Gender Affirmation Surgery: A Synopsis Using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases

Breast Reduction Epidemiology and Complications in Nonbinary, Transgender, and Cisgender Adults

INTRODUCTION

Research in gender-affirming chest surgery has primarily compared cisgender versus transgender and gender-diverse (TGD) people, without specifically addressing nonbinary people. This study will assess surgical complications between cisgender, transgender, and nonbinary adults undergoing breast reductions.

METHODS

The National Surgical Quality Improvement Program databases from 2015 to 2021 were used to identify TGD patients who underwent breast reduction (Current Procedural Terminology code: 19318) and cisgender patients who underwent this procedure for cosmesis or cancer prophylaxis. Analysis of variance tests, chi-squared tests, unpaired t-tests, and regression models compared complications among cisgender, transgender, and nonbinary patients.

RESULTS

A total of 1222 patients met the inclusion criteria: 380 (31.1%) were cisgender, 769 (62.9%) were transgender, and 73 (6.0%) were nonbinary. The proportion of TGD patients grew significantly relative to cisgender patients over the study period (P < 0.001). The overall all-cause complication rate was 3.4%, with 4.2% of cisgender, 1.4% of nonbinary, and 3.1% of transgender patients experiencing surgical complications. After adjusting for confounding variables, no statistically significant difference was observed in all-cause complication rates between the cohorts. In the sample, 19 transgender patients (2.5%) underwent reoperation. Transgender patients had a lower likelihood of wound complications (odds ratio: 0.172; 95% confidence interval: 0.035-0.849; P = 0.031) compared to cisgender patients and nonbinary patients. None of the patients experienced a severe systemic complication.

CONCLUSIONS

The findings emphasize the growing demand and safety of gender-affirming breast reductions. They underscore the importance of continued research and tailored approaches to delivering care to nonbinary and transgender patients, addressing their diverse needs and improving access to gender-affirming surgeries.

Temporary Declines and Demand Resurgence: Gender-Affirming Surgery Volume and Complication Trends During and After the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic prompted surgical volume reductions due to lockdown measures. This study evaluates COVID-19's impact on gender-affirming surgery (GAS) volume and complications from the pandemic onset through the recovery period.

METHODS

The 2019-2021 National Surgical Quality Improvement Program databases were queried for transgender or gender-diverse patients using ICD-10 codes. Five time periods were analyzed: Pre-pandemic, Immediate pre-pandemic and COVID-19 outbreak, Initial COVID-19 peak, Pre-COVID-19 vaccine, and Post-vaccine release. Complications included reoperation, urinary tract infections, and wound complications. Multivariate logistic regressions assessed factors associated with undergoing surgery during the initial COVID-19 peak and experiencing surgical complications.

RESULTS

Out of 2,963,230 patients, 4637 underwent GAS between 2019 and 2021. Chest feminizing and masculinizing procedures comprised 60.1% of all GAS. During the initial COVID-19 peak, all GAS surgeries nearly halved, with breast augmentations dropping to 15.3% of pre-pandemic volumes. White patients constituted a significantly higher proportion of GAS patients during the initial COVID-19 peak than in 2019 (74.7% vs. 61.0%, p = 0.014). Post-vaccine, GAS levels surged, exceeding pre-pandemic volumes by 45.5% and initial peak levels by 188.5%. The overall complication rate was 4.9%, and was significantly associated with older age, increased operative time, feminizing and masculinizing genital surgeries, and hysterectomies. The initial COVID-19 peak showed no significant correlations with surgical complications.

CONCLUSIONS

GAS volume temporarily decreased during the initial COVID-19 outbreak and has since rebounded and surpassed pre-pandemic levels, corresponding with past-decade trends. Complication risks remained consistent despite the pandemic, though the results highlight potentially significant race-based disparities in GAS access during COVID-19.

