In brief
After a gender-affirming vaginoplasty or phalloplasty, a surgical revision is common and is not a failure. After vaginoplasty I correct the labia, clitoris, stenosis of the introitus and urinary spraying. After phalloplasty I deal with aesthetic revisions, while urethral complications I manage together with a urologist. I usually operate under general anaesthesia.
Why talk about it openly
Gender-affirming genital surgery, that is vaginoplasty in the transition from male to female (trans women) and phalloplasty or metoidioplasty in the transition from female to male (trans men), is among the most complex reconstructive surgeries. Studies show that a second procedure is common even when the first was performed correctly: tissues heal differently from person to person, scars retract, volumes change.
For many people asking for a revision is difficult: there is the weariness of a long journey, and sometimes the fear of seeming ungrateful towards those who operated. I see it differently: a revision is a stage of the journey, and anyone who asks for one deserves the same listening and the same care received the first time. I worked for 12 years alongside Prof. Renato Marten Perolino in male-to-female gender-affirming surgery, and this taught me how much the details matter (about us).
Revision after vaginoplasty (male-to-female transition, trans women)
What can be corrected
| Problem | What is done |
|---|---|
| Flat, empty or asymmetrical labia majora | Reshaping and fat grafting (lipofilling), that is transferring your own fat to restore volume |
| Absent or poorly defined labia minora | Revision labiaplasty, to recreate a natural vulvar profile |
| Clitoris too exposed, with hypersensitivity | Repositioning of the clitoris and reconstruction of the hood that covers it |
| Stenosis of the introitus or of the vaginal canal | Release of scars and local plasties, followed by resumption of dilations |
| Spraying: the urinary stream scatters or deviates | Correction and repositioning of the urethral meatus (distal urethroplasty) |
Often several corrections can be made in the same session. A recent series of 58 women with aesthetic requests after vaginoplasty found mainly problems with the labia and clitoris, and 81% underwent reoperation with good satisfaction.
Revision after phalloplasty or metoidioplasty (female-to-male transition, trans men)
In masculinising surgery most complications concern the urethra, which is lengthened to allow urinating while standing. The most frequent are fistulas (urine leaves from a point other than the meatus) and strictures (narrowings that make urinating difficult). A systematic review reports rates of roughly 20 to 36%, with large differences between techniques and centres.
How I work
- Aesthetic revisions: scrotum, insertion or repositioning of testicular implants, shape of the glans and of the neophallus. I perform these myself.
- Urethral complications (fistulas, strictures, difficulty urinating): I assess and treat them together with a urologist. I believe this is the most appropriate approach, because urethral reconstruction requires specific urological expertise.
How the procedure is carried out
The consultation
Everything starts with an unhurried specialist consultation: I listen to what you are not satisfied with, examine the tissues and, if possible, read the documentation of previous procedures. Then I explain what is realistic to achieve and what is not. My principle is prima comprendere ("understand first"): no decision should be taken in a hurry.
Timing and anaesthesia
I usually operate under general anaesthesia: these are uncomfortable procedures, often on areas that have already been operated on and are very sensitive, and general anaesthesia lets the person stay at ease and me work with precision. Before a revision I generally wait for the tissues to stabilise, usually several months after the first procedure, except for complications that need treating straight away.
Recovery
Recovery times vary a great deal depending on what is corrected: fat grafting (lipofilling) of the labia majora is not comparable to the treatment of a stenosis, which requires you to resume dilations consistently. For this reason we define the timings for work, sport and intercourse together, case by case, before the procedure.
Choices to know about before the first procedure
Those who have not yet had primary surgery can consider options that reduce some risks:
- Reduced-depth (zero-depth) vaginoplasty: the vulva is reconstructed without creating the vaginal canal. It is designed for those who do not want penetrative intercourse: it avoids the complications linked to the canal and the dilations, but it is a choice that is hard to change later.
- Phalloplasty without urethral lengthening: it greatly reduces the risk of fistulas and strictures, because the urethra is not extended, but it does not allow urinating while standing.
Frequently asked questions
Why might a revision be needed after vaginoplasty?
For aesthetic reasons (flat or asymmetrical labia majora, poorly defined labia minora, clitoris too exposed) or functional reasons (narrowing of the introitus or canal, scattering urinary stream). It does not mean the first procedure was wrong: it often depends on how the tissues heal.
Which revisions does Dr Maggi perform after a vaginoplasty?
All those described on this page: reshaping and fat grafting (lipofilling) of the labia majora, correction of the labia minora, covering or repositioning of the clitoris, treatment of stenosis of the introitus or canal and repositioning of the urethral meatus in case of spraying.
And after phalloplasty or metoidioplasty?
I deal with aesthetic revisions, such as the scrotum, testicular implants and the shape of the glans. Urethral complications, that is fistulas and strictures, I assess and treat together with a urologist, because I believe this is the most appropriate approach.
What anaesthesia is used?
Usually general anaesthesia: these are uncomfortable procedures, often on tissue that has already been operated on, and under general anaesthesia the patient is more at ease and I can work with precision.
Are revisions common?
