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Feminizing Procedures

Feminizing gender-affirming procedures span the breast / chest, genitalia, face, neck, and voice, each with distinct techniques, outcomes, and considerations. For overview principles, see GAS Overview; for revisions, see Revision & Salvage GAS.

Breast Augmentation​

Breast augmentation is a commonly sought feminizing GAS procedure; in the 2022 U.S. Transgender Survey, 10% of 23,776 trans women respondents reported receiving it and 39% wanted it in the future.1 Timing should account for the patient's hormone goals, breast development, anatomy, and preferences; several years of hormonal development may change implant planning. See the adult eligibility framework below rather than treating one duration as mandatory for every patient.23

Technical and outcome considerations:

  • Implant placement. Subglandular or subpectoral, depending on body habitus and patient preference. In a retrospective comparison of 153 transfeminine and 250 cisgender patients, transfeminine patients had wider breast base widths, longer sternal-notch-to-nipple distances, and larger median implants (500 mL versus 350 mL).4 A separate 36-patient operative series described routine inframammary-fold lowering as part of its planning algorithm.2
  • Complications. A meta-analysis of 1,864 transfeminine patients found pooled rates of capsular contracture 3.6%, hematoma / seroma 0.6%, and implant asymmetry / malposition 3.9%. Comparisons with historical cisgender cohorts found higher hematoma / seroma and malposition rates; this was not a randomized comparison.5
  • Satisfaction. High satisfaction was reported in a 36-patient operative series. In the Dutch survey, 773 of 3,073 invitees responded; 80% of respondents with augmentation were satisfied, while approximately one-third reported health complaints attributed to implants.6
  • Reoperation. Among the 99 of 159 patients who completed follow-up questionnaires a median four years after surgery, 14% underwent reoperation overall, including 5% for surgical complications; most other reoperations replaced PIP/Rofil implants.7

Vaginoplasty​

Vaginoplasty is the most frequently sought feminizing genital surgery; in the 2022 U.S. Transgender Survey, 11% of 23,767 trans women reported receiving surgery in the vaginoplasty/labiaplasty/SRS/GRS category and 48% wanted it in the future.1 The goal is to create an aesthetic and functional vulva and vaginal canal enabling receptive intercourse, erogenous clitoral sensation, and a downward-directed urine stream.8

Surgical Techniques​

  • Penile inversion vaginoplasty (PIV). This is the most widely performed technique.9103 A vaginal canal is dissected between the urethra and rectum and lined with inverted penile skin; a full-thickness scrotal graft can extend the lining when needed.1112 Scrotal skin forms the labia majora, and dorsal glans tissue on its neurovascular pedicle forms the sensate clitoris.1112 The shortened, ventrally splayed urethra forms the meatus and inner labial tissue.11 Plan permanent hair removal with the surgeon for skin that will line the canal or contact urine; the required area depends on the technique.9103
  • Peritoneal pull-through vaginoplasty. Increasingly used when penile skin is insufficient (e.g., prior circumcision, puberty blocker use). Laparoscopically harvested peritoneal flaps are combined with inverted penile skin. In a 52-patient series, mean depth at six months was 14.7 cm, about 96% reported satisfaction, and seven had complications.13
  • Intestinal (sigmoid) vaginoplasty. Intestinal vaginoplasty has been described when penoscrotal skin is insufficient or primary reconstruction has failed.14 The bowel lining produces mucus.12 A systematic review of gender-affirming intestinal vaginoplasties reported 215 complications among 654 patients and return to the operating room in 108 of 608 patients in studies reporting that outcome (18%); reported complications included stenosis, mucorrhea, prolapse, conduit vascular compromise, and late intra-abdominal events.15
  • Minimal-depth (vulvoplasty). For patients who do not desire vaginal penetration; creates external female genitalia without a vaginal canal. Detailed in Non-Binary & Nullification.8