IMPORTANT POINTS

During the COVID-19 pandemic, public health measures led to severe volume reductions in gender-affirming surgical (GAS) procedures. Since the initial COVID-19 peak, GAS volumes have fully recovered and surpassed pre-pandemic volumes. Surgical complication rates for various GAS procedures were within expected ranges, emphasizing the overall safety of these surgeries. The study's results highlight racial disparities in undergoing GAS during the COVID-19 pandemic, with White patients disproportionately represented among those who had surgery during the COVID-19 lockdown.

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 .

Vaginal Preservation in Shaft-Only Phalloplasty: Y-to-V Advancement Technique for Clitoral Hood Redundancy and Reduction Labiaplasty

SUMMARY

As the prevalence and understanding of genital gender-affirming surgery have grown, so has the spectrum of surgical techniques to better serve a wider range of transgender and nonbinary individuals. Given the diverse spectrum of individuals seeking phalloplasty, patient-driven decision-making, beginning with the initial consultation, is critical. Phalloplasty is not a one-size-fits-all surgery, but instead should be viewed as an individually customized approach. This article discusses the technical details of vaginal preservation without scrotoplasty or clitoral tissue burial in a shaft-only phalloplasty. The technique involves degloving the clitoral shaft with inset at the ventral base of the phallus, addressing the redundant clitoral hood, and accompanying reduction labiaplasty with a Y-to-V adjacent tissue transfer. The phallus may be neurotized with clitoral nerves from one side of the clitoris and/or the ilioinguinal nerve. This technique obliterates the degloved clitoral hood and resuspends the labia minora anteriorly, improving final aesthetics and striving to meet the patient's genital goals.

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.

Gender dysphoria and gender-affirming surgery: The New York state experience

BACKGROUND

Transgender and gender nonconforming (TGNC) individuals experience incongruence between their self-identified gender versus their birth-assigned sex. In some cases, TGNC patients undergo gender-affirming surgical (GAS) procedures. Although GAS is an evolving surgical field, there is currently limited literature documenting patient characteristics and procedures. Addressing this knowledge gap, this retrospective cohort analysis described the characteristics of New York State's TGNC residents with gender dysphoria (GD) diagnosis, including patients undergoing at least one gender-affirming surgical procedure.

METHODS

Using the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2002 to 2018, we identified patients' first-time TCNC records and their risk characteristics. Patients who received GAS procedures were sub-classified as top-only, bottom-only, or combined top/bottom procedures and were compared with TGNC patients who did not receive GAS.

RESULTS

Of 24,615 records extracted from TGNC SPARCS database, 11,427 (46.4%) were transmasculine (female-to-male) and 13,188 (53.6%) were transfeminine (male-to-female). Overall, 2.73% of transgender patients received at least one GAS procedure. Of these patients, 78.2% had masculinizing and 21.8% had feminizing surgeries. After a diagnosis of GD, the positive predictors for a GAS-based procedure included female birth sex, pediatric age (<18 years) or older age (60+ years), commercial insurance coverage, and Hispanic race. In contrast, negative GAS predictors included male birth sex and government insurance coverage (i.e., Medicare and Medicaid).

CONCLUSIONS

Compared with transgender women, transgender men were more likely to receive at least one GAS procedure. Because the race, ethnicity, and payor status of TGNC patients can impact GAS treatment rates, additional research is warranted to examine post-diagnosis GAS treatment disparities among TGNC patients.

Pain mechanisms in the transgender individual: a review

Specific Aim

Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research.

Methods

A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research.

Results

While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain.

Conclusions

While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.

