Trends in Gender-affirming Surgery in Insured Patients in the United States

Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes

Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.

Breast augmentation in the transgender patient: narrative review of current techniques and complications

Gender-affirming surgery (GAS) is often a crucial step during the journey to identity actualization for transgender patients. Surgical breast augmentation, or "top surgery", is frequently cited as the most important and sometimes only gender-affirming procedure sought by transfeminine patients. The breast augmentation process is remarkably similar in transgender and cisgender patients. However, there are unique guidelines, anatomic considerations, and contextual issues for the transgender patient population that must be taken into account by providers to achieve optimal outcomes. The aim of this review is to outline the current state of breast augmentation for transfeminine patients. We walk through our suggested pre-surgical evaluation, breast augmentation options, and post-surgical care. In the preoperative period, providers must establish a positive provider-patient relationship that allows for thorough history taking, physical examination, and goal setting. Providers must be able to select an appropriate implant, incision location, and operative plane to balance patient desires and pre-existing anatomic characteristics in transfeminine patients. Postoperatively, the provider must address acute and chronic needs to allow for continued satisfaction and safety. After reading this review, we aim for providers to be well-equipped to provide the highest quality breast augmentation care for their transfeminine patients. As research into best practices for breast augmentation in transfeminine patients continues to develop, we expect that surgical practice will continue to evolve.

Transgender surgery - Knowledge gap among physicians impacting patient care

Transgender surgeries are increasingly performed across the globe and in the United States. Although comprehensive centers exist, which are well equipped to cater and tailor to the needs of this population subset, quite often their resultant complications are handled at a different institution owing to the acuity of the condition. However, interestingly the psychosocial needs, medical pathophysiology, available surgical procedures, and their resultant complications are still not a part of the regular medical curriculum. This translates into inadequate care when physicians from vast majority of institutions that do not routinely perform transgender surgery encounter these patients with complications from gender-affirming surgeries. We present a case of a patient who underwent complex multiple gender-affirming surgeries, presenting to our emergency department with an acute abdomen; this resulted in a diagnostic and management dilemma and review of brief pertinent literature. We recommend that transgender medicine and its basics needs should be exposed to currently practicing physicians by continuing medical education, trainees and medical students alike via incorporation into their curriculum, to decrease health disparities among the lesbian, gay, bisexual, transgender, and queer community.

Building a Multidisciplinary Academic Surgical Gender-affirmation Program: Lessons Learned

Background:

Every day, we see more patients present to hospitals and clinics seeking gender-affirmation care to ameliorate the symptoms of gender dysphoria. However, to provide a multidisciplinary approach, it is important to offer an integrated clinical program that provides mental health assessment, endocrine therapy, physical therapy, research, and the full spectrum of surgical services devoted to transgender patients. This article describes our experience on building a specialized, multidisciplinary, academic state-of-the-art gender-affirmation program.

Methods:

Herein, we describe the main and critical components on how to build a multidisciplinary academic gender-affirmation program. We share our lessons learned from this experience and describe how to overcome some of the obstacles during the process.

Results:

Building a multidisciplinary academic gender-affirmation program requires an invested team, as each and every member is essential for feedback, referrals, and to improve patient’s experience. Institutional support is essential and by far the most important component to overcome some of the obstacles during the process. Having all team members working under the same institution provides all the critical components needed to improve outcomes and patient satisfaction. In addition, the collection of prospective data with a well-structured research team will provide information needed to improve clinical services and standardize clinical protocols, while leaving space for innovation.

Conclusions:

This article describes the steps and experience needed to build a multidisciplinary holistic academic gender-affirmation program. We provide our lessons learned during the process that will help guide those who intend to start an academic gender-affirmation program.

Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

BACKGROUND

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

METHODS

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

RESULTS

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%-2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%-<1%) and 1% (CI <1%-2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin's regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

CONCLUSIONS

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index

INTRODUCTION

Feminizing gender-affirming surgery (GAS) has been an increasingly used procedure in the United States and worldwide for transgender women with gender dysphoria. Studies on patient-reported quality of life outcomes in those undergoing GAS remain limited.

OBJECTIVE

To provide recent insights from the literature on sexual metrics in the evaluation of the transgender women.

