Scientific Abstract Presentations: Gender Affirming 2 Saturday, October 28 Sat, Oct 28 10:30 a.m.-12:30 p.m. CDT

Simple dilation of urethral strictures has been proven ineffective in the cismale and post phalloplasty populations. However, a novel paclitaxel-coated urethral balloon dilator has shown unexpectedly good results in the treatment of cismale strictures, achieving a shocking 3 year success rate of 77%. This new treatment was applied to an intended 20 patients with post phalloplasty strictures, as a pilot study to determine its efficacy. Most post-phalloplasty urethral strictures are found at the distal anastomosis, at the connection point between the pars fixa (labia minora) and penile (skin flap) urethra. All patients had short strictures in this area that would otherwise would have required open surgical repair. Methods. All patients had pre intervention IPSS (International Prostate Symptom Score) and uroflow determinations. Strictures were dilated up to 24 F with an uncoated balloon dilator, then dilated to 30 F with the paclitaxel coated balloon. Urinary catheters were not placed. Strictures were uniformly tight, narrowly fitting a 0.038 inch guidewire, and with an estimated circumference of 1-3 F. Results: 16 patients completed the study to date. The mean IPSS pre op was 27 (severe symptoms). The mean uroflow maximum was 6 ml/second, including 3 patients who could not void at all and had a suprapubic tube in place for urinary retention. 4/16 (25%) of patients failed definitively and required subsequent open urethroplasty, with a mean followup of 100 days so far (range up to 300 days). Recruitment of an additional 4 patients, and long term followup of treated patients is ongoing. Conclusions. Post phalloplasty stricture patients treated with a paclitaxel-coated urethral balloon dilation had a certain early failure rate of 25%, but in 75% patients, prolonged unobstructed voiding was achieved without the need for open surgical intervention. Longer followup, and better definition of the ideal treatment window after phalloplasty will be required. There are currently no effective nonoperative treatment methods for urethral stricture, and the potential to obviate complicated urethroplasty in this population without the need for open surgery will be a welcome addition to the treatment armamentarium. Even when not curative, balloon dilation was a beneficial as a minimally invasive, safe method to temporize patients with highly symptomatic strictures until curative urethroplasty could be arranged.

Purpose: Enhanced recovery after surgery (ERAS) clinical pathways are a continuously evolving approach to postoperative care that serves to identify factors that delay recovery, and to minimize complications.1,2 Gender Affirming phalloplasty (GAP) is a complex, multi-surgeon operation and patients have intensive postoperative care needs.3,4 Our purpose is to present the phalloplasty ERAS pathway from one of the highest volume phalloplasty practices in the United States, The Crane Center for Transgender Surgery.3,5

Methods and Materials: This ERAS pathway was applied to 121 patients undergoing single stage GAP from January 2021 to December 2022, representing the 10 phalloplasties a month performed by our center; 85 by radial forearm free flap, 35 by anterolateral thigh flap, and 1 by latissimus dorsi flap. Our ERAS pathway including flap monitoring, medications, and activity is summarized.

Experience: Post operative day (POD) 0 includes bedrest, intensive care unit levels of staffing, hourly flap checks and continuous monitoring with T-Stat visible light spectroscopy tissue oximeter. On POD 1, the patient-controlled analgesia pump is weaned to oral narcotics and once it becomes clear the patient will not require an operative takeback, a clear liquid diet and DVT prophylactic enoxaparin is started. POD 2, non-steroidal anti inflammatory medications are begun. Floor status levels of staffing occurs on POD 3 and patient is out of bed to chair with T-stat monitoring while sitting. POD 4 twice daily ambulation with physical therapy begins, T-stat is removed, and transition to all by mouth medications occurs. The patient is discharged from the hospital on POD 5 after: urethral drain and negative pressure wound dressing removal, dressing/suprapubic catheter daily gentamicin irrigation teaching, and suprapubic catheter transitioned from gravity drainage to flip flo catheter valve.

Summary of Results: In our cohort, the average hospital stay was 5.1 days. 93% of patients were able to leave the hospital on or before postoperative day 5.

Conclusions: We present a successful post-phalloplasty ERAS pathway, developed at our high volume center, as a resource for other centers seeking optimal post operative care for GAP patients.

References:

1.) Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery. JAMA Surg. 2017;152(3):292-298. doi:10.1001/jamasurg.2016.4952

2.) Mericli AF, McHugh T, Kruse B, DeSnyder SM, Rebello E, Offodile AC. Time-driven activity-based costing to model cost utility of enhanced recovery after surgery pathways in Microvascular Breast Reconstruction. J Am Coll Surg. 2020;230(5). doi:10.1016/j.jamcollsurg.2020.01.035

3.) Carter EE, Crane CN, Santucci RA. Established and experimental techniques to improve phalloplasty outcomes/optimization of a hypercomplex surgery. Plast Aesthet Res. 2020;2020. doi:10.20517/2347-9264.2020.81

4.) Berli JU, Monstrey S, Safa B, Chen M. Neourethra creation in gender phalloplasty: Differences in techniques and staging. Plast Reconstr Surg. 2020;147(5). doi:10.1097/prs.0000000000007898

5.) Rifkin WJ, Daar DA, Cripps CN, et al. Gender-affirming phalloplasty: A postoperative protocol for success. Plast Reconstr Surg Glob Open. 2022;10(6). doi:10.1097/gox.0000000000004394

Background: Breast neurotization has improved post-operative sensation amongst patients undergoing breast reconstruction after cancer-related mastectomy. (1) Patients undergoing gender-affirming mastectomy with free nipple grafting (FNG) experience similar sensory deficits, however restoration of breast sensation in this population is less well-explored. Our team recently described a technique for targeted nipple reinnervation (TNR) amongst patients undergoing female-to-male (FTM) gender-affirming mastectomies with FNG using direct coaptation and allografts. The purpose of this study is to describe a technique in which TNR with an intercostal nerve autograft may be used for breast reinnervation in patients undergoing gender-affirming mastectomy.

Methods: Using TNR in a gender-affirming mastectomy, the sensory branches of intercostal nerves (T3-T5) are coapted to the dermatosensory elements of the newly positioned free nipple graft. For patients whose donor nerves do not provide sufficient length for direct coaptation, an intercostal nerve autograft is used for reinnervation. An intercostal nerve branch that would otherwise be sacrificed during a mastectomy is harvested and coapted to the donor nerve in an end-to-end fashion. This newly formed complex is then coapted to the newly grafted NAC.

Results: TNR using intercostal nerve autografts allows for breast reinnervation amongst patients undergoing gender-affirming mastectomy when direct nerve coaptation is not possible.