Trends in Gender-Affirming Surgeries in the United States from 2010 to 2021

Introduction:  In 2017, an estimated 1.6 million adults and 150,000 teenagers identified as transgender in the United States. With ever-changing legislative developments regarding health care benefits for this population and the increasing number of patients presenting for gender-affirming surgery (GAS), there is a scarcity of literature on the temporal trends within the past decade. The objective of this study was to examine the temporal trends of the utilization of GAS. Methods:  We conducted a cross-sectional study using TriNetX, a federated research network containing deidentified aggregate patient data. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients with a diagnosis of gender dysphoria who underwent GAS from 2010 to 2021. Basic demographic information and complications were analyzed. Complications of interest included site failure, infection, and systemic complications. Results:  We identified a total of 8,403 patients who underwent GAS between January 2010 and December 2021. The number of procedures per year increased nearly 500% between 2016 and 2021 from 421 procedures to 2,224 procedures. Our demographic results were consistent with previous survey-based studies. The average age of patients who underwent masculinizing surgeries was consistently younger than those who underwent feminizing surgeries. Most patients undergoing GAS were of white race. The overall complication rate was 4.7%. Conclusion:  In conclusion, our study reveals a significant and rapid rise in the utilization of GAS in the United States, with a fivefold increase in procedures between 2016 and 2021. The demographic characteristics and low complication rates observed highlight the evolving landscape of health care for transgender individuals and the need for ongoing assessment and support in this field.

[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.

Racial Disparity in Gender Affirming Surgery: A Comparative Study on Plastic Surgeon Social Media Use

In the past 5 years, social media use among plastic surgeons has grown to become a common modality used to promote one's practice. However, surgeons lack the necessary ethical training to understand how their published content impacts patient opinions and behavior. Social media trends among plastic surgeons may contribute to the reduced rate of Black (non-White) patients accessing gender affirming surgery.

Methods

In total, 250 gender affirming surgeons and 51,698 individual posts from social media platform, Instagram, were manually extracted and analyzed. Posts were assessed for inclusion and categorized by the subject's skin color (White versus non-White) using the Fitzpatrick scale.

Results

Of the 3101 included posts, 375 (12.1%) portrayed non-White subjects. Of the 56 included surgeons, White surgeons were found to be 2.3 times less likely to include non-White subjects in their posts, compared with non-White surgeons. Regionally, surgeons practicing in the Northeast had the most racially diverse social media accounts, with over 20% of all posts including a non-White subject. Analyzing data over the past 5 years demonstrated no relative increase in the amount of non-White subjects being displayed on social media, while social media use by gender affirming surgeons had increased by over 200%.

Conclusions

The low number of non-White individuals portrayed by surgeons on social media perpetuates the racial disparity seen in patients accessing gender affirming surgery. Surgeons must be conscious of the demographic they portray on social media, as a lack of representation may influence patients' self-identify and decision to utilize gender affirming surgical treatment.

Thinking like a Lawyer-Human Rights and Their Association with the Plastic Surgeon of Today

Plastic surgeons are trained to perform a wide repertoire of surgeries-ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal interpretation falls within the remit of legal experts. However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights (ECHR). LEVEL OF EVIDENCE V: "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 ."

Patient reported symptoms and adverse outcomes seen in Canada's first vaginoplasty postoperative care clinic

IMPORTANCE

Vaginoplasty is a relatively common gender-affirming surgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery.

OBJECTIVE

To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective chart review of the first 80 patients presenting to a gender-affirming surgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables.

RESULTS

The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%).

CONCLUSIONS AND RELEVANCE

Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.

Gender Affirmation Surgery on the Rise: Analysis of Trends and Outcomes

Purpose: Gender-affirming surgery (GAS) has become an important component of the treatment of gender dysphoria. Although the frequency of these procedures is on the rise, a complete safety profile has yet to be established. The goal of our study is to analyze the trends and outcomes of these surgical procedures. Methods: All patients with a primary diagnosis of gender dysphoria undergoing GAS were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between the years 2009 and 2018. Patient demographics and 30-day postoperative outcomes were recorded. We performed a multivariate logistic regression for postoperative complications, controlling for several confounding variables. Results: We identified 2956 patients, of which 1767 (59.78%) were transgender men and 1189 (40.22%) were transgender women. The number of patients undergoing GAS per year increased from 7 in 2010 to 1069 in 2018, a 152-fold increase. For patients undergoing top surgery, Black race (odds ratio [OR] = 2.255, 95% confidence interval [CI] 1.189-4.277, p = 0.013) and diabetes (OR = 4.156, 95% CI 1.571-10.999, p = 0.004) were independent predictors of 30-day postoperative complications. For patients undergoing bottom surgery, total operative time in minutes (OR = 1.005, 95% CI 1.003-1.007, p = 0.001) was an independent predictor of 30-day postoperative complications. Conclusion: The demand for GAS has increased exponentially since 2014. While postoperative complication rates are acceptable, Black race was shown to be an independent predictor of postoperative morbidity in patients undergoing top surgery, a finding that calls for further investigation of racial disparities among transgender patients.