METHODS

We queried PubMed to identify studies assessing sexual function metrics in those undergoing feminizing GAS.

RESULTS

There is no single validated method to establish preoperative and postoperative sexual function. Assessment currently remains institutionally dependent. Evaluation can involve questionnaires including but not limited to the International Index of Erectile Function, the Female Sexual Function Index, and the Male to Female Sexual Function Index.

CONCLUSION

In this literature review, we discuss considerations for the evaluation of sexual function for patients considering feminizing GAS with vaginoplasty. Although we describe some of the major tools currently used in evaluating sexual function in this patient population, a need for a validated method remains. Syed JS, Honig S. Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index. Sex Med Rev 2021;9:236-243.

Considerations for Transgender Patients Perioperatively

With a shift in the cultural, political, and social climate surrounding gender and gender identity, an increase in the acceptance and visibility of transgender individuals is expected. Anesthesiologists are thus more likely to encounter transgender and gender nonconforming patients in the perioperative setting. Anesthesiologists need to acquire an in-depth understanding of the transgender patient's medical and psychosocial needs. A thoughtful approach throughout the entirety of the perioperative period is key to the successful management of the transgender patient. This review provides anesthesiologists with a culturally relevant and evidence-based approach to transgender patients during the preoperative, intraoperative, and postoperative periods.

Impact of Mastectomy on Body Image and Sexuality from a LGBTQ Perspective: A Narrative Review

Although mastectomy could lead to a decrease in sexual performance among patients, only a handful of studies focused on the psychological and sexual behavioral aspects after the surgery. Research on post-mastectomy sexuality has focused mainly on female subjects but barely on lesbian, gay, bisexual, transgender, queer (LGBTQ), and male patients. This narrative review aimed to explore the importance of sexuality after mastectomy from a LGBTQ perspective. Each sexual minority group has been addressed individually. In general, sexual and gender minority breast cancer (BC) patients undergoing bilateral mastectomy expect a complex treatment plan in terms of physical and emotional outcomes. Bilateral mastectomy or top surgery for masculinization reasons was reported to be the most popular procedure among transmen, which resulted in a significant improvement in the quality of life. Heterosexual and lesbian female patients are willing to undergo mastectomy after repeated lumpectomies or to avoid radiation, despite potential post-operative somatic and quality-of-life complications. Transwomen would seek gender-affirming surgery to improve physical satisfaction and psychological well-being. There is not enough evidence for non-oncological reasons and consequences of mastectomy in gay men and cisgender heterosexual men. Establishing the awareness of the sexuality impact of mastectomy will allow the implementation of tailored perioperative psychological care.

Mastectomy and Chest Masculinization in Transmasculine Minors: A Case Series and Analysis by Ethical Principles

ABSTRACT

Mastectomy for chest masculinization is a commonly performed gender-affirming surgery in minor patients, a vulnerable population with unique developmental and psychosocial needs. We aimed to use principles of medical ethics (eg, autonomy, beneficence, nonmaleficence, and justice) as a framework to analyze preoperative clinical decision making by pediatric plastic surgeons who work with transmasculine and nonbinary adolescents designated female at birth presenting for chest masculinization. Two patients were selected for inclusion in this case series based on the senior author's (J.F.C.) clinical experience. A retrospective chart review was conducted to extract relevant psychosocial and clinical information from clinic notes and supplemental documentation (eg, letters from outside providers) available in the electronic medical record. In case A, a 17-year-old patient presented to a plastic surgery clinic with mixed parental support and restrictive insurance requirements. In case B, a 16-year-old patient presented to the emergency room after an attempt to remove his own breasts. The cases highlight the role of the plastic surgeon in advocating for adolescent autonomy and justice by facilitating shared family decision making and navigating barriers to care. In addition, we recommend multidisciplinary care, including trusted, transcompetent mental health professionals, to ensure beneficence and nonmaleficence by providing timely care when appropriate.

Classification of Transgender Man's Breast for Optimizing Chest Masculinizing Gender-affirming Surgery

The purpose of mastectomy for the female-to-male transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique; these have generally been based on the degree of breast ptosis and the quality and elasticity of the skin. We present a series of subcutaneous mastectomies operated on by 1 surgeon during the last 2 decades. Based on our experience, we suggest a classification system for selecting surgical technique.

Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Gender-Affirming Genital Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Services

BACKGROUND

To date, a comprehensive state-by-state assessment of transgender transition-related health care coverage for gender-affirming hormone therapy (GAHT) and genital gender-affirming surgery (GAS) has not been reported.

AIMS

The aims of this study were 1) to verify which U.S. states' Medicaid systems do/do not cover GAHT and GAS; 2) to assess the ease/difficulty for patients to determine whether GAHT and GAS are Medicaid-covered benefits; and 3) to understand possible state-related predictors of Medicaid coverage for gender-affirming care.

METHODS

We reviewed the official Medicaid Handbook and website for all 51 states (+D.C.) and 5 territories to confirm whether GAHT and GAS are covered benefits. When indeterminate, we called the Medicaid office in each state, and for many, Medicaid managed care organizations (MCOs), and individual in-state providers, to confirm coverage. We recorded our experiences, number of, and duration of phone calls to confirm coverage.

OUTCOMES

The main outcome was a definitive answer from the state/territory's Medicaid program or MCOs regarding whether GAHT and GAS are/are not covered benefits. Secondary outcome measures included responses we received and the total number/duration of phone calls necessary to confirm coverage.

RESULTS

Only 12 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAHT in their Medicaid Handbook/webpages. We confirmed that 34 of 51 state Medicaid programs do cover GAHT, whereas 9 of 51 states' and 2 of 5 territories' do not. We could not confirm coverage of GAHT in 8 of 51 states and 3 of 5 territories. Only 26 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAS in their Medicaid Handbook/webpages. We confirmed that 25 of 51 state Medicaid programs do cover GAS, whereas 22 of 51 states' and 3 of 5 territories' do not. We could not confirm coverage of GAS in 4 of 51 states and 2 of 5 territories. Up to 12 calls, lasting up to 125 minutes, were required to confirm coverage for GAHT/GAS.

CLINICAL IMPLICATIONS

Our findings indicate that important health care access barriers/disparities exist today and warrant improvement.

STRENGTHS & LIMITATIONS

To our knowledge, this is the most comprehensive assessment of transgender transition-related health care coverage. Limitations include possible bias, as it could be that we were more persistent than actual patients would be to determine service coverage, and a lack of specificity regarding which specific hormone formulations or procedures are/are not covered.

CONCLUSION

Our findings show that only 34 of 51 (67%) states' Medicaid programs include GAHT and 25 of 51 (49%) include GAS as covered benefits. Our experience suggests that the process to confirm coverage can be especially time-consuming and frustrating for patients. Zaliznyak M, Jung EE, Bresee C, et al. Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Genital Gender-Affirming Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Service. J Sex Med 2021;18:410-422.

The modern testicular prosthesis: patient selection and counseling, surgical technique, and outcomes

The testicular prosthesis can be an afterthought for providers when performing an orchiectomy for testicular cancer, torsion, atrophic testis, or trauma. However, data suggest that patients find the offer of a testicular prosthesis and counseling regarding placement to be extremely important from both a pragmatic and a psychosocial perspective. Only two-thirds of men undergoing orchiectomy are offered an implant at the time of orchiectomy and of those offered about one-third move forward with prosthesis placement. The relatively low acceptance rate is in stark contrast with high patient satisfaction and low complication rates for those who undergo the procedure. The most common postoperative patient concerns are minor and involve implant positioning, size, and weight. Herein, we provide an up-to-date review of modern preoperative evaluation, patient selection, expectation management, surgical technique, and expected outcomes for testicular prostheses.

An abnormal clinical Allen's Test is not a contraindication for free radial forearm flap

An abnormal clinical Allen's test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen's test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen's test.

Female-to-Male Transgender Chest Contouring: A Systematic Review of Outcomes and Knowledge Gaps

PURPOSE

The number of gender affirmation surgeries performed in the United States is increasing. Frequently, chest contouring is the first surgery for female-to-male transgender patients; it fosters assimilation into the new gender role with a desired sense of masculinity. Creating an aesthetic male chest requires adjustment of breast tissue volume, proper nipple-areolar complex placement, and abolishment of the inframammary fold. Although much has been published on various techniques and outcomes, there is no consensus on how to approach transmale top surgery. We have reviewed the most up-to-date literature and in so doing have uncovered significant knowledge gaps.

