Quality of life improvement after chest wall masculinization in female-to-male transgender patients: A prospective study using the BREAST-Q and Body Uneasiness Test

Nonbinary and Transgender Male Patient Preferences for Gender-Affirming Top Surgery

BACKGROUND

This study aimed to identify patient preferences and outcomes of chest masculinization surgery in patients identifying as nonbinary versus transgender (trans-) males.

METHODS

Patients who underwent chest masculinization (2003-2022) were included. Demographics, medical comorbidities, surgical approaches, complications, secondary procedures, and BODY-Q chest module survey responses were compared between cohorts.

RESULTS

Three hundred two patients were included. Thirteen percent identified as nonbinary and 87% as trans-male. The most common surgical approach in both groups was double incision with free nipple-areola graft (63% vs 71%, P = 0.33). Nonbinary patients more frequently opted for double incision without free nipple areola graft compared to trans-male patients (18% vs 2.7%, P < 0.001). Other unique surgical requests of nonbinary patients included nipple areola preservation and small breast mound preservation (5.2%) and balance between losing bulk and achieving a more androgynous appearance (5.3%). The survey response rate was 31% (93/302). Both groups reported improved quality of life postoperatively ( P = 0.16). Three nonbinary patients elected not to keep their nipple-areola complexes ( P = 0.005). Trans-male patients were more likely to report having a male chest as very important for their gender identity (82% vs 95%, P = 0.043). Nonbinary patients were less likely to prefer small nipples (82% vs 95%, P = 0.033) and 18% stated that they preferred no nipples (vs 2.7% trans-male patients, P < 0.001).

CONCLUSIONS

Nonbinary patients have distinct surgical preferences regarding nipple-areola complexes. Chest masculinization planning can differ for this group of patients compared to their trans-male counterparts.

Ultrasound-Assisted Liposuction for Top Surgery in Transgender Men: Clinical Experience and Evaluation of Satisfaction and Quality of Life with TRANS-Q and BREAST-Q

BACKGROUND

During the last decade, the demand for top surgery in female-to-male transgender (FMT) has increased worldwide. This study aims to present our initial experience with the novel use of ultrasound-assisted liposuction (UAL) in top surgery. Additionally, we evaluate the satisfaction and quality of life with TRANS-Q and BREAST-Q.

METHODS

We conducted a retrospective study analyzing FMT undergoing UAL in top surgery from 2019 to 2021 at a single institution. We analyzed demographic variables, comorbidities, surgical techniques, operative time, complications, and follow-up time. We used TRANS-Q and BREAST-Q to evaluate patient-reported outcomes. A p value < 0.05 was considered significant.

RESULTS

We performed 34 UAL combined subcutaneous mastectomies in 17 patients. Twelve patients (70.6%) underwent mastectomy double incision with free nipple grafting (DIFNG), and 29.4% underwent concentric circular mastectomy. In the DIFNG group, BMI (p < 0.02), the weight of each mammary gland (p < 0.001), and use of chest binder (p < 0.03) were significantly higher. The mean operative time was 115 min. The complication rate was 11.7% (one hematoma and three hypertrophic scars). The mean follow-up was 29.4 months, and no aesthetic revision surgeries was reported. The response rate for TRANS-Q and BREAST-Q was 76.5%, and high satisfaction with the results and significant improvement in quality of life were reported.

CONCLUSIONS

We present the first cohort of transgender men who underwent UAL in top surgery. With proper training, the use of UAL could be a feasible and safe technique, offering good long-term esthetic results. Additionally, TRANS-Q and BREAST-Q demonstrated improved satisfaction and quality of life.

LEVEL OF EVIDENCE IV

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Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.

Patient-reported satisfaction and health-related quality of life after chest masculinization in transgender men using the BODY-Q Chest module and the 15D instrument

Chest masculinization is the most common surgical intervention in transgender men. Studies indicate good patient-reported postoperative satisfaction, but only recently has a patient-reported outcome instrument, the BODY-Q Chest module, been developed and validated for this patient group. This study aimed to evaluate postoperative patient-reported satisfaction and health-related quality of life (HRQoL) using the BODY-Q Chest module and the 15D after surgical chest masculinization in transgender men. The data comprised all patients receiving chest masculinization from 2005 to 2018. The patients were invited by letter to complete the BODY-Q Chest module and the 15D questionnaire in May 2020. Of the 220 patients invited, 123 completed the survey, resulting in a response rate of 56%. The median chest and nipple scores were 76 and 68 out of 100, respectively. The number of secondary corrections was negatively associated with the chest score (p value < 0.001). The 15D index score was lower compared with the age-standardized male population (p value < 0.001), but similar to the age-standardized female population. Psychiatric comorbidity was associated with lower 15D index scores (p value < 0.001). There were no statistically significant differences between the BODY-Q Chest module scores or the 15D index score among the different surgical techniques. The postoperative satisfaction with chest masculinization was good and in line with previous literature. HRQoL resembles that of the reference population. The periareolar technique is not associated with better satisfaction despite causing less scar burden. The negative association between the chest score and number of secondary corrections is unsettling and requires further examination in a prospective setting.

Factors Affecting the Choice to Forgo Nipple Grafts in Gender-Affirming Chest Surgery

INTRODUCTION

Some patients pursuing gender-affirming mastectomy prefer to forgo autologous nipple and areolar reconstruction, instead choosing a "no nipple" option. The objective of this study is to evaluate the motives and influences contributing to this decision.

METHODS

A retrospective survey-based study of patients undergoing gender-affirming mastectomy over a 4.6-year period was conducted. All patients were offered nipple and areolar reconstruction. A survey was distributed to those who elected to forgo nipple and areolar reconstruction exploring the factors influencing that choice and postoperative satisfaction.

RESULTS

Five hundred thirty-six patients underwent gender-affirming mastectomy and 13% chose to forgo nipple and areolar reconstruction. The survey response rate was 72%. Most respondents identified as nonbinary (48%) or transmasculine (42%). Body image, defined in the context of this study as an improvement in body image satisfaction due to achievement of a more gender-congruent appearance, was the most highly cited and most heavily weighted decision-making factor. Concerns about nipple graft outcomes were frequently cited as important but carried less weight. There were no differences between transmasculine and nonbinary patients in terms of motivations for choosing this surgical option. Fifty-eight percent of respondents pursued or planned to pursue chest tattoos, whereas 42% preferred no further chest modifications. Patient satisfaction was high postoperatively (98%), and 82% of respondents would choose to forgo nipple and areolar reconstruction again even if surgical outcomes of free nipple grafts were improved.

CONCLUSIONS

Gender-affirming mastectomy without nipple and areolar reconstruction was requested by 13% of patients presenting for gender-affirming chest surgery over the study period and had high postoperative satisfaction among patients who chose this option. This modification of gender-affirming mastectomy is a variation that surgical teams should be aware of. Many reasons to forgo nipple preservation were cited, most of which related to body image. Secondary factors were easier recovery and/or concern about outcomes of free nipple grafts. Many patients wished information about this surgical option was more widely available.

Association between genital gender-affirming surgery and psychiatric comorbidities in individuals with gender incongruence

BACKGROUND

Previous studies present mixed evidence on the relationship between psychiatric comorbidities and genital gender-affirming surgery (GGAS) in individuals with gender incongruence (GI).

AIM

This research aims to investigate the psychiatric comorbidity rates post-GGAS in the GI population-namely, depressive disorders, anxiety disorders, posttraumatic stress disorders, substance abuse disorder, and suicidality.