Health Insurance Prevalence Among Gender Minority People: A Systematic Review and Meta-Analysis

Purpose

Gender minority (GM) (people whose gender does not align with the sex assigned at birth) people have historically been insured at lower rates than the general population. The purpose of this review is to (1) assess the prevalence of health insurance among GM adults in the United States, (2) examine prevalence by gender, and (3) examine trends in prevalence before and after implementation of the Affordable Care Act.

Methods

Published articles from PubMed, EMBASE, and Web of Science databases before April 26th, 2019, were included. This review is registered on PROSPERO (CRD42019133627). Analysis was guided by a random-effects model to obtain a meta-prevalence estimate for all GM people and stratified by gender subgroup. Heterogeneity was assessed using a Q-test and I 2 measure.

Results

Of 55 included articles, a random pooled estimate showed that 75% GM people were insured (95% confidence interval [CI]: 0.71-0.79; p<0.001). Subgroup analysis by gender determined 70% of transgender women (95% CI: 0.64-0.76; p<0.001; I 2=97.16%) and 80% of transgender men (95% CI: 0.77-0.83; p=0.01; I 2=54.51%) were insured. Too few studies provided health insurance prevalence data for gender-expansive participants (GM people who do not identify as solely man or woman) to conduct analysis.

Conclusion

The pooled prevalence of health insurance among GM people found in this review is considerably lower than the general population. Standardized collection of gender across research and health care will improve identification of vulnerable individuals who experience this barrier to preventative and acute care services.

Recognizing Racial Disparities in Postoperative Outcomes of Gender Affirming Surgery

Purpose: Given the increasing frequency with which gender affirming surgery (GAS) is performed, understanding risk factors for poor outcomes is imperative. Recent investigations highlight inferior health outcomes experienced by Black transgender and gender expansive (TGE) individuals. Herein, we evaluate the relationship between race and postoperative outcomes in TGE patients undergoing GAS, utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Methods: We conducted a retrospective review of ACS NSQIP from 2010 to 2018. Patients with a primary diagnosis of gender dysphoria undergoing GAS were identified and grouped by race. Patient characteristics and 30-day postoperative outcomes were recorded. Univariate analysis was used to compare patient characteristics and postoperative outcomes across groups. Multivariate logistic regression was used to determine independent predictors of complications. Results: We included 2308 patients (1780 White, 419 Black, 109 Asian). Gender, body mass index, smoking status, and type of surgery performed differed significantly between groups (p < 0.001). Univariate analysis revealed significant differences in 30-day readmission and organ space surgical site infection (SSI) across groups (p = 0.03). Multivariate logistic regression, adjusted for confounders, revealed that Black patients had higher odds of reoperation (odds ratio [OR] 1.82, p = 0.047), 30-day readmission (OR 2.46, p = 0.003), and organ space SSI (OR 4.65, p = 0.024) than White patients. Conclusion: We found that race was an independent predictor of important short-term postoperative outcomes in GAS. Inclusive clinical research, effective engagement with the TGE community, and surgery-specific enhanced recovery after surgery protocols may help address disparities, but we must acknowledge race as a social determinant of health.

Building a gender-affirming surgery service: The fundamentals

BACKGROUND

As the healthcare needs of transgender patients become increasingly recognized and supported, gender-affirming surgery services are in increasing demand. However, establishing a gender-affirming surgery service is unlike many other surgical specialties and requires unique expertise and administrative support. The aim of this article is to outline the considerations for starting a gender-affirming surgery service and identify pearls for success.

