphoria is the discomfort or distress caused by a discrepancy between a person's natal sex (sex assigned at birth, usually according to external genitalia or chromosomes) and that person's gender identity (innate sense of being male or female) (table 1) [1].

Transgender individuals affected by gender dysphoria may choose to undergo a variety of treatments to transition physically and socially to the gender role that they feel to be their true selves [1]. Transitioning involves learning to express and live socially in the individual's desired gender role and may include feminizing or masculinizing hormone therapy and/or surgical procedures (known as gender affirmation surgery), depending on the individual's personal goals [2]. Mental health care and social support play a critical role throughout the transition process, and a multidisciplinary approach to the treatment of transgender individuals is recommended. Treatment, including hormonal therapy and/or surgery, is medically necessary to alleviate gender dysphoria in many individuals, and with treatment, many distressing symptoms may be alleviated [1-4]. A study of 2015 survey data reported that undergoing one of more types of gender-affirming surgery was associated with reduced rates of past-month psychological distress, past-year smoking, and past-year suicidal ideation [4].

Surgical options include feminizing procedures, breast ("top") surgery, and genital ("bottom") surgery. These procedures can be performed independently or in combination. The incidence of gender-affirming genital surgery appears to be increasing. An observational study of the United States National Inpatient Sample reported that, for inpatients with a diagnostic code for transsexualism or gender-identity disorder undergoing gender-affirming surgery, the incidence of genital surgery increased from 72 to 84 percent between the time periods 2000 to 2005 and 2006 to 2011 [5]. Approximately 44 percent of patients had insurance coverage for these procedures (private insurance, Medicare, and Medicaid), which, in part, reflects data indicating that transgender care is both affordable and cost-effective [6]. This increase in gender-affirming genital surgery highlights the need to prospectively assess quality metrics such as treatment efficacy and patient-centered outcomes (including patient satisfaction, complications, and reversal surgery), as well as ensure proper clinical training of surgeons and other health care providers.

A broad overview of the care of transgender individuals, including presentation, assessment, diagnosis, and medical management, is covered separately. (See "Transgender women: Evaluation and management" and "Transgender men: Evaluation and management".)

WPATH Standards of Care — The World Professional Association for Transgender Health (WPATH; formerly known as the Harry Benjamin International Gender Dysphoria Association) is an international professional society dedicated to promoting the highest evidence-based principles for the care of transsexual, transgender, and gender-diverse people [1]. The Standards of Care (SOC) are a series of flexible guidelines for clinical practice set forth by the society based on evidence and expert consensus and may be modified to meet the needs of an individual [1]. The guidelines provide a framework for the health care community providing assessment; mental and physical health care; hormone therapy; and surgery for transgender and gender-diverse individuals.

Perioperative management of systemic estrogen therapy — The management of perioperative estrogen therapy has been debated as data are evolving.

●Preoperative – Consensus on the management of estrogen therapy during the preoperative period is lacking as evidence specific to gender-affirming surgery is limited. The decision to stop or continue estradiol perioperatively must balance the individual's risk factors, mode of estrogen administration, and potential side effects of cessation [7]. The concern is that continuation of exogenous estrogen at doses used for transfeminine individuals may significantly increase their risk of venous thromboembolism (VTE) during and after surgery. Management strategies include estrogen cessation for two to four weeks preoperatively, estrogen continuation but at a reduced dose, and estrogen continuation at usual levels. The decision is individualized based on patient risk factors, benefits of continued treatment, type of surgery, anticipated recovery (eg, mobility expectations), and mode of estrogen administration (oral versus transdermal) [7]. (See "Transgender women: Evaluation and management", section on 'Estrogen therapy'.)

•Drug cessation – Some experts discontinue estrogen therapy two to four weeks prior to surgery to reduce VTE risk [7,8]. However, absolute benefits of VTE reduction with this approach compared with risks of abrupt hypoestrogenism (eg, hot flashes, mood changes) are not yet known and may be small. A retrospective review of 407 transfeminine individuals undergoing labiaplasty with (n = 212) and without (n = 190) estrogen use reported only one episode of VTE, which occurred in a patient whose hormones had been stopped preoperatively [9].

•Continuation with dose reduction – The rationale for this approach is to limit the risk of estrogen-induced VTE without increasing side effects of abrupt hypoestrogenism. The authors reduce the estrogen dose to 1 mg of oral estradiol starting three weeks prior to the surgery. The same regimen is used for patients using transdermal formulations of estradiol. Alternatively, transdermal dosing can be maintained at 0.1 mg per day leading up to surgery.

•Continuation at usual dose – This approach avoids potential side effects of reduced estrogen levels, including hot flashes, night sweats, and mood disturbance. The absolute increased risk of postoperative VTE with this approach is not known and likely varies by type of surgery, postoperative mobility, and patient risk factors. In our experience, most surgeons performing feminizing gender-affirming surgery do not use this approach for the management of estradiol in the perioperative period.

●Intraoperative – Estrogen therapy is not dosed during the surgical procedure. The patient should receive prophylaxis against VTE, as appropriate for the individual's risk factors and the type of procedure. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

●Postoperative – There are no data to support current practice as it relates to estrogen dosing after surgery. In our practice, we allow patients to restart their low-dose 1 mg oral estradiol one week postoperatively for the subsequent two weeks following their surgery. Once this time period has passed, they are allowed to resume their prescribed preoperative regimens. (See "Transgender women: Evaluation and management", section on 'Estrogen therapy'.)

Lack of standardized and validated reporting outcomes — Available outcomes data for gender-affirming surgeries are mainly retrospective and nonvalidated. There is a pressing need to identify and describe patient-centered outcomes for these procedures to facilitate patient care and reporting of research [10-12].

Brief history of vaginoplasty surgery — While cases have been reported throughout history of males feminized by means of castration, "sex-reassignment surgery" (now referred to as gender affirmation surgery) was not described before the 20^th century. The first feminizing genital surgeries were performed in the 1930s in Germany. At that time, the term "transsexual" had been coined by the sexologist Magnus Hirschfeld, who cared for and studied transgender individuals.