METHODS

Based on the TriNetX health care database, an international database with >250 million patients, a cross-sectional study was executed comparing psychiatric comorbidity rates among cases of GI with and without GGAS. Individuals were matched for demographic and health-related variables, which included history of cardiovascular disease, diabetes, and obesity.

OUTCOMES

The main focus was to establish the rates and changes in psychiatric comorbidities following GGAS.

RESULTS

Among individuals with GI, the study identified 4061 with GGAS and 100 097 without. At 1 year post-GGAS, there was a significant decrease in depression (odds ratio [OR], 0.748; 95% CI, 0.672-0.833; P < .0001), anxiety (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), substance use disorder (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), and suicidality (OR, 0.530; 95% CI, 0.425-0.661; P < .0001), and these reductions were maintained or improved on at 5 years, including posttraumatic stress disorder (OR, 0.831; 95% CI, 0.704-0.981; P = .028).

CLINICAL IMPLICATIONS

The findings indicate that GGAS may play a crucial role in diminishing psychiatric comorbidities among individuals with GI.

STRENGTHS AND LIMITATIONS

This is the largest known study to evaluate the effect of GGAS on psychiatric comorbidities in the GI population, offering robust evidence. The reliance on the precision of CPT and ICD-10 codes for data extraction poses a limitation due to potential coding inaccuracies.

CONCLUSION

The evidence suggests a significant association between GGAS and reduced psychiatric comorbidities in individuals with GI.

Understanding Public Perceptions of Nipple and Scar Characteristics After Chest Wall Masculinization Surgery

BACKGROUND

Surgical chest masculinization procedures, especially gender-affirming top surgery (GATS), are becoming increasingly prevalent in the USA. While a variety of surgical techniques have been established as both safe and effective, there is limited research examining ideal aesthetic nipple appearance and incision scar pattern. This study employs patient images to understand the public's perception on top surgery outcomes when adjusting for BMI ranges and Fitzpatrick skin types.

METHODS

Images from RealSelf modified via Adobe Photoshop depicted various scar types and nipple-areolar complex (NAC) sizes/positions. A Qualtrics survey was distributed utilizing Amazon Mechanical Turk. Statistical analysis was performed through JMP Pro 17 for ordinal and categorical values, with a p value less than or equal to 0.05 statistically significant.

RESULTS

A moderately sized and laterally placed NAC was preferred. A transverse scar that resembles the pectoral border between the level of the inframammary fold and pectoral insertion was deemed most masculine and aesthetic. Majority of results demonstrated that this is unaffected by Fitzpatrick skin types. Increased BMI images impacted public preferences, as a nipple placed farther from the transverse incision (p = 0.04) and a transverse scar position closer to the IMF was preferred in higher BMI patients.

CONCLUSIONS

An understanding of the most popular NAC and scar choices, as well as how these factors may differ when considering a Fitzpatrick skin type or BMI categorization was attained. This validates the importance of patient-centered approach when employing surgical techniques in GATS. Future studies intend to obtain reports from actual patients considering GATS.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable.

The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth

PURPOSE

Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB).

METHODS

In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr).

RESULTS

We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group.

CONCLUSION

Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.

Prospective assessment of the quality of life and nipple sensation after gender-affirming chest surgery

BACKGROUND

In the existing literature, assessing transgender patients' quality of life after surgery, especially using standardized surveys, is rare. The nipple sensation regarding the operating technique has neither been studied in a prospective nor standardized way.

METHODS

For one year, we prospectively assessed transgender patients operated on for a gender-affirming chest surgery in our unit. Each patient answered the BREAST-Q© survey and the BODY-Q© chest module survey before and six months after the surgery. In addition, a measure of nipple sensation was performed using Semmes-Weinstein monofilaments pre-and post-operatively to compare surgical techniques.

RESULTS

Fifty-one patients (102 breasts) were included in our study. The average age was 23.1 years and the average BMI was 24.8 kg/m2. Twenty-one patients (45%) had double incision and free nipple graft mastectomy, 14 (27%) patients had double incision and inferior pedicle mastectomy, while the 14 (27%) other patients had a semi-circular technique. Our study shows an improvement in all the scores of the surveys after surgery (p < 0.0001). Patients with double incision and inferior pedicle mastectomies rated a significantly higher satisfaction with nipples (p = 0.013) and significantly better sexual well-being (p = 0.007) than other techniques. In addition, preservation of nipple sensation was shown in patients operated by semi-circular technique (p < 0.001) and inferior pedicle technique (p < 0.0001).

CONCLUSIONS

Our prospective study confirms the significant improvement in the quality of life of transgender patients after chest gender-affirming surgery. Double incision with inferior pedicle seems to provide better satisfaction with nipples, higher sexual well-being, and preservation of nipple sensation.

Sexual Function in Post-surgical Transgender and Gender Diverse Individuals

Surgical treatment for gender dysphoria consists of facial, chest, and genital surgery. Chest and genital gender affirmation surgeries alter the form and function of the native organs. This can have a profound impact on sexual function for transgender and gender- diverse individuals. In this article, the authors will discuss the impacts that chest and genital gender affirmation surgeries can have on sexual function.

Anesthesia for gender-affirming surgery: a practical review

PURPOSE OF REVIEW

Gender-affirming surgery (GAS) is an effective, well studied, and often necessary component of gender-affirming care and mitigation of gender dysphoria for transgender and gender-diverse (TGD) individuals. GAS is categorized as chest surgeries, genitourinary surgeries, facial feminization/masculinization, and vocal phonosurgery. Despite increased incidence of GAS during recent years, there is a gap in knowledge and training on perioperative care for TGD patients.

RECENT FINDINGS

Our review discusses the relevant anesthetic considerations for the most common GAS, which often involve highly specialized surgical techniques that have unique implications for the anesthesia professional.

SUMMARY

Anesthesiology professionals must attend to the surgical and anesthetic nuances of various GAS procedures. However, as many considerations are based on common practice, research is warranted on anesthetic implications and outcomes of GAS.

Comparing Gender Congruency in Nonsurgical versus Postsurgical Top Surgery Patients: A Prospective Survey Study

Background

Gender dysphoria can result in reduced quality of life. Treatments include hormone replacement therapy (HRT) and gender-affirming surgery. Our study compared congruency, satisfaction, and discrimination in patients who underwent top surgery and HRT versus HRT alone. We hypothesized improved outcomes in top surgery patients but that lack of access is a common barrier.

Methods

Transgender and nonbinary subjects who underwent at least 6 months of HRT were recruited and answered questions on gender congruency, discrimination, and barriers to care. Surgical patients were asked about postoperative satisfaction using the BREAST-Q. A Mann-Whitney test compared survey responses between study arms.

Results

One hundred twelve eligible subjects completed the survey. Surgical subjects answered significantly more positively (P < 0.001) on all questions regarding gender congruency. The greatest difference was observed in how subjects' physical bodies represented their gender identity, where the surgery group rated higher on the five-point Likert scale by 2.0 points (P < 0.001). Surgical patients also reported less violence, verbal abuse, and discrimination (P < 0.003). Within the hormone arm, 87.1% stated desire for surgery and 62.5% declared barriers to surgery, with cost and insurance coverage representing the most common barriers. Finally, surgical subjects reported high satisfaction on the BREAST-Q, scoring more than 3.0 in all categories of breast augmentation and more than 2.6 for breast reduction on a four-point Likert scale.