Conclusion: TNR is a novel technique that has the potential to significantly improve post-operative sensation outcomes amongst patients undergoing gender-affirming mastectomy with free nipple grafting. Short-term results demonstrate that the use of autologous intercostal nerve grafts for breast reinnervation improves sensation and decreases the risk of post-operative numbness/neuropathic pain.

(1) Harish V, Haffner ZK, Bekeny JC, Sayyed AA, Song DH, Fan KL. Preserving Nipple Sensitivity after Breast Cancer Surgery: A Systematic Review and Meta-Analysis. Breast J. 2022;2022:9654741. Published 2022 Nov 19. doi:10.1155/2022/9654741

BACKGROUND: Medical conscientious objection is defined as a refusal of healthcare workers to provide patient services that conflict with one's personal, moral, or religious beliefs. Conscientious objection is a federally protected right, which was broadened to include religious-based objections to transgender healthcare in 2020.(1–3) As insurers and healthcare institutions expand their scope to include gender-affirming care, there will be increased exposure of medical trainees to gender-diverse individuals in clinical settings.(4) It is therefore increasingly prudent for physician training programs to consider anticipatory policies on conscientious objection, yet no published literature examines provider objections to gender-affirming healthcare. This study aims to characterize conscientious objection and formal policies related to the care of gender-diverse individuals within relevant subspecialty training programs.

METHODS: A cross-sectional survey was administered to program leadership of accredited plastic surgery and urology residencies from February to March 2023. The survey contained questions regarding trainee exposure to gender-affirming care, content of related institutional policies, and programmatic experience with objections to gender-affirming care. Results were analyzed using descriptive statistics.

RESULTS: Program leadership from 13 plastic surgery (36%) and 23 urology (64%) residencies completed the survey. Many programs incorporated formal didactic training on gender-affirming surgery (83%, n=30) and direct clinical exposure to gender-affirming care (78%, n=27). However, only six programs (17%) were aware of existing institutional policies related to conscientious objection, one of which explicitly included gender-affirming care. Of these respondents, one program's policy was used by faculty and trainees to object to gender-affirming interventions, fertility preservation, and emergency care for gender-diverse persons. Of the programs who did not have or were uncertain of an existing policy (83%, n=30), three (10%) reported incidents of faculty and trainee objection to gender-affirming surgeries and peri-operative care.

CONCLUSION: Many accredited residency training programs in plastic surgery and urology engage in didactic and clinical training related to gender-affirming care, yet few have official policies related to faculty and trainee objection to these services. Although the prevalence of objection is low in this cohort, these incidents do occur and programs may benefit from creating official policies to address objectors. More comprehensive studies are required to understand the impact of conscientious objection and formal protective policies on both healthcare providers and gender-diverse patients.

WORKS CITED: 1.) Fry-Bowers EK. A Matter of Conscience: Examining the Law and Policy of Conscientious Objection in Health Care. Policy Polit Nurs Pract. 2020;21(2):120-126. doi:10.1177/1527154420926156 2.) Keith K. HHS Strips Gender Identity, Sex Stereotyping, Language Access Protections From ACA Anti-Discrimination Rule. Health Aff. https://www.healthaffairs.org/do/10.1377/forefront.20200613.671888/. Published June 13, 2020. Accessed March 2, 2023. 3.) Nondiscrimination in Health and Health Education Programs or Activities, Delegation of Authority. Federal Register. https://www.federalregister.gov/documents/2020/06/19/2020-11758/nondiscrimination-in-health-and-health-education-programs-or-activities-delegation-of-authority. Published June 19, 2020. Accessed March 2, 2023. 4.) Morrison SD, Dy GW, Chong HJ, et al. Transgender-Related Education in Plastic Surgery and Urology Residency Programs. J Grad Med Educ. 2017;9(2). doi:10.4300/JGME-D-16-00417.1

Introduction: Body mass index (BMI) is often used in surgical settings to determine a patient's risk of complication. Some research has identified BMI as a significant surgical risk factor for specific outcomes, while other research has found no associations between perioperative outcomes and BMI alone. In the context of gender-affirming surgeries, which are performed to increase transgender individuals' sense of congruence between their bodies and gender identity, BMI requirements limit access to care for overweight or obese patients. There is a critical need to understand the influence of BMI on surgical risk for this population.

Methods: We conducted a retrospective chart review of the first 250 consecutive gender-affirming masculinizing chest reconstructions performed between 2017 and 2021 at a multi-specialty surgical center housed in a large academic medical institution. The included patients identified as transgender and/or nonbinary, were between 15-35 years old, and had a masculine gender identity. Study data were independently abstracted by 2 separate reviewers to ensure accuracy. Outcomes were chosen from the literature on gender affirming mastectomy and dichotomized for analysis. First, the relationship between (pre)operative factors and BMI was assessed using Pearson's correlation. Outcomes were then analyzed via univariate logistic regression using BMI at surgery as a continuous variable. Multivariate logistic regression was also performed to control for preoperative factors. Finally, the relationship between BMI and surgical satisfaction was assessed using ordinal logistic regression.

Results: Patients were an average of 19.9 (SD: 3.6) years old at surgery. A majority of patients were White and non-Hispanic. 90% of surgeries were performed through double incision mastectomy; the remainder were performed through the periareolar approach. Higher BMI was associated with longer drain stays, larger volume of tissue resected, higher likelihood of having nipple grafts, and lower likelihood of having periareolar surgery. Higher BMI at surgery was statistically significantly related to the likelihood of experiencing dog ears in the intermediate term (p=0.002). Multivariate logistic regression did not reveal any statistically significant impacts of BMI on the likelihood of experiencing complications at any study time points. No other complications were associated with BMI.

Conclusions: Masculinizing chest reconstruction was found to be safe and satisfactory for patients across the range of BMI. As expected, higher BMI was associated with a number of (pre)operative characteristics related to the amount of tissue resected. The only complication more likely to be experienced by patients with higher BMI was dog ears, a largely aesthetic complication without any additional safety concerns. Surgeons offering masculinizing chest reconstructions should inform patients with higher BMIs about what outcomes to expect but should not preclude these patients from having surgery.