Lili Elbe, a Danish transgender woman, is historically regarded as one of the first to undergo gender affirmation surgery in Dresden, Germany, in the 1930s. She underwent several surgeries and died from complications related to her final surgery. Wide publicity and attention was brought to the United States in the 1950s when Christine Jorgensen, a former United States Army soldier, was the first American to undergo gender affirmation surgery in Europe.

In the late 1950s, the French plastic surgeon Dr. Georges Burou was one of the first to publish the modern penile inversion vaginoplasty technique. Modifications of this technique are still commonly used today. Nearly a decade after Dr. Burou's work, gender affirmation surgery became available at a few academic centers in the United States, including Johns Hopkins Medical Center and Stanford University. In the late 1970s and early 1980s, a shift in paradigm occurred, with most surgeries performed by private practicing surgeons. These operations have returned to academic centers in the United States and formal training programs for this type of surgery now exist.

Fertility preservation — Gender-affirming surgeries such as orchiectomy and vaginoplasty irreversibly inhibit the ability for people to have genetically related children in the future. Many transgender women have an expressed interest in fertility [13]. Fertility preservation techniques such as semen cryopreservation or the surgical retrieval or cryopreservation of sperm, followed by use of assisted reproductive technologies, can provide transgender women with the ability to have biologic children after competition of gender-affirming surgeries. WPATH guidelines advise that fertility preservation be reviewed with patients prior to gender affirmation treatments that involve reproductive structures [1]. People undergoing orchiectomy and/or vaginoplasty are advised to use gender-affirming hormones for at least a year prior to surgery. Therefore, most transgender women seeking surgery have already had a discussion with a hormone providing provider about future fertility. However, it prudent to review this again prior to fertility-impacting gender-affirming surgeries.

●(See "Fertility and reproductive hormone preservation: Overview of care prior to gonadotoxic therapy or surgery".)

●(See "Fertility preservation: Cryopreservation options".)

NONGENITAL/NONBREAST SURGERIES — Nongenital/nonbreast surgeries include a range of feminizing surgeries. While facial feminization and thyroid cartilage reduction are discussed here, other feminizing procedures include body contouring (eg, liposuction) and body implants (eg, buttock implants). WPATH has published recommended criteria that need to be met by patients considering and clinicians performing these types of surgeries [1]. Patients should be fully counseled and informed of the risks and benefits prior to proceeding with surgery [1,14].

Facial feminization surgery — Many different components of the face, including individual features (such as the eyes, jaw, or brow), facial configuration, and dimensional structure contribute to an individual's desired gender (figure 1) [15,16]. While facial surgery may be regarded by some as cosmetic, feminizing alterations to the face may lead to reduction in gender dysphoria, high patient satisfaction, and greater social acceptance of transgender women [3,14,17]. Since 2013, the number of patients seeking facial feminization surgery in the United States has risen exponentially [18], likely as a result of increased insurance coverage for certain procedures.

●Components – Facial feminization surgery aims to feminize masculine features of the face through a wide variety of craniomaxillofacial procedures, frequently performed by specialized plastic surgeons [14,19,20]. Facial feminization surgery may include:

•Forehead contouring and hairline advancement

•Blepharoplasty (eye and lid modification)

•Cheek augmentation

•Rhinoplasty (nose reshaping)

•Lip augmentation

•Mandibular angle reduction (figure 2)

•Genioplasty (chin width reduction) (figure 3)

•Other facial rejuvenation procedures

●Outcomes

•Combined techniques and outcomes – A 2016 systematic review of 15 retrospective case reports and series detailing the techniques and outcomes of facial feminization surgery for over 1100 transgender patients reported only 7 complications [14]. However, not all studies specifically reviewed surgical complications, and this finding should be interpreted with caution. While patient satisfaction appeared high, many of the included studies were limited by use of nonvalidated techniques or instruments for measuring satisfaction.

•Patient-reported outcomes – In a retrospective analysis of 33 patients who underwent a total of 180 facial feminization operations with a minimum follow-up of 24 months, all patients reported improvement in quality of life, measured as positive responses to a survey assessing physical, emotional, and social domains [21]. When assessed objectively by independent surgeons, aesthetic improvement was noted to be "very much improved" in nearly 88 percent and "significantly improved" in 12 percent [21]. No major postoperative complications were observed in this study.

Thyroid cartilage reduction (chondrolaryngoplasty) — The laryngeal prominence, or Adam's apple, is perceived as a distinctly male characteristic. Chondrolaryngoplasty, also known as thyroid cartilage reduction or Adam's apple reduction, involves excision of the superior thyroid notch and rim, reducing the appearance of the laryngeal prominence and altering the contour of the anterior neck to achieve a more feminine appearance (figure 4) [14,22,23]. In natal men, the thyroid lamina fuse in the midline at an approximate 90-degree angle, forming a more pronounced laryngeal prominence and contributing to greater vocal cord length and a deeper voice compared with the natal woman, in whom fusion of the thyroid lamina occurs at approximately 120 degrees [24]. Complications of the procedure include hematoma, infection, laryngeal cutaneous fistula, loss of voice, laryngeal edema, numbness of the larynx, or superior laryngeal nerve neuralgia, though none of these complications were observed in a mean 10-year follow-up of 31 patients [23]. Transient hoarseness, voice weakness, and pain with swallowing were more frequently observed following the procedure.

Of note, chondrolaryngoplasty is a separate procedure from feminizing voice surgery and does not aim to change an individual's vocal pitch. Patients considering feminizing voice surgery are advised to consult with a voice and communication specialist for pre- and postoperative support [1].

CHEST (TOP) SURGERY (BREAST AUGMENTATION) — US data suggest that breast or chest surgery is the most commonly performed group of gender-affirming surgeries [25].

Criteria for surgery — WPATH has published suggested criteria for patients considering, and clinicians performing, these surgeries [1]. These criteria have replaced older documents set forth by WPATH and the 2017 Endocrine Society clinical practice guidelines [26].

Surgical technique and preoperative planning — While feminizing estrogen hormone therapy results in breast growth within two to three months, which may continue up to two years, up to 70 percent of transgender women reportedly seek breast augmentation due to insufficient development with hormones alone [27-29]. Surgical technique is similar to augmentation in cisgender women, but the anatomic differences in the chest of natal men must be considered [30]. A wider chest, greater muscle mass, and smaller, wider-set nipple-areolar complex with shorter distance to the inframammary crease may require adjustment in the planned location of the inframammary crease, release of the lower sternal attachments of the pectoralis major muscle, and alterations in implant positioning. For these reasons, an inframammary incision and subpectoral pocket with form-stable implants are commonly chosen for augmentation in transgender women, while a periareolar incision is usually avoided due to the smaller size of the areola [8].