Conclusions

Top surgery, in addition to HRT, significantly improves gender congruency and decreases discrimination and abuse, compared with HRT alone. Unfortunately, barriers including cost and lack of insurance continue to be obstacles for care.

National Legislative Favorability and Insurance Coverage for Adult and Adolescent Gender-Affirming Surgery

BACKGROUND

Despite established medical necessity, laws prohibiting coverage discrimination, and increasing numbers of transgender and gender-diverse patients seeking gender-affirming surgery (GAS), cost and restrictive insurance policies continue to be the most common barriers. As recent legislation places further restrictions on GAS, this study aimed to provide an updated review of insurance policies and assess the relationship between legislative favorability and coverage.

METHODS

Insurance policies of groups representing 80% market coverage in each state were collected for gender-affirming chest, genital, and facial surgery. Policies were categorized based on previously published methodologies: never-covered, case-by-case, and preauthorization. The relationship between established scores of legislative favorability and policy coverage in each state was analyzed and compared across regions.

RESULTS

Of the 316 analyzed policies, coverage was preauthorized most often for genital (94.0%), masculinizing top (93%), feminizing top (74%), and facial reconstruction (24%). Higher legislative scores in the Northeast and West, and individual states were predictive of increased genital, facial, and all forms of adolescent GAS, but were not correlated to chest GAS.

CONCLUSIONS

Compared with previous studies, our findings suggest that there is a growing acceptance of GAS as medically necessary. However, the correlation between legislative scores and genital, face, and adolescent GAS coverage may suggest increased reliance on sociopolitical factors for access in the absence of comprehensive medical guidelines, which are more established for chest reconstruction. Significantly higher coverage of masculinizing versus feminizing chest surgery suggests additional burden of proof for GAS with a cosmetic overlap.

Gender-Affirming Mastectomy: Psychosocial and Surgical Outcomes in Transgender Adults

BACKGROUND

Limited literature exists examining the effects of gender-affirming mastectomy on transmasculine and nonbinary patients that is prospective and uses validated survey instruments.

STUDY DESIGN

The psychosocial functioning of transmasculine and nonbinary patients was compared between patients who underwent gender-affirming mastectomy and those who had not yet undergone surgery. Participants were enrolled in a single-site, combined study of surgical and psychosocial outcomes, including a cross-sectional cohort of preoperative and postoperative patients, as well as separate prospective cohort. Participants completed the BREAST-Q psychosocial and sexual well-being modules, the BODY-Q satisfaction with chest and nipples modules, the Body Image Quality of Life Inventory, the Transgender Congruence Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 scale before and after surgery. We also examined how patient demographic factors correlated with postoperative surgical and psychosocial outcomes.

RESULTS

A total of 111 transmasculine and nonbinary patients 18 to 63 years of age (mean ± SD 26.5 ± 8) underwent mastectomy and were included in the study. All were included in the cross-sectional cohort, and 20 were enrolled in the prospective cohort. More than one-third (34.2%) of patients were nonbinary. After surgery, psychosocial and sexual well-being, satisfaction, body image-related quality of life, and gender congruence were increased (p < 0.001) in both cohorts, and depression (p < 0.009 cross-sectional), and anxiety (p < 0.001 cross-sectional) were decreased. The most common adverse event was hypertrophic scarring, which occurred in 41 (36.9%) participants.

CONCLUSIONS

In this study of transmasculine and nonbinary adults, gender-affirming mastectomy was followed by substantial improvements in psychosocial functioning.

Qualitative Assessment of the Experiences of Transgender Individuals Assigned Female at Birth Undergoing Gender-Affirming Mastectomy for the Treatment of Gender Dysphoria

Purpose

Evaluation and comparison of outcomes following gender-affirming mastectomy have been hindered by the lack of a validated population- and surgery-specific patient-reported outcome measure (PROM). The purpose of this study was to explore the lived experiences of transgender individuals assigned female at birth (AFAB) from before-to-after gender-affirming mastectomy to identify key qualitative themes that might inform the creation of a quantitative PROM in the future.

Methods

Identified candidates were transgender men AFAB, 18-65 years of age (mean±standard deviation: 30.3±12.2), who had undergone gender-affirming mastectomy from 2015 through 2017 (n=53). Twelve individuals participated in either focus groups (6) or phone interviews (6), carried out in a semistructured fashion. Verbatim transcriptions were anonymized. Conventional content analysis was used to code all transcripts.

Results

Content analysis identified six key themes experienced by transgender men undergoing gender-affirming mastectomy. In contrast to their experiences before surgery, participant reported that after surgery they experienced fewer symptoms of gender dysphoria, lower anxiety associated with gender dysphoria, less fear about physical safety, no need to hide a female chest shape, and that they passed as male. Also explored were themes about experiences with the health care team.

Conclusion

This study presents the first qualitative data based on the lived experiences of transgender individuals AFAB who underwent gender-affirming mastectomy. These qualitative themes should be heavily considered when creating a quantitative PROM that will fully capture the changes transgender individuals AFAB experience from before-to-after gender-affirming mastectomy.

Patient-Reported Outcomes on Subjective Nipple Sensation After Double-Incision and Periareolar Mastectomy for Chest Masculinization: Subjective Nipple Sensation After Chest Masculinization

ABSTRACT

We evaluated patient-reported outcomes to assess for patient and procedural factors associated with postchest masculinization subjective nipple sensation. Patients who underwent double-incision or periareolar mastectomies for chest masculinization by a single senior surgeon (2015-2019) were surveyed at 2 time points regarding postoperative nipple sensation and satisfaction, including patient-reported outcomes using BODY-Q modules (Q-Portfolio.org). Demographic, operative, and postoperative variables were obtained from medical records. Patients were stratified according to survey responses. Univariate and multivariate analyses were performed.Response rate was 42% for survey 1 and 22% for survey 2. Of the 151 survey 1 responders, 138 (91.4%) received double-incision mastectomies and 13 (8.6%) received periareolar mastectomies. Among Survey 1 responders, 84.6% periareolar patients and 69.6% double-incision patients reported "completely" or "a little" nipple sensation preservation, and the difference trended toward significance (P = 0.0719). There was a stepwise increase in proportion of patients reporting sensation with greater recovery time until response to survey 1. Obesity (P = 0.0080) and greater tissue removed (P = 0.0247) were significantly associated with decreased nipple sensation. Nipple satisfaction scores were significantly higher for patients reporting improved nipple sensation (P = 0.0235). Responders to survey 2 who reported greater satisfaction with nipple sensation were significantly more likely to report preserved sensitivity to light touch (P = 0.0277), pressure (P = 0.0046), and temperature (P = 0.0031). Preserved erogenous sensation was also significantly associated with greater satisfaction (P = 0.0018).In conclusion, we found that nipple sensation may be associated with postoperative nipple satisfaction. Operative techniques to optimize nipple sensation preservation may improve this population's postoperative satisfaction.

Masculinizing chest-wall surgeries in transgender patients, a retrospective single-center study

INTRODUCTION

Masculinizing chest-wall contouring surgery is an important surgical intervention for most transmasculine patients; a vast improvement in quality of life for this group of patients has been documented as a result of receiving surgery. The aim of this study was to evaluate the results of such surgeries performed at our university hospital between 2008 and 2020, as well as the current quality of life of the patients.

METHODS

All 16 patients operated between 2008 and 2020 were sent a questionnaire consisting of both BREAST-Q and BODY-Q modules, considered fitting for our study purposes, as well as the BECK Depression Index and a short two-question form with space for feedback. Patients were divided into groups called double incision (DI) and periareolar (PA) depending on the surgical technique used.