METHODS

An electronic literature review was performed. PubMed search keywords included combinations of "female-to-male," "transgender surgery," "chest contour," and "nipple-areolar complex." Articles were included if the patients were transgender female to male.

RESULTS

Our literature search yielded 67 unique articles, 22 of which met our inclusion criteria. A total of 2447 unique patients were analyzed. The articles discussed aspects of chest surgery in female-to-male transsexuals including mastectomy and nipple aesthetics. Relevant data trends were extracted and subsequently investigated.

DISCUSSION

Female-to-male transgender patients often undergo chest contouring as their initial gender affirmation surgery. As the surgical treatment of gender dysphoria continues to grow, it is imperative for plastic surgeons to understand the surgical options and associated outcomes for transmasculine top surgery. Future research is needed to improve patient selection, surgical decision making, and patient-reported outcomes for different chest contouring techniques. In addition, there is a significant knowledge gap for the ideal nipple-areolar complex shape, size, and location.

Evaluating Patient Benefit From Laryngochondroplasty

OBJECTIVES/HYPOTHESIS

To elucidate and review current literature on the surgical technique for laryngochondroplasty in male-to-female transgender patients. To determine the degree of benefit afforded to male-to-female transgender patients by laryngochondroplasty using the Glasgow Benefit Inventory (GBI).

STUDY DESIGN

Retrospective case series.

METHODS

After institutional review board approval was obtained, the GBI survey was given to patients who underwent laryngochondroplasty by the author. Demographic information was analyzed including age, race, wait time to surgery, distance traveled, median zip code income, and concomitant gender-affirming surgeries such as vaginoplasty, breast augmentation, or facial feminization.

RESULTS

From April 2016 to April 2020, 209 patients received laryngochondroplasty within the Kaiser Permanente Northern California Medical System. Of those, 91 received laryngochondroplasty with the author and were given the GBI, with 73 patients (80%) responding. Patients were on average 31.4 years old, traveled 45.4 miles to the surgical site, lived in a zip code with a median income of $86,793.61, and waited 95.7 days for surgery. Patients had a statistically significant improvement in all three subscores (general, social, and physical) of the GBI as well as in their overall score.

CONCLUSIONS

Laryngochondroplasty is a safe and effective procedure to reduce thyroid cartilage prominence (Adam's apple) in male-to-female transgender patients. There was a statistically significant improvement in the overall score and all subscores of the GBI after laryngochondroplasty LEVEL OF EVIDENCE: 4 Laryngoscope, 130:S1-S14, 2020.

The Mount Sinai Patient-Centered Preoperative Criteria Meant to Optimize Outcomes Are Less of a Barrier to Care Than WPATH SOC 7 Criteria Before Transgender-Specific Surgery

Objectives: With expanding coverage of gender-affirming care in the United States, many insurers default to the World Professional Association for Transgender Health (WPATH) Standards of Care 7 (SOC 7) to establish eligibility requirements for surgery coverage. Informed by bariatric and transplant surgery evaluation models, the Mount Sinai Center for Transgender Medicine and Surgery (CTMS) developed patient-centered criteria to assess readiness for surgery, focusing on concerns that could impair recovery. To make recommendations for the next version of the WPATH SOC, SOC 8, we compared Mount Sinai patient-centered surgical readiness criteria with the WPATH SOC 7 criteria. Methods: Data were extracted from a deidentified data set developed as part the quality dashboard for CTMS. The data set included all patients seeking vaginoplasty who were evaluated by a single mental health provider, from July 2016 through August 2018, and who completed the full CTMS assessment. The number of patients eligible for surgery based on the Mount Sinai CTMS criteria was compared with the number of patients eligible for surgery according to WPATH SOC 7 criteria. Results: Of 139 patients identified, 63 (45%) were ready for surgery immediately based on the Mount Sinai patient-centered model. By contrast, only 21 (15%) out of the 139 met criteria for surgery based on WPATH SOC 7. Fifty patients (40%) were ready for surgery as per Mount Sinai patient-centered readiness review but not WPATH criteria. Conclusion: An assessment designed to better prepare patients for surgery may also result in fewer barriers to care than existing criteria used by insurance companies in the United States.

