Scientific Abstract Presentations: Gender Affirming 1 Friday, October 27 Fri, Oct 27 2:00-3:30 p.m. CDT

Introduction: Over 1.4 million individuals in the United States identify as transgender or non-binary (TGNB), a large proportion of which seek gender-affirming surgery (GAS).1 One of the greatest barriers to obtaining GAS is the cost, affirming the significant role insurers play in transition.2 The purpose of this study is to determine GAS procedures that are commonly denied among our TGNB population, and whether insurer criteria for coverage limit patient access to TGNB surgical care.

Methods: The authors examined 159 consecutive GAS insurance submissions of a single plastic surgeon (S.D.), 90 of which had documented insurance coverage decisions. Of the 90 submissions, eleven insurance companies were identified as denying coverage for a GAS procedure. Web-based search of each insurer was completed and publicly available policies on top, bottom, and facial GAS were evaluated for coverage decisions and required criteria.

Results: Of the eleven insurance companies that denied a GAS procedure, two (18.2%) had no publicly available policy. The remaining nine insurers had a publicly available policy and statement of coverage for GAS. Compared to all nine insurers covering masculinizing top surgery (MTS) (100%), 77.8% of insurers (n=7) covered breast augmentation (BA) with an average of six required criteria for coverage. Two companies denied BA, stating the procedure was cosmetic and not medically necessary. Feminizing and masculinizing bottom surgery were universally covered (100%), with 6.8 criteria on average. Only one insurer (11.1%) covered facial feminization with eight required criteria. The remaining eight companies (89%) considered the procedure to be cosmetic. Evaluation of criteria among companies yielded eight insurers (88.9%) that denied GAS coverage when under the age of 18, however, two of the denying insurers (22.2%) reviewed adolescent submissions for MTS on a case-by-case basis. Eight companies (88.9%) had requirements for gender-affirming hormone therapy duration, specifically for bottom surgery in five insurers (55.6%). Six insurers (66.7%) required patients to publicly live in their desired gender role for at least twelve months, five of which (55.6%) were specific to bottom surgery. Four companies (44.4%) required evaluation by a mental health provider for other mental health disorders prior to coverage.

Conclusions: Most insurers that denied coverage for a GAS procedure had a publicly available policy for review. Whereas MTS and bottom surgery were universally covered among the companies, BA and facial procedures were often considered cosmetic and medically unnecessary. In general, companies that did provide coverage had multiple criteria outside of the recommendations made by WPATH Standards of Care 7. Discrepancies in what is considered cosmetic, along with multiple criteria required for coverage, create a barrier to receiving surgical care in our state's TGNB community.

1. Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? Los Angeles: the Williams Institute, June 2016
2. Nolan, Ian T.B.M.; Daar, David A. M.D.; Poudrier, Grace B.A.; Motosko, Catherine C. M.D.; Cook, Tiffany E. B.G.S.; Hazen, Alexes M.D. Barriers to Bottom Surgery for Transgender Men, Plast. Reconst. Surg.: March 2020 - Volume 145 - Issue 3 - p 667e-669e.

Introduction: In 2016, the Department of Health and Human Services barred discrimination based on gender identity for federal health system entities, including Medicare and Medicaid. However, in August 2022, the state of Florida took a step in the opposite direction and banned Medicaid coverage of all gender-affirming treatment, including surgery (GAS). The purpose of this project is to determine the effect of this ban on the rate of insurance coverage for patients with both private and public insurance seeking GAS in the state of Florida.

Methods: The authors evaluated 159 consecutive insurance submission forms for GAS in Florida from a single plastic surgeon (S.D.). Of these submissions, 69 lacked a documented decision for insurance coverage and therefore, were excluded. The remaining 90 submissions with a clear statement on coverage status available were categorized into either approved or denied. Chart review of remaining 90 submissions for 85 patients determined the date of insurer decision, type of GAS (top, bottom, facial, other), insurer, individual plan, and possible reasons for denial including a web-search of the insurer website.

