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Revision & Salvage GAS

Revision and salvage surgery in gender-affirming care is a critical and growing subspecialty, driven by the high baseline complication rates of primary procedures — particularly genital reconstruction — and the increasing volume of patients presenting with functional and aesthetic concerns requiring secondary intervention. This page is organized by primary procedure. For primary techniques, see Feminizing and Masculinizing procedures.

Revision After Vaginoplasty (Transfeminine)​

Up to one-third of patients require secondary surgical revision after penile inversion vaginoplasty (PIV), addressing both functional and aesthetic concerns.1 In a large institutional series of 240 PIVs, the overall reoperation / revision rate was 7.9%, with cosmesis (3.8%) and neovaginal stenosis (2.1%) being the most common indications.2

External genital (vulvar) revisions are the most frequently performed secondary procedures. In a series of 35 patients undergoing vulvar revision, the majority required concurrent corrections in multiple categories:3

  • Labial concerns (77.1%) — excess tissue, asymmetry, or insufficient labia minora / majora.
  • Clitoral concerns (57.1%) — buried clitoris, excess hooding, or inadequate sensation.
  • Urologic concerns (48.6%) — meatal stenosis, spraying urine stream, or urethral redundancy.
  • Introital concerns (34.3%) — posterior introital webbing limiting penetration, or canal stenosis.

Common revision techniques include posterior introital web release, revision labiaplasty, clitoral unhooding / repositioning, and meatoplasty.13 Patients who developed minor postoperative complications after primary PIV (granulation tissue, intravaginal scarring) were significantly more likely to require revision. After revision, 82.4% reported satisfaction and 76.5% reported resolution of genital dysphoria.4

Salvage for Neovaginal Stenosis​

Neovaginal stenosis — the most consequential long-term complication — occurs in up to 30% of vaginoplasty patients and is the primary consequence of inadequate dilation.5 Salvage options include:

  • Robotic peritoneal flap revision — in 24 patients with stenotic or absent canals after PIV, robotic peritoneal flap mobilization achieved a mean vaginal depth of 13.6 cm and width 3.6 cm at mean follow-up of 410 days, with no rectal injuries and minimal complications.6
  • Robot-assisted sigmoid vaginoplasty (RSV) — in 25 patients undergoing revision RSV for stenosis, preoperative vaginal depth improved from a mean of 3.4 cm to 17.6 cm. No fistulas developed, and most patients expressed satisfaction. Two patients developed sigmoid-skin anastomotic strictures requiring intervention.7
  • Laparoscopic intestinal vaginoplasty — in a comparison of 21 intestinal vs 32 full-thickness skin graft (FTSG) revision vaginoplasties, intestinal vaginoplasty achieved significantly greater depth (15.9 cm vs 12.5 cm, p < 0.001).8
  • Right colon vaginoplasty — in 22 patients (all revision cases), 100% reported satisfaction. Complications included neovaginal prolapse (5 patients) and introital stenosis (4 patients), all successfully managed.9

Rectoneovaginal Fistula​

Rectoneovaginal fistula is rare but serious, occurring in 0.8% of primary and 6.3% of revision vaginoplasties (OR 8.6 for revision cases).10 In a series of 1,082 patients, 25 (2.3%) developed neovaginal fistulas (13 rectoneovaginal, 11 urethroneovaginal). Management approaches include:101112

  • Intraoperative rectal injury (3–7% incidence) — immediate two- or three-layer primary repair; if repair is tenuous, a rectoprostatic-fascia reinforcement flap can be interposed, with 100% success and no recurrence at 1-year follow-up.1112
  • Delayed rectoneovaginal fistula — fecal diversion (temporary colostomy / ileostomy) followed by delayed fistulectomy and primary closure or local advancement flap. In most patients, surgical repair was successful without impairment of neovaginal function.10
  • Urethroneovaginal fistula — often arises secondary to meatal stenosis; managed with fistulectomy and temporary suprapubic cystostomy when needed.10