Burden of arrythmias in transgender patients hospitalized for gender-affirming surgeries

BACKGROUND

We sought to describe the burden of arrhythmias and their impact on in-hospital outcomes in transgender patients who underwent gender re-assignment surgery.

METHODS

The study utilized data from the National Inpatient Sample from January 2012 to September 2015.

RESULTS

16 555 adult transgender patients were included in this study. A total of 610 adults developed arrhythmia out of which atrial fibrillation (N = 475, 2.87%) was the most frequent arrhythmia. In-hospital mortality increased substantially with arrhythmias.

CONCLUSIONS

New-onset arrythmias, while infrequent in the inpatient setting is associated with significantly higher in-hospital mortality and resource utilization.

Medically assisted gender affirmation: when children and parents disagree

Institutional guidelines for transgender children and adolescent minors fail to adequately address a critical juncture of care of this population: how to proceed if a minor and their parents have disagreements concerning their gender-affirming medical care. Through arguments based on ethical, paediatric, adolescent and transgender health research, we illustrate ethical dilemmas that may arise in treating transgender and gender diverse youth. We discuss three potential avenues for providing gender-affirming care over parental disagreement: legal carve-outs to parental consent, the mature minor doctrine and state intervention for neglect. Our discussion approaches this parent-child disagreement in a manner that prioritises the developing autonomy of transgender youth in the decision-making process surrounding medically assisted gender affirmation. We base our arguments in the literature surrounding the risks and benefits of gender-affirming therapy in transgender children and the existing legal basis for recognising minors' decision-making authority in certain medical situations.

Registered Nurses as Optimizers of Gender-Affirming Care Within a Transgender and Intersex Specialty Care Clinic

An estimated 1.4 million transgender adults live in the United States; this equates to approximately 0.6% of the U.S. population (Lane et al., 2018). Clinical focus on gender dysphoria has significantly increased over the past 30 years (MacCarthy, Reisner, Nunn, Perez-Brumer, & Operario, 2015), with burgeoning evidence from across disciplines documenting the positive outcomes associated with gender-affirming interventions. The purpose of this article is to illustrate how RNs optimize psychosocial, hormonal, and surgical gender-affirming care through performing comprehensive assessments, coordinating care, and providing education and health coaching.

Chlamydia, Gonorrhea, and Human Immunodeficiency Virus Infection Among Transgender Women and Transgender Men Attending Clinics that Provide Sexually Transmitted Disease Services in Six US Cities: Results From the Sexually Transmitted Disease Surveillance Network

BACKGROUND

Transgender women and transgender men are disproportionately affected by human immunodeficiency virus (HIV) infection and may be vulnerable to other sexually transmitted diseases (STDs), but the lack of surveillance data inclusive of gender identity hinders prevention and intervention strategies.

METHODS

We analyzed data from 506 transgender women (1045 total visits) and 120 transgender men (209 total visits) who attended 26 publicly funded clinics that provide STD services in 6 US cities during a 3.5-year observation period. We used clinical and laboratory data to examine the proportion of transgender women and transgender men who tested positive for urogenital and extragenital chlamydial or gonococcal infections and who self-reported or tested positive for HIV infection during the observation period.

RESULTS

Of the transgender women tested, 13.1% tested positive for chlamydia and 12.6% tested positive for gonorrhea at 1 or more anatomic sites, and 14.2% were HIV-infected. Of transgender men tested, 7.7% and 10.5% tested positive for chlamydia and gonorrhea at 1 or more anatomic sites, and 8.3% were HIV-infected. Most transgender women (86.0% and 80.9%, respectively) and more than a quarter of transgender men (28.6% and 28.6%, respectively) with an extragenital chlamydial or gonococcal infection had a negative urogenital test at the same visit.

CONCLUSIONS

Publicly funded clinics providing STD services are likely an important source of STD care for transgender persons. More data are needed to understand the most effective screening approaches for urogenital, rectal, and pharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae infections in transgender populations.

