Cosmetic dissatisfaction is a common reason for reoperation after gender-affirming genital surgery in transgender women; however, the literature regarding the classification and management of postoperative cosmetic concerns is sparse. Some common reasons for cosmetic dissatisfaction include labial hypertrophy, redundant skin with a scrotum-like appearance, dog ears at the end of labial incisions, and a large clitoris that is not adequately covered by a clitoral hood. In this study, we seek to better define the types of cosmetic concerns voiced by patients following genderaffirm and to characterize the current management patterns at our institution.

We conducted a retrospective chart review of patients with a history of genderaffirming vaginoplasty who subsequently presented to our gender care clinic between January 2020 and March 2023. Patients with any documented cosmetic complaints in the postoperative period were included in our study, regardless of intervention or date of initial surgery. We then compiled the causes of cosmetic dissatisfaction and categorized them into anatomic subgroups including clitoral, labial, introital, and mons concerns. Patients with functional complaints or other non-cosmetic complications were excluded from the study. Finally, we evaluated the management patterns utilized for each concern, subdividing interventions into expectant management, in-office procedures, and operative procedures.

A total of 59 patients who underwent prior genderaffirming vaginoplasty were seen in our ender  linic, of whom 22 (37%) expressed cosmetic concerns. 49 of these patients were operated on at our institution, whereas 10 had their procedures done at outside institutions. Of patients operated on at our institution alone, 18 (37%) had cosmetic concerns. Common complaints included labial issues (n=12), clitoral issues (n=6), excessive granulation tissue (n=5), mons issues (n=4), and introital issues (n=2). Several patients had multiple cosmetic complaints and were counted in multiple groups.
Depending on patient bother and surgeon judgment,  between expectant management, office-based procedures, and major revisions in the operating room. Out of the 12 patients who were seen for labial problems, underwent labial revision surgery and were planned for revision but were subsequently lost to follow up. Of the patients with clitoral complaints, underwent clitoroplasty and were planned for revision but lost to follow up. Of the patients with mons complaints, all underwent monsplasty. Of the patients with excessive granulation tissue formation, were treated with in-office application of silver nitrate, while was treated by electrocautery application in the OR simultaneously with another procedure.
Of all the patients presenting to our clinic with cosmetic dissatisfaction, 17/22 (77%) were treated with surgical management. Out of the total 49 patients operated on at our institution, 15 
(30%) ultimately underwent revision surgery for cosmetic concerns. Of these patients, 100% reported satisfaction with cosmetic outcome following revision. The median follow-up duration between initial vaginoplasty and revision procedure was approximately 8 months.

Cosmetic dissatisfaction is a subjective outcome that makes up an important part of the overall satisfaction of patients following genderaffirming vaginoplasty. Rates of cosmetic dissatisfaction following  procedure at our institution are relatively high at 37%, though there have been reports in the literature of dissatisfaction rates as high as 54% (Hontscharuk et al. 2021). This is an important parameter to document and measure, as per our study, the resultant rate of reoperation can be as high as 77%. 
Labial redundancy was the most common cause of cosmetic dissatisfaction, closely followed by an overexposed clitoris with inadequate hooding. Given the relatively high rates of cosmetic dissatisfaction and revision, it is important during preoperative counseling to discuss with patients that cosmetic outcomes can vary, revisions are not uncommon, and to otherwise set realistic expectations for their final outcomes. Furthermore, the majority of patients appear happy with the cosmetic results following revision, with 100% of our small cohort expressing satisfaction following revision. 
The range of  was highly variable, with patients presenting with complaints as early as 2 months and a small number presenting as long as 10 years following their initial procedure. The earliest surgical reconstruction was performed at 3.9 months after the initial surgery. It is usually recommended to wait a minimum of 3 months before proceeding with a secondary revision due to cosmetic dissatisfaction, as the appearance of the surgical site will continue to change as the wound heals and swelling abates (Gaither et al. 2018).

Cosmetic dissatisfaction after genderaffirming genital surgery is a major concern that leads to frequent rate of follow ups and secondary procedures. Common cosmetic complaints include labial redundancy, overexposed clitoris, mons fullness, and granulation tissue. Given the relatively high rate of reoperation for cosmetic reasons, in-depth preoperative counseling is imperative to set realistic expectations for the patient. Larger-scale studies are needed to further define the types of cosmetic complaints and the best management strategy to take for each.

Hontscharuk R, Alba B, Hamidian Jahromi A, Schechter L. Penile inversion vaginoplasty outcomes: Complications and satisfaction. Andrology. 2021 Nov;9(6):1732-1743. doi: 10.1111/andr.13030. Epub 2021 May 27. PMID: 33955679.
Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, Breyer BN. Postoperative Complications following Primary Penile Inversion Vaginoplasty among 330 Male-to-Female Transgender Patients. J Urol. 2018 Mar;199(3):760-765. doi: 10.1016/j.juro.2017.10.013. Epub 2017 Oct 12. PMID: 29032297.
Mañero I, Arno AI, Herrero R, Labanca T. Cosmetic Revision Surgeries after Transfeminine Vaginoplasty. Aesthetic Plast Surg. 2023 Feb;47(1):430-441. doi: 10.1007/s00266-022-03029-9. Epub 2022 Aug 24. PMID: 36002774; PMCID: PMC9944700.

Continence 7S1 (2023) 101028
DOI: 10.1016/j.cont.2023.101028