RESULTS

We found an overall complication percentage of 31.3%, with the DI group scoring 33.3% and PA 28.6%, while secondary aesthetic corrections were necessary for 50% of all patients. The questionnaires yielded 6 responses (37.5%). Participants rated on a scale of 1 to 10 their willingness to undergo the operation again if given the choice; the DI group averaged 10/10, and the PA group 9/10, despite the statistically significant complication and correction rates.

CONCLUSIONS

Masculinizing chest-wall contouring surgery has significant complication risks. In our study, frequency of complications did not appear to depend on the surgical technique used. Additionally, the complication rates found in our low volume centre seem to be comparable with those reported from bigger units.

Female-to-Male Chest Surgery in Transgender Patients: A Comparison Between 2 Different Techniques and a Satisfaction Study in a Single Center

Background

Gender dysphoria is a distress caused by a mismatch between gender identity and the sex assigned at birth. About 0.5% of the population suffer from gender dysphoria, which represents 25 million people worldwide. Gender-affirming mastectomy is the most common procedure for female-to-male patients.

Objectives

The aim of this single-center retrospective study is to present the outcomes after mastectomy and to evaluate patient satisfaction using the BODY-Q questionnaire.

Methods

Several data regarding patient characteristics and surgery have been collected. A satisfaction survey has been sent to patients. Two groups, "NAC grafts" and "semicircular," have been compared for complications and satisfaction.

Results

A total of 103 patients have had a transgender mastectomy performed by 3 surgeons, representing 206 mastectomies. There were 5 wound infections (4.8%), 8 seromas (6.8%), 10 hematomas (6.8%), and 23 partial/total nipple areolar complex (NAC) necrosis (20.4%). The complication rates in this study are similar to others in the literature. Few studies express interest in patient satisfaction after this type of surgery and even fewer use a suitable questionnaire.

Conclusions

Transgender mastectomy is a safe and often necessary procedure to improve the quality of life of patients suffering from gender dysphoria. Nevertheless, there is currently no validated tool to assess postoperative satisfaction within this specific population group.

Level of Evidence 3

Quantifying Nipple-Areolar Complex Shape and Location After Transmasculine Top Surgery: A Study of Postoperative Photographs Posted on Social Media and Surgeons' Professional Websites

Purpose

The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions.

Methods

In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed.

Results

We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012).

Conclusion

Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.

Association of High Body Mass Index With Postoperative Complications After Chest Masculinization Surgery

PURPOSE

Body mass index (BMI) requirements for transgender and nonbinary patients undergoing chest masculinization surgery (CMS) are not standardized and based on small sample sizes. This is the largest and first national retrospective study to determine the association between BMI and postoperative complications.

METHODS

The National Surgical Quality Improvement Program 2012-2020 was queried for CMS patients. The primary outcome was incidence of at least one complication within 30 days. Secondary outcomes were incidence of major and minor complications. Body mass index (in kilograms per square meter) was categorized as category 0 (<30), 1 (30-34.9), 2 (35-39.9), 3 (40-44.9), 4 (45-49.9), and 5 (≥50). Logistic regression was used to evaluate the association between BMI and outcomes.

RESULTS

Of 2317 patients, median BMI was 27.4 kg/m 2 (interquartile range, 23.4-32.2 kg/m 2 ). Body mass index range was 15.6 to 64.9 kg/m 2 . While increasing BMI was significantly associated with greater odds of at least one complication, no patients experienced severe morbidity, regardless of BMI. Patients with BMI ≥50 kg/m 2 had an adjusted odds ratio [aOR, 95% confidence interval (CI)] of 3.63 (1.02-12.85) and 36.62 (2.96->100) greater odds of at least one complication and urinary tract infection compared with nonobese patients, respectively. Patients with BMI ≥35 kg/m 2 had an adjusted odds ratio (95% CI) of 5.06 (1.5-17.04) and 5.13 (1.89-13.95) greater odds of readmission and surgical site infection compared with nonobese patients, respectively.

CONCLUSIONS

Chest masculinization surgery in higher BMI patients is associated with greater odds of unplanned readmission. Given the low risk for severe complications in higher BMI individuals, we recommend re-evaluation of BMI cutoffs for CMS patients.

Developing Gender-Affirming Surgery Curricula for Plastic Surgery Residency and Fellowship via Delphi Consensus

BACKGROUND

Gender-affirming surgery (GAS) is a rapidly growing field within plastic surgery, and residents and fellows must receive appropriate training. However, there are no standardized surgical training curricula. The objective of this study was to identify core curricula within the field of GAS.

METHODS

Four GAS surgeons from different academic institutions identified initial curricular statements within six categories: (1) comprehensive GAS care, (2) gender-affirming facial surgery, (3) masculinizing chest surgery, (4) feminizing breast augmentation, (5) masculinizing genital GAS, and (6) feminizing genital GAS. Expert panelists consisting of plastic surgery residency program directors and GAS surgeons were recruited for three rounds of the Delphi-consensus process. The panelists decided whether each curriculum statement was appropriate for residency, fellowship, or neither. A statement was included in the final curriculum when Cronbach α value was greater than or equal to 0.8, meaning that 80% or more of the panel agreed on inclusion.

RESULTS

A total of 34 panelists (14 plastic surgery residency program directors and 20 GAS surgeons representing 28 US institutions) participated. The response rate was 85% for the first round, 94% for the second, and 100% for the third. Out of 124 initial curriculum statements, 84 reached consensus for the final GAS curricula, 51 for residency, and 31 for fellowship.

CONCLUSIONS

A national consensus on core GAS curriculum for plastic surgery residency and GAS fellowship was achieved by a modified Delphi method. Implementation of this curriculum will ensure that trainees in plastic surgery are adequately prepared in the field of GAS.

The Effect of Preoperative Diagnosis of Depression and/or Anxiety on Patient-Reported Outcomes Following Chest Wall Masculinization Surgery

BACKGROUND

Individuals with gender dysphoria have disproportionately high rates of depression and anxiety compared to the cisgender population. Although the benefits of gender affirmation surgery have been well documented, it is unclear whether depression and anxiety affect postoperative patient-reported outcomes (PRO).

OBJECTIVES

The authors evaluated the impact of preoperative anxiety or depression on clinical and PRO in patients undergoing chest masculinization surgery.

METHODS

Patients who underwent chest masculinization surgery within a 5-year period were reviewed. Demographics and clinical variables were abstracted from medical records. PRO of chest, nipple, and scar satisfaction were obtained postoperatively with the BODY-Q. Groups were stratified by preoperative anxiety, preoperative depression, both, or no history of mental health diagnosis. Univariate and multivariate analyses were performed.

RESULTS

Of 135 patients with complete survey responses, 10.4% had anxiety, 11.9% depression, 20.7% both diagnoses, and 57.0% no diagnosis. Clinical data and outcomes were similar. Patients with preoperative depression correlated with lower satisfaction scores for scar appearance (P = .006) and were significantly more likely to report feelings of depression postoperatively (P = .04). There were no significant differences in chest or nipple satisfaction among groups.

CONCLUSIONS

Although anxiety and depression are prevalent in gender minorities, we found no association with postoperative clinical outcomes. Patients with preoperative depression were more likely to report lower satisfaction with scar appearance and feelings of depression postoperatively. However, there were no differences in chest or nipple satisfaction. These results highlight the importance of perioperative mental health counseling but also suggest that patients can be satisfied with their results despite a coexisting mental health diagnosis.