The Current State of Gender-Affirming Surgery Training in Plastic Surgery Residency Programs as Reported by Residency Program Directors

BACKGROUND

The purpose of this Web-based survey was to elucidate the current perspectives of plastic surgery residency program directors on training residents to perform gender-affirming surgery.

METHODS

Web-based surveys were distributed to 79 plastic surgery program directors. Demographic information and perspectives on training of gender-affirming surgery in plastic surgery residency were queried.

RESULTS

Of 79 distributed surveys, there were 43 responses (54 percent). Overall, program directors reported that their trainees were prepared to address plastic surgery-related transgender concerns (67 percent), and believe plastic surgeons are the most appropriate specialty referral for each type of gender-affirming surgery (top/chest, 98 percent; facial, 95 percent; and bottom/genital, 79 percent). Ninety-three percent of program directors noted that transgender surgery is becoming more accepted and/or practiced in their referral area, with 26 percent reporting a dedicated clinic experience. There was a mixed response on the need for additional fellowship training for gender-affirming surgery. Residents are exposed to significantly more bottom (p = 0.0018), top (p = 0.0013), and facial operations (p = 0.00005) if they rotate through a "gender" clinic.

CONCLUSIONS

Of the queried program directors, the majority feel their residents are well-trained in gender-affirming surgery. However, residents have more clinical exposure in facial and top (chest) gender-affirming surgery as compared to bottom (genital) surgery. Although most program directors agree that plastic surgeons are the most important referral for top, bottom, and facial operations, there is less consensus over the role of fellowship training. Most program directors reported a desire to devote additional CME time to the topic in the coming years.

Outcome Measures in Gender-Confirming Chest Surgery: A Systematic Scoping Review

BACKGROUND

The aim of this scoping review was to provide an overview of outcome measures in gender-confirming chest surgery.

METHODS

A comprehensive literature search was performed in PubMed, EMBASE, CINAHL, PsycINFO, Scopus and the Cochrane Library to find studies evaluating gender-confirming chest surgery in a non-cis gender population. The systematic scoping review followed the PRISMA extension for scoping reviews. Data were charted for outcome measures including complications, reoperations, revision surgery, aesthetic outcome and patient-reported outcome measures.

RESULTS

Our search yielded 849 records, which were screened on title, abstract and full text. Of these, 47 were included in the review. Feminising gender-confirming chest surgery was evaluated in 11 studies, and masculinising gender-confirming chest surgery was evaluated in 39 studies. Clinician-reported outcome categories were used in 40 studies and included complications, reoperation, revision surgery and aesthetic outcome. Categories of patient-reported outcomes were used in 29 studies and included aesthetic outcome, functional outcome and mental health parameters. The summary of outcome domains and classifications showed that there are large variations in outcome evaluation between studies. Although several studies reported on similar outcome categories, there was a high level of heterogeneity of domains and classifications of outcomes.

CONCLUSIONS

Evaluation of outcomes in gender-confirming chest surgery showed large variations in reporting, and further streamlining of reporting is therefore required to be able to compare surgical outcomes between studies.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes

BACKGROUND

Chest reconstruction ('top surgery') is an important component of transition in the transmasculine population that can substantially improve gender incongruence. The aim of this study was to evaluate the demographic characteristics, surgical technique, and postoperative outcomes following transmasculine chest surgery.

METHODS

Using ICD codes, we identified all cases of gender-affirming transmasculine chest surgery from the ACS NSQIP database (2010-2017). CPT codes were used to categorize patients by reconstructive modality: reduction versus mastectomy (± free nipple grafting [FNG]). Univariate analysis was conducted to assess for differences in demographics, comorbidities, and postoperative complications. Multivariable regression analysis was used to control for confounders.

RESULTS

A total of 755 cases were identified, of whom 591 (78.3%) were mastectomies and 164 (21.7%) were reductions. No significant differences were noted in terms of age or BMI. Mastectomies had shorter operative times, but similar length of stay compared to reductions. Rates of postoperative complications were low, with 4.7% (n = 28) of mastectomies and 3.7% (n = 6) of reductions experiencing at least one all-cause complications. Postoperative complication rates were not statistically different between mastectomy with (3.4%) and without (5.6%) FNG. After controlling for confounders, there was no difference in terms of risk of all-cause complications between reduction and mastectomy, with or without FNG.