Introduction and Objective: With the rise of social media platforms, consumer-style web-based health information has become more accessible to patients. The objective of this study was to analyze the quality, understandability, and actionability of metoidioplasty content on the social media platform YouTube. Methods: A YouTube search for "Metoidioplasty" was conducted, and the first 100 relevant video results were analyzed. Videos greater than 30 minutes in length, non-English speaking, or exclusively showing a surgical procedure were excluded, and 79 videos were analyzed. Each video was characterized by speaker and presenter demographics, channel/video statistics, and clickbait. Completeness was calculated based on what percentage of the categories of anatomy, treatment options, outcomes, benefits, and risks were discussed. A complete video discussed all five topics. Calculated scores for validated DISCERN and PEMAT metrics were the primary outcome variables and were used to quantify the quality, actionability, and understandability. Cut-offs of DISCERN ≥ 3 and PEMAT 75% were used to differentiate between "poor" versus "good/sufficient." Multivariate and univariate logistic regressions were performed to assess associations and the impact of variables on primary outcome variables (alpha < 0.05). Results:
Of the videos analyzed,19 (24%) were of low quality, 78 (99%) had poor understandability, and 79 (100%) had poor actionability. Patients/consumers were the most common content publishers (n=71, 90%) and narrators (n=71, 90%). 5 (6%) contained moderate-high misinformation. Of all the video characteristics analyzed, there was a statistically significant association between completeness and good actionability (OR, 0.64; 95%CI, .012, 6.94; p=0.05). Conclusion: Informational videos available to transgender patients interested in metoidioplasty on YouTube have overall poor quality, actionability, and understandability. In the videos that were complete, content creators were less likely to suggest actionable steps viewers can take to learn more about metoidioplasty. The information that is available to patients on social media influences the patient's ability to make informed decisions on options for gender affirmation. As such, it is essential for physicians to be aware of the quality of content and source of their patient's information. At this time, it is unclear whether the overall lack of high-quality videos and a lack of videos published by accredited physicians and hospitals are attributed to a lack of created content or the preferential display of patient-centered content curated by YouTube's internal algorithm.

Purpose: Sexual orientation, gender identity, and assigned sex at birth (SOGI/ASAB) have been routinely excluded from demographic data collection tools, including in electronic medical record (EMR) systems.1 Many healthcare organizations do not house structured data capture elements for SOGI within their EMR, leading to invisibility and misclassification of sexual and gender minority patients.2 There exist formal calls to standardize and collect this data, as well as strategies for standardization to minimize provider bias, while being affirming for patients.3-5 We assess the ability of adding structured SOGI/ASAB data capture to improve identification of transgender and nonbinary (TGNB) patients compared to using only International Classification of Diseases (ICD) codes and text mining and comment on the ethics of these cohort formation methods.

Methods: We conducted a retrospective chart review to classify patient gender at a single institution using ICD-10 codes, structured SOGI data, and text mining for patients presenting for care between March 2019 and February 2021. Medical records flagged for additional review included any record with one or more of the following: 1) an ICD-10 diagnosis code of gender dysphoria, 2) any record with completed SOGI/ASAB questions, and 3) any clinical note containing a TGNB-related keyword. Charts with ambiguous or conflicting flags received additional review which incorporated manual cross-reference of organ inventories or laboratory values, medical problem lists, medications, and clinical notes. Two independent reviewers performed the chart review. Discrepancies were resolved by a third reviewer. Positive predictive value (PPV) of each identification method was calculated using tabulation of both true and false positives.

Results: 1,530,154 EMR records were queried. Overall, 154,712 contained relevant data fields, and 2,964 were manually reviewed. This approach identified a final 1,685 TGNB patient cohort. PPV was 56.8%, with ICD-10 codes, SOGI data, and text mining having PPV of 99.2%, 47.9%, and 62.2%, respectively. ICD-10, SOGI, and text mining data each exclusively captured 165 (10.3%), 704 (41.8%), and 118 (7.0%) patients; the remainder had multiple signals. Overall, 1343 (79.7%) patients were identified by SOGI data capture. 1,279 false positive records were tabulated. Most false positives were identified when the gender identity field was indeterminate (n=554, 43.3%). After indeterminate patients were removed, the overall and SOGI-specific PPVs improved from 56.8% to 69.6% and 47.9% to 68.4%, respectively.

Conclusions: A defined TGNB cohort yields the ability to analyze health disparities, perform quality evaluation and improvement, and guide cultural competency training to improve patients' access to and experience high-quality equitable healthcare. This is one of the first studies to use a combination of structured SOGI/ASAB data capture with keyword terms and ICD codes to identify TGNB patients. Our approach revealed that though structured SOGI/ASAB documentation was less than 10% in our health system, 1,343/1,685 (79.7%) of TGNB patients were identified using this method. Our study suggests that as health systems implement widely-used and well-structured SOGI/ASAB data capture systems, other methods to identify TGNB patients may be retired. This will require further refinement of SOGI/ASAB selection and wider adoption of its use.

REFERENCES: 1. Reisner SL, Conron KJ, Scout, et al. "Counting" transgender and gender-nonconforming adults in health research: recommendations from the gender identity in US surveillance group. TSQ Transgender Stud Q. 2015;2(1):34-57. 2. Deutsch MB, Keatley JA, Sevelius J. Collection of Gender Identity Data Using electronic medical records: survey of current end-user practices. J Assoc Nurses AIDS Care. 2014;25(6):657-663. 3. Deutsch MB, Green J, Keatley J, et al. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Med Inform Assoc. 2013;20(4):700-703. 4. Nguyen A, Lau BD. Collecting Sexual Orientation and Gender Identity Information: Filling the Gaps in Sexual and Gender Minority Health. Med Care. 2018;56(3):205-207. 5. The Fenway Institute Released New Tools To Help Healthcare Organizations Collect Sexual Orientation And Gender Identity Data To Improve Quality Of Care And Reduce LGBT Health Disparities. Fenway Health Institute.

Purpose: Patients with gender dysphoria face significant health disparities and barriers to care. Transition-related care includes hormonal therapy, mental healthcare, and gender-affirming surgeries. Studies have described favorable surgical outcomes and patient satisfaction, however the degree to which these procedures impact mental health conditions are not fully understood. The purpose of this study was to evaluate the effect of gender affirming plastic surgery on mental health and substance abuse in the transgender population.

Methods and Materials: A national insurance claims-based database was used for data collection. Patients with a diagnosis of gender dysphoria were propensity score-matched for likelihood of undergoing gender affirming surgery (no surgery being the control cohort), based on comorbidities, age and listed sex. Primary outcomes included post-operative antidepressant use and prevalence of mental health conditions.

Results: A total of 3,134 patients with gender dysphoria were included in each cohort. Patients in the surgery group had overall lower rates of mental health conditions, substance abuse and SSRI/SNRI use. Among patients that underwent surgery, the majority of which were female to male procedures (74.7%), with chest masculinization the most common (71.2%). There was an absolute decrease of 8.8% in SSRI or SNRI prescription after gender affirming plastic surgery (p<0.001), and significant decreases in post-operative depression (7.7%), anxiety (1.6%), suicidal ideation (5.2%) and attempts (2.3), alcohol abuse (2.1), and drug abuse (1.9%).