LEVEL OF EVIDENCE: 4

[Thoracic reassignment surgeries]

Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy

Importance

There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments.

Objective

To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy.

Design, Setting, and Participants

For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020.

Exposure

Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy.

Main Outcomes and Measures

Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders.

Results

A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses.

Conclusions and Relevance

In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

Preoperative breast imaging and histopathological findings in chest contouring surgery on transmen

BACKGROUND

Chest contouring is the most common surgical procedure transmen receive. Only a few articles discuss the importance of preoperative imaging and postoperative histopathological analysis of excised breast tissue. We studied the findings of preoperative breast imaging and the results of postoperative histopathological analysis in a clinical setting.

MATERIALS AND METHODS

Data from 220 patients were collected retrospectively from 2005 to 2018. Preoperative imaging modalities and their findings were recorded and classified according to the American College of Radiology Breast Imaging Reporting and Data System. The histopathological findings in breast specimens were categorized based on the World Health Organization Classification of Breast Tumors (5th edition).

RESULTS

Preoperative imaging was performed in 133 (60.5%) patients. Patients in the ultrasound-only group were younger (mean age 22.8) than the other groups (mammogram (MGR) 37 years and MGR+US 35.5 years). Preoperative imaging results were normal in 131 (98.5%) patients. Two patients needed further evaluation. Histopathological results were available on 206 (93.6%) patients. The most common histopathological findings were fibrosis (67.5%), atrophy (34.3%), and chronic mastopathy (14.5%). There were no high-risk or malignant findings.

CONCLUSIONS

The need for further examinations based on routine preoperative imaging was low (1.5%). Therefore, more individualized patient selection for preoperative imaging is justified. There were no high-risk or malignant findings in histopathological analysis, and the occurrence of benign findings was similar to that reported in previous studies. Despite our findings, based on current knowledge, histopathological examination of excised breast tissue can still be recommended. Therefore, future studies are needed to define clear guidelines.

Prospective Evaluation of Psychosocial Changes After Chest Reconstruction in Transmasculine and Non-Binary Youth

PURPOSE

This study sought to prospectively examine the effects of gender-affirming chest reconstruction on gender congruence and chest dysphoria in transmasculine and nonbinary adolescents and young adults.

METHODS

Individuals between the ages of 15-35 who were seeking gender-affirming chest surgery were enrolled as part of a broader, longitudinal study of transgender surgical experiences. Their chest dysphoria and gender congruence were measured at baseline, six months, and one year, using the Transgender Congruence and Chest Dysphoria scales. Repeated measures analysis of variance were used to detect differences in scores across assessment points. Where there were significant differences indicated, Tukey's honestly significant difference test was used to determine which differences in mean scores were significant between assessment points, as well as how results differed by demographic factors.

RESULTS

The analytical sample consisted of 153 individuals who had completed both the baseline and at least one follow-up assessment - 36 (24%) endorsing a nonbinary gender and 59 (38%) under the age of 18. Repeated measures analysis of variance indicated significant differences in gender congruence, appearance congruence, and chest dysphoria between at least two assessment points for the total sample and each subgroup (binary/non-binary and adult/minor). Honestly significant difference tests indicated no significant differences between the postoperative assessments by age or binary gender.

DISCUSSON

Gender-affirming chest reconstruction improves gender and appearance congruence and reduces chest dysphoria in both non-binary and binary populations of adolescents and young adults. These data support the need to improve access to gender-affirming chest reconstruction for adolescents and young adults and to remove legislative and other barriers to care.

A Scoping Review of the Application of BREAST-Q in Surgical Research

Background

Collection of patient-reported outcome (PRO) data can facilitate cost-effective, evidence-based, and patient-centered care. The BREAST-Q has become the gold standard tool to measure PRO data in breast surgery. The last review of its application indicated that it was underutilized. Considering the evolution in breast surgery, the purpose of this study was to perform a scoping review of BREAST-Q application since 2015 and identify emerging trends and potential persistent gaps to guide patient-centered practice and future research in breast surgery.

Methods

We performed an electronic literature review to identify publications published in English that used the BREAST-Q to assess patient outcomes. We excluded validation studies, review papers, conference abstracts, discussions, comments, and/or responses to previously published papers.

Results

We identified 270 studies that met our inclusion criteria. Specific data was extracted to examine the evolution of the BREAST-Q application and examine clinical trends and research gaps.

Discussion

Despite a significant increase in BREAST-Q studies, gaps in the understanding of the patient experience remain. The BREAST-Q is uniquely designed to measure quality of life and satisfaction with outcome and care. The prospective collection of center-specific data for every type of breast surgery will generate important information for the provision of patient-centered and evidence-based care.

Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries

OBJECTIVE

To determine if and how race impacts the 30-day outcomes of gender-affirming chest surgeries.

BACKGROUND

Little is currently known about how race may affect the outcomes of gender-affirming surgeries.

METHODS

We analyzed data from the National Surgical Quality Improvement Program (NSQIP) database of 30-day complications of gender-affirming chest surgeries from 2005 to 2019. All participants had a postoperative diagnosis code for gender dysphoria and at least one procedure code for bilateral mastectomy, bilateral breast reduction, or bilateral augmentation mammoplasty. Differences by racial group were analyzed through Pearson χ 2 and multivariate logistic regression.

RESULTS

There were no racial differences in the all-complication rates for both transmasculine and transfeminine individuals undergoing gender-affirming chest surgeries. Black patients undergoing masculinizing procedures were significantly more likely to experience mild systemic [adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.02-4.65] and severe complications (aOR: 5.63, 95% CI: 1.99-15.98) when compared with White patients. Patients of unknown race had increased odds of experiencing severe complications for masculinizing procedures compared with White patients (aOR: 3.77, 95% CI: 1.39-10.24). Transmasculine individuals whose race was unknown were 1.98 times more likely (95% CI: 1.03-3.81) to experience an unplanned reoperation compared with White individuals. Black transfeminine individuals were 10.50 times more likely to experience an unplanned reoperation (95% CI: 1.15-95.51) than their White peers.

CONCLUSIONS

Although overall complications are uncommon, there is evidence to suggest that there are racial disparities in certain 30-day outcomes of gender-affirming chest surgeries.

Defining sexual dimorphism in masculinizing chest surgery using 3-dimensional imaging

There is no consensus on the ideal scar location and inframammary fold (IMF) placement in the gender-affirming double-incision mastectomy technique. Recent advances in imaging technology have facilitated noninvasive investigations into anatomic variability, in many cases, obviating the traditional approach of cadaveric dissection to answer anatomic questions. A better understanding of chest wall sexual dimorphism may allow surgeons who perform gender-affirming procedures to achieve more natural-appearing results. A total of 60 chests were analyzed using either cadaveric dissection (n = 30) or virtual dissection with 3-dimensional (3-D) reconstructions of computed tomography (CT) images (n = 30) using the Vitrea® software. Chest proportions were recorded using each technique, correlating surface anatomy with muscular and bony landmarks. Cadaveric and 3-D radiography chest analysis revealed that natal male chest walls are, on average, wider and longer than natal female chest walls. The pectoralis major muscle dimensions and the location of its insertion were not found to significantly differ between male and female chests. The male nipple-areolar complex (NAC) tended to be narrower in length and width, with a less projecting nipple than the female NAC. Finally, the IMF was found to lie over the interspace between the fifth and sixth rib in both male and female chests. Our findings confirm natal male and female IMF are positioned between the 5th and 6th ribs. This fact affirms the senior author's technique of masculinizing the chest, keeping the masculinized IMF at approximately the same level as the natal female IMF and following the pectoralis major muscle edges to define the resulting scar in a way that differs from previously reported techniques.

Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review

Importance

Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.

Objective

To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.

Evidence Review

In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).

Findings

In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.

Conclusions and Relevance

In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.

High Self-Reported Satisfaction After Top Surgery in Gender-Affirming Surgery: A Single-Center Study

Purpose

Top surgery, or masculinization of the chest, is often the first and sometimes only procedure in gender-affirming surgery for transgender- and gender-diverse persons assigned female at birth. In recent years, there has been improved access to care for transgender individuals and increased demand for top surgery. Our aim was to investigate the degree of satisfaction with the postoperative outcome after top surgery in transgender men.

Methods

Ninety transgender men who underwent top surgery between September 1, 2013 and August 31, 2018 were included. Patients were surveyed from 5 to 62 months after surgery. Participants' files were evaluated for complications, and 84 (response rate 93.3%) participants answered a questionnaire evaluating patient satisfaction postoperatively.

Results

Patients were either satisfied or partially satisfied with the overall experience of undergoing surgery and the postoperative result in 90.5% of responses. Patients were very satisfied with their clothed appearance in 89.3% of responses, whereas only 44.1% were very satisfied with their nonclothed appearance and 46.4% partially satisfied. Patients were also very satisfied with postoperative scars in 47.6% of responses and nipple reconstruction in 48.8%. Only two patients expressed their regret.

Conclusion

Satisfaction outcomes after top surgery are generally positive, especially in respect of clothed appearance, self-confidence, and self-acceptance.

Effect of Sex Reassignment Surgery on Satisfaction and Quality of Life: A Systematic Review

Gender dysphoria refers to a feeling of awkwardness or discomfort in an anatomically compatible gender role and a desire to have a body of the opposite sex, as well as the negative emotion associated with marked incompatibility between the sex they have and their experienced or expressed gender. It is known that sex reassignment surgeries cause critical changes in the lives of individuals with gender dysphoria. For this reason, it is thought that it is important to follow up individuals before and after surgery. In this systematic review study, it is aimed to examine the effect of sex reassignment surgery for individuals with gender dysphoria on body and sexual satisfaction and quality of life. The framework of the research question was created on the basis of PICOS steps. PubMed, PsycARTICLES and ULAKBİM databases were used in the literature review. The review is based on studies that measure body and sexual satisfaction and quality of life before and after sex reassignment surgery. The study was created using the preferred reporting elements for the PRISMA Statement checklist. The publication year range of the articles evaluated within the framework of inclusion and exclusion criteria among the total articles reached is 2014-2022. The studies were examined in two separate groups: studies on body and sexual satisfaction and studies on quality of life. After examining the articles, it was concluded that sex reassignment surgery increases the body and sexual satisfaction of individuals as well as enhancing the quality of life.

Gender Affirming Mastectomy Improves Quality of Life in Transmasculine Patients: A Single-center Prospective Study

OBJECTIVE

To determine the impact of gender-affirming mastectomy on depression, anxiety, and body image.

BACKGROUND

There are many cross-sectional and ad-hoc studies demonstrating the benefits of gender-affirming surgery. There are few prospective investigations of patient-reported outcomes in gender-affirming surgery using validated instruments.

METHODS

In this prospective study, patients presenting to the University of Michigan for gender-affirming Mastectomy were surveyed preoperatively and 6-months postoperatively. Primary outcomes were patient-reported measurements of anxiety measured by General Anxiety Disorder-7, depression measured by Patient Health Questionnaire-9, body image measured by BODY-Q and Body Image Quality of Life Index, psychosocial and sexual functioning measured by BREAST-Q, and satisfaction with decision measured by BREAST-Q. Linear regression analysis was used to control for presence of complication and existing history of mental health conditions.

RESULTS

A total of 70 patients completed the study. The average age of participants was 26.7. The mean Patient Health Questionnaire-9 score pre-operatively was 7.8 and postoperatively was 5.4 ( P =0.001). The mean preoperative and postoperative General Anxiety Disorder-7 scores were 7.6 and 4.6, respectively ( P <0.001). There were significant improvements in both psychosocial (35 to 79.2, P <0.001) and sexual (33.9 to 67.2, P< 0.001) functioning related to chest appearance as measured by the BREAST-Q and global psychosocial functioning (-15.6 to +32, P <0.001) as measured by the Body Image Quality of Life Index. Satisfaction with chest contour (14.3 to 93.8, P <0.001) and nipple appearance (29.3 to 85.9, P <0.001) measured by the BODY-Q significantly improved. Patients had a mean satisfaction with outcome score of 93.1.

CONCLUSIONS

Patients undergoing gender-affirming mastectomy in this single-center prospective study reported significant improvements in anxiety, depression, body image, psychosocial, and sexual functioning after this procedure. Patients were extremely satisfied with the decision to undergo this operation.

Age-related Outcomes of Chest Masculinization Surgery: A Single-surgeon Retrospective Cohort Study

Many transmasculine individuals face chest dysphoria, an emotional distress associated with breast development. The definitive management for reduction of existing breast tissue and alleviation of chest dysphoria comes in the form of chest masculinization surgery. Over the years, a substantial increase in the number of youth seeking gender-affirming chest masculinization surgery was observed globally. The study was hypothesized to answer the question as to whether the age limit of chest masculinization surgery should be lowered to include adolescents.

Methods

A retrospective cohort study was conducted, based on the experience of a single surgeon over a period of 20 years.

Results

Two-hundred eight patients were included in this cohort. Patients were divided into two equal groups based on their age. No statistically significant differences between the groups were observed in terms of resected breast tissue (P = 0.62 and 0.30, for the right and left breast, accordingly), auxiliary liposuction (P = 0.30), liposuction volume (P = 0.20), procedure (P = 0.15), postoperative drains (P = 0.79), and surgery duration (P = 0.72). Statistically significant differences were found in the 18 years or younger group, with lower rates of complication (P < 0.001), lower rates of revision surgery (P = 0.025), and higher satisfaction rankings (P < 0.001). Apart from age, no other factors were found to potentially explain the different rates of complications between the age groups.

Conclusion

Patients aged 18 or younger opting for chest masculinization surgery experience fewer complications and revision procedures while having higher satisfaction rates with the surgical outcome.

Factors Associated with Experiences of Gender-Affirming Health Care: A Systematic Review

Purpose

Transgender people often pursue gender-affirming health care (GAH), such as hormone therapy and/or surgeries. While research has begun to explore influences on general health care for transgender individuals, less is known about the experiences of GAH specifically. We aimed to systematically review the factors associated with experiences of GAH.

Methods

PubMed, EMBASE, PsycInfo, and Web of Science were systematically searched for relevant literature using a predetermined search strategy. Studies were screened by two researchers to determine whether they fit the inclusion criteria. Following quality appraisal and data extraction, results were thematically analyzed.

Results

Thirty-eight studies were included in the review. Factors associated with experiences of GAH were broadly categorized as follows: (i) sociodemographic factors, (ii) treatment-related factors, (iii) psychosocial factors, and (iv) health care interactions, with health care interactions, in particular, being strong determinants of experience.