Results: Ninety insurance claims were submitted for 85 patients. Overall coverage rate was 80.0%, with top surgery being the most common surgery submitted (n= 66, 73.3%) and covered (n=56, 62.2%). No significant difference was noted in the total rate of coverage provided before and after the Medicaid ban (75.8% vs 82.5%; p=0.4439), though the number of claims submitted to private insurers approached significance (72.7% vs 89.5%; p=0.0752). Of the 33 claims (36.6%) submitted before the Medicaid ban, 24 (72.7%) were submitted to a private insurer and nine were submitted to either Medicare (n=5) or Medicaid (n=4). Fifty-seven procedures (63.3%) were submitted after the ban, with 89.5% of claims (n=51) to a private insurer and 10.5% to Medicare (n=1) or Medicaid (n=5). Overall approval rates declined for top surgery by 8.3% (90.5% to 82.2%) and bottom surgery by 14.3% (100% to 85.7%) following the Medicaid ban. Meanwhile, approval of facial feminization increased by 41.7% (33.3% vs 75.0%; p=0.2657). While the number of top surgery submissions to public insurers remained consistent (n=7 to n=6), submissions for top surgery to private insurers increased after the ban (n=14 to n=39), approaching significance (p=0.0571). Of the eighteen patient insurance denials during the study period, ten (55.6%) patients had identified reasons for denial consistent with the stated policy on the insurers' websites, while five patients were denied for unknown reasons (27.8%).

Conclusions: Approvals among all insurers for top and bottom surgery decreased following the Medicaid ban in Florida. This was contrasted by an increase in both the coverage provided for facial feminization procedures and the number of top surgery insurance claims submitted to private companies rather than public insurers. Though the findings may be limited by the relatively short duration of 5 months of data collection since the ban was passed and possible selection bias, these data suggest that as patients with public insurance may become affected by the new state legislature, the coverage provided by private insurers may be improving.

Purpose Dilator use following vaginoplasty maintains neovaginal patency and prevents neovaginal stenosis. Anecdotally, surgeons and patients may feel driven to incrementally increase (or "size up") dilators quickly following surgery in order to rapidly maximize neovaginal canal dimensions. While postoperative dilating practices are associated with improved post-surgical outcomes and satisfaction,1 there is limited evidence examining the extent of benefit offered by increased neovaginal canal depth and width.

Methods The present study included 426 total postoperative visits of 197 unique patients who underwent primary vaginoplasty with the Mount Sinai Center for Transgender Medicine and Surgery (CTMS), had their first postoperative follow-up visit between 10/31/2017-9/3/2020, and reported introitus depth. The researchers created a Gender Dysphoria Index (GDI), defined as patient-reported gender dysphoria. Preoperative and postoperative GDI (on a 0-10 Likert scale, where 10 is maximum gender dysphoria), neovaginal canal width (in dilator color), and introitus canal depth (in dilator dot) were analyzed. Reduction in GDI was calculated by subtracting postoperative from preoperative GDI; dilator colors and dots were converted to inches. Due to patient-dependent variations affecting the time course between surgery and postoperative clinical visits, data were stratified into four groups by days following vaginoplasty and analyzed using simple linear regression accounting for dilator width and depth as quantitative variables.

Results and Discussion Mean preoperative GDI was 5.77 (±2.82), mean postoperative GDI was 2.76 (±2.20), and reduction in GDI following vaginoplasty was significant (p<0.001). There was no statistically significant association between neovaginal canal depth and GDI reduction across any time point ([0-30 days] p=0.956; [31-90 days] p=0.248; [91-180 days] p=0.573; [181-365 days] p=0.682). Neovaginal canal width at one month and six month postoperative visit time points revealed a weak negative correlation ([0-30] r= -0.0433, p=0.0046; [91-180] r= -0.0121, p=0.03) and may be incidental. Width did not reveal significant correlation with GDI reduction at follow-up visit at the three month and one year time point following primary vaginoplasty ([31-90] p=0.603; [181-365] p=0.605).

Because gender dysphoria has limitations as a quality of life measure among post-surgical transgender patients, GDI is a clinically and analytically useful quantitative tool. There are opportunities for investigations to determine the role neovaginal canal width, depth, external genitalia appearance, trends over time of these variables, or any post-surgical loss play in reducing gender dysphoria and improving patient satisfaction and quality of life.

Conclusions Vaginoplasty significantly reduced gender dysphoria index (GDI) among patients who underwent primary vaginoplasty at CTMS. Across all postoperative visit time points, neovaginal introitus depth and canal width in inches were not meaningfully associated with GDI reduction. These findings indicate that while it is highly likely that undergoing vaginoplasty improves patient quality of life, rapidly maximizing neovaginal canal depth and width postoperatively may not be as substantial.