METHODS

In this article, we describe the critical components of building and maintaining a successful gender-affirming surgery service. We intersperse findings from our own experiences developing a gender-affirming surgery service.

RESULTS

A successful gender-affirming surgery service starts by developing a clear vision of the patient population within your hospital system's area, as well as the design of your center. Establishing a center relies on early engagement of hospital administration and its continued support. A multidisciplinary team with intensive interpersonal and operative training offers the best patient experience and surgical outcomes. By following these steps, our service has been able to provide gender-affirming surgery to more than 200 patients since its inception. Future goals entail partnerships with other institutions and continued outcomes evaluation to ensure sustained success of all gender-affirming surgery services.

CONCLUSION

Although there are unique challenges and considerations for establishing a gender-affirming surgery service, careful planning and stakeholder engagement allow providers to deliver high-quality care. We hope that our experience can serve as a model for future much needed gender-affirming surgery services.

Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review

BACKGROUND

Feminizing and masculinizing hormone treatments are established components of management in transgender patients. Exogenous hormones have been associated with hemostatic effects, which are well-studied in cis-gender individuals on hormone replacement therapy (HRT). Unfortunately, comprehensive understanding of their effects on venous thromboembolism (VTE) risk in the transgender population is lacking.

AIM

This manuscript aims to identify the risk of VTE among transgender individuals undergoing cross-sex hormone therapy.

METHODS

A Systematic review of the literature was performed in March 2020 for studies reporting VTE rates in transgender patients undergoing hormone treatment and rates in cis-gender patients on HRT. Data regarding demographics, hormone therapy, and VTE incidence were collected and pooled for analysis.

OUTCOME

The primary outcome of interest was the development of a VTE event in association with concurrent hormone administration.

RESULTS

Overall, 22 studies were included with 11 reporting VTE rates among transgender patients, 6 in cis-female patients, and 5 in cis-male patients. Data from 9,180 transgender patients (6,068 assigned male at birth [AMAB] and 3,112 assigned female at birth [AFAB]) undergoing hormone treatment and 103,713 cis-gender patients (18,748 female and 84,965 male) undergoing HRT were pooled. The incidence of VTE was higher in AMAB patients compared to AFAB patients (42.8 vs 10.8 VTE per 10,000 patient years; P = .02). The rate of VTE incidences in AMAB patients appears similar or higher than the rate demonstrated in cis-females on HRT. VTE incidence in AFAB patients, however, is similar to the published rates in cis-males on HRT.

CLINICAL IMPLICATIONS

AMAB patients on hormone therapy have higher VTE rates than AFAB patients. AMAB and AFAB patients may have similar VTE incidence to cis-female and cis-male patients on hormone replacement therapy, respectively.

STRENGTHS & LIMITATIONS

This is the first study to aggregate and quantify the development of VTE events in association with hormone therapy in transgender patients. It places these values in the context of rates published in more widely studied populations. It is limited by its retrospective data and heterogenic data.

CONCLUSION

Surgical planning regarding perioperative and postoperative VTE prophylaxis or cessation of hormone therapy should take into account each patient's Caprini risk assessment and the nature of each intervention. Kotamarti VS, Greige N, Heiman AJ, et al. Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review. J Sex Med 2021;18:1280-1291.

