Scientific Abstract Presentations: Gender Affirming 4 Sunday, October 29 Sun, Oct 29 10:30 a.m.-12:30 p.m. CDT

Purpose:
To compare levels of self-reported pain and of opioid use between two groups of patients receiving different pain management protocols, after penile inversion vaginoplasty in a single institution from June 2021 to January 2023. Methods: The study was approved by Mayo Clinic IRB. A retrospective chart review was performed for transgender patients who underwent gender-affirming primary penile inversion vaginoplasty (PIV) at a single institution. The study excluded patients who underwent minimal depth vaginoplasty or revision cases. Pain levels were assessed on the surgical floor using the Numeric Pain Rating Scale. The amount of narcotic medication used orally and intravenously were recorded during the hospitalization, and the hospital length of stay was also reported. The average and maximum pain reported by patients were calculated per day and per hospital stay. The total amount of narcotics the patient received in the postoperative period was converted to Morphine Milligram Equivalents (MME). The Kolmogorov-Smirnov test was conducted to evaluate the distribution of the sample. If the sample proves to be normally distributed, a parametric test like Student's T-test would be used to compare both the reported pain levels as well as the total narcotic used. The study compared two groups of patients who were given different postoperative pain management protocols (Group A and Group B). Group A was defined by patients receiving standard post-operative analgesics: oral acetaminophen (Tylenol) and NSAIDs, PRN oral narcotic, and PRN intravenous narcotic. Group B was defined by patients receiving an enhanced recovery protocol: oral acetaminophen (Tylenol) and NSAIDs, PRN oral narcotic, PRN intravenous narcotics, and additionally ketorolac (Toradol) in the immediate postoperative period, scheduled oral gabapentin, and celecoxib. Results: Fifty patients underwent PIV within the study period. The average hospital length of stay for all patients was 4.92 days (±0.237). Group A had a slightly longer average stay of 5.0769 days, with a lower standard deviation (±0.215) compared to Group B 4.75 (±0.429). The average level of postoperative pain for all patients was 4.2474 (±0.418) on a scale of 0 to 10. Group A had a slightly higher average pain level of 4.28 (±0.579), while Group B had a slightly lower average pain level of 4.2121 (±0.618). The maximum level of postoperative pain experienced by any patient was 7.8 (±0.423). Group A had a slightly higher maximum pain level of 7.8462 (± 0.602), while Group B had 7.75 (±0.604). Kolmogorov-Smirnov test showed that the sample data is not significantly different from a normally distributed population (P= 0.9715). While overall reported pain levels did not vary significantly between the two groups (P >0.05), there was a significant decrease in MMR used in group B (group A – mean 271 (± 213) MME vs group B – mean 138 MME (± 112), P = 0.009). Conclusions: Despite the overall high patient post-operative satisfaction, patients can experience significant post-operative pain after surgery which may lead to high levels of post-operative opioid use. This study highlights the effectiveness of non-opioid medications used in the immediate post-operative setting in significantly decreasing opioid use following PIV.

Background: As Plastic Surgeons lead the growing field of transgender reconstruction and gender affirming facial surgery, they must pay close attention in understanding the ethical issues surrounding the field of Transgender Medicine. However, there is a paucity of literature regarding ethical issues surrounding Facial Feminization Surgery (FFS). Our aim was to identify the Top 5 ethical issues surrounding FFS and outlining both sides of each issue.

Methods: A focus group was used to create a 50-question survey for both Health Care Providers and Transwomen that was aimed at identifying the Top 5 ethical issues surrounding FFS. Once created, this questionnaire was administrated to FFS providers and perioperative patients (n=450). Based on ranking scores of ethical issue importance the Top 5 issues were nominated. An extensive literature search was used to critique both sides of the issue.

Results: The Top 5 ethical issues identified by our structured questionnaire were: 1) Societal Construct of Gender (Has society's changing view of gender impacted the importance of FFS?), 2) Medical Necessity (Is FFS medically necessary? Should insurances cover it?), 3) Barriers and Access (Should society invest resources in removing barriers to accessing FFS?), 4) Irreversibility and Age of Consent (Should the irreversibility of FFS be a deterrent to patient selection? What should be the age of consent to FFS?), Femininity and Beauty (How do beauty and femininity constitute each other?). Detailed look at the both sides of each of these issues will be discussed and an approach for reconciliation in practice will be identified.

Conclusions: Plastic surgeons are in the unique position to shape the growing field of transgender medicine and FFS but a critical look at ethical issues are important to shape the lives of patients and the view of gender in society.