References 1. Luikenaar, R.A., Santucci, R.A. and DeLeon, A.N., 2022. Vaginal Dilators and Dilating after Vaginoplasty. Context, Principles and Practice of TransGynecology: Managing Transgender Patients in ObGyn Practice, p.119.

Introduction: Top surgery is the most frequently performed gender-affirming surgical procedure.1 Due to many similarities between masculinizing top surgery and mastectomy for malignancy, transgender and nonbinary (TGNB) patients that receive this procedure are likely to experience comparable amounts of postoperative pain. However, in contrast to mastectomy for breast cancer, postoperative pain outcomes have yet to be adequately assessed for top surgery in the transgender and nonbinary (TGNB) community. The purpose of this study is to evaluate postoperative pain and practices for pain management in TGNB patients that receive masculinizing top surgery at our institution.

Methods: Retrospective review identified 50 consecutive patients with documented gender dysphoria that underwent masculinizing top surgery between June 2020 and February 2023. Patients with malignancy, that were cisgender, or those with severe comorbidities were excluded. Information regarding demographics, medical history, surgical technique, anesthetic pain regimens, and available reported pain scores were extracted from documented clinic or operative notes. SPSS v28 was used for statistical analysis.

Results: Fifty patients had a mean age of 28.2 years and BMI of 28.3 kg/m2. Average pain score recorded in the post-anesthesia care unit (PACU) was 3.26, with 38% of patients (n=19) having pain classified as moderate to severe. Preoperative and intraoperative pain regimens did not have a significant effect on PACU pain scores (p>0.151). Patients with moderate and severe PACU pain scores received pain medication in the PACU significantly more often than patients with mild scores (100% vs 31%; p<0.001). The pain score in the PACU was also positively correlated with body mass index (BMI) (p=0.041), with upwards of 30% of patients (n=5) with a BMI greater than 30 reporting pain categorized as severe. Eighteen total patients (36%) reported pain during a follow-up clinic visit. Compared to patients with mild PACU pain score, patients that had moderate or severe pain had significantly more reports of postoperative pain in clinic (45% and 30%; p<0.001) and more medication refill requests (19% vs 6.4%; p<0.001). Patients that self-reported opioid consumption were also 36% more likely to report pain during follow-up visits than the patients that took NSAIDs only (95% CI 0.22-0.50; p<0.001). No significant difference was noted in quantitative pain outcomes between patient age, gender identity, hormone therapy, nipple grafting, incision technique, anesthesia technique, and morphine milliequivalents (MME ) prescribed at discharge.

Conclusions: Outcomes of this study suggest that the pain experienced after masculinizing top surgery can be significant, emphasizing the importance of pain management in the TGNB population. It is possible that TGNB patients are being overprescribed postoperative opioid medications, as taking an opioid medication did not decrease reported pain on patient follow-up. Patient factors such as BMI may also play a role in the amount of postoperative pain that TGNB patients experience., Pprospective studies with greater sample sizes are indicated to identify risk factors for poor pain control and to further characterize the pain experience and optimal treatment for it.

1. Institute TW. How Many Adults and Youth Identify as Transgender in the United States ; 2022.

Background

Area deprivation index, a validated composite measure of neighborhood deprivation, has previously been associated with difficulty accessing surgical care. Access to timely care is especially important in the context of gender-affirming surgery, as prior work has shown that presentation at later ages is associated with worse mental health status among people seeking gender-affirming care.[1] Here we examine whether neighborhood deprivation impacts latency to care and outcomes of patients receiving gender-affirming top surgery.

Methods

Patients who received gender-affirming top surgery between 2019-2022 were included. We collected demographic information, rural-urban commuting area (RUCA) codes, comorbidities, dates of social transition, dates of hormone therapy initiation, dates of surgery, complications, and length of follow-up. National ADI percentiles were determined using 9-digit ZIP codes, based on the 2020 ADI database. Differences in time to hormone therapy initiation and top surgery were assessed using multivariate Cox regressions and outcomes/complications were analyzed using comparative statistics between the patients in the most deprived ADI tertile versus all other patients.