Additional information on the surgical technique of breast augmentation in general is discussed separately. (See "Implant-based breast reconstruction and augmentation".)

Postoperative care — A compression bra is used for several weeks after surgery, and gentle breast massage is recommended postoperatively [8]. Thrombophlebitis of the thoracoepigastric veins, known as Mondor disease, may occur following approximately 1 percent of breast augmentations [31]. Patients are also advised to limit upper body exercise to avoid displacement of the implants [8]. Following implant surgery, transgender women with no increased risk of breast cancer are advised to follow the same screening guidelines as for natal women, regardless of use of hormone therapy [32].

Complications of breast augmentation — Complications following augmentation mammoplasty should be evaluated and managed by a plastic surgeon with expertise in the procedure. Short-term and immediate postoperative complications include hematoma, seroma, and infection. Long-term complications may include capsular contracture, malposition or asymmetry, implant displacement, implant rupture or leak, pain, dissatisfaction with cosmetic appearance, and the need for reoperation [8]. In a 10-year retrospective review of patients receiving implant exchange or removal, which included 24 transgender female patients, indications for primary replacement of implants among those individuals who were transgender included contracture only (n = 7, 29.1 percent), size only (n = 11, 45.8 percent), capsular contracture and size (n = 1, 4.1 percent), asymmetry/malposition (n = 4, 16.6 percent), and shape (n = 1, 4.1 percent) [33]. Six patients underwent two reoperations, and two underwent greater than two reoperations, totaling eight implant replacements (80 percent) and two hematoma evacuations (20 percent). Indications for secondary reoperations included capsular contracture (n = 3, 30 percent), hematoma (n = 2, 20 percent), rupture (n = 2, 20 percent), and size (n = 3, 30 percent). More details on implant-related complications are discussed separately. (See "Complications of reconstructive and aesthetic breast surgery".)

GENITAL (BOTTOM) SURGERY (VAGINOPLASTY) — In our experience, many transgender women seek head, neck, and breast augmentation surgery, while relatively fewer seek genital surgery.

Preoperative planning and care — WPATH has published suggested criteria for patients considering, and clinicians performing, these surgeries [1]. Issues to be addressed include adequate pre- and postoperative counseling, reproductive options, duration of hormone therapy (if tolerated), mental health concerns and support, and ability to obtain postoperative care. Surgical consultation prior to vaginoplasty should involve an extensive discussion between the surgeon and patient on the individual's history and rationale for surgery, as well as extensive counseling on the types or routes of surgeries available, the risks and benefits related to surgery, and the limitations and expected outcome of the surgery.

In addition to standard surgical preparation, we address the following issues with our patients undergoing vaginoplasty:

●Depilatory procedures (hair removal) – Long-lasting depilatory procedures (eg, electrolysis or laser hair removal) are recommended for patients undergoing penile inversion vaginoplasty with use of local penoscrotal grafts to optimize surgical results and to avoid hair growth in the neovagina and the potential complications of folliculitis, hairballs, and dyspareunia [34,35]. Hair removal should be performed on the areas of the scrotum and perineum that will be used to line the neovagina (posterior to the penile shaft, approximately 2 cm medial to the groin creases and 4 to 5 cm anterior to the anus). The procedures may be performed on other genital hair-bearing areas, or they may be left intact to achieve the individual's desired hair distribution and aesthetic outcome following surgery. We do not use split-thickness skin grafts of scrotal tissue, which would potentially allow removal of the hair follicle layer, because the scrotal skin produces a much thinner graft and is difficult to split in such a way to separate the hair follicles.

Laser hair removal uses a laser light source to target pigmented hair, destroying the follicle with heat [36]. Electrolysis destroys the hair follicle through use of an electric current directed through a needle or probe, and can be used on pigmented or unpigmented (eg, gray, red, or blonde) hair [36]. These procedures may be uncomfortable, and lidocaine jelly or lidocaine-prilocaine cream may be prescribed to reduce pain associated with the procedure [36]. Multiple treatments are required for optimal results, and it is recommended that hair removal be stopped four to six weeks prior to surgery. Further details on hair removal techniques is found elsewhere. (See "Removal of unwanted hair".)

●Thromboprophylaxis – Multiple factors may lead to the observed increased incidence of venous thromboembolic events (VTE) observed in the male-to-female transgender population including the use of exogenous estrogen, prolonged surgical procedures, and postoperative bed rest [37]. Prior to surgery and in the perioperative period, the Endocrine Society clinical practice guideline recommends that surgeons and endocrinologists collaborate to manage hormone therapy [32]. (See 'Perioperative management of systemic estrogen therapy' above.)

Patients should receive appropriate VTE prophylaxis in the perioperative and postoperative periods. In our practice, patients receive prophylactic subcutaneous heparin and wear sequential compression devices in the preoperative and immediate postoperative period. Prophylactic subcutaneous enoxaparin is then administered for one week following hospital discharge. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)

●Surgical consent – In addition to routine surgical risks such as bleeding and infection, surgical consent for vaginoplasty must address risks specific to this procedure.

Our surgical consent for vaginoplasty contains the following language:

"We discussed the risks and benefits of the surgical procedure in great detail. The goal is to achieve good cosmesis and functioning; she understands that each body is different and results vary.

Risks include, but are not limited to, bleeding/hemorrhage, transfusion, hematoma, seroma, infection/abscess, wound healing issues, injury to surrounding organs (bowel, rectum, bladder, urethra) and possible development of fistula, vaginal stenosis/stricturing/shortening/narrowing, abnormal urinary stream, urinary incontinence, inability to orgasm or change in orgasm, pain and scarring, neuropathies, and need for additional surgery.

We also discuss that removal of the gonads (testes) at the time of vaginoplasty will lead to inability to conceive biologically related children. Preservation of gametes (sperm) preceding surgery remains an option for some patients.