Complications​

Complication rates have been documented as high as 70%, though most are minor and do not alter long-term outcomes.8 In a 2018 single-surgeon cohort of 117 patients, the most common complications were granulation tissue (26%), intravaginal scarring (20%), and prolonged pain (20%).11 Major complications include rectovaginal fistula, rectal injury, and urethral or introital stenosis.8 A meta-analysis of 27 PIV studies (3,388 patients in total) estimated poor or splayed stream at 11.7%, meatal stenosis at 6.9%, retention requiring catheterization at 5.1%, and incontinence at 8.7%.16 In a systematic review of 59 primary-vaginoplasty studies (7,338 patients), vaginal canal stenosis was reported in 5.83%, and a combined endpoint of canal or introital stenosis and contracture in 9.68%.17 Difficulty maintaining dilation can contribute, but scarring, pain, pelvic-floor dysfunction, and operative or wound problems also require assessment.1819

Outcomes and Satisfaction​

Despite moderate complication risk, among 66 survey respondents (56% of the 117 patients), 94% reported feeling positively about their genitals, 94% would undergo the operation again, and 71% reported resolution of gender dysphoria.11 A 2025 prospective study, with 48 complete respondents and a 55% response rate, reported postoperative improvement in depression (PHQ-9), anxiety (GAD-7), gender congruence, body image, and sexual function scores, with pain returning to baseline by 12 months.20

Registries, outcome datasets and the limits of current vaginoplasty outcome data are summarized in Outcome Data Sources and Registries.

Robotic peritoneal-flap outcomes​

A 500-case retrospective series (published online in 2025; print 2026) provides larger follow-up data: 425/500 patients had at least one year of follow-up; across all 500, 20 (4%) had a complication requiring procedural intervention and 61 (12%) underwent elective revision.21 Median self-reported vaginal depth at one year was 14.5 cm.21 In a single-center, two-surgeon retrospective comparison of 40 peritoneal-flap and 40 penile-inversion primary cases, median vaginal depth at six months was 18 versus 15 cm; rectal injury occurred in none versus three patients, while stenosis and granulation rates were similar.22

Postoperative Care​

  • Dilation. Follow the operating team's long-term schedule. New pain, resistance, bleeding, or loss of depth warrants assessment; avoid forcing a dilator through resistance. Difficulty dilating should prompt support and investigation rather than assuming non-adherence.81923
  • Hygiene and discharge. Care depends on whether the canal is skin-, peritoneum-, or bowel-lined. Persistent odor or discharge warrants examination for retained debris, granulation, infection, or fistula. Antiseptic douches and empiric antimicrobials are not a universal routine; follow the surgical team's tissue-specific regimen.812
  • Retained prostate. Prostate cancer assessment remains relevant. When an examination is indicated, an endovaginal approach may improve access because the neovagina can separate the prostate from the rectum; examination route is not itself a screening program.2312
  • Visual surveillance. Annual visual examination of the neovagina has been described to assess epithelialization, loss of caliber or length, and new lesions such as persistent hair, abnormal discharge, or genital skin conditions including lichen sclerosus or squamous cell cancer; biopsy or excision confirms the diagnosis when a finding requires it. Pap smears are not currently recommended for the neovagina. This interval is the cited authors' practice recommendation rather than a validated screening schedule.24
  • STI risk. Evaluate the actual exposed sites and reconstructed tissue, using current infection guidance and an anatomy-specific examination.23

Facial Feminization Surgery (FFS)​

FFS is a group of craniomaxillofacial procedures that modify masculine facial features toward feminine proportions. It is often prioritized by patients because the face is the most publicly visible feature and directly affects social perception and safety.10 In a needs assessment, 65% of transfeminine respondents desired at least one FFS procedure.25

Common Procedures by Facial Third262728​

  • Upper third (49% of all FFS procedures). Forehead recontouring / frontal bone reduction (most common single procedure at 34.6%), brow lift, hairline advancement.
  • Middle third. Rhinoplasty (12.8%), cheek augmentation, blepharoplasty.
  • Lower third. Chin remodeling / genioplasty (12.2%), mandible / jaw reduction, lip lift, vermilion reconstruction.