Conclusion: Gender-affirming surgery in appropriately selected gender dysphoric patients is associated with decreased postoperative rates of SSRI or SNRIs use and improved mental health.

Purpose: To determine the outcomes of primary penile inversion vaginoplasty (PIV) performed at a single institution from January 2017 to January 2023. Methods: Retrospective IRB-approved study of 178 patients who underwent primary penile inversion vaginoplasty at a single institution over six years. The study excluded patients who underwent zero-depth vaginoplasty or revision cases. Demographic characteristics, complications, revision, and readmission rates were collected. Minor and major complications were defined, and logistic regression analysis was used to determine odds ratios for factors associated with surgical complications. The data were tested for normal distribution using the Kolmogorov-Smirnov test. BlueSky Statistics software was used for analysis. The median follow-up was 7.38 months. Results: The sample population had a non-normal distribution (p 0.0043). The majority of the patients had an above-normal BMI (60%), while 17% had respiratory comorbidities and 29% were former smokers. The median age at the time of the procedure was 33.87 (26.99, 48.31), the intra-operative vaginal depth reached was 12cm (10.16, 15.24), the surgical time was 3h31 (4h48-7h16), the hospital stay was 5 days (5,6), and the hormone therapy duration was 863 days (543.25, 1360.75). The readmission rate was 8%, and 28% of patients required revision surgery, of which 32% were for both cosmetic and functional purposes. Additionally, 36.5% of patients underwent other gender-affirming surgeries. Major complications were experienced by 24.7% of patients, neovaginal stenosis (13%) being the most prevalent. Rectovaginal fistula was seen in 2 patients (1.1%): one managed intraoperatively, and other was readmitted for surgical management. Minor complications were experienced by 73% of patients, with wound dehiscence (48%) being the most prevalent, they were generally resolved within six months. The logistic regression analysis found that increasing age was significantly associated with increased odds of graft loss occurring (OR=1.04, p=0.002), as well as increased odds of stenosis occurring (OR=1.05, p=0.005). Longer hospital stays were also associated with increased odds of stenosis (OR=1.5, p=0.02) and surgical site infections (OR=1.8, p=0.01) occurring, as well as an increased odds of any major complication occurring (OR=1.7, p=0.005) and wound dehiscence occurring (OR=1.5, p=0.002). Comorbidities such as respiratory and cardiovascular conditions were also significantly associated with increased odds of certain complications occurring. For instance, respiratory comorbidities were associated with increased odds of any major complication occurring (OR=4.1, p=0.001), epidermolysis occurring (OR=4.2, p=0.008), and revision surgery occurring (OR=2.7, p=0.01), while cardiovascular comorbidities were associated with an increased odds of bleeding occurring (OR=18.58, p=0.02). Smoking was found to be marginally associated with increased odds of revision surgery occurring (OR=4.46, p=0.07). Finally, increasing age was found to be associated with increased odds of major graft loss (OR=1.09, p=0.01), while respiratory comorbidities were associated with increased odds of major tissue necrosis (OR=8, p=0.02). Conclusions: These findings suggest that several patient-related factors may increase the odds of surgical complications following this procedure. Overall, major complications are less prevalent, and with early diagnosis and intervention, PIV shows to be a reasonably safe and effective gender-affirming procedure in transfemale patients. It's important to emphasize early, constant, and progressive neovaginal dilation to avoid stenosis.

Introduction: Transgender healthcare is a rapidly evolving multidisciplinary field with exponential growth in recent decades with an estimate of 25 million transgender people worldwide (1,2), therefore a significant number of transgender and gender diverse groups are in constant search of gender-affirming medical/surgical treatment. (2,3) "Top Surgery" or gender-affirming mastectomy has become one of the most common gender-affirming surgery performed (2,3,4). Critical evaluation of techniques and outcomes must be constantly reassessed to offer, not only a loss of breast and skin tissue, but a true contouring chest masculinzation (3,4). The authors presented a 7-year experience with a novel gender-affirming double-incision markings mastectomy (inframammary fold) technique using superthin dermoglandular inferior-pedicle flaps. Objective: Evaluate the safety and outcomes of the authors' "Top Surgery" technique as a surgical alternative with long-term predictable results, establishing a comparison of pre- and post-postoperative quality of life. Methods: A retrospective study was performed in all the transgender male patients who undergo gender-affirming mastectomy between 2014 and 2021 in single Binary and non-Binary multidisciplinary private center. Data analysis included patient's demographic including cross-sex hormone therapy, intraoperative findings, postoperative complications, postsurgical outcomes, and quality of life based on the Breast-Q and Body Uneasiness Test [BUT-A]) (5) surveys results.
Results: A total of 520 subcutaneous mastectomies were performed in 260 transgender male patients. Of those, 353 mastectomies were performed using an author´s technique and 167 were excluded because an alternative technique was done, incomplete surveys or lost during follow-up. Minor complications occurred in % of the patients, hematoma being the most frequent etiology n= 31(8.7%), followed by seroma n=23(6.5%). Partial/total loss of flap were seen in n=8(2.2%), without significant association of age or smoking. Only n=9(2.5%) required secondary revisions. From the GENDER-Q and BUT-A surveys, significant improvements were observed. Conclusions: Our patients cohort demonstrate that gender-affirming double-incision markings mastectomy (inframammary fold technique) technique using superthin dermoglandular inferior-pedicle flaps represents a safe alternative with predictable long-term results with low complication rates and marked increase in quality of life. 1. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. Published 2022 Sep 6. doi:10.1080/26895269.2022.2100644 2. Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 2018;15(4):582-590. doi:10.1016/j.jsxm.2018.01.016 3. Wilson SC, Morrison SD, Anzai L, et al. Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes. Ann Plast Surg. 2018;80(6):679-683. doi:10.1097/SAP.0000000000001354 4. Ammari T, Sluiter EC, Gast K, Kuzon WM Jr. Female-to-Male Gender-Affirming Chest Reconstruction Surgery. Aesthet Surg J. 2019;39(2):150-163. doi:10.1093/asj/sjy098 5. Cuzzolaro M, Vetrone G, Marano G, Garfinkel PE. The Body Uneasiness Test (BUT): development and validation of a new body image assessment scale. Eat Weight Disord. 2006;11(1):1-13. doi:10.1007/BF03327738

INTRODUCTION: Gender differences in frontal sinus morphology and their implications for frontal cranioplasty have been previously described. However, we sought to investigate differences in forehead morphology and frontal sinus characteristics stratified by ethnicity to better inform preoperative planning for gender-affirming facial feminization surgery (FFS).