●Antibiotic prophylaxis – Guidelines for prophylactic antibiotic use do not exist for vaginoplasty in the transgender population; therefore, appropriate prophylaxis should be administered for urogenital procedures [38]. The specific antibiotic selection and length of administration is based on expert opinion. In our practice, perioperative intravenous cefazolin is administered, followed by oral trimethoprim-sulfamethoxazole for prevention of infection while the urinary catheter and vaginal packing remain in place up to one week following surgery.

●Bowel preparation – The use of a mechanical bowel preparation prior to penile inversion vaginoplasty is surgeon dependent. Many experts may choose to perform some degree of modified bowel preparation prior to surgery to avoid fecal contamination in the rare event of a rectal injury, and to delay the immediate return of postoperative bowel movements while a vaginal packing is in place. Modified bowel preparation regimens may involve a combination of clear liquid diet the day prior to surgery and mechanical bowel preparation or enemas. Rectal wash out is performed at the time of surgery with povidone-iodine solution. For intestinal segment vaginoplasty, full mechanical bowel preparation and oral antibiotics are recommended to reduce the risk of surgical-site infection and anastomotic leak [39].

●Intraoperative positioning – Careful attention should be paid to surgical positioning given the potentially extended length of time required for the procedure. Patients should be positioned in dorsal lithotomy position in adjustable padded stirrups, keeping the hip, knee, and ankle aligned, avoiding hyperflexion or hyperextension of the knees and hips. The arms should be positioned out on arm boards for ease of access during penile inversion vaginoplasty, or with arms tucked in neutral position at the patient's sides for intestinal vaginoplasty, where laparoscopic abdominal access may be employed. Sufficient padding should line the operative table, and additional adhesive padding applied to the patient's heels and sacrum may be added for prevention of pressure sores.

Surgical techniques — The goal of vaginoplasty surgery is to achieve an aesthetic and functional vagina, vulva, and clitoris. Patients should be counseled that each body is different and results will vary depending on body habitus, tissue availability, and other individual medical factors such as a history of prostatic disease. The most commonly performed technique, especially in the United States, is the penile inversion vaginoplasty. Many modifications of this technique exist, and one of these modifications is described below. Intestinal vaginoplasty procedures are also performed and described. Graft materials are mainly used in revision surgeries.

Orchiectomy – Some patients undergo removal of the testes only. For some patients this is the final stage of their gender affirmation surgical process while for others it is a first step in their pursuit of genital gender affirmation. Patients who choose to undergo orchiectomy often only have intolerance to anti-androgen therapy or have a challenging time suppressing their endogenous androgens despite anti-androgen therapy. Other patients experience significant genital dysphoria as a result of their testes and benefit from their removal.

The procedure can be done in the outpatient setting. A 3 cm incision is made in the midline of the scrotum below the penis and the testes are brought to the incision. The spermatic cord is skeletonized and then suture ligated, after which the testes are removed. Patients seeking further genital reconstruction following orchiectomy remain good candidates for the surgery as no genital skin is disturbed or removed during this procedure.

Vulvoplasty procedures ("no depth" or "zero depth" vaginoplasty) — Some patients choose not to undergo the creation of the vaginal canal as part of their surgical transition and request a feminizing genital surgery that involves construction of the female external genitalia only. This procedure is becoming more common among surgeons who perform feminizing genital surgery. Vulvoplasty alone is also commonly performed in patients who have a history of prostate cancer who have undergone prostatectomy and/or radiation treatment in order to reduce the surgical risks associated with the creation of a vaginal canal. In the majority of cases, however, the choice to undergo vulvoplasty alone is based on patient preference rather than contraindications to performing the vaginal reconstructive portion of the procedure [40].

Penile inversion vaginoplasty — The most common technique performed for primary male-to-female transgender vaginoplasty is penile inversion vaginoplasty [41]. The technique has been widely researched and described, and modifications have been made over time to improve aesthetic outcome and functional results [42-44]. Penile inversion vaginoplasty is irreversible and generally includes orchiectomy (if not previously performed), penile deconstruction, formation of a sensate neoclitoris from a portion of the glans penis on its dorsal neurovascular pedicle, creation of a neourethral meatus, creation of a vaginal cavity and lining of the neovagina with local penoscrotal skin flaps, and labiaplasty to create an aesthetic and feminine external appearance of the genitalia. Surgery may be performed by a variety of surgical specialists in plastic surgery, urology, gynecology, and female pelvic medicine and reconstructive surgery.

We use the following technique in performing modified penile inversion vaginoplasty, which is also presented in the video (movie 1):

●The scrotal flap, which will later be used to line the neovagina, is marked (figure 5). The borders of the graft are the base of the penile shaft anteriorly, 2 to 4 cm medial to the groin creases laterally, and 4 to 5 cm above the anus posteriorly. The flap is incised sharply, then excised from the underlying subcutaneous tissue using electrosurgery. To prepare the graft, all excess subcutaneous tissue is removed sharply, creating a split thickness skin graft. If hair removal is suboptimal, remaining hair follicles can be electrosurgically coagulated. The graft is kept moist with saline-soaked sponges.

●Next, electrosurgery is used to remove excess subcutaneous tissue by skeletonizing the underlying penile structures down to Buck fascia. If testes are present, orchiectomy is performed (figure 6). A circumferential incision is made around the glans of the penis, thus freeing the epithelium from the underlying tunica albuginea (figure 7). If excess distal penile skin is present, the distal penile skin and prepuce may be left intact with the glans for later creation of a clitoral hood and labia minora. The penile structures are then sharply de-epithelized leaving a penile tube. The suspensory ligament of the penis is released. A urinary catheter is placed to drain the bladder.

●Attention is then turned to creation of the neovagina. A transverse incision is made in the perineum below the bulbous urethra, transecting the perineal tendon and creating a cavity by separating the levator ani muscles laterally (figure 8). Dissection is performed, first sharply and then bluntly. Our preference is to perform this dissection with one finger inside the rectum and the other in the neovaginal cavity (figure 9). Care is taken to delineate the borders of the rectum and to palpate the urinary catheter during the dissection to avoid injury to the rectum or lower urinary tract. Dissection is carried past the level of the prostatic urethra anterior to the rectoprostatic fascia for a total length of approximately 15 cm (figure 10). Once adequate caliber and depth are achieved, meticulous hemostasis is obtained to avoid hematoma formation. A bubble test may be performed to assess for rectal injury by filling the neovagina with irrigation solution, then insufflating the rectum using a large syringe. If bubbles are seen in the neovaginal cavity, further investigation for rectal injury should be performed.