Revision After Phalloplasty (Transmasculine)​

Phalloplasty carries the highest revision burden of any gender-affirming procedure, with 73% of patients requiring revision surgery for urethral complications alone in one series.13 A multicenter patient-reported survey found 281 complications requiring 142 revisions among 129 patients.14

Urethral Complications — The Dominant Driver of Revision​

  • Urethrocutaneous fistula — reported in 27–54% of phalloplasty patients. Notably, 19–54% of fistulae resolve spontaneously without surgical intervention. For persistent fistulae, repair options include fistulectomy with primary closure, local flap coverage, or buccal mucosa graft urethroplasty.151617
  • Urethral stricture — reported in 25–63% of phalloplasty patients. Open surgical techniques demonstrate significantly better long-term outcomes than endoscopic management (dilation / DVIU): 82% recurrence-free at 3 years for open repair vs 43% for endoscopic approaches (p = 0.002). Specific open techniques include Heineke-Mikulicz procedure (78% success), excision and primary anastomosis (100%), and two-stage urethroplasty without graft (100%).51317
  • Colpectomy (vaginectomy) is a critical adjunct — primary colpectomy reduces fistula incidence from 48% to 21% (p < 0.05).1718
  • Persistent vaginal remnant — occurs in ~10% of metoidioplasty cases and can serve as a reservoir for infection and a source of recurrent fistulae; requires surgical excision.16

After treating urethral complications, 70–91.5% of patients ultimately achieve standing micturition from the tip of the phallus, with no clinically relevant differences in urological functioning compared with preoperative status.1314

Flap Failure and Redo Phalloplasty​

Flap failure represents the most challenging salvage scenario. In a Dutch series of 18 patients who underwent secondary reconstruction after primary flap failure:19

  • Reconstruction involved a new shaft flap (n = 7), new urethral flap (n = 4), or both (n = 7).
  • Zero redo flap failures occurred.
  • 81% achieved standing micturition after redo urethroplasty.
  • 72% were satisfied or very satisfied with penile appearance.
  • 100% would undergo the surgery again.

An algorithmic framework from two high-volume centers (Johns Hopkins / Harvard and GU Recon / Buncke Clinic) guides the critical decision between salvaging the existing neophallus vs complete redo phalloplasty:20

  • Preserve the original flap when feasible — partial tissue loss can often be addressed with local flaps or skin grafts.
  • Additional free flaps may be required for significant tissue deficiency.
  • Complete redo phalloplasty is reserved for severe cases (total flap loss, multiple concomitant complications).
  • Multidisciplinary collaboration (plastic surgery, urology, microsurgery) is essential.

Common non-urethral complications requiring revision include excess bulk / lymphedema, phalloplasty malposition, hypertrophic / keloidal scarring, and donor-site issues.2021

Penile Prosthesis Revision (Transmasculine)​

Penile prosthesis implantation after phalloplasty carries exceptionally high revision rates compared with cisgender populations, reflecting the unique challenges of implanting into a denervated, insensate flap without native corporal tissue.

  • In the largest Dutch cohort (50 patients, 85 implantation procedures including 35 secondary implantations), the 3-year explantation-free survival was only 39% for hydraulic and 31% for malleable prostheses.22
  • Secondary (redo) implantations carry 3.5× higher complication risk than primary procedures (OR 3.5, p = 0.03), and urethral lengthening increases late complication risk (HR 2.6, p = 0.01).22
  • In a single-surgeon series using the infrapubic approach, 40% required surgical revision at mean follow-up of 35 months. The most common complications were device detachment (7/30), malposition (3/30), and infection (1/30). No neophallus erosions or flap losses occurred.23
  • Of all implanted prostheses (including revisions) in one series, 44% were ultimately replaced or removed.24
  • A 2026 Delphi consensus protocol from 21 international experts now provides standardized recommendations for pre-, peri-, and postoperative care of penile prosthesis implantation after phalloplasty, aiming to reduce complication rates through consistent practice.25
  • Surgical experience significantly reduces complications — infection probability decreased with increasing case number at experienced centers.23