METHODS: We performed a retrospective review of patients undergoing evaluation for de novo FFS at our institution from May 2019 to February 2023. Patients were included if they had CT maxillofacial images for analysis of frontal sinus characteristics. Preoperative maxillofacial CT scans were analyzed for sinus height, depth and thickness 1, 2 and 3 centimeters from the midline. Degree of lateral orbital hooding, ideal forehead slope – or the expected slope of the frontal bone achieved after setback or recontouring (plane from nasion to a point tangent to the slope of the frontal bone irrespective of the glabella protrusion) – and actual forehead slope (line from nasion tangent to glabellar protrusion) were measured.1 Frequency and distance of protrusion of the sinus beyond the 'ideal slope line'1 (indicator of requiring setback rather than burring alone during cranioplasty) were also recorded. Data were analyzed using ANOVA, Kruskal-Wallis H tests, Mann-Whitney U tests, Spearman's Rank Order, and Chi-Squared tests.

RESULTS: 157 patients (ages 32.0 - 10.0 years) were included in our review. Clinical measurements of brow protrusion (from 16mm) were positively correlated with estimated forehead setback on exam (range 1 to 6mm) (rs=0.9, p<0.001), VSP-predicted forehead setback (range 2.5-6mm, rs=0.5, p<0.001) and actual operative setback (range 2.5-6mm, rs=0.6, p<0.001). Operative setback measurements were positively correlated with CT measurements of frequency of sinus protrusion beyond the ideal forehead slope (U=1221.5, p<0.005), differences between the actual and ideal forehead slope (rs=0.5, p<0.001) and distance of brow protrusion rs=0.5, p<0.001), whereas nasofrontal angle demonstrated a negative correlation with setback measurements (rs=-0.3, p=0.004). When stratified by ethnicity, Asian and Latina patients demonstrated lower clinical measurements of brow protrusion compared to Caucasian and African American patients (A:11 L:12.5 vs C:14 AA:13, p<0.001; p=0.04, respectively). However, there was no significant difference in frontal sinus measurements on CT imaging or operative approach between cohorts.

CONCLUSIONS: Clinical estimations of brow protrusion are accurate predictions of operative frontal setback. Meanwhile, ethnicity does not appear to have a significant influence on frontal sinus measurements or operative plan. Put another way, individual variability within ethnicities is as significant as any differences between ethnicities in regard to these variables. As a result, individualized preoperative planning is recommended to optimize outcomes in frontal bone setback and recontouring.

REFERENCES: 1. Lee MK, Sakai O, Spiegel JH. CT measurement of the frontal sinus - gender differences and implications for frontal cranioplasty. J Craniomaxillofac Surg. 2010 Oct;38(7):494-500. doi: 10.1016/j.jcms.2010.02.001. Epub 2010 Mar 23. PMID: 20335041.

Background: Gender dysphoria, when left untreated, can lead to reduced quality of life and increased rates of depression and suicide.1-3 Current treatments include hormone replacement therapy (HRT) and gender affirming surgeries.4-5 Prior studies on top surgery have evaluated patients who underwent surgical treatment or those who have received HRT alone. None have evaluated the additive effect of surgery and why some patients choose not to undergo 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 financial burden is a common barrier for operation. Methods: Self-reported transgender subjects who were at least 15 years of age and have undergone at least 6 months of HRT were recruited. Those with a history of gender affirming facial or bottom surgeries were excluded. Subjects who have undergone gender affirming top surgery were assigned into the surgery arm, and those undergoing HRT alone were assigned to the hormone therapy arm. All subjects 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 twenty-one eligible subjects completed the survey. Seventy (57.9%) participants were female-at-birth and 51 (42.1%) were male-at-birth. Forty-four (36.4%) participants identified as female, 57 (47.1%) identified as male, while 20 (16.5%) identified as non-binary or gender non-conforming. Within the hormone arm, 83.6% stated desire for surgery and 60.7% declared barriers to surgery, with cost and insurance coverage representing the most common barriers. Subjects in the surgery arm 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 5-point Likert scale by 2.0 points (p3.0 in all categories of breast augmentation and >2.6 for breast reduction on a 4-point Likert scale. Conclusions: Top surgery, in addition to HRT, significantly improves gender congruency and decreases discrimination and abuse, compared to HRT alone. Our data further supports that top surgery can markedly improve someone's life. Unfortunately, barriers including cost and insurance coverage continue to be an obstacle for care.

References: 1. Bockting WO, Miner MH, Romine RE, et al. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103:943–951. 2. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51:53–69. 3. Reisner SL, White JM, Mayer KH, Mimiaga MJ. Sexual risk behaviors and psychosocial health concerns of female-to-male transgender men screening for STDs at an urban community health center. AIDS Care. 2014;26:857–864. 4. American Medical Association House of Delegates. H-185.950 Removing Financial Barriers to Care for Transgender Patients. American Medical Association: Chicago, IL, 2008. 5. S.E. James, J.L. Herman, S. Rankin, et al. The report of the 2015 U.S. Transgender survey National Center for Transgender Equality, Washington, DC (2016)

Purpose: Gender affirming "top" surgery (i.e., chest reconstructive mastectomy or augmentation) is a safe and commonly performed surgery for transgender and gender diverse (TGD) adults.1-2 In 2016, Padula et al. conducted a cost utility analysis (CUA) demonstrating coverage for gender affirming care (including surgery) is cost-effective from the perspective of an insurance provider in the United States.3 In Canada, where medical care is publicly funded and the responsibility of provincial health authorities, the impact of top surgery has yet to be appraised.

Methods: A CUA was performed to examine the incremental cost per quality adjusted life year (QALY) gained, a standardized patient impact measure, associated with receiving top surgery. A Markov model, adapted from Padula et al. (2016), was created using TreeAge software.3 The study population was TGD individuals over 18 years old desiring top surgery. A public health payer perspective was chosen. Given differences in funding between provinces, Ontario was chosen as the base province for the model. Top surgery was compared to no surgery, where each arm included sub-groups with and without hormone therapy (HT). Before entering the Markov nodes, patients were either cycled into the HT branch or the no HT branch after receiving top surgery or not. Once in the Markov node, patients experienced outcomes over one-year cycles for 10 cycles. A half cycle correction was applied to the model. Health care costs and QALYs were outcomes of interest. A cohort size of 1,000 was used to represent a conservative estimate of TGD patients awaiting surgery each year. Costs, utility values, and probabilities were derived from health authority reports and the literature.