●Attention is returned to the penile structures. A dorsal flap containing the dorsal penile neurovascular blood supply to the neoclitoris (created from a portion of the dorsal glans penis) and a ventral urethral flap are created. The deep penile arteries are ligated at the inferior margins of the crura of the corpora cavernosa. The corpora cavernosa, located between the dorsal clitoral flap and the ventral urethral flap, are excised (figure 11).

●The excess glans is excised, and the clitoral flap is folded on itself to position the neoclitoris at the level of the insertion of the adductor longus tendon in the groin creases, which is where the transclitoral line is located in the natal female. The flap is secured to the underlying fascia. Care must be taken not to kink the blood supply or place the flap on tension, which could result in necrosis of the neoclitoris (figure 12).

●Excess corpus spongiosum is excised from the urethral flap. The urethra is transected in the midline on the ventral side over the catheter until the level of the pubic bone to ensure that the urethral meatus will lie flush with the bony pelvis to avoid urinary stream spraying. The urethral flap is trimmed and secured to the underlying fascia, leaving a mucosal bridge lining the area between the neourethral meatus and the neoclitoris (figure 13).

●The prepared graft is sewn onto a large vaginal stent (figure 14). The stent is then passed through the penile tube and the flaps are sutured together (figure 15). The vaginal tube and stent are then placed into the neovaginal cavity, and the stent is removed. Mattress sutures are placed to take tension off the flap, and the vagina is tightly packed.

●An incision is made anteriorly through the penile flap, exposing the underlying clitoris, mucosal urethral flap, and urethral meatus. Labia minora and a clitoral hood are created using the maintained distal penile skin, or can alternatively be created by suturing the edges of the anterior penile flap (figure 16). Drains are placed to drain the labia majora, and the labia majora incision lines are closed in an aesthetically appealing way. Immediate postoperative results are shown in the picture (picture 1).

Intestinal vaginoplasty — Transgender women with penoscrotal hypoplasia or those who have failed a primary penile inversion vaginoplasty procedure may be candidates for intestinal vaginoplasty [45,46]. Intestinal vaginoplasty involves use of a segment of small intestine (ileum) or sigmoid colon to create a neovagina, with the advantages of self-lubrication, depth, and reduced risk of stenosis [47]. Disadvantages of the procedure include the risks of abdominal surgery and the creation of a bowel anastomosis, excessive discharge and/or malodor, and prolapse of the neovagina [47]. Patients with a history of cancer, inflammatory bowel disease, or extensive intraabdominal adhesions are not candidates for this procedure [47].

The procedure is performed through a combined abdominal and perineal approach [46,47]. The perineal portion of the procedure includes perineal dissection of the neovaginal cavity, disassembly of the penile structures, formation of a neoclitoris, neourethral meatus, labia minora, labia majora, and bowel-perineal anastomosis. The neovaginal dissection, penile disassembly, and creation of vulvar structures are performed similarly to the techniques described above for penile inversion vaginoplasty. (See 'Penile inversion vaginoplasty' above.)

The abdominal portion may be performed via laparoscopy, laparoscopic-assisted laparotomy, or laparotomy, depending on surgeon experience, and includes harvest of an intestinal segment (ileum or sigmoid colon) on its vascular pedicle and bowel anastomosis [47]. Surgeons may also choose to perform a suspension procedure to the sacral promontory to prevent prolapse of the neovagina [47].

Use of graft materials — Use of nongenital full-thickness or split-thickness skin grafts is less common and is generally reserved for revision surgery [41,48]. Few small retrospective studies have described surgical technique, complications, and outcomes [41]. In one study, revision vaginoplasty was performed using abdominal full-thickness skin grafts in six patients with no reported postoperative complications [49]. All patients reported satisfaction with the results and the ability to have sexual intercourse. Vaginal depth was reported as 12 cm at 7 months (range 3 to 18 months). Others have described the use of a penile skin graft and a split-thickness graft (n = 12) or penile flap and inguinopudendal neurovascular island pedicle flap (n = 109) [50]. Complications reported included vaginal stenosis (n = 5 in the first group, n = 4 in the second group), and urethral meatus stricture (n = 7) in the second group. Other reported complications were neovaginal hair growth and flap necrosis in the inguinopudendal flap group. Adequate vaginal depth of 8 to 10 cm was reported.

A prospective study of transgender women undergoing penile inversion vaginoplasty with penile skin length of 7 to 12 cm added an additional full-thickness skin graft [51]. Satisfaction, sexual function, and genital self-image were evaluated. Thirty-two patients out of 100 included in the study underwent penile-inversion vaginoplasty with additional full-thickness skin graft augmentation. Aesthetic outcome as reported by both patients and clinicians improved over time, and satisfaction scores did not differ significantly between groups. Preoperative penile skin length was significantly shorter in the full-thickness skin graft group (14.6±1.8 cm versus 11.5±2.3 cm, p <0.001), but postoperative mean neovaginal depth at one year did not differ between groups (11.3±2.7 cm versus 11.6±2.1 cm, p = 0.65). Sexual function as assessed by the Female Sexual Function Index was not different between groups, but scores were below levels consistent with sexual dysfunction in cisgender women. Genital self-image as assessed by the Female Genital Self-Image Scale was not different between groups and scores were indicative of positive self-image.

Peritoneal flap ("pull-through") vaginoplasty — An alternative to penile inversion vaginoplasty is a modification of the Davydov procedure that is a surgical treatment for patients with congenital agenesis. The procedure uses similar techniques to the penile inversion vaginoplasty with regard to penile deconstruction and reconstruction of the vulvar structures. However, peritoneum is mobilized abdominally using conventional or robotic-assisted laparoscopically to elongate the distally grafted neovagina. This procedure is sometimes performed for patients with hypoplasia of the male genitalia (eg, cases of puberty suppression in younger patients) and cases of revision surgery when vaginal stenosis has occurred [52].