Revision After Chest Surgery​

Masculinizing Top Surgery​

The lowest revision burden among GAS procedures:

  • Revision rates range from 5.4–25.6% across series, with the periareolar technique having higher revision rates than double incision with free nipple grafting.262728
  • Most common indications — residual breast tissue, nipple-areola complex malposition, contour irregularity, and dog-ear deformity.2729
  • Concomitant liposuction at primary surgery significantly reduces revision rates (p = 0.026).26
  • In a 560-patient series, touch-up procedures were performed in 9% of patients.29
  • Hematoma is the most common complication (10.8–14%), with testosterone use as a positive risk factor.2829

Transfeminine Breast Augmentation Revision​

  • Reoperation rate due to complications is approximately 5%, with capsular contracture being the most common indication.30
  • In a 30-year Amsterdam cohort of 527 patients (median follow-up 11.2 years), long-term reoperations included implant rupture (5.7%), capsular contracture (4.9%), and aesthetic concerns (3.8%).31
  • Capsular contracture (Baker III–IV) occurs in 3–5.6% of transfeminine patients, comparable to cisgender women.3132
  • Management follows standard principles — capsulectomy, implant exchange, and / or plane change. Acellular dermal matrix may reduce recurrence, though long-term data are limited.33
  • Transfeminine patients have higher rates of implant malposition (3.89%) and hematoma / seroma (0.63%) compared with cisgender women, likely related to wider chest dimensions and larger implant sizes.3234

Revision Facial Feminization Surgery​

Secondary FFS is increasingly common as primary FFS volume grows. In a series of 161 FFS patients, 25.5% underwent secondary surgery, consisting of additional procedures on previously unoperated areas (n = 32) and / or revision of previously operated areas (n = 30).35

  • Most commonly revised areas — nose (36.6%), forehead / brow (26.8%), cheeks (17.1%), chin (17.1%), lips (12.5%).35
  • Dominant indication — undercorrection to feminine ideals across all facial units.3536
  • Feminizing rhinoplasty revision rate — 16.7% in a 102-patient series, most commonly for persistent dorsal hump (36.4%) and tip concerns (36.4%). No patient characteristics were significantly associated with revision need.37
  • Revision rates for gender-affirming rhinoplasty are comparable to those reported for cosmetic rhinoplasty in the general population.38
  • Causes of poor outcomes after FFS include inadequate bone reduction, asymmetric contouring, visible hardware, and soft-tissue complications (alopecia at coronal incision, temporal hollowing).36

Overarching Principles for Revision & Salvage GAS​

Several cross-cutting themes emerge:

  1. Multidisciplinary teams are essential — revision cases often involve concurrent urologic, plastic surgical, and colorectal issues that require coordinated planning.1620
  2. High-volume centers achieve better outcomes — surgical experience is a significant predictor of reduced complications, particularly for penile prosthesis implantation and urethral reconstruction.1923
  3. Patient counseling is paramount — patients should be informed preoperatively that revision is common (not a failure) and that satisfaction remains high even after multiple procedures. Across all studies, the vast majority of patients report they would undergo surgery again despite complications.419
  4. Pelvic floor dysfunction affects up to 94.1% of transgender men after genital surgery and significantly impacts urinary and sexual function. Pelvic floor physical therapy before and after surgery can substantially reduce dysfunction rates.5
  5. Standardized outcome reporting remains a major gap — inconsistent complication definitions and lack of transgender-specific patient-reported outcome measures (PROMs) hinder comparison across centers and techniques.525