Introduction: Early detection via screening for breast cancer has been shown to significantly reduce long-term mortality in cis-gender women [1]. Breast cancer screening rates for the transgender and non-binary (TG/NB) community remain as low as 2-7% [2]. Research regarding adherence to screening guidelines for breast cancer as well as incidence of breast cancer and post-mastectomy breast reconstruction for the TG/NB population is limited. This study sought to examine current screening and incidence rates for breast cancer and reconstruction among the TG/NB population.

Methods: A cross-sectional analysis in the All of Us National Database, which includes adults aged 18 and older from 2018-present, was performed. Participants enroll as direct volunteers or through participating health care provider organizations and complete health surveys. The database was queried to identify individuals who self-identify as TG/NB. Genetic susceptibility (as defined by the presence of the BRCA1 or BRCA2 gene), breast cancer screening incidence, use of hormone-replacement therapy (HRT), breast cancer malignancy incidence, mastectomy rates, and breast reconstruction rates were isolated.

Results: A total of 1383 TG/NB subjects were identified. The majority of respondents (63%) identified as White. One hundred and seventy (12%) of respondents identified as Hispanic or Latino. Four hundred and twenty-seven (30%) of respondents were aged 45 and above.

Thirteen (<1%) of TG/NB respondents reported having a diagnosis of breast malignancy. Thirteen (<1%) of TG/NB respondents underwent mammographic or sonographic screening for breast cancer; of these, 2 (<1%) reported having a diagnosis of breast malignancy. A total of 282 (20.4%) TG/NB individuals reported taking HRT; of these, 5 (<1%) had undergone screening for breast cancer, and 7 (<1%) reported having a diagnosis of breast malignancy. In comparison, 52,919 (14.3%) of all respondents reported taking HRT; of these, 3,700 (<1%) reported having a diagnosis of breast malignancy. One (<1%) TG/NB individual underwent mastectomy. No TG/NB patients underwent breast reconstruction of any kind.

Conclusion: While rates of breast cancer screening and malignancy are lower in the TG/NB population as compared to all survey respondents, results may be skewed towards a younger population, as over two-thirds of TG/NB respondents were under the age of 45, and therefore may not yet be eligible for routine breast cancer screening. Notably, a larger percentage of TG/NB individuals reported taking HRT when compared to total All of Us respondents; yet <1% of TG/NB individuals taking HRT were screened. Given the increased risk of developing breast cancer for patients on HRT [3], it is critical to monitor these patients and screen for breast cancer regularly.

References 1. Duffy, S.W., et al., Mammography screening reduces rates of advanced and fatal breast cancers: Results in 549,091 women. Cancer, 2020. 126(13): p. 2971-2979. 2. Luehmann, N., et al., A Single-Center Study of Adherence to Breast Cancer Screening Mammography Guidelines by Transgender and Non-Binary Patients. Annals of Surgical Oncology, 2022. 29(3): p. 1707-1717. 3. Vinogradova, Y., C. Coupland, and J. Hippisley-Cox, Use of hormone replacement therapy and risk of breast cancer: nested case-control studies using the QResearch and CPRD databases. BMJ, 2020. 371: p. m3873.

Introduction Gender-affirming surgery utilizes various techniques that can be performed as a single, multispecialty procedure or as multiple, single-specialty, staged procedures. The primary components of transmasculine gender-affirming surgery include hysterectomy, phalloplasty, and urethroplasty, with other procedures such as scrotoplasty, vaginectomy, oophorectomy, and implants performed based on patient preferences.¹ Rates of complications in phalloplasty are high, especially those which affect voiding and sexual function.²⁻³ This study aimed to assess the types and frequency of complications in single and staged phalloplasty and provide treatment recommendations for providers. Methods This retrospective cohort study was conducted at a single institution from March 2019 to December 2022. Patients were 18 years or older at the time of surgery, had a diagnosis of gender dysphoria, and underwent phalloplasty. Patients were assigned groups based on whether they had a single or staged procedure. Single procedures involved the phalloplasty, hysterectomy, and urethroplasty in one surgery. Staged procedures had each procedure performed as separate surgeries. Staged procedures only accounted for phalloplasty performed by plastic surgery. Complications were defined as need for reoperation, urethral stricture, urethral fistula, necrosis of neophallus, infection, wound dehiscence, and flap loss. A univariate analysis was conducted. Results Thirty-two patients underwent phalloplasty, with 21 from the South, 4 from the Midwest, 3 from the Northeast, and 4 from the West. There were 19 (59.4%) patients receiving single procedures and 13 (40.6%) patients receiving planned staged procedures. The mean operative time for single procedures was 15.1 ± 3.8 hours, and the mean operative time for staged procedures was 6.5 ± 4.8 hours (p<0.001). Overall complication rates were higher in the single procedure group (68.4%) than in the staged procedure group (8.3%) (p<0.001). Urethro-cutaneous fistulas were the only specific complication that significantly differed between the groups. Single procedures had a rate of 42.1%, while staged procedures had a rate of 8.3% (p<0.05). In the single procedure group, reoperations were performed in 57.9% of cases whereas only 8.3% of staged procedures required reoperation (p<0.01). Single procedures were associated with a longer time from surgery to discharge (9.1 ± 5.7 days) than staged procedures (4.5  1.6 days) (p<0.005). Discussion Staging hysterectomy, urethroplasty, and phalloplasty for gender-affirming surgery in transgender men appears to provide clear benefits. Staged procedures have better surgical outcomes as evidenced by a decrease in overall complication rates, urethro-cutaneous fistula rates, and reoperation rates. Although single procedures may be preferred for patients traveling long distances, their increased rates of complications necessitate frequent reoperations, attenuating their potential benefits. Larger, multi-institutional studies are needed to better understand the differences in complications from single and staged procedures.