Patients self-identify their brows (54.5%), jaws (33.3%), and chins (30.3%) as the most masculine aspects of their faces.29

Outcomes​

Systematic reviews of facial feminization surgery report high patient satisfaction.2630 In a prospective multicenter cohort of 66 adults, median Facial Feminization Outcome Score increased from 47.2 before surgery to 80.6 at six months or later (p < 0.0001).29 In a separate prospective FACE-Q cohort, 65 of 154 enrollees completed baseline and at least one postoperative survey; mean facial-appearance satisfaction increased from 34.3 before surgery (n = 65) to 92.2 at 12 months (n = 19), with higher social and psychological function scores after surgery.31

Chondrolaryngoplasty (Tracheal Shave)​

This procedure reduces the anterior projection of the thyroid cartilage ("Adam's apple") and is frequently combined with other FFS procedures.3233 Desired by 45% of transfeminine individuals in one survey.25

  • Techniques. Transcervical, transoral, and endoscopic-assisted approaches have been described; laryngoscopic assistance allows vocal-fold visualization.32 In transcervical reduction, laryngoscopic needle localization of the anterior commissure can guide the lower cartilage-resection limit, and a 2026 systematic review of heterogeneous series reported postoperative voice changes in 5/177 cases with vocal-fold localization and 24/81 without it.34
  • Complications. In one 32-patient endoscopic-assisted series, one patient had transient hoarseness resolving within six weeks.32 Injury near the anterior commissure can cause persistent voice change, so vocal-fold visualization and protection are operative safety priorities; patients with chronic voice complaints after outside procedures have required laryngologic assessment.35 Scarring, dissatisfaction with cartilage reduction, hematoma and laryngospasm also warrant discussion.33

Voice Feminization​

Across all 234 transgender and nonbinary participants in one online needs assessment, voice had the highest median dysphoria score among surveyed body regions (7/10); among 122 transfeminine participants, the voice median was 8/10.25 Options include voice therapy, surgery, or a combined approach.

  • Voice therapy (VT). A nonoperative option associated with higher speaking fundamental frequency (SF0; pooled g = 0.86) and improved quality of life in a systematic review.36
  • Wendler glottoplasty. A recent review describes it as the preferred surgical intervention. It creates an anterior glottic web to shorten the vibrating length of the vocal folds. Effect size for SF0 improvement g = 1.21.3637
  • Feminization laryngoplasty. Thomas describes reducing laryngeal and pharyngeal structures with the aim of raising vocal pitch and resonance.38 In a 2025 meta-analysis, two feminization-laryngoplasty studies (n = 189) yielded a pooled speaking-fundamental-frequency effect size of g = 3.05; heterogeneity across techniques prevents ranking them by effect size.36
  • Combined approach. A 2024 review reports greater fundamental-frequency gain with voice therapy plus surgery than with voice therapy alone.37

For glottoplasty, a 2026 Brazilian laryngology expert consensus (grade D) advises preoperative videolaryngoscopy and acoustic voice assessment and treats professional voice use as a relative contraindication because vocal range, phonation time, and loudness may decrease.39 Counsel about reduced projection and persistent dysphonia; postsurgical voice rehabilitation may improve outcomes.37

Perioperative Hormone Management​

A clinical question is whether to continue or discontinue estrogen perioperatively due to VTE concerns. See also the Gender-Affirming Hormone Therapy hub.

  • Observational evidence. Among 407 primary vaginoplasty cases, the comparison included 212 continuing estrogen and 190 holding it; there were no VTE events in the continuing group and one in the holding group.40 In a separate 183-patient cohort, VTE occurred in 1/138 patients continuing estradiol (0.7%) and 0/45 temporarily holding it under a risk-based algorithm.41 In a retrospective FFS cohort of 953 patients, one postoperative DVT occurred among 714 who continued full-dose hormones; no VTE occurred among patients with reduced or absent hormone exposure.42
  • WPATH SOC8 recommends collaboration between hormone prescribers and surgeons. Assess formulation, personal VTE risk, procedure, prophylaxis, and the effects of hormone withdrawal; SOC8 does not mandate cessation or unconditional continuation for every operation.3
  • Practice variation persists. 51 of 150 invited surgeons responded to a survey; 43% reported stopping hormones for feminizing genital surgery. The survey reports practice variation but cannot identify the best protocol.43
  • Transdermal estradiol may be preferred when VTE risk is elevated; much of the route-specific evidence is extrapolated from menopausal populations.44
  • VTE prophylaxis. In a 1,588-patient claims cohort after vaginoplasty, 1.1% had a coded VTE within 90 days; prior VTE, older age and greater comorbidity were associated with events.45 The study did not compare estrogen strategies.45 Tailor mechanical and pharmacologic prevention to the operation, mobility, bleeding risk, and patient factors.46433