Footnotes​

  1. Morris MP, Wang CW, Lane M, Morrison SD, Kuzon WM. "Common Revisions After Penile Inversion Vaginoplasty: Techniques and Clinical Outcomes." Plast Reconstr Surg. 2022;149(6):1198e–1201e. doi:10.1097/PRS.0000000000009159 ↩ ↩2

  2. Levy JA, Edwards DC, Cutruzzula-Dreher P, et al. "Male-to-Female Gender Reassignment Surgery: An Institutional Analysis of Outcomes, Short-Term Complications, and Risk Factors for 240 Patients Undergoing Penile-Inversion Vaginoplasty." Urology. 2019;131:228–233. doi:10.1016/j.urology.2019.03.043 ↩

  3. Dy GW, Salibian AA, Blasdel G, Zhao LC, Bluebond-Langner R. "External Genital Revisions After Gender-Affirming Penile Inversion Vaginoplasty: Surgical Assessment, Techniques, and Outcomes." Plast Reconstr Surg. 2022;149(6):1429–1438. doi:10.1097/PRS.0000000000009165 ↩ ↩2

  4. Boas SR, Ascha M, Morrison SD, et al. "Outcomes and Predictors of Revision Labiaplasty and Clitoroplasty After Gender-Affirming Genital Surgery." Plast Reconstr Surg. 2019;144(6):1451–1461. doi:10.1097/PRS.0000000000006282 ↩ ↩2

  5. Motiwala ZY, Misra S, Desai A, et al. "Postoperative Urogynecologic Complications After Gender-Affirming Surgery: A Narrative Review." Int Urogynecol J. 2026;37(4):805–822. doi:10.1007/s00192-025-06405-6 ↩ ↩2 ↩3 ↩4

  6. Dy GW, Blasdel G, Shakir NA, Bluebond-Langner R, Zhao LC. "Robotic Peritoneal Flap Revision of Gender Affirming Vaginoplasty: A Novel Technique for Treating Neovaginal Stenosis." Urology. 2021;154:308–314. doi:10.1016/j.urology.2021.03.024 ↩

  7. Sljivich M, Torres C, Chen D, et al. "Feasibility and Outcomes After Robot-Assisted Sigmoid Vaginoplasty for Gender Dysphoria." Urology. 2025. doi:10.1016/j.urology.2025.06.003 ↩

  8. Van der Sluis WB, Bouman MB, Buncamper ME, Mullender MG, Meijerink WJ. "Revision Vaginoplasty: A Comparison of Surgical Outcomes of Laparoscopic Intestinal Versus Perineal Full-Thickness Skin Graft Vaginoplasty." Plast Reconstr Surg. 2016;138(4):793–800. doi:10.1097/PRS.0000000000002598 ↩

  9. Garcia MM, Shen W, Zhu R, et al. "Use of Right Colon Vaginoplasty in Gender Affirming Surgery: Proposed Advantages, Review of Technique, and Outcomes." Surg Endosc. 2021;35(10):5643–5654. doi:10.1007/s00464-020-08078-2 ↩

  10. van der Sluis WB, Bouman MB, Buncamper ME, et al. "Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women." Obstet Gynecol. 2016;127(6):1118–1126. doi:10.1097/AOG.0000000000001421 ↩ ↩2 ↩3 ↩4

  11. Pansritum K, Thomrongdullaphak S, Suwajo P. "A Rectoprostatic Fascia Reinforcement Flap for Rectal Injury and Rectoneovaginal Fistula in Gender-Affirmation Surgery." Plast Reconstr Surg. 2022;150(4):909–913. doi:10.1097/PRS.0000000000009575 ↩ ↩2

  12. Morris MP, Wang CW, Holan C, et al. "Rectal Injury During Penile Inversion Vaginoplasty: An Algorithmic Approach to Prevention and Management." Plast Reconstr Surg. 2023;152(2):326e–337e. doi:10.1097/PRS.0000000000010246 ↩ ↩2