Conclusion

Findings suggest that experiences of GAH may be determined by a number of diverse factors, which have implications for understanding how to better support those undergoing transition. In particular, health care professionals play a key role in determining how transgender people experience treatment, which should be considered when providing care for this population.

Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone before Top Surgery Really Necessary?

BACKGROUND

Gender-affirming mastectomy, or "top surgery," has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone before top surgery. This is the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone.

METHODS

This retrospective review included patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, before May of 2019, all patients were required to discontinue testosterone before surgery; all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographic characteristics and postoperative outcomes compared among groups.

RESULTS

A total of 490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients; 104 patients never received testosterone therapy. Demographic characteristics were similar among groups and there was no difference in rates of hematoma (2.9% versus 2.8% versus 2.9%, respectively; P = 0.99), seroma (1.1% versus 0% versus 1%, respectively; P = 0.31), venous thromboembolism (0% versus 0.5% versus 0%, respectively; P = 0.99), or overall complications (6.9% versus 4.3% versus 5.8%, respectively; P = 0.54).

CONCLUSIONS

Our results demonstrate no difference in postoperative complication rates among groups. Whereas further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Health State Utility Values in Patients Undergoing Chest Masculinization Surgery

BACKGROUND

Chest masculinization surgery is the most common gender-affirming procedure performed in transgender and gender-diverse individuals. While evidence on the health-related quality of life (HRQL) impact of chest masculinization is starting to emerge, data on health state utility values (HSUVs) associated with the surgery is largely missing. The objectives of this study were to estimate the HSUVs using EQ-5D for patients seeking chest masculinization surgery and assess the determinants of EQ-5D score at 6 months postoperatively.

METHODS

Patients seeking chest masculinization at a single community plastic surgery clinic by 2 surgeons completed 3 patient-reported outcome measures - EQ-5D-3L, Patient Health Questionnaire (PHQ)-9, and BODY-Q Chest module - preoperatively and postoperatively at 6 weeks and 6-months. Friedman test was used to assess the differences in PROM scores at the 3 timepoints. Simple and backward stepwise regression analyses of 6-month postoperative EQ-5D scores were performed.

RESULTS

A total of 113 patients (mean [SD] age, 25.7 [6.9] years) were included. The mean [SD] EQ-5D scores at preoperative, postoperative 6 weeks and 6 months were 0.81 [0.15], 0.84 [0.15] and 0.87 [0.12], respectively. Postoperatively, problems were most frequently reported in the dimensions "pain/discomfort" and "anxiety/depression". Preoperative PHQ-9 score was a predictor of 6-month postoperative EQ-5D scores following simple (p < 0.01) and backward stepwise linear regression analysis (p < 0.01).

CONCLUSION

Chest masculinization was associated with an improvement in overall HRL at 6 months postoperatively; however, this did not achieve statistical significance. Preoperative depression severity was a significant determinant of postoperative HRL. Consequently, additional support must be offered to patients who have a higher level of preoperative depression.

3D CT Urethrography With Cinematic Rendering (3DUG): A New Modality for Evaluation of Complex Urethral Anatomy and Assessment of the Postoperative Phalloplasty Urethra

OBJECTIVE

To develop an imaging modality for the postoperative phalloplasty urethra. Despite high urologic complication rates after masculinizing genital surgery, existing methods for postsurgical evaluation after phalloplasty have drawbacks. Fluoroscopic studies like the retrograde urethrogram have limitations like user-dependence and need for meticulous positioning but also are inadequate for the evaluation of the anatomically complex postphalloplasty urethra. We developed a novel protocol utilizing CT urethrography with 3D reconstruction using cinematic rendering (3DUG) for neo-urethral imaging.

MATERIALS AND METHODS

Patients who underwent 3DUG after either phalloplasty, metoidioplasty, or prior to revision surgery were included. Low-dose imaging protocols were used to avoid any increases in radiation exposure. The first iteration of our protocol utilized retrograde contrast administration via the penile urethra, whereas the second iteration of our protocol utilized an antegrade technique with contrast instillation via the suprapubic catheter and a voiding scan. Imaging was initially obtained according to symptoms and then per protocol at 3 weeks after urethral lengthening.

RESULTS

Twenty-six patients were included in the series. Among postoperative phalloplasty patients imaged for symptoms, contrast extravasation/fistula was identified in 5 (63%), vaginal remnant in 3 (38%), and stricture in 2 (25%) compared to 5 (45%), 1 (9%), and zero respectively for patients imaged routinely. When intervention was required, operative findings correlated to anatomy on imaging.

CONCLUSION

We present a new protocol for the use of 3D CT urethrography with cinematic rendering for neo-urethral reconstruction. This technique has the potential to improve surgical planning and surveillance of urologic complications in postphalloplasty patients.

Selecting a chest masculinization plastic surgeon: a survey of transgender patients

Background

Chest masculinization is a commonly performed gender-affirming procedure in transmasculine and non-binary patients and has increased in prevalence in recent years despite continued barriers to surgical care. With the expansion of insurance coverage and trained surgeons, patients at times have the opportunity to be selective in choosing their gender-affirming surgeon. This study aimed to investigate factors that transmasculine individuals consider important when selecting their chest masculinization plastic surgeon.

Methods

All patients who underwent chest masculinization with a single surgeon between January 2018 and December 2021 were surveyed via an online questionnaire to rate 21 factors associated with surgeon selection. Multiple-choice questions and free text space were included to further clarify patient preferences. Results were analyzed to rate factors in order of importance.

Results

One hundred three individuals completed the survey, generating a response rate of 49.5%. Average patient age at time of surgery was 27.0 years, and 2.0% of patients had prior gender affirmation surgery (GAS). The top five most important factors were surgeon specialization in GAS, insurance coverage, board certification, number of times surgeon has performed procedure, and availability of Before and After photographs. The five least important factors were age of surgeon, medical publications, availability of YouTube videos, location of training, and surgeon presence on social media.

Conclusions

Transmasculine patients employ distinct criteria when selecting a chest masculinization gender-affirming plastic surgeon. An improved understanding of these factors informs providers of ways to enhance patient access to information and gender-affirming care.Level of evidence: Not gradable.

Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults

Importance

Transgender and nonbinary (TGNB) adolescents and young adults (AYA) designated female at birth (DFAB) experience chest dysphoria, which is associated with depression and anxiety. Top surgery may be performed to treat chest dysphoria.

Objective

To determine whether top surgery improves chest dysphoria, gender congruence, and body image in TGNB DFAB AYA.

Design, Setting, and Participants

This is a nonrandomized prospective cohort study of patients who underwent top surgery between December 2019 and April 2021 and a matched control group who did not receive surgery. Patients completed outcomes measures preoperatively and 3 months postoperatively. This study took place across 3 institutions in a single, large metropolitan city. Patients aged 13 to 24 years who presented for gender-affirming top surgery were recruited into the treatment arm. Patients in the treatment arm were matched with individuals in the control arm based on age and duration of testosterone therapy.

Exposures

Patients in the surgical cohort underwent gender-affirming mastectomy; surgical technique was at the discretion of the surgeon.

Main Outcomes and Measures

Patient-reported outcomes were collected at enrollment and 3 months postoperatively or 3 months postbaseline for the control cohort. The primary outcome was the Chest Dysphoria Measure (CDM). Secondary outcomes included the Transgender Congruence Scale (TCS) and Body Image Scale (BIS). Baseline demographic and surgical variables were collected, and descriptive statistics were calculated. Inverse probability of treatment weighting (IPTW) was used to estimate the association of top surgery with outcomes. Probability of treatment was estimated using gradient-boosted machines with the following covariates: baseline outcome score, age, gender identity, race, ethnicity, insurance type, body mass index, testosterone use duration, chest binding, and parental support.