Eligibility and Timing Summary​

For adults, use the SOC8 eligibility framework: one competent assessment opinion is ordinarily sufficient if documentation is required. Hormones and their duration depend on the desired procedure and individual goals; they are not compulsory when unwanted or contraindicated. For gonadectomy, SOC8 suggests considering at least six months of tolerated hormone therapy when appropriate to the patient’s goals. For genital reconstruction, it suggests stability on the current regimen, which may include six months or longer when needed for the intended result; hormones are not required when unwanted or contraindicated. Breast augmentation timing also depends on breast development. Older Endocrine Society guidance used a one-year genital-surgery interval; local documentation requirements may differ from current clinical guidance.473

Footnotes​

  1. Rastogi A, Menard L, Miller GH, et al. "Health and Wellbeing: A Report of the 2022 U.S. Transgender Survey." Advocates for Transgender Equality; 2025. Report ↩ ↩2

  2. Coon D, Lee E, Fischer B, Darrach H, Landford WN. "Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results." Plast Reconstr Surg. 2020;145(6):1343–1353. doi:10.1097/PRS.0000000000006819 ↩ ↩2

  3. Coleman E, Radix AE, Bouman WP, et al. "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8." Int J Transgend Health. 2022;23(Suppl 1):S1–S259. doi:10.1080/26895269.2022.2100644 ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  4. 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 ↩

  5. 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 ↩

  6. de Blok CJM, Staphorsius AS, Wiepjes CM, et al. "Frequency, Determinants, and Satisfaction of Breast Augmentation in Trans Women Receiving Hormone Treatment." J Sex Med. 2020;17(2):342–348. doi:10.1016/j.jsxm.2019.10.021 ↩

  7. 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 ↩

  8. Morrison SD, Claes K, Morris MP, et al. "Principles and Outcomes of Gender-Affirming Vaginoplasty." Nat Rev Urol. 2023;20(5):308–322. doi:10.1038/s41585-022-00705-y ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  9. Cronin B, Stockdale CK. "Health Care for Transgender and Gender Diverse Individuals." American College of Obstetricians and Gynecologists, 2021. ↩ ↩2

  10. Wylie K, Knudson G, Khan SI, et al. "Serving Transgender People: Clinical Care Considerations and Service Delivery Models in Transgender Health." Lancet. 2016;388(10042):401–411. doi:10.1016/S0140-6736(16)00682-6 ↩ ↩2 ↩3

  11. Massie JP, Morrison SD, Van Maasdam J, Satterwhite T. "Predictors of Patient Satisfaction and Postoperative Complications in Penile Inversion Vaginoplasty." Plast Reconstr Surg. 2018;141(6):911e–921e. doi:10.1097/PRS.0000000000004427 ↩ ↩2 ↩3 ↩4 ↩5

  12. UCSF Gender Affirming Health Program. "Vaginoplasty procedures, complications and aftercare." 2016. Clinical guidance. ↩ ↩2 ↩3 ↩4 ↩5

  13. Castanon CDG, Matic S, Bizic M, et al. "Laparoscopy Assisted Peritoneal Pull-Through Vaginoplasty in Transgender Women." Urology. 2022;166:301–302. doi:10.1016/j.urology.2022.05.001 ↩

  14. van der Sluis WB, Tuynman JB, Meijerink WJHJ, Bouman MB. "Laparoscopic intestinal vaginoplasty in transgender women: An update on surgical indications, operative technique, perioperative care, and short- and long-term postoperative issues." Urol Clin North Am. 2019;46(4):527–539. doi:10.1016/j.ucl.2019.07.007 ↩

  15. Robinson IS, Cripps CN, Bluebond-Langner R, Zhao LC. "Operative management of complications following intestinal vaginoplasty: A case series and systematic review." Urology. 2023;180:105–112. doi:10.1016/j.urology.2023.07.005 ↩

  16. Ding C, Khondker A, Goldenberg MG, et al. "Urinary complications after penile inversion vaginoplasty in transgender women: Systematic review and meta-analysis." Can Urol Assoc J. 2023;17(4):121–128. doi:10.5489/cuaj.8108 ↩