Results: Top surgery was cost-effective compared to no surgery over a 10-year time horizon when the impacts of related adverse health states (e.g., psychologic distress, suicidal ideation, and smoking) were considered. Costs were reported in 2022 Canadian dollars. A typical willingness to pay (WTP) threshold of $50,000/QALY was applied. The 10-year incremental cost effectiveness ratio (ICER) was $-81,183.56 per QALY gained. The net monetary benefit (NMB) was $394,050.00. A probabilistic sensitivity analysis demonstrated robustness of the results, finding top surgery was cost-effective in 97.5% of simulations and dominated in 75.4% of simulations.

Conclusions: Over time, provision of top surgery results in a reduction of costs for a public payer system and an improved general health state for TGD adult patients desiring surgical care. These findings may support advocacy efforts to reduce accessibility barriers for TGD patients desiring top surgery.

References: 1. Cuccolo NG, Kang CO, Boskey ER, et al. Masculinizing Chest Reconstruction in Transgender and Nonbinary Individuals: An Analysis of Epidemiology, Surgical Technique, and Postoperative Outcomes. Aesthetic Plast Surg. 2019;43(6):1575-1585. doi:10.1007/s00266-019-01479-2

2. Cuccolo NG, Kang CO, Boskey ER, et al. Epidemiologic Characteristics and Postoperative Complications following Augmentation Mammaplasty: Comparison of Transgender and Cisgender Females. Plast Reconstr Surg Glob Open. 2019;7(10):e2461. doi:10.1097/GOX.0000000000002461

3. Padula W v., Heru S, Campbell JD. Societal Implications of Health Insurance Coverage for Medically Necessary Services in the U.S. Transgender Population: A Cost-Effectiveness Analysis. J Gen Intern Med. 2016;31(4):394-401. doi:10.1007/s11606-015-3529-6

PURPOSE: Demand for gender-affirming surgery among transgender and gender diverse individuals has increased over the past 20 years1; however, patient, provider, and systemic factors often prevent equitable access to these surgeries.2 We performed a scoping review to describe the literature on barriers impacting access and provide a robust evidence base to guide systematic change and future research to improve access to these vital surgeries.

METHODS: A scoping review was conducted utilizing the Arksey and O'Malley framework.3 Seven databases were queried from inception through March 14, 2022 with search strings adapted from previously existing searches based on gender-affirming surgery and barriers of access to care. Three researchers screened titles and abstracts for inclusion, and two researchers conducted full-text screens on the included articles. All conflicts were resolved, and data extracted included study characteristics and barriers of access to gender-affirming surgery.

RESULTS: Our search yielded 5,719 unique articles of which 139 were selected for full-text review and 56 were included. Most studies were observational (n=49) and utilized online research settings (n=36). Articles spanned multiple procedure types including transfeminine (n=24) and transmasculine genital surgery (n=22) and transmasculine (n=22) and transfeminine top surgery (n=17). The most common barriers in accessing gender-affirming surgery included insurance coverage (n=32), finances, including direct and indirect costs (n=31), preoperative medical eligibility and letters (n=19), healthcare provider attitudes (n=15), lack of healthcare provider knowledge (n=15), and lack of patient educational resources (n=14). Additional barriers identified included: availability of surgeons, both the number and those in-network (n=12), fear of surgery, complications, recovery, and stigma (n=10), and uneven geographic distribution of surgeons (n=10).

CONCLUSIONS: While access to gender-affirming surgery has increased over time, significant barriers continue to exist. There is a large opportunity to pursue future research to address and reduce these barriers. Specifically, these data support the need for greater exposure to gender-affirming surgery in medical training programs to increase provider education and the number of practicing gender-affirming surgeons, as well as improve healthcare provider attitudes towards transgender healthcare. In addition, expansion of insurance coverage and standardization of preoperative eligibility requirements should be implemented as they were cited as the most common causes of individuals' lack of access to these critical surgeries.

References 1. Canner JK, Harfouch O, Kodadek LM, et al. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg. 2018;153(7):609-616. doi:10.1001/jamasurg.2017.6231 2. El-Hadi H, Stone J, Temple-Oberle C, Harrop AR. Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care. Plast Surg. 2018;26(4):263-268. doi:10.1177/2292550318767437 3. Arksey H, O'Malley L. scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19-32. doi:10.1080/1364557032000119616

Background Minimizing surgical blood loss is imperative to avoid surgical morbidity and mortality, as well as aesthetic compromise. A pharmacologic prevention employed across multiple surgical specialties is the use of anti-fibrinolytic agents, most commonly tranexamic acid (TXA). Its role in plastic surgery appears promising, however, a paucity of data still exists outside of craniofacial surgery. There are a few articles describing the use of TXA in breast cancer patients undergoing mastectomy or lumpectomy, but at present there is no literature regarding TXA administration in transmasculine chest surgery.

Methods A prospective cohort study was conducted involving transmasculine patients undergoing chest reconstruction surgery for chest dysphoria. The procedures were performed by a single surgeon at a single institution over the course of 8 months (May through January). Patients receiving perioperative TXA were compared to multiple historic control groups. The TXA protocol was 500mg iv prior to incision and 500mg topical prior to incision (500mg TXA mixed into 1L of tumescent solution which was then infiltrated throughout the chest - 500cc each side). Other than TXA administration, all surgeries were performed in the exact same manner with the exact same methods for achieving hemostasis. The primary outcome was significant hematoma requiring intervention at any point during the post-operative and follow up period.

Results 125 consecutive patients (250 breasts) who received perioperative TXA were studied over a 8 month period. The control groups included historical cases that did not receive TXA (125 consecutive patients per 6-8 month time block for each of the past 5 years). The average hematoma rate was 3.5% in the control groups compared to .8% in the TXA group (1 hematoma in the entire cohort).

Conclusion The combined use of TXA intravenously and topically in transmasculine chest surgery significantly reduced hematoma rates. The promising results of the study thus far encourages the ongoing expansion of TXA indications in plastic surgery.

Introduction: In recent years, there has been increasing demand for facial feminization surgery (FFS) as insurance coverage and access to care have improved and transgender females increasingly seek surgery to address their gender dysphoria. This study presents our experience at a major academic hospital with partial-FFS (P-FFS) and single-stage full-FFS (F-FFS), with particular focus on surgical planning and the alignment of patient goals and expectations.