Results

180 patients were included. 40% of patients belonged to the most disadvantaged ADI tertile. Patients in the most disadvantaged tertile were less likely to live in urban areas (p=0.002), more likely to have diabetes (p=0.038), and more likely to be current smokers (p=0.008). Age at social transition was comparable between groups, with a median age of 19 years old (p = 0.421). Average time from hormone initiation to top surgery was 2.19 years in the less disadvantaged group, compared to 2.58 years in the most disadvantaged tertile. Multivariate Cox regression analysis controlling for rurality and age at social transition showed that belonging to the most deprived tertile was associated with greater latency from hormone therapy initiation to top surgery, though this association did not reach significance (Hazard ratio (HR) 0.683, 95% Confidence Interval (CI) [0.464-1.006], p=0.053). Age at social transition was also associated with differences in elapsed time from hormone initiation to surgery, with patients who transitioned between ages 20-30 experiencing shorter latency to surgery than patients who transitioned under 20 (HR 1.709, 95% CI [1.099-2.658], p=0.017). ADI tertile was not associated with differences in latency from social transition to hormone initiation, or from social transition to top surgery (p≥0.224). ADI tertile was not associated with differences in complication rates or length of follow-up (p≥0.104).

Conclusion

Neighborhood deprivation may be associated with increased latency to top surgery following hormone therapy initiation, although this difference is small and may not be clinically significant. Neighborhood deprivation does not appear to impact age at social transition or latency to hormone therapy initiation. Patients from more disadvantaged neighborhoods experience comparable complication rates and follow-up care following gender-affirming top surgery. Investigating reasons for delay between hormone initiation and top surgery in patients from under-resourced areas seeking this care may inform ways to improve access to gender affirming surgical care for all patients.

1. Sorbara JC, Chiniara LN, Thompson S, Palmert MR. Mental Health and Timing of Gender-Affirming Care. Pediatrics. Oct 2020;146(4)doi:10.1542/peds.2019-3600

ABSTRACT BODY: Background: Transgender and non-binary (TGNB) youth experience a high level of depressive symptoms compared to the general population. The combination of gender-affirming hormone therapy (GAHT) and surgery (GAS) during adolescence has been found to alleviate gender dysphoria and steadily improve psychological functioning into young adulthood. This study aimed to evaluate depressive symptoms in adolescent and young adult TGNB individuals over time, relative to start of GAHT and gender-affirming mastectomies.

Methods: Participants were 61 adolescent and young adult TGNB patients receiving gender-affirming medical treatment at Rady Children's Hospital in San Diego. Patients completed the Patient Health Questionnaire-2 (PHQ-2), a brief depression screening tool, at various clinic visits. Using linear mixed effects (LME) modeling we evaluated the relationship between PHQ-2 score and surgery type over time, specifically before and after surgery.

Results: Patients underwent gender-affirming mastectomy either with keyhole mastectomy (28%) or double incision mastectomy with free nipple grafts (72%). We evaluated the impact of time and surgery type subgroups on PHQ-2 scores. LME analyses found that, taken together, time and surgery significantly affected PHQ-2 scores such that scores decreased by about 0.42 ± 0.12 (standard errors (SEs)) over time (p < .0001). Changes in depressive symptoms over time did not significantly differ between surgery type.

Conclusion: Adolescent and young adult TGNB individuals who undergo GAS experience a decrease in depressive symptoms over time. As the number of adolescents seeking gender-affirming care continues to rise, medical providers should be familiar with the impact these medical interventions can have on patients' psychological health.

Purpose:

The overall goal of rhinoplasty as a part of facial feminization surgery (FFS) is to achieve a softening of the face. While the major consideration of rhinoplasty is the removal of stereotypically masculine features from the nose in order to attain a more feminine facial structure, something that is just as important to consider is the ethnicity and racial background of the person undergoing the procedure. Conceptualizations of gender and perception of femininity and masculinity are often informed by concepts of ethnicity.[1] Rhinoplasty techniques have historically mainstreamed ideals of European populations, underrepresenting the more expansive view of aesthetic variations and preferences that exist in other communities. Multiple papers have examined and redefined the aesthetically ideal nose in varying populations, proposing recommendations on how to provide more ethnically congruent surgical outcomes to patients.[2]

This study examined patient-reported outcomes and attitudes within the transgender and gender-diverse Black and African-American populations following facial feminizing rhinoplasty, focusing primarily on patient perceptions of the maintenance of the ethnic congruence of their nasal structure.