  17. De Rosa P, Kent M, Regan M, Purohit RS. "Vaginal stenosis after gender-affirming vaginoplasty: A systematic review." Urology. 2024;186:69–74. doi:10.1016/j.urology.2024.02.005 ↩

  18. Horbach SE, Bouman MB, Smit JM, et al. "Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques." J Sex Med. 2015;12(6):1499–1512. doi:10.1111/jsm.12868 ↩

  19. Bishop MD, Morgan-Daniel J, Alappattu MJ. "Pain and Dysfunction Reported After Gender-Affirming Surgery: A Scoping Review." Phys Ther. 2023;103(7):pzad045. doi:10.1093/ptj/pzad045 ↩ ↩2

  20. Haley C, Roblee CV, Blasdel G, et al. "Gender-Affirming Vaginoplasty Improves Quality of Life in Transfeminine Individuals: A Single-Center Prospective Study." Ann Surg. 2025. doi:10.1097/SLA.0000000000006988 ↩

  21. Blasdel G, Hemal K, Dubach-Reinhold C, et al. "Gender-affirming Vaginoplasty Using Robotic Peritoneal Flap Method: Long-term Outcomes of 500 Cases." Ann Surg. 2026;283(6):1068–1074. Published online 2025. doi:10.1097/SLA.0000000000006621 ↩ ↩2

  22. Allan CJ, Sljivich M, Kahan D, et al. "Robot-Assisted Peritoneal Flap Vaginoplasty Versus Penile Inversion Vaginoplasty for Gender Affirming Surgery." Andrology. 2026. doi:10.1111/andr.70351 ↩

  23. Jackson Q, Yedlinsky NT, Gray M. "Lifelong Care of Patients After Gender-Affirming Surgery." Am Fam Physician. 2024;109(6):560–565. ↩ ↩2 ↩3

  24. Mishra K, Ferrando CA. Urogynecologic Care and Management for Transgender Women and Men. In: Garcia M, ed. Genital Gender Affirming Surgery: An Illustrated Guide and Video Atlas. Springer; 2024:101–109. doi:10.1007/978-3-031-69997-9_10 ↩

  25. Ziltzer RS, Lett E, Su-Genyk P, Chambers T, Moayer R. "Needs Assessment of Gender-Affirming Face, Neck, and Voice Procedures and the Role of Gender Dysphoria." Otolaryngol Head Neck Surg. 2023;169(4):906–916. doi:10.1002/ohn.329 ↩ ↩2 ↩3

  26. Siringo NV, Berman ZP, Boczar D, et al. "Techniques and Trends of Facial Feminization Surgery: A Systematic Review and Representative Case Report." Ann Plast Surg. 2022;88(6):704–711. doi:10.1097/SAP.0000000000002952 ↩ ↩2

  27. Ellis M, Choe J, Barnett SL, Chen K, Bradley JP. "Facial Feminization: Perioperative Care and Surgical Approaches." Plast Reconstr Surg. 2024;153(1):181e–193e. doi:10.1097/PRS.0000000000010886 ↩

  28. Azizi A, Sun A, Cheng LH, Hassan B, Liang F. "Facial Gender-Affirming Surgery: Upper and Middle Face Feminization." Clin Plast Surg. 2025;52(4):435–452. doi:10.1016/j.cps.2025.07.002 ↩

  29. Morrison SD, Capitán-Cañadas F, Sánchez-García A, et al. "Prospective Quality-of-Life Outcomes After Facial Feminization Surgery: An International Multicenter Study." Plast Reconstr Surg. 2020;145(6):1499–1509. doi:10.1097/PRS.0000000000006837 ↩ ↩2

  30. Morrison SD, Vyas KS, Motakef S, et al. "Facial Feminization: Systematic Review of the Literature." Plast Reconstr Surg. 2016;137(6):1759–1770. doi:10.1097/PRS.0000000000002171 ↩

  31. Nguyen NH, Argame A, Newton K, et al. "The power of facial feminization surgery: A prospective study of validated patient-reported outcomes measures." J Plast Reconstr Aesthet Surg. 2026;118:242–251. doi:10.1016/j.bjps.2026.05.037 ↩

