Management of cosmetic concerns after gender-affirming vaginoplasty: a retrospective case series and guide to revisions

This retrospective study examines 58 transgender women who presented with cosmetic concerns following gender-affirming vaginoplasty between January 2020 and April 2023. The cohort’s mean age was 36.8 years (±9.8), with a mean BMI of 29.5 kg/m² (±7.1). Most patients were Black or African American (41.4%) or White (31.4%), and 43.0% had wound healing comorbidities. Of the total cohort, 62.1% (36/58) underwent penile inversion vaginoplasty (PIV), 31.0% (18/58) robotic-assisted vaginoplasty with peritoneal flaps, and 6.9% (4/58) shallow-depth vaginoplasty. A total of 36.2% (21/58) patients reported cosmetic concerns, most frequently labial (20.7%), clitoral (12.1%), hypergranulation tissue (8.6%), mons pubis fullness (5.2%), and introital scarring (5.2%). Management included expectant care, in-office procedures (e.g., silver nitrate for hypergranulation), and surgical revision. Surgical revision was performed in 80.9% of patients, with all reporting post-operative cosmetic satisfaction. A guide to surgical revision is discussed for each cosmetic concern subgroup. A tiered approach involving expectant management, in-office interventions, and surgical revision can effectively address these issues and enhance patient satisfaction.