Methods: A retrospective review of the electronic medical record was carried out for all patients 18 and older diagnosed with gender dysphoria who were referred to the senior surgeon for FFS between January 2019 and December 2022. Patients were grouped as either P-FFS, when a multi-stage operative approach was taken, or F-FFS, when the upper, middle, and lower facial thirds were addressed in a single anesthetic event.

Results: We identified 200 patients who underwent FFS. The majority had P-FFS, as these patients preferred to acclimate to their post-surgical facial features before making a decision to have additional FFS. Virtual surgical planning was employed in all cases and helped clarify and align patient goals and expectations. Patients from both groups were highly satisfied with their outcomes.

Conclusions: Both P-FFS and F-FFS are safe and reliable approaches to gender-affirming surgery that each confer specific advantages to patients and surgeons. A staged approach to FFS benefits from virtual surgical planning and allows for a less invasive and more personalized approach to facial gender affirmation.

Purpose: Gender affirming top surgery (GATS) refers to procedures focusing on reconstruction of the breast or chest wall, that includes breast augmentation, fat grafting, breast reduction or subcutaneous mastectomy. Following hormonal therapy procedures often represent the initial surgical step in gender affirmation.1 This study aims to evaluate quality of life, satisfaction and level of regret following GATS using validated surveys in both male-to-female (MTF) and female-to-male (FTM).

Methods: We conducted a retrospective anonymous online survey at a quaternary academic medical center in the Midwest on transgender patients who underwent MTF or FTM GATS by a single surgeon from 2018-2022. The validated Breast-Q Augmentation (MTF), TRANS-Q (FTM) and Decision Regret Scale surveys assessed patients' satisfaction with respect to physical, psychosocial and emotional health.2,3,4 Pertinent socio-demographic data was collected to assess diversity of the studied population. Following IRB-approval, the survey was distributed to 76 patients (17 MTF/59 FTM).

Results: We received a total response rate of 72% (10/17 MTF;45/59 FTM). 50% were White, 33% African American, 6% Asian and 5% Hispanic. Age at the time of GATS was statistically different between the two groups at 36.1 ± 10.4 (MTF) and 26.6 ± 7.8 (FTM) (p= 0.003). 64% of patients utilized private insurance and 96% were transitioning for a minimum of 1-2 years prior to undergoing GATS. Generalized anxiety disorder(60%), depression(60%), post-traumatic stress disorder(33%) and bipolar disorder(13%) was observed. 95% of patients agreed/strongly agreed that symptoms of their mental disease improved after GATS (MTF 4.4 ± 0.5/FTM 4.5 ± 0.8).56% of patients acknowledge thoughts of self-harm or suicide prior to undergoing GATS; 16% and 38% stated GATS eliminated or improved these thoughts, respectively. The decision regret score is scaled from 0 to 100 with 0 representing no regret. The overall score for MTF had a mean of 6.0 ± 12.9 versus 22.0 ± 39.8 for FTM (p=0.031). The TRANS-Q survey reported satisfaction was good/very good for overall procedure(91%), chest shape(89%), sexual confidence(80.5%) and scar location(78%). Comparably, decreased satisfaction was observed with nipple sensation(44%), nipple appearance(54%), nipple color(68%) and scar size(61%). However, 100% and 96% of TRANS-Q respondents agreed/strongly agreed that they would recommend GATS to others or would choose GATS again. The mean score for the Breast-Q Augmentation psychosocial well-being and outcome satisfaction modules were 70.8±21.1 and 79.3±22.2, respectively.

Conclusion: Our study suggests that GATS improves self-confidence, physical, psychosocial, emotional and mental health. Yet, few noted regret. Future prospective studies on larger cohorts using validated measures are needed to evaluate underlying factors contributing to regret in order to improve healthcare delivery in this population.

1.Claes KEY, D'Arpa S, Monstrey SJ. Chest Surgery for Transgender and Gender Nonconforming Individuals.Clinics in Plastic Surgery.2018;45(3):369-380.doi:https://doi.org/10.1016/j.cps.2018.03.010

2.Pusic AL, Reavey PL, Klassen AF, et al.Measuring Patient Outcomes in Breast Augmentation:Introducing the BREAST-Q© Augmentation Module.Clinics in Plastic Surgery.2009;36(1):23-32.doi:https://doi.org/10.1016/j.cps.2008.07.005

3.Wanta J, Gatherwright J, Knackstedt R, et al."TRANS"-questionnaire (TRANS-Q):a novel, validated pre- and postoperative satisfaction tool in 145 patients undergoing gender confirming mastectomies.European Journal of Plastic Surgery.019;42(5):527-30.doi:https://doi.org/10.1007/s00238-019-01547-5

4.Brehaut JC, O'Connor AM, Wood TJ, et al.Validation of a Decision Regret Scale.Medical Decision Making.2003;23(4):281-292.doi:https://doi.org/10.1177/0272989x03256005

Providing gender-affirming care is a critical medical service that is rapidly evolving given the dynamic insurance and political landscape. There is limited information in the literature documenting an increase in willingness to provide care in the medical and surgical community. Plastic Surgery (PS), Urology, and Obstetrics/Gynecology (OB/GYN) are the disciplines most likely to perform gender-affirming surgeries (GAS). Anecdotally, these groups are most likely to view this population favorably. Targeting residents and fellows within these surgical residencies, we aimed to gauge the willingness to provide surgical care for this patient population in the US.

Plastic surgery, Urologic surgery, and OB/GYN trainees from all U.S. training programs were asked to complete a cross-sectional 26-question survey between August 2020 and January 2022. Respondents were queried regarding their demographic background. We focused on addressing transgender curricular exposure, knowledge of services offered at their institution, and comfort surrounding the training opportunities in transgender patient care. Additionally, respondents were queried on their desire or willingness to perform gender-affirming care or surgeries. Demographic data including personal gender identity and connection to the LGBTQ community was also collected.

164 responses across specialties were collected. Statistical analysis demonstrated distinct trends across specialties in exposure, comfort, gender, and region. Additionally, individual text-based responses from the survey were compiled. Our survey demonstrated consistency with prior studies on regional exposure to GAS but revealed interesting perspectives regarding the morality of providing this care. Namely, whether trainees have the option to opt in or opt out of surgical gender training despite the prevailing belief that these services are necessary.