  32. James AJ, Assi PE, Torres-Guzman RA, et al. "Optimizing Safety and Aesthetics in Facial Feminization: Laryngoscopic-Assisted Chondrolaryngoplasty (2019–2023)." J Craniofac Surg. 2025;36(2):750–753. doi:10.1097/SCS.0000000000010398 ↩ ↩2 ↩3

  33. Goslawski A, Spiegel JH. "Chondrolaryngoplasty." J Craniofac Surg. 2025;36(2):738–743. doi:10.1097/SCS.0000000000011134 ↩ ↩2

  34. Abu Bandora E, Chaushu H, Icht M, et al. "Transgender Women's Voice Outcome After Laryngochondroplasty—A Systematic Literature Review." OTO Open. 2026;10(3):e70264. doi:10.1002/oto2.70264 ↩

  35. Nuyen B, Qian ZJ, Rakkar M, Thomas JP, Erickson-DiRenzo E, Sung CK. "Diagnosis and Management of Vocal Complications after Chondrolaryngoplasty." Laryngoscope. 2023;133(9):2301–2307. doi:10.1002/lary.30518 ↩

  36. Lanham K, Melnick BA, O'Connor MJ, et al. "Efficacy and Patient Satisfaction in Voice Feminization Procedures: A Systematic Review and Meta-Analysis." Otolaryngol Head Neck Surg. 2025;172(5):1521–1538. doi:10.1002/ohn.1173 ↩ ↩2 ↩3

  37. McBrinn S, Antoni C, Al Yaghchi C. "Current Approaches to Gender-Affirming Vocal Care." Curr Opin Otolaryngol Head Neck Surg. 2024;32(3):143–150. doi:10.1097/MOO.0000000000000967 ↩ ↩2 ↩3

  38. Thomas JP. "Feminization Laryngoplasty — A Comprehensive Approach to Reducing the Size of the Larynx and Pharynx." Otolaryngol Clin North Am. 2022;55(4):739–748. doi:10.1016/j.otc.2022.05.002 ↩

  39. Aires MM, Nunes AAA, Campos E Santos EC, et al. "Glottoplasty for vocal feminization in transgender women: position paper of the Brazilian Academy of Laryngology and Voice (ABLV)." Braz J Otorhinolaryngol. 2026;92(3):101777. doi:10.1016/j.bjorl.2026.101777 ↩

  40. Kozato A, Fox GWC, Yong PC, et al. "No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery." J Clin Endocrinol Metab. 2021;106(4):e1586–e1590. doi:10.1210/clinem/dgaa966 ↩

  41. Herndon J, Gupta N, Davidge-Pitts C, et al. "Genital Surgery Outcomes Using an Individualized Algorithm for Hormone Management in Transfeminine Individuals." J Clin Endocrinol Metab. 2024;109(11):2774–2783. doi:10.1210/clinem/dgae269 ↩

  42. Li AY, Park MJ, Fick J, Ousterhout DK, Deschamps-Braly JC. "Perioperative estrogen hormonal therapy does not increase venous thromboembolism risk in facial feminization surgery." Plast Reconstr Surg. 2024;154(6):1309–1315. doi:10.1097/PRS.0000000000011437 ↩

  43. Hung YC, Assi PE, Park BC, et al. "Patterns of Perioperative Hormone Therapy for Gender-Affirming Surgery." Ann Plast Surg. 2024;92(4):442–446. doi:10.1097/SAP.0000000000003820 ↩ ↩2

  44. Nolan BJ, Cheung AS. "Estradiol Therapy in the Perioperative Period: Implications for Transgender People Undergoing Feminizing Hormone Therapy." Yale J Biol Med. 2020;93(4):539–548. ↩

  45. Snyder L, Hebert KJ, Horns JJ, et al. "Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database." Urology. 2023;182:95–100. doi:10.1016/j.urology.2023.08.041 ↩ ↩2

  46. Maharaj SK, Yu A, Singh A, Khanijow K. "Transforming Culture: Postoperative Venous Thromboembolism Prophylaxis in a Transgender Patient on Estrogen." J Gen Intern Med. 2025. doi:10.1007/s11606-025-09668-3 ↩

  47. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. "Endocrine Treatment of Gender-Dysphoric / Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline." J Clin Endocrinol Metab. 2017;102(11):3869–3903. doi:10.1210/jc.2017-01658 ↩