Methods:

An anonymous questionnaire was distributed from November 15th, 2021 – February 15th, 2022 to patients ≥ 18 years of age who underwent elective closed or open rhinoplasty as a part of their FFS between 2015 and 2021, from our single institution. Participants ranked items from the validated Rhinoplasty Outcome Evaluation questionnaire and an extended questionnaire on a Likert Scale. Using Python version 3.8, data were summarized using descriptive statistics and t-tests comparing demographic responses and Likert Scale scores were performed, with significance set at p<0.05.

Results:

Forty-five patient responses were collected. The mean age of respondents was 35 years of age, 44 respondents identified as transgender women, and 1 had another identifier. Of the respondents, 44.4% were White, 37.7% were Black/African-American, 20.0% were Native American/Alaska Native, 13.3% identified as multiple races/ethnicities, 4.4 % were Asian/Asian American, 2.2% were Native Hawaiian/other Pacific Islander, and 51.1% identified as having Hispanic or Latino origin or descent. There was no difference in satisfaction between the White and the African-American respondents. When compared to the White cohort, Black and African-American respondents were more likely to desire the preservation of their ethnic features (p=0.02). Surgeon consultation and communication were cited as major reasons that patients had confidence in their surgeon's abilities to perform the rhinoplasty in a way that maintained their ethnic features.

Conclusions:

Over 50% of African-American and Black patients included in this study prioritized the maintenance of their ethnic features as a part of their facial feminizing rhinoplasty. Surgeons can increase patient confidence in their ability to perform a rhinoplasty that preserves patients' ethnic variations using culturally competent consultation and communication that allows ethnic and racial considerations to be a part of conversations surrounding their patients' surgical planning.

References:

1. Plemons E. Gender, Ethnicity, and Transgender Embodiment: Interrogating Classification in Facial Feminization Surgery. Body & Society. 2019;25(1):3-28. doi:10.1177/1357034X18812942

2. Boahene KDO. Management of the Nasal Tip, Nasal Base, and Soft Tissue Envelope in Patients of African Descent. Otolaryngol Clin North Am. 2020;53(2):309-317. doi:10.1016/j.otc.2019.12.007

Purpose: Gender-affirming mastectomies have increased in accessibility over the past decade, with upwards of a 13-fold increase in procedures performed. Further assessment of risk factors, including exogenous testosterone use, would improve patient outcomes. Despite numerous investigations over the past decade, there has not been a consensus regarding a relationship between testosterone use and post-op complications. We aim to further elucidate any association that may exist.

Methods: A retrospective review of patients undergoing gender-affirming mastectomy was conducted over 32 months. The relationship between preoperative testosterone use and post-operative complications and revisions were evaluated.

Results: 228 patients who underwent gender-affirming mastectomy were identified. 210 patients took testosterone preoperatively (92.1%). Mean time on testosterone was 2.49 years (SD 2.16). There was no difference between patients who were on testosterone and those who were not in rates of revisions (p = 0.424) or complications (p = 0.615). There was no difference in time on testosterone for revision or no revision groups (p = 0.189). Time on testosterone was longer for those who had complications (4.34 vs 2.31 years), though not significant (p= 0.08).

Conclusion: Our results show that testosterone use had no significant effects on rates of revisions or complications in gender-affirming mastectomy patients. Additionally, time on testosterone did not have an effect. We suggest that the use of gender-affirming hormones preoperatively is not a contraindication in these procedures. Further research is necessary to assess other risk factors for complications and revisions and to compare results across a range of patients, surgeons, and hospitals.

Background: Rectovaginal fistula (RVF) remains a complex complication following gender affirming vaginoplasty. Multiple RVF repair methods have been described; yet, the optimal approach remains unclear. This review aims to evaluate RVF repair techniques and outcomes following vaginoplasty.

Methods: A systematic review was performed per PRISMA guidelines. Ovid MEDLINE, Ovid EMBASE, Cochrane, and Web of Science were queried for records pertaining to RVF repair following vaginoplasty. Study characteristics, operative details, and demographics were collected. Outcomes included RVF repair method, recurrence rate, and complications.