Amongst all specialties, survey takers felt that residents should not have the option to opt out of curriculum specific to gender diverse patients (80.99%, 115/142) nor the option to opt out of caring for gender diverse (82.39%, 117/142). Similarly, most respondents to the survey do not have a moral/ethical objection to care for (90.85%, 129/142) nor to provide surgical care (82.39%, 117/142) for gender diverse patients. When looking at specialty specific responses, PS had the highest exposure to GAS. However, 20/68 plastic surgery respondents thought that residents should have the option to opt out of gender-affirming care, which was found to be significantly more than the other surgical specialties (p=0.013) with only 5 other respondents in OB/GYN or urology programs responding in favor of opting out. There was no statistical significance to respondents having moral/ethical objections to providing neither care or surgeries for gender diverse patients, despite the significance in PS residents in favor of opting out of services. OB/GYN had the overall lowest exposure to surgical cases with urology being exposed to the highest number of revision surgeries. Numerous other significant results were noted in our study.

Residency programs have made meaningful strides in offering more accessible and competent gender-affirming training. Differences in support exist among the included specialties. Plastic surgery for instance is most likely to teach GAS in their curricula but is more likely than their other specialties to opt out of training. This could be explained by preference among learners in subspecialty interests other than GAS. More interesting is that this finding does not seem to be a result of moral or ethical grounding. As most bottom surgery complications are urologic, it makes sense that revision surgeries are high in urologic training programs. Finally, the option to opt out of gender-affirming care also parallels the opt out option for abortion training in OB/GYN residencies but is not a standardized option amongst PS, urology, or OB/GYN training programs. This is the first survey of this kind to survey multiple surgical specialties providing gender-affirming surgical care and query resident sentiment and highlights the need for more questions to be asked about how to address GAS training in residency programs.

Background

The recent increase in the number of scientific publications on Chest-Wall Contouring Surgery in gender reassignment in female-to-male (FtM) transsexuals, reflects their importance in strengthening the patients' self-image and facilitating living in the new gender role. To masculinize the chest by removing the female contour and optimise aesthetic outcomes, an appropriate pre-operative plan is crucial. We describe a novel algorithm which we used in our group of FtM transexual patients and we validated this using the TRANS-Q questionnaire.

Methods

From 2016 to 2023, 97 consecutive FtM transgender patients underwent surgical procedure by the senior author (LR). A new algorithm is based on the simple assessment of the position of the nipple areola complex (NAC) to the Pectoralis Major and can easily guide the surgeon between the two surgical options: 1) Peri-Areolar (PA) or 2) a Double Incision (DI) Technique. The PA technique is used when the NAC is on the inferior border of pectoralis major; the DI technique is used when NAC is on the inferior border of pectoralis major. The TRANS-Q questionnaire was used to evaluate patient-reported outcomes (PROs), pre and post-operatively, and differences evaluated using the Wilcoxon Sign Rank Test.

Results

Eighty-three patients underwent DI technique, with median BMI 22.6 and median age of 26. Comparing pre- versus post-operative TRANS-Q scores, the median score for satisfaction with chest shape increased from 1 to 5 (p<0.0001); satisfaction with how chest looks with clothes on increased from 1 to 5 (p<0.0001); satisfaction with how chest looks with clothes off increased from 1 to 5 (p<0.0001); satisfaction with chest symmetry increased from 1 to 5 (p<0.0001); feeling confident sexually increased from 1 to 4 (p<0.0001); satisfaction with sex life increased from 2 to 4 (p<0.0001); feel sexy/attractive in clothes increased from 1 to 5 (p<0.0001). Six patients (7%) had seroma and no patients had partial/total nipple necrosis. Fourteen patients underwent PA technique, with median BMI 22.6 and median age of 24. Comparing pre- versus post-operative TRANS-Q scores, the median score for satisfaction with chest shape increased from 1 to 3.5 (p<0.01); satisfaction with how chest looks with clothes on increased from 1 to 5 (p<0.01); satisfaction with how chest looks with clothes off increased from 1 to 5 (p<0.01); satisfaction with chest symmetry increased from 1 to 5 (p<0.01); feeling confident sexually increased from 1 to 4 (p<0.01); satisfaction with sex life increased from 1 to 3.5 (p<0.0001); feel sexy/attractive in clothes increased from 2 to 5 (p<0.01). Four patients (29%) had seroma and no patients had partial/total nipple necrosis.

Conclusion

The authors propose a new algorithm to approach FtM transgender surgery. The high level of satisfaction validated by the TRANS-Q questionnaire can be guaranteed only by a clear pre-operative plan as per this new algorithm that we believe can simplify the surgical choice and maximize the aesthetic outcomes.

Introduction Over the past decade, there has been an improvement in access to gender affirming surgical care for the transgender population. Even with these improvements, this population still faces continued high level of disparities and access to specialized care. This includes both gender affirming surgery along with hormonal therapy, which are both critical to a patient's ability to safely and fully transition. Limited access to these lines of care have been associated with poorer outcomes and increased comorbidities, which hinder the long-term health and personal fulfillment of this patient population. Facial gender affirming surgery (FGAS), in addition to both top and bottom surgery, help patients align with their internal gender identify. While studies have focused on trends of top and bottom surgery, this study is unique by providing trends in FGAS within the United States from 2012 to 2019, with the primary aim of identifying areas for improving access to FGAS.

Methods The National Inpatient Sample (NIS) was utilized to identify patients who underwent FGAS from 2012 to 2019. The diagnostic codes for gender identity disorder and transsexualism were used to identify the desired patient population. Demographics and surgical variables, such as ICD coding for gender affirming surgery, were used within the NIS database to extract the patient population who received FGAS. Frequency distributions from the patient population was analyzed within Statistical Analysis System 9.4 to identify statistically significant trends amongst demographic and surgical variables. Nonparametric Kruskal-Wallis test was utilized and statistical significance was defined as a p-value <0.05.

Results In total, 132 patients underwent FGAS from 2012 to 2019. The incidence for FGAS has significantly increased over the time frame, rising by 1433%. Geographically, these surgeries were more likely to be performed in the West and Northeast geographical regions. Interestingly, hospital stay was increased amongst procedures performed in the Midwest (p=0.001). However, charges for FGAS by geographical location were not statistically significant (p=0.48). Stratifying by race, there was no significant difference with either hospital length of stay or the total number of charges (p=0.29 and p=0.48). Focusing on insurance type, patients with different providers did have different lengths of stay when undergoing FGAS (p=0.04).

Conclusion FGAS is the quickest growing amongst all types of gender affirmation surgery. With the transgender population, it is important and critical that FGAS remains affordable and accessible. While a majority of FGAS are performed in the Northwest and West, it appears that patients within the Midwest and with certain insurance providers have longer length of stays compared to fellow FGAS patients. While this is one of the first studies to focus solely on FGAS, future studies are warranted to understand and analyze differences in care amongst the transgender population receiving FGAS.