Postoperative care — Postoperatively, pain is controlled with intravenous patient-controlled analgesia and, once diet is advanced, oral narcotic pain medication. Diet is restricted to ice chips on postoperative day 0, then advanced to clear liquids on postoperative day 1 and later to a regular diet as tolerated. A stool softener is administered for bowel regimen. Activity is initially restricted to bed rest in beach chair position to avoid undue tension on the suture lines or pressure on the grafts until the dressings and drains are removed on postoperative day 2 to 3. After drain removal, activity can be increased to light ambulation. Tight vaginal packing and an indwelling bladder catheter remain in place until postoperative day 6 to 7, when they are removed and vaginal dilation is taught. Vaginal dilation is performed using progressively larger rigid dilators three times daily for 12 weeks, then once to twice daily for another 12 weeks. Six months after surgery, patients are encouraged to dilate at least weekly if they are sexually active, or daily if they are not.

Special populations

Revision surgery — In a retrospective study of 475 transgender women who underwent penile inversion vaginoplasty, revision vaginoplasty was performed in 14 patients (2.9 percent), all secondary to neovaginal stenosis [53]. In comparison with primary penile inversion vaginoplasty, revision vaginoplasty carries higher rates of complications, including intraoperative rectal injuries and postoperative complications such as fistula formation [48]. Surgery is more difficult due to adhesions and contracture of previous grafts. Options for revision include intestinal vaginoplasty, use of full-thickness skin grafts from various donor sites, or a peritoneal pull-through procedure. Each technique carries different and specific advantages and disadvantages. Intestinal vaginoplasty provides depth, natural lubrication, and lower risk of stenosis but confers the risk of bowel-related complications. The use of full-thickness skin grafts is less invasive and avoids abdominal surgery, but carries complications related to skin grafting including donor site scarring, graft contracture, and poor graft taking.

A retrospective comparison of laparoscopic intestinal vaginoplasty versus perineal full-thickness skin graft vaginoplasty performed in 50 transgender women and 3 cisgender women reported two rectal perforations (10 percent) and one bladder neck injury in the intestinal group and six rectal perforations (19 percent; p = 0.46) in the full-thickness perineal skin graft group [48]. Operative time was significantly shorter for the perineal skin graft group (130±35 minutes) than for the laparoscopic intestinal vaginoplasty group (191±45 minutes; p <0.01). Intraoperative intestinal neovaginal length was significantly greater after intestinal vaginoplasty, but adequate intraoperative depth was able to be achieved in 31 of 32 skin graft vaginoplasties. Both groups were hospitalized for a mean of eight days. Complications in the laparoscopic intestinal vaginoplasty group leading to prolonged hospitalization included fecal peritonitis in a patient with intraoperative rectal perforation, stenosis of the anastomosis, and intestinal torsion. In the perineal skin graft group, prolonged hospitalization occurred secondary to rectal perforation in three patients and superficial wound infection in one patient. In long-term follow-up (median 3.8 years, range 1.1 to 19.7 years), nearly all sigmoid neovaginas (90 percent) and perineal skin graft neovaginas (80 percent; p = 0.45) were of adequate depth for intercourse. Two sigmoid neovaginas required removal, one due to compromised vasculature and necrosis, the other due to excessive fibrosis. Five cases of complete stenosis were observed in the perineal skin graft group. Other complications in the intestinal group included one case of neovaginal prolapse and two cases of introital stenosis. In the skin graft group, three patients underwent revision of the labia majora, and two were treated for granulation tissue at the neovaginal apex.

Patients on puberty blockers — Adolescents who meet eligibility and readiness criteria may initiate hormone therapy beginning with gonadotropin-releasing hormone (GnRH) puberty hormone suppression, later incorporating cross-sex steroids for development of secondary sexual characteristics congruent with the individual's gender identity [32]. A detailed discussion of hormone therapy interventions for adolescents is discussed separately. (See "Management of transgender and gender-diverse children and adolescents".)

Young adult transgender women who have been treated with puberty suppression therapy may exhibit penoscrotal hypoplasia, resulting in less genital skin availability for reconstructive surgery [54]. In this setting, alternatives to penile inversion vaginoplasty including primary intestinal vaginoplasty, or the use of grafts or peritoneum must be considered as described above [54]. (See 'Intestinal vaginoplasty' above and 'Use of graft materials' above.)

When considering surgery in the young adult transgender population, the individual patient's maturity and risk of regret must be carefully considered [1,54]. WPATH offers specific recommendations regarding the medical and surgical treatment of adolescents, including that the individual have the capacity to make an informed decision and consent for surgery [1].

Complications of vaginoplasty

Type of complication by timing

●Intraoperative – Intraoperative complications of vaginoplasty include bleeding and injury to surrounding organs including the rectum, bladder, and urethra.

•Bleeding – Excessive bleeding and hematoma formation is often a result of bleeding from the remaining corpus spongiosum surrounding the urethra. Corpus spongiosum bleeding is typically treated by applying pressure or hemostatic agents as suturing this delicate tissue often worsens the bleeding. Excessive bleeding may also occur during the neovaginal dissection and result from disruption of branches of the inferior gluteal, inferior vesical, and pudendal vascular supply to the levator ani [55]. Surgical management with direct visualization and ligation of bleeding vessels is preferred. Interventional radiology embolization of bleeding vessels is generally not recommended, as this may compromise the flaps and result in flap necrosis.

•Rectal injury – In cases of intraoperative rectal injury, primary layered closure may be undertaken, and a protective colostomy may be considered to allow for wound healing and prevention of rectovaginal fistula formation.

•Urinary tract injury – Urethral or bladder injuries are typically managed with primary layered closure and prolonged urinary catheter drainage. Ureteral injury is a rare complication as the ureters are not in close proximity to the operative field. If a ureteral injury is suspected, or if a cystotomy is encountered near the bladder trigone that raises concern for ureteral compromise, intraoperative specialist consultation can be obtained to discuss possible imaging (eg, retrograde pyelogram) and ureteral stenting. No specific surgical considerations are needed to address the fact that these patients have a prostate.