Yes. After gender-affirming genital surgery a significant share of people ask for at least one correction: in a recent series, of 58 women with aesthetic requests after vaginoplasty, 81% underwent reoperation. After phalloplasty, urethral fistulas and strictures occur in 20–36% of cases.
How long should I wait after the first procedure?
Generally several months, until swelling and scars have stabilised. Operating too early on tissue that is still changing risks worsening the result. The exception is complications that need to be treated straight away.
Can a vaginoplasty be done without a vaginal canal?
Yes, reduced-depth (zero-depth) vaginoplasty exists, for those who do not want penetrative intercourse. It is a choice to be made before the first procedure: it involves fewer complications linked to the canal and does not require dilations, but it cannot easily be reversed.
Is the consultation confidential?
Yes. We talk calmly, with the utmost confidentiality and without judgement. You can bring the documentation of previous procedures with you: it helps me a great deal to understand what has been done.
Scientific bibliography
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Smith JB, Hefnawy A, Chen G, Kocjancic E, Acar O – Management of cosmetic concerns after gender-affirming vaginoplasty: a retrospective case series and guide to revisions
Source: International Journal of Impotence Research, 2025 – doi.org/10.1038/s41443-025-01039-0
What it covers: Analyses 58 trans women with aesthetic requests after vaginoplasty: labia, clitoris, granulation tissue, mons pubis, introital scars. 81% underwent a surgical revision.
Why it matters: Proposes a stepwise approach (waiting, small outpatient treatments, surgical revision) and shows that aesthetic revisions are common and well tolerated.
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Buncamper ME et al. – Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women
Source: Plastic and Reconstructive Surgery, 2016;138(5):999-1007 – PubMed
What it covers: Reviews the results of 475 vaginoplasties using the penile inversion technique performed in Amsterdam, with complications and reoperations.
Why it matters: It is one of the largest series: it documents, among other things, the frequency of introital stenosis and of reoperations, both aesthetic and functional.
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Millman A, Morgantini L, Acar O, Kocjancic E – Revision clitorolabiaplasty and urethroplasty after gender-affirming vaginoplasty
Source: The Journal of Sexual Medicine, 2022;19(4 Suppl 1):S118 (conference abstract) – doi.org/10.1016/j.jsxm.2022.01.250
What it covers: Describes a case of flat labia, a clitoris that was too exposed and urinary spraying, corrected in a single procedure: repositioning of the meatus, repositioning of the clitoris and labiaplasty.
Why it matters: It is a single case, hence weak evidence, but it illustrates well how several corrections can be combined in the same session.
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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
Source: The Journal of Urology, 2020 – doi.org/10.1097/JU.0000000000000795
What it covers: Studies the functional results and urological complications after phalloplasty and metoidioplasty with urethral lengthening.
Why it matters: Confirms that urethral fistulas and strictures are the main complications of this surgery and that they often require more than one procedure.
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Ortengren CD, Blasdel G, Damiano EA et al. – Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review
Source: Translational Andrology and Urology, 2022;11(12):1762-1770 – Transl Androl Urol
What it covers: Systematic review of studies on urethral complications after metoidioplasty and phalloplasty.
Why it matters: Reports strictures and fistulas in about 20–36% of cases, with wide variation between techniques and centres: figures to know before choosing.
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Chen ML, Reyblat P, Poh MM, Chi AC – Overview of surgical techniques in gender-affirming genital surgery
Source: Translational Andrology and Urology, 2019;8(3):228-238 – Transl Androl Urol
What it covers: Overview of gender-affirming genital surgery techniques, feminising and masculinising, including the options without a vaginal canal or without urethral lengthening.
Why it matters: Useful for understanding the choices possible already at the first procedure and their consequences for revisions.
For a broader overview of intimate and genital surgery:
Medically reviewed by Dr Giulio Maria Maggi, Plastic Surgeon — last review:
Article written by
Dr Giulio Maria Maggi
Aesthetic Plastic Surgeon — Turin, Asti and Alessandria
Medical Director — Aesthetic Clinic (Turin)
Registered with the Turin Medical Council (Ordine dei Medici di Torino) no. 20595
Full Member of AICPE — Italian Association of Aesthetic Plastic Surgery (verify)
Expertise and areas of interest
Dr Maggi trained specifically in intimate medicine and surgery by working for 12 years alongside Prof. Renato Marten Perolino, urologist and plastic surgeon, at Villa Maria Pia Hospital and, privately, at Clinica Fornaca and Clinica Cellini in Turin. From him he learned male-to-female gender-affirming surgery, and he was first operator in breast augmentation procedures on Prof. Perolino's patients in gender transition. He also trained internationally with Prof. José Guerrero Santos in Guadalajara and with Prof. Andrew A. Jacono in New York, for the Deep Plane facelift technique.
He focuses in particular on:
- Functional and aesthetic intimate surgery, male and female
- Deep Plane facelift
- Blepharoplasty
- Liposculpture and fat grafting (lipofilling)
- Breast surgery
- Body contouring
Clinical approach: «Prima comprendere» ("Understand first"). No promises of results: indications, risks and limits explained frankly, so that every patient can make a truly informed choice.