  13. Veerman H, de Rooij FPW, Al-Tamimi M, et al. "Functional Outcomes and Urological Complications After Genital Gender Affirming Surgery With Urethral Lengthening in Transgender Men." J Urol. 2020;204(1):104–109. doi:10.1097/JU.0000000000000795 ↩ ↩2 ↩3

  14. Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. "Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients." J Sex Med. 2021;18(4):800–811. doi:10.1016/j.jsxm.2021.01.183 ↩ ↩2

  15. Nassiri N, Maas M, Basin M, Cacciamani GE, Doumanian LR. "Urethral Complications After Gender Reassignment Surgery: A Systematic Review." Int J Impot Res. 2020;33(8):793–800. doi:10.1038/s41443-020-0304-y ↩

  16. Elyaguov J, Isakov R, Nikolavsky D. "Evaluation and Management of Urologic Complications Following Transmasculine Genital Reconstructive Surgery." Neurourol Urodyn. 2023;42(5):979–989. doi:10.1002/nau.25100 ↩ ↩2 ↩3

  17. de Rooij FPW, Falcone M, Waterschoot M, et al. "Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men." J Sex Med. 2022;19(2):377–384. doi:10.1016/j.jsxm.2021.12.006 ↩ ↩2 ↩3

  18. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. "Colpectomy Significantly Reduces the Risk of Urethral Fistula Formation After Urethral Lengthening in Transgender Men Undergoing Genital Gender Affirming Surgery." J Urol. 2018;200(6):1315–1322. doi:10.1016/j.juro.2018.07.037 ↩

  19. van der Sluis WB, Al-Tamimi M, Pigot GLS, et al. "Redo Phalloplasty and / or Urethraplasty After Previous Flap Failure in Phalloplasty in Transgender Men: Surgical Considerations and Outcomes." J Sex Med. 2024;21(11):1085–1093. doi:10.1093/jsxmed/qdae119 ↩ ↩2 ↩3

  20. Keller PR, Chen ML, Ovadia SA, et al. "Revision Phalloplasty: Evaluation, Algorithms, and Techniques for Salvage After Major Complications." Plast Reconstr Surg. 2024;154(2):362e–373e. doi:10.1097/PRS.0000000000010960 ↩ ↩2 ↩3

  21. Loughran A, Coon D. "Advanced Phalloplasty: Management of Complications and Techniques for Revision." Clin Plast Surg. 2025;52(4):507–514. doi:10.1016/j.cps.2025.06.007 ↩

  22. Levy M, van der Sluis WB, van Abbema EL, et al. "Hydraulic and Malleable Female-to-Male Penile Implants After Phalloplasty in Transgender Individuals: A Retrospective Cohort Analysis." BJU Int. 2025. doi:10.1111/bju.16911 ↩ ↩2

  23. Sun HH, Isali I, Mishra K, et al. "Surgical Outcomes at a Single Institution of Infrapubic Insertion of Malleable Penile Prosthesis in Transmen." Urology. 2023;173:209–214. doi:10.1016/j.urology.2023.01.001 ↩ ↩2 ↩3

  24. van der Sluis WB, Pigot GLS, Al-Tamimi M, et al. "A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty." Urology. 2019;132:195–201. doi:10.1016/j.urology.2019.06.010 ↩

  25. Levy M, Falcone M, Bohr J, et al. "Penile Implants After Phalloplasty in Transgender Individuals: A Consensus-Based Surgical Clinical Protocol Concerning Pre-, Peri-, and Postoperative Care." J Sex Med. 2026;23(2):qdaf365. doi:10.1093/jsxmed/qdaf365 ↩ ↩2

  26. Kuruoglu D, Alsayed AS, Melson VA, et al. "Masculinizing Chest Wall Gender-Affirming Surgery: Clinical Outcomes of 73 Subcutaneous Mastectomies Using the Double-Incision and Semicircular Incision Techniques." J Plast Reconstr Aesthet Surg. 2023;85:515–522. doi:10.1016/j.bjps.2023.02.020 ↩ ↩2