●Immediate postoperative – In the immediate postoperative period, bleeding, hematoma or seroma, wound infection or abscess, wound dehiscence, flap necrosis, or VTE may be observed. Postoperative rectovaginal or pararectal abscess or feculent vaginal discharge should alert the surgeon to the possibility of an undetected rectal injury, and further investigation including imaging and/or examination under anesthesia is recommended. Neovaginal prolapse may require local excision in the setting of a sigmoid neovagina if the prolapse is limited to mucosa only, or neovaginopexy may be performed for complete prolapse.

●Late postoperative – Late postoperative complications include neovaginal or introital stenosis, genitourinary or rectovaginal fistula formation, abdominal urinary stream (ie, upward or abnormal urinary stream), urethral meatal stenosis, and sexual dysfunction. Patients with significant complications should be referred to the original surgeon or to a surgeon with expertise in vaginoplasty techniques for assessment and management. In cases of vaginal stenosis, revision surgery may be indicated for severe stenosis (complete neovaginal revision) or an obvious skin bridge or scar obstructing the introits (introitus plasty). Other cases of neovaginal or introital stenosis may be managed conservatively with neovaginal dilation. Urethral meatal stenosis often presents as abnormal urinary stream spraying and may be addressed by release of the stenosis or revision of an obstructing skin bridge.

Minor postoperative complications that can be managed in the office may include vaginal spotting, vaginitis, and hair growth in the neovagina. Vaginal spotting often occurs secondary to granulation tissue formation in the neovagina and can be managed locally with silver nitrate or excision. A trial of vaginal estrogen may be acceptable, although there is no evidence for this intervention. Yeast vaginitis may occur as a result of the warm, moist neovaginal environment, and postoperative skin sloughing may also contribute to symptoms of excessive discharge and malodor [56]. Douching with a vinegar or povidone-iodine solution, or with a mixture of baby soap and warm water may be recommended for routine hygiene [57]. If preoperative hair removal procedures are not performed or are inadequate, excessive hair growth within the neovagina may lead to tangling and knotting, which requires trimming and removal in the office setting.

Incidence — The overall risk of major complication from gender-affirming vaginoplasty is relatively low. One retrospective cohort study evaluating 488 vaginoplasties reported severe postoperative complications (Clavein-Dindo grade 3-4) occurred in 5.5 percent of patients; most of the complications involved wound issues, return to operating room, or readmission [58]. In addition, it is not known if the surgical indication of gender affirmation impacts the risk of complication compared with vaginoplasty performed for other gynecologic indications, including vaginal agenesis, cancer, and trauma.

The types and frequency of complications vary with the surgical techniques:

●Penile inversion vaginoplasty – A meta-analysis of 26 studies including over 1400 patients who underwent penile inversion vaginoplasty reported the following complications [41]:

•Wound dehiscence – 12 to 33 percent

•Stricture of the neovaginal introitus – Average 12 percent (range 4.2 to 15 percent)

•Neovaginal stricture other than the introitus – Average 7 percent (range 1 to 12 percent)

•Rectovaginal fistula – 1 to 17 percent

•Vaginal shrinkage – 2 to 10 percent

•Surgical bleeding – 3 to 10 percent

In addition, abscess, hematoma, or urethral meatal stenosis occurred in approximately 5 percent of patients, partial necrosis of the neovagina or rectal injury occurred in 2 to 4 percent, and clitoral necrosis or neovaginal prolapse occurred in 1 to 3 percent. A different study of 31 transgender men who underwent vaginoplasty reported 19 percent noted some degree of urinary incontinence at three years of follow-up [59]. In other studies including over 500 transgender women who underwent gender confirmation surgery, postoperative genital pain occurred in 3 to 9 percent of patients [60,61].

●Intestinal vaginoplasty – In a systematic review of intestinal vaginoplasty that included nearly 900 patients (combined transgender and gynecologic indications), overall complications rates were 6.4 percent for sigmoid vaginoplasty, and 8.3 percent for ileal vaginoplasty [46]. Severe complications occurred in 0.6 percent of sigmoid vaginoplasties and included necrosis of the sigmoid conduit, necrotizing fasciitis, bilateral lower extremity compartment syndrome, and intraluminal abscess at the neovaginal apex. In addition, a 0.9 percent incidence of small bowel obstruction was reported. No severe complications were reported following ileal segment vaginoplasty; however, two cases of anastomotic stenosis were reported. Introital stenosis was reported in 8.6 percent and 1.2 percent of sigmoid and ileal segment vaginoplasties, respectively, with diffuse stenosis occurring in 3.5 percent and 3.0 percent. Other sources have reported intestinal neovaginal stenosis rates up to 43 percent in the transgender population [41]. Additional reported complications may include necrosis (one patient), rectovaginal fistula (two patients), prolapse of the sigmoid vaginal segment (mean 7.7 percent; 6.5 percent mucosal prolapse only), and excessive discharge (0.7 percent) or malodor [41,46].

●Peritoneal flap ("pull-through") vaginoplasty – A series of 52 patients who underwent laparoscopic peritoneal pull-through over a five-year period reported the same complications inherent to all vaginoplasty procedures: vulvar hematoma, neovaginal introitus dehiscence, and superficial skin necrosis of the vulva [62]. There were no abdominal complications or events directly related to the laparoscopic peritoneal harvesting and flap mobilization. A different series of 100 patients who underwent robot-assisted peritoneal flap vaginoplasty reported the following complications: need for transfusion (6 percent), rectovaginal fistula (1 percent), bowel obstruction (2 percent), pelvic abscess (1 percent), and vaginal stenosis (7 percent) [52].

Outcomes

Sexual function — Prospective studies that evaluate sexual function and quality of life following feminizing genital surgery are limited. In a systematic review of 140 studies (66 percent cross-sectional or retrospective-cohort) including 12 vaginoplasty techniques, a median of 81 percent (range 64 to 98) reported satisfaction with general sexual function and a median of 80 percent (range 17 to 100) were able to orgasm following surgery [63].

Surgical outcomes — As there are no standardized outcome measures for gender-affirming surgery and the sample sizes of available studies are small, direct comparison of the surgical techniques by outcome is limited [41]. Both approaches appear to result in functional sexual anatomy and satisfied patients.