CONCLUSION

Mastectomy and reduction mammaplasty are both safe procedures for chest reconstruction in the transmasculine population. These results may be used to encourage shared decision making between patient and surgeon such that the reconstructive modality of choice best aligns with the desired aesthetic outcome.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Historical and Current State of Dermatologic Care for Sexual and Gender Minority Populations

The lesbian, gay, bisexual, transgender, and queer or questioning/sexual and gender minority (LGBTQ/SGM) community is a growing population with unique lifestyles, sexual practices, beliefs, health issues, and concerns. Although significant advances have been achieved in recent years to establish better care for LGBTQ/SGM patients, they still face insurmountable stigmatization and health care inequality. Dermatologists play an important role in LGBTQ/SGM patients' well-being because they not only treat their skin conditions, but also help them achieve desirable physical characteristics. This article discusses historical perspectives and current state of LGBTQ/SGM dermatology and attempts to define directions for future research and improvement.

Donor Site Morbidity in Phalloplasty Reconstructions: Outcomes of the Radial Forearm Free Flap

The radial artery forearm free flap (RFFF) is the workhorse technique for phallus reconstruction. The RFFF provides good cosmesis and potential sensory recovery. However, the donor site is large in comparison to other applications of the RFFF which may increase the potential for donor site morbidity, such as nerve injury, delayed wound healing, and decreased hand strength. This study systematically reviewed the current literature to assess the donor site morbidity associated with RFFF phalloplasty (RFFFP).

A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery

For individuals with gender dysphoria, gender-affirming surgeries (GAS) are one means of reducing the significant distress associated with primary and secondary sex characteristics misaligned with their gender identity. This article uses a systematic review to examine the existing literature on the psychological benefits of GAS. Findings from this review indicate that GAS can lead to multiple, significant improvements in psychological functioning. Methodological differences in the literature demonstrate the need for additional research to draw more definitive conclusions about the psychological benefits of GAS.

Providing Gender Confirmation Surgery at an Academic Medical Center: Analysis of Use, Insurance Payer, and Fiscal Impact

BACKGROUND

Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center.

METHODS

This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix.

RESULTS

A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018.

CONCLUSIONS

We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.

Mastectomy in Transgender and Cisgender Patients: A Comparative Analysis of Epidemiology and Postoperative Outcomes

Background:

Mastectomy is a commonly requested procedure in the transmasculine population and has been shown to improve quality of life, although there is limited research on safety. The aim of this study was to provide a nationwide assessment of epidemiology and postoperative outcomes following masculinizing mastectomy and compare them with outcomes following mastectomy for cancer prophylaxis and gynecomastia correction in cisgender patients.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2017 was queried using International Classification of Diseases and Current Procedural Terminology codes to create cohorts of mastectomies for 3 indications: transmasculine chest reconstruction, cancer risk-reduction (CRRM), and gynecomastia treatment (GM). Demographic characteristics, comorbidities, and postoperative complications were compared between the 3 cohorts. Multivariable regression analysis was used to control for confounders.

Results:

A total of 4,170 mastectomies were identified, of which 14.8% (n = 591) were transmasculine, 17.6% (n = 701) were CRRM, and 67.6% (n = 2,692) were GM. Plastic surgeons performed the majority of transmasculine cases (85.3%), compared with the general surgeons in the CRRM (97.9%) and GM (73.7%) cohorts. All-cause complication rates in the transmasculine, CRRM, and GM cohorts were 4.7%, 10.4%, and 3.7%, respectively. After controlling for confounding variables, transgender males were not at an increased risk for all-cause or wound complications. Multivariable regression identified BMI as a predictor of all-cause and wound complications.

Conclusion:

Mastectomy is a safe and efficacious procedure for treating gender dysphoria in the transgender male, with an acceptable and reassuring complication profile similar to that seen in cisgender patients who approximate either the natal sex characteristics or the new hormonal environment.