Results

Overall, 81 patients were enrolled (mean [SD] age, 18.6 [2.7] years); 11 were lost to follow-up. Thirty-six surgical patients and 34 matched control patients completed the outcomes measures. Weighted absolute standardized mean differences were acceptable between groups with respect to body mass index, but were not comparable with respect to the remaining demographic variables baseline outcome measures. Surgical complications were minimal. IPTW analyses suggest an association between surgery and substantial improvements in CDM (-25.58 points; 95% CI, -29.18 to -21.98), TCS (7.78 points; 95% CI, 6.06-9.50), and BIS (-7.20 points; 95% CI, -11.68 to -2.72) scores.

Conclusions and Relevance

Top surgery in TGNB DFAB AYA is associated with low complication rates. Top surgery is associated with improved chest dysphoria, gender congruence, and body image satisfaction in this age group.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Current Practices in the Pathologic Assessment of Breast Tissue in Transmasculine Chest Surgery

BACKGROUND

No guidelines exist regarding management of breast tissue for transmasculine and gender-nonconforming individuals. This study aims to investigate the experiences and practices regarding perioperative breast cancer risk management among the American Society of Plastic Surgery (ASPS) surgeons performing chest masculinization surgery.

METHODS

An anonymous online 19 question survey was sent to 2517 US-based ASPS members in October 2019.

RESULTS

A total of 69 responses were analyzed. High volume surgeons were more likely from academic centers (OR 4.88 CI 1.67 - 15.22; p=0.005). Age ≥40 (85.5%, n=59) and family history of breast cancer in first-degree relatives (68.1%, n=47) or family with a diagnosis before age 40 (71.0%, n=49) were the most common indications for preoperative imaging. 27.5% (n=19) of the respondents routinely excise all macroscopic breast tissue, with 30.4% (n=21) routinely leaving breast tissue. 73.9% (n=51) of respondents routinely send specimens to pathology. There was no significant correlation between surgical volume or type of practice and odds of sending specimens to pathology. High patient costs and patient reluctance (39.1%, n=27, and 35.3%, n=24, respectively) were the most often cited barriers for sending specimens to pathology. 8.7% (n=6) of respondents have found malignant or premalignant lesions in masculinizing breast specimens.

CONCLUSION

Large variation was found among surgeons' perioperative management of chest masculinizing surgery patients regarding preoperative cancer screening, pathologic assessment of resected tissue, and postoperative cancer surveillance. Standardization of care and further studies are needed to document risk, incidence, and prevalence of breast cancer in the transmasculine population before and after surgery.

Evaluation of Life Improvement in Trans Men After Mastectomy: A Prospective Study Using the TRANS-Q

BACKGROUND

Mastectomy is the most common and sometimes the only surgery performed in FtM transgender individuals. In this study, it was aimed to evaluate the improvement in life standards of patients who underwent double incision mastectomy with free nipple-areolar complex graft and periareolar mastectomy by using TRANS-Q in trans men.

MATERIALS AND METHODS

TRANS-Q was performed in 71 trans men at the preoperative and postoperative 1st year, and the revision and complication rates in both groups were compared.

RESULTS

A statistically significant difference was observed in the postoperative satisfaction rates in both groups. We observed that the patients who underwent periareolar mastectomy had significantly higher satisfaction rates than the patients who underwent double incision mastectomy with free nipple areolar complex graft. In both groups, postoperative satisfaction rates were found to be significantly higher.

CONCLUSION

Improvement in life standards has been observed in trans men who underwent mastectomy, and late results should be evaluated with further prospective studies.

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 .

Crowdfunding for Gender-Affirming Mastectomy: Balancing Fundraising With Loss of Privacy

INTRODUCTION

Limitations in insurance coverage may cause patients to turn to crowdfunding to raise money for gender-affirming procedures. In this study, we analyze the impact of Medicaid insurance coverage on gender-affirming mastectomy campaigns posted on GoFundMe.com.

METHODS

Between March 1 and 12, 2021, we accessed GoFundMe.com to analyze available campaigns requesting monetary contributions for gender-affirming mastectomy. Campaigns were identified using the search term "top surgery" followed by the state's name. Duplicate campaigns, campaigns whose primary goal was not gender-affirming mastectomy, and ongoing campaigns were excluded. Campaigns were then categorized according to their state's coverage of gender-affirming surgery: explicit exclusion (EE), explicit inclusion (EI), or no explicit statement of gender-affirming care. We collected data on the number of donors and shares, the fundraising goal, and the total amount raised for each campaign. Common themes within campaign narratives were identified and assessed by each reviewer. Finally, we collected data on the photographs posted by campaign creators.

RESULTS

Our search yielded 790 campaigns, with an overall mean of 58 ± 99 donors and 212 ± 288 shares. The mean fundraising goal and amount raised among all campaigns were $6811 ± $5027 and $2579 ± $3072, respectively. Fundraising goals were most likely to be met in an EI state than an EE state (26.3% vs 8.1%; P < 0.001). The mean amount sought was highest in EE states and lowest in EI states, whereas the mean amount raised was lowest in EE states and highest in EI states. Of the campaigns, 97.1% mentioned personal or situational characteristics in the narrative section; 16.2% of all campaigns expressed negative feelings about posting on GoFundMe.com to raise money for their surgeries.

CONCLUSION

Disparities in health care coverage of gender-affirming surgeries were seen between state categories, with a decreased need for crowdfunding in states explicitly including coverage of gender-affirming surgery. Many transgender patients used crowdfunding to pay for transition-related health care costs, relying on the kindness of strangers and their social network at the expense of their personal privacy. Expansion of legislative coverage of gender-affirming surgeries may alleviate some of this financial burden and reduce transgender patients' reliance on crowdfunding campaigns.

Preoperative Body Image Factors Are Associated with Complications after Breast Reconstruction

BACKGROUND

Psychological factors are broadly understood to contribute to overall health, but their contribution to wound healing is less well defined. Limited data exist on the association of preoperative psychological factors such as body image and postoperative complications. The present study analyzed the association between preoperative body image factors and postoperative complications following breast reconstruction.

METHODS

This was a prospective cohort study of 302 breast cancer patients undergoing breast reconstruction from 2011 to 2015. All patients completed the BREAST-Q; demographics, surgical details, and postoperative complications were recorded. The association of body image factors by means of the BREAST-Q and postoperative complications was analyzed.

RESULTS

On univariate analysis, patients who reported lower preoperative satisfaction with how they appeared in the mirror unclothed, or felt less self-confident or attractive, were significantly more likely to develop an infection postoperatively. Preoperative satisfaction scores were not associated with complications when analyzed in a multivariate fashion. On binomial logistic regression analysis, after controlling for age, body mass index, reconstruction technique, and use of radiotherapy, patients who reported less preoperative satisfaction with how comfortably bras fit or how they appeared in a mirror unclothed were at an increased risk for delayed wound healing.

CONCLUSIONS

Patients with lower preoperative body satisfaction were found to have an increased incidence of infections and delayed wound healing. Although postoperative outcomes are multifactorial, the data suggest that baseline psychological factors such as body image may play a role in postoperative outcomes. Broader use of prehabilitative therapies, targeted at psychosocial factors, may warrant further investigation to optimize postoperative outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.