  27. Donato DP, Walzer NK, Rivera A, Wright L, Agarwal CA. "Female-to-Male Chest Reconstruction: A Review of Technique and Outcomes." Ann Plast Surg. 2017;79(3):259–263. doi:10.1097/SAP.0000000000001099 ↩ ↩2

  28. Huber PD, Bittencourt RC, Jeziorowski A. "Masculinizing Mammoplasty for Female-to-Male Transgenders: 10 Years' Experience." Aesthetic Plast Surg. 2024;48(19):3825–3835. doi:10.1007/s00266-024-03931-4 ↩ ↩2

  29. Lo Russo G, Scortecci L, Ruccia F, Khajuria A, Gada L. "A New Algorithm for Masculine Chest-Wall Contouring in 560 Trans-Afab Patients: Clinical Outcomes and Patient-Reported Satisfaction Using the TRANS-Q Questionnaire." Aesthetic Plast Surg. 2025. doi:10.1007/s00266-025-04942-5 ↩ ↩2 ↩3

  30. Schoffer AK, Bittner AK, Hess J, Kimmig R, Hoffmann O. "Complications and Satisfaction in Transwomen Receiving Breast Augmentation: Short- and Long-Term Outcomes." Arch Gynecol Obstet. 2022;305(6):1517–1524. doi:10.1007/s00404-022-06603-3 ↩

  31. Sijben I, Timmermans FW, Lapid O, Bouman MB, van der Sluis WB. "Long-Term Follow-Up and Trends in Breast Augmentation in 527 Transgender Women and Nonbinary Individuals: A 30-Year Experience in Amsterdam." J Plast Reconstr Aesthet Surg. 2021;74(11):3158–3167. doi:10.1016/j.bjps.2021.03.107 ↩ ↩2

  32. Liu C, Shahid M, Yu Q, et al. "Complications Following Breast Augmentation in Transfeminine Individuals: A Systematic Review and Meta-Analysis." Plast Reconstr Surg. 2024;153(6):1240–1251. doi:10.1097/PRS.0000000000010691 ↩ ↩2

  33. Boyd CJ, Chiodo MV, Lisiecki JL, Wagner RD, Rohrich RJ. "Systematic Review of Capsular Contracture Management Following Breast Augmentation: An Update." Plast Reconstr Surg. 2024;153(2):303e–321e. doi:10.1097/PRS.0000000000010358 ↩

  34. Torres Perez-Iglesias CA, Heyman A, Koh DJ, et al. "Technical and Clinical Differences Between Transgender and Cisgender Females Undergoing Breast Augmentation." Ann Plast Surg. 2023;91(5):534–539. doi:10.1097/SAP.0000000000003706 ↩

  35. Rochlin DH, Chaya BF, Rodriguez Colon R, et al. "Secondary Surgery in Facial Feminization: Reasons and Recommendations." Ann Plast Surg. 2022;89(6):652–655. doi:10.1097/SAP.0000000000003308 ↩ ↩2 ↩3

  36. Simon D, Capitán L, Coon D, et al. "Secondary Facial Gender Surgery: Causes of Poor Outcomes and Strategies for Avoidance and Correction." Plast Reconstr Surg. 2023;152(2):347e–357e. doi:10.1097/PRS.0000000000010324 ↩ ↩2

  37. Rothberg SE, Bao E, Bastidas N. "Feminizing Rhinoplasty in Transfeminine Patients: Complications and Outcomes in 102 Patients." J Craniofac Surg. 2025. doi:10.1097/SCS.0000000000011515 ↩

  38. Lehmann RJ, Kruglik CP, Nuara MJ, Cole AM. "Gender-Affirming Rhinoplasty: A Scoping Review." Laryngoscope. 2025. doi:10.1002/lary.32339 ↩