Health Equity and Healthcare Disparities in Plastic Surgery: What We Can Do

Amidst the unexpected losses and challenges of 2020, healthcare disparities and health equity have presided as noteworthy topics of national discussion among healthcare workers, governmental officials, and society at large. Health equity, defined as the opportunity for everyone to be as healthy as possible, may be achieved through the alleviation of healthcare disparities. Healthcare disparities are defined as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations." While these concepts may be perceived as a departure from the core responsibility of plastic surgeons, it is of paramount importance to recognize how race, socioeconomic status (SES), and physical environment impact access to care, surgical outcomes, and postoperative recovery for vulnerable populations. In this communication, our purpose is two-fold: 1) to elucidate the existent healthcare disparities and associations with race and SES in craniofacial, trauma, breast, hand, and gender-affirming reconstruction; and 2) provide tangible recommendations to incorporate the concepts of health equity and healthcare disparities in clinical, research, community, and recruitment settings for plastic surgeons. Through such knowledge, plastic surgeons may glean important insights that may enhance the delivery of equitable and accessible care for patients.

Association of Chest Dysphoria With Anxiety and Depression in Transmasculine and Nonbinary Adolescents Seeking Gender-Affirming Care

PURPOSE

The purpose of this study was to determine the existence and strength of association between chest dysphoria and mental health in transmasculine and nonbinary adolescents.

METHODS

This is a cross-sectional cohort study of transmasculine and nonbinary adolescents designated female at birth between 12 and 18 years old. None had undergone prior top surgery. Patients complete the Chest Dysphoria Measure and Youth Inventory-4 (YI-4) upon presentation to our institution. Outcomes were retrospectively reviewed. The primary outcome of interest was the association between chest dysphoria and anxiety and depression symptom severity, as measured by the YI-4.

RESULTS

One hundred fifty-six patients met inclusion criteria. Mean age was 15.3 years (standard deviation [SD] = 1.7). Most patients identified as transmasculine (n = 132); 18 identified as nonbinary and 6 as questioning. Mean (SD) YI-4 symptom severity scores were 10.67 (6.64) for anxiety and 11.99 (7.83) for depression. Mean (SD) Chest Dysphoria Measure composite score was 30.15 (9.95); range 2-49. Chest dysphoria was positively correlated with anxiety (r = .146; p = .002) and depression (r = .207; p < .001). In multivariate linear regression models, chest dysphoria showed a significant, positive association with anxiety and depression, after accounting for gender dysphoria, degree of appearance congruence, and social transition status.

CONCLUSIONS

Chest dysphoria is associated with higher anxiety and depression in transmasculine and nonbinary adolescents designated female at birth. This association is independent of level of gender dysphoria, degree of appearance congruence, and social transition status. Treatment options aimed at alleviating chest dysphoria should be made accessible to adolescents and tailored to individual needs.

Current Trends in Facial Feminization Surgery: An Assessment of Safety and Style

BACKGROUND

Facial feminization surgery (FFS) plays an instrumental role in the process of gender affirmation. These procedures are becoming increasingly appreciated for their ability to improve patient satisfaction and gender identity in a way that alleviates gender dysphoria and improves the quality of life. Despite the recent surge in popularity across the US, the current literature lacks evidence on the safety profile of combined facial feminization procedures. Our goal was to determine the safety profile of facial feminization procedures registered on a national surgical database.

METHODS

Patients with a primary diagnosis of gender dysphoria undergoing facial surgical procedures were identified from the National Surgical Quality Improvement Program database between the years 2013 and 2018. Demographic characteristics along with 30-day postoperative complications were recorded. Logistic regression models adjusted for confounders were used to determine the independent predictors of postoperative complications.

RESULTS

A cohort of 77 patients who underwent a total of 220 procedures was identified. The number of patients undergoing surgery per year increased from three (3.9%) in 2013 to 41 (53.2%) in 2018, a 13.6-fold increase. The most commonly performed procedure was forehead contouring/frontal sinus setback, performed on 52 patients (67.5%), followed by orbital contouring (n = 37, 48%), rhinoplasty (n = 34, 44%), mandibuloplasty (n = 34, 44%), chondrolaryngoplasty (n = 27, 35.1%), genioplasty (n = 11, 14%), brow lift (n = 9, 11.7%), cheek augmentation (n = 9, 11.7%), and lip lift (n = 7, 9.1%). The number of patients who underwent 5 or more procedures in a single anesthetic event was 41 (53.2%). The complication rate was 3.9%. Univariate analysis suggested an association between older age and postoperative morbidity (P  < 0.02). However, this was not found to be an independent predictor on multivariate analysis adjusted for confounders (P < 0.083). Additionally, an increase in operative time and the number of procedures performed during a single anesthetic were not independent predictors of 30-day postoperative complications (P < 0.317 and P  < 0.19, respectively).