Results: Among 282 screened citations, 17 articles representing 41 patients were included. RVF repair methods identified included four conservative management approaches (n=12 patients), two non-reconstructive surgical techniques (n=22), 10 reconstructive surgical techniques (n=18). The most common non-reconstructive technique was primary closure with or without fistulectomy (n = 17) followed by ileostomy or colostomy. The most common reconstructive techniques were V-Y full thickness advancement with rectal flap (n=5) and infragluteal fasciocutaneous flap (n=4). Median time to recurrence was 6 months (IQR 7.5). Reported RVF repair complications included RVF recurrence (n=5, 14.7%) and wound complication or dehiscence (n=2, 5.88%). RVF repair success rate was 75.0% (n=9), 54.5% (n=12), and 88.9% (n=16) for conservative management, non-reconstructive techniques, and reconstructive techniques, respectively. Three cases of RVF recurred after non-reconstructive surgery, including ileostomy (n=2) and colostomy (n=1), while two cases of recurrence followed reconstruction.

Conclusion: There remains a high level of variability in the approach to RVF repair following vaginoplasty. Reconstructive surgical techniques may be a more optimal solution without necessitating ostomies, but this decision must be considered in the context of RVF location, individual patient expectations, and clinical presentation.

Introduction
Top surgery, also known as mastectomy and masculinization of the chest wall, is a significant procedure that is commonly pursued by female-to-male (FTM) transgender individuals or males with gynecomastia to improve their body image perception. The number of transgender individuals opting for this surgery often as their sole gender-affirming procedure is rapidly increasing, yet no study has queried a large patient-centered database to evaluate patient satisfaction following the procedure. The aim of this study is to analyze patient satisfaction with top surgery through a systematic analysis of RealSelf and determine if procedure cost plays a role.

Methods
RealSelf.com was queried for patient reviews following chest masculinization surgery. A web scraper application was utilized to extract all relevant tabular data, including date of procedure, overall satisfaction ("Worth It" vs. "Not Worth It"), price, and written comments. An AI natural language tool powered by a neural network rule-based system was then used to perform objective sentiment analysis on all patient reviews. Reviews were classified as either positive or negative with a quantifiable confidence level. Pearson tests were performed to determine correlation between sentiment and price. Mann-Whitney U tests were conducted to identify significant differences in price on overall satisfaction levels.

Results From a total of 363 reviews for masculinizing top surgery, 350 (96.42%) were identified as having overall satisfaction. Satisfied patients also had significantly higher median positive sentiment levels (0.91 vs. 0.56, p<0.001), validating the natural language quantification process. Among patients with overall satisfaction, the median cost of surgery was $7,900 (IQR: 5,950 – 10,000). This was not statistically significant (p=0.927) from the median cost of surgery for patients with overall dissatisfaction was $8,705 (IQR, 7,000 – 9,500). Moreover, Pearson testing did not show any significant correlation between price and strength of positive or negative sentiment regarding the outcomes.

Conclusion
Our study suggests that the quality of outcome and patient satisfaction are not dependent on the cost of the procedure, as there is no significant correlation between a patient's satisfaction with their post-procedure results and the cost of the surgery. Additionally, our analysis of RealSelf reviews, utilizing both individual assessments and natural language quantification tools, indicates a high level of overall satisfaction among patients who have undergone top surgery. The natural language AI tools effectively analyze patient reviews, offering surgeons reliable feedback on patient satisfaction that can be utilized to enhance quality of care.

Background: Rhinoplasty is one of the most commonly performed facial gender-affirming surgeries (FGAS) for transfeminine patients. While surgical techniques for feminization of the nose have been previously described, there is a lack of quantitative data describing the associated anthropometric changes. In this study, we aimed to quantify the changes made with feminization rhinoplasty and describe clinical patient reported outcomes.

Methods: Three-dimensional photogrammetric (VECTRA, Canfield Scientific, Parsippany, N.J.) evaluation of the nose was performed preoperatively and postoperatively in transfeminine patients who underwent FGAS. Additional associated procedures included frontal sinus setback/forehead contouring, brow contouring, hairline advancement, genioplasty, mandibular contouring, malar implants, lip lift, and/or chondrolaryngoplasty. Anthropometric measurements assessed included alar width, nasal tip width, dorsal height, middorsal width, tip projection, nasofrontal angle, and nasolabial angle. Patients were surveyed preoperatively and postoperatively for satisfaction using the FACE-Q Nose module. Paired t-tests were utilized to assess for changes in postoperative measurements and changes in FACE-Q Nose satisfaction scores.