●Penile inversion vaginoplasty – In a meta-analysis of five studies of 223 transgender women who underwent penile inversion vaginoplasty, a mean of 75 percent reported the ability to have vaginal intercourse (range 33 to 87 percent), 70 to 84 percent reported the ability to orgasm, 76 to 100 percent reported satisfaction with vaginal length, and 2 to 6 percent reported dyspareunia [41]. Eighty-four to 100 percent were satisfied with the aesthetic appearance of their genital reconstruction. A different study of 232 transgender women reported that patients rated their happiness with sexual function as an average of 7.8 on a 10-point scale [60]. Patients rated their overall satisfaction with the surgery as 8.7 (10-point scale) while 6 percent of patients had some degree of regret.

●Intestinal vaginoplasty – Two studies of intestinal vaginoplasty (n = 89, 81 of 89 patients underwent gender confirmation surgery) reported that 63 to 79 percent were sexually active one year after surgery [64,65]. Based on scores from the Female Sexual Function Index, a different study reported that 78 percent of intestinal vaginoplasty patients had satisfactory sexual function (n = 86, 27 transgender) [66]. In the subset of 28 transgender patients from a combined study, 89 percent reported a "good aesthetic appearance" while 11 percent felt their appearance was "fair" [65]. While data on overall satisfaction are limited, one study evaluated patients with the Beck Depression Inventory questionnaire and reported that 30 percent of transgender patients had scores consistent with depression, but preoperative scores were not available for comparison [66].

●Peritoneal flap ("pull-through") vaginoplasty – Although a newer approach compared with traditional penile inversion vaginoplasty and intestinal vaginoplasty, two observational studies published favorable outcomes for peritoneal flap vaginoplasty with regards to vaginal depth and patient-reported satisfaction with surgery [52,62].

Regret — The rate of regret after gender-affirming surgery appears to be low. Overall regret rates of 0 to 3.8 percent have been reported [67-72].

●Low regret – The etiology of regret is complex, and currently, little is known about the patient experience as it relates to this important outcome.

•In a cross-sectional study of surgeons performing gender-affirming surgery, the regret rate was reported to be 0.3 percent and etiologies of regret included: true gender-related regret (42 percent), social regret (37 percent), and medical regret (8 percent) [73].

•A meta-analysis including over 7900 transgender patients who underwent any type of gender-affirming surgery reported a one percent regret rate (pooled prevalence of regret after surgery 1 percent, 95% CI <1 to 2 percent) [72]. The largest included study reported gonadectomy was associated with regret rates of 0.3 percent for transmen and 0.6 percent for transwomen [71].

●Improved mental health – In addition, a cross-sectional survey study of nearly 700 transgender individuals reported that patients who underwent definitive bottom surgery had lower rates of depression and anxiety, and higher levels of body-gender congruence and body image satisfaction, compared with patients who received less treatment or no treatment [74].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Transgender health".)

SUMMARY AND RECOMMENDATIONS

●Language and terminology – The language and terminology used to describe gender and sexuality is presented in the table (table 1). (See 'Terminology' above.)

●Overview of transition process – Transgender and gender-diverse individuals affected by gender dysphoria may choose to undergo a variety of treatments to transition physically and socially to the gender role in which they feel to be their true selves. Transitioning involves learning to express and live socially in the individual's desired gender role and may include feminizing or masculinizing hormone therapy and/or surgical procedures. (See 'Overview of transition process' above.)

●Standards of care – The World Professional Association for Transgender Health (WPATH) is an international professional society dedicated to promoting the highest evidence-based principles for the care of transsexual, transgender, and gender-nonconforming people. The Standards of Care are a series of flexible guidelines for clinical practice set forth by the society based on evidence and expert consensus. (See 'WPATH Standards of Care' above.)

●Preoperative management of estrogen therapy – For patients who use estrogen therapy undergoing major surgery, we suggest lowering the dose of estrogen therapy rather than continuation of the full dose or complete cessation (Grade 2C). We reduce the estrogen dose to 1 mg of oral estradiol starting three weeks prior to the surgery. This approach is based on limited data and our clinical experience. (See 'Perioperative management of systemic estrogen therapy' above.)

●Facial and neck procedures – Common nongenital/nonbreast surgeries include a combination of procedures for facial feminization and thyroid cartilage reduction (chondrolaryngoplasty). (See 'Nongenital/nonbreast surgeries' above.)

●Chest (top) surgery – Chest, or top, surgery typically consists of breast augmentation with implants after a period of feminizing hormone therapy. WPATH has created criteria for chest surgery (ie, breast augmentation in male-to-female transgender individuals). (See 'Chest (top) surgery (breast augmentation)' above.)

●Genital (bottom) surgeries – Genital, or bottom, gender confirmation surgery consists of vaginoplasty and orchiectomy, if not already performed. WPATH provides criteria to help assess candidate appropriateness. (See 'Preoperative planning and care' above.)

•Vaginoplasty – The goal of vaginoplasty surgery is to achieve an aesthetic and functional vagina, vulva, and clitoris. The most commonly performed technique, especially in the United States, is the penile inversion vaginoplasty. Intestinal vaginoplasty procedures are also performed and described. Graft materials are mainly limited to revision surgeries or patients taking puberty blockers with resultant penoscrotal hypoplasia. (See 'Surgical techniques' above.)

•Unique populations – Patients who require revision surgery or who have been treated with puberty-blocking drugs have unique considerations for their care. (See 'Special populations' above.)

•Surgical complications – Intraoperative complications of vaginoplasty include bleeding and injury of the surrounding organs. Common immediate postoperative period complications include bleeding, hematoma or seroma, wound infection or abscess, wound dehiscence, flap necrosis, or venous thromboembolic events. Late postoperative complications include neovaginal or introital stenosis, genitourinary or rectovaginal fistula formation, urethral meatal stenosis, and sexual dysfunction. (See 'Type of complication by timing' above.)

•Surgical outcomes – There are no standardized outcome measures for gender-affirming surgery, and the sample sizes of available studies are small, which limits direct comparison of the surgical techniques. Vaginoplasty procedures appear to result in functional sexual anatomy and satisfied patients in the majority of cases. (See 'Outcomes' above.)

ACKNOWLEDGMENTS — The UpToDate editorial staff acknowledges Tonya N Thomas, MD, who contributed to earlier versions of this topic review.