CONCLUSIONS

FFS can be safely performed and has a low risk of postoperative morbidity. The number of patients seeking FFS surgery has risen exponentially, with the highest demand seen for the reconstruction of the upper facial third. These findings should guide expectations for patients seeking FFS, as well as for plastic surgeons looking to perform multiple procedures per anesthetic event.

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.

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients

BACKGROUND

Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies.

AIM

To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes.

METHODS

A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image.

OUTCOMES

Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty.

RESULTS

Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004).

CLINICAL IMPLICATIONS

These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males.

STRENGTHS & LIMITATIONS

These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire.

CONCLUSION

Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.

Power-assisted Liposuction and a Single Incision Pull-through Technique for Top Surgery: A Case Report

Various treatment approaches exist for female-to-male subcutaneous mastectomy, also known as “top surgery.” The most commonly performed techniques for patients with decreased volume of breast tissue, no ptosis, and good skin elasticity continue to involve areolar or periareolar incision. Here, we report a case of a 17-year-old patient who underwent top surgery performed through power-assisted liposuction and a non-areolar single-incision “pull-through” technique. Operative management included initial liposuction for contouring of adipose tissue. Surgical subcision of excess breast tissue adherent to the subdermal plane was then performed and removed with a grasp-and-pull motion using the pull-through technique. We obtained a favorable result with low scar burden, preserved nipple sensation, and no nipple contracture. No complications were reported. This procedure is limited for patients with small breast size (A cup, <100 grams of glandular tissue per side), minimal to no ptosis, appropriate nipple size and position, soft fibroglandular tissue, and good skin elasticity.

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.

Navigating Insurance Policies in the United States for Gender-affirming Surgery

Patients with gender dysphoria seeking to undergo gender affirmation surgery are often challenged by lack of insurance coverage. The authors aim to review gender affirmation surgery policies and to highlight discrepancies between qualifying criteria across top insurance companies in the United States.

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).

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.

Variations in Testing for HIV and Other Sexually Transmitted Infections Across Gender Identity Among Transgender Youth

Purpose: Transgender youth are at high risk for human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), but their rates of screening are unknown. This study sought to quantify HIV and other STI testing levels and to examine variations in testing levels across three categories of gender identity: transgender men, transgender women, and nonbinary individuals. Methods: Between June 2017 and June 2018, 186 transgender youth aged 15-24 years were recruited into a randomized trial of home HIV testing supplemented with telehealth-based counseling. Information on sociodemographics, health care utilization, sexual activity, stress and resilience, and history of HIV and other STI testing was obtained. Multivariable logistic regression models were formulated to identify variations in testing for HIV and other STIs across gender identities. Results: Twenty-eight of 186 participants (15.1%) reported testing for HIV in the past year, and 42 (22.6%) reported testing for other STIs. Transgender women were less likely to have been tested for HIV (adjusted odds ratio [aOR]: 0.15, 95% confidence interval [CI]: 0.03-0.78) and other STIs (aOR: 0.33, 95% CI: 0.11-0.99), but nonbinary individuals were equally likely to have been tested compared with transgender men. Participants who agreed that their health care provider is knowledgeable about transgender health issues were thrice as likely to have been tested for HIV (aOR: 3.29, 95% CI: 1.36-7.97) and other STIs (aOR: 3.05, 95% CI: 1.40-6.63) compared with those who disagreed. Conclusion: Low levels of testing among transgender youth highlight the exigency of improving gender- and age-appropriate HIV and other STI prevention services. Given that provider knowledge of transgender health issues was strongly associated with testing, training health care providers in transgender-related care could prove beneficial.