Results: A total of 18 patients underwent FGAS during the study period. The average time between surgery and postoperative three-dimensional images was 7.2 ± 5.7 months. Rhinoplasty in combination with forehead reconstruction (frontal sinus setback and brow contouring) was performed in all 18 patients. Alar width, dorsal height, and middorsal width all decreased significantly (p<0.05). Nasofrontal angle increased by a mean of 3.3° (142.5 ± 8.1° to 145.8 ± 7.0°. p=0.02); there was no significant changes for the nasolabial angle. The mean FACE-Q score for satisfaction with nose increased by 43.0 (36.4 ± 13.0 preoperatively versus 79.4 ± 17.2 postoperatively, p<0.001). The mean scores for satisfaction with facial appearance overall, psychological function, and social function all increased significantly as well (p<0.05).

Conclusion: The main goals in feminization rhinoplasty are to create feminine nasal features and to enhance facial and nasal harmony. We found that decreases in alar width, dorsal height and middorsal width as well as an increase in the nasofrontal angle are correlated with nasal feminization and high patient satisfaction with their nose.

Purpose
Despite the remarkable growth of gender-affirming surgery, most literature remains concentrated within high-income countries (HICs); fewer than one-fifth of the studies come from low- and middle-income countries (LMICs). Transgender or non-binary (TGNB) individuals in LMICs face unique barriers in accessing safe surgical care (1,2). This is the first systematic review assessing preoperative characteristics and postoperative surgical outcomes following GAS in LMICs.

Methods
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, five databases were systematically searched for original studies and case reports on GAS within LMICs. Excluded were: surgeries unrelated to gender affirmation, surgeries performed in HICs, animal studies and secondary studies. Patient demographics, surgical characteristics, and postoperative outcomes were analysed using descriptive statistics.

Results A total of 21 studies with n=3431 patients were included in this review. Mean patient age was 30.2 years. 10 studies (47.6%) were from lower-middle-income countries and 11 studies (52.4%) were from upper-middle-income countries. No studies originated from low-income countries. Of n=3431 TGNB patients included, n=3392 (98.9%) underwent GAS. 8 studies reported on preoperative demographics (38.1%) and 19 studies (90.5%) reported on postoperative outcomes. A total of 9 studies included patients who underwent masculinizing GAS (n=2165, 63.1%) and 12 studies included patients who underwent feminizing GAS (n=1266, 36.9%). The most common masculinizing GAS was metoidioplasty (n=1286/2165, 59.4%), with a caveat that this statistic is driven by a single institution reporting on overwhelmingly metoidioplasty outcomes (n=1286). The most common feminizing GAS was vaginoplasty (n=929/1266, 73.4%). Mean follow-up was 31 months. Of n=2165 patients who underwent masculinizing GAS, n=250/2165 (11.5%) required revision and n=458/2165 (21.1%) experienced at least 1 complication, with the most common being urethral fistula (n=202, 9.3%). Of n=1266 patients who underwent feminizing GAS, 94/1266 (7.4%) required revision and n=188 (14.8%) experienced at least 1 complication, with the most common being flap necrosis (n=33, 2.6%). A total of 12 (57.1%) studies with 2005 patients reported on quality of life and patient satisfaction measures. Of these 2005 patients, 1310 (65.3%) reported improved quality of life and satisfaction following GAS. Of the studies that assessed for post-surgical regret, none of the 216 patients surveyed reported regret. Notably, 2 (9.5%) studies with 15/3431 (0.44%) patients were performed in settings where GAS was not formally legalised.

Conclusions Existing literature on GAS in LMICs remains concentrated in select institutions and is poorly representative of global trends. This indicates the poor access to and lack of robust literature on GAS in LMICs. Nevertheless, the present review demonstrates reports of successful GAS performed in LMICs, with low incidence of complications and revisions. Further research is needed to better understand psychosocial factors, access, and quality of life of TGNB patients seeking GAS in LMICs.

References 1. Ologunde R, Maruthappu M, Shanmugarajah K, Shalhoub J. Surgical care in low and middle-income countries: Burden and barriers. International Journal of Surgery. 2014;12(8):858-863. doi:10.1016/J.IJSU.2014.07.009 2. Scheim A, Kacholia V, Logie C, Chakrapani V, Ranade K, Gupta S. Health of transgender men in low-income and middle-income countries: a scoping review. BMJ Glob Health. 2020;5(11):e003471. doi:10.1136/BMJGH-2020-003471