References 1. Wu CA, Jolly D, Boskey ER, Ganor O. A systematic review of staging and flap choice in gender-affirming phalloplasty. Journal of Reconstructive Microsurgery Open. 2022;07(02). doi:10.1055/s-0042-1748884 2. Nassiri N, Maas M, Basin M, Cacciamani GE, Doumanian LR. Urethral complications after gender reassignment surgery: A systematic review. International Journal of Impotence Research. 2020;33(8):793-800. doi:10.1038/s41443-020-0304-y 3. Bryson C, Honig SC. Genitourinary complications of gender-affirming surgery. Current Urology Reports. 2019;20(6). doi:10.1007/s11934-019-0894-4

Introduction: There are approximately 1.6 million transgender adults and youths in the United States, and these individuals are disproportionately affected by the human immunodeficiency virus (HIV). Prior investigations have yielded mixed results regarding postoperative outcomes in patients with HIV, and research specific to gender-affirming surgery (GAS) outcomes in HIV-positive individuals is sparse. We used a national database to depict demographics, surgical characteristics, and postoperative outcomes within this patient population and assess any risk of complications in GAS conferred by HIV.

Methods: Using the IBM® MarketScan® Research Database, patients with a diagnosis of gender dysphoria who underwent gender-affirming surgery (GAS) (mastectomy, breast augmentation, hysterectomy, orchiectomy) between 2007 and 2021 were identified using the International Classification of Disease, ninth (ICD-9) and tenth (ICD-10) edition, and Common Procedural Terminology (CPT) codes. Among these, HIV-positive individuals were defined as those who had an HIV diagnosis and/or a highly active antiretroviral therapy (HAART) prescription, identified with National Drug Code Numbers. In both HIV-positive and -negative cohorts, patient demographics and procedure-related complications within 90 days of the index surgery (seroma, hematoma, dehiscence, infection, fat necrosis, tissue necrosis, deep vein thrombosis or other vascular complication, and non-specified complications) were recorded. Although patients who underwent multiple GAS procedures simultaneously were included, patients were excluded if they underwent subsequent procedures within the 90-day window following the index GAS procedure(s). Chi-squared, Schapiro-Wilk, Wilcoxon-Mann-Whitney, and multivariate logistic regression testing were used for statistical analysis.

Results: Of 5,772 patients meeting the criteria (mean age 28.90 ± 10.46), 538 (9.3%) were categorized as HIV-positive. Mastectomy was the most common (65%), followed by hysterectomy (22%), orchiectomy (13%), and breast augmentation (7%). HIV-positive patients were, on average, more often young adults (p = 0.007), underwent the index procedure(s) more recently (p < 0.001) and more often in the Northeast US region (p < 0.001), and had higher comorbidity levels (p < 0.001). HIV-positive patients more often underwent breast augmentation and orchiectomy (p ≤ 0.001), and underwent multiple GAS procedures simultaneously (p = 0.002). 9% of patients experienced at least one complication following the index GAS procedure(s). In a multivariable regression model, additional simultaneous GAS procedures (OR 2.618; p < 0.001) and Elixhauser index scores of four or higher (OR 1.558; p < 0.001) were associated with increased odds of experiencing one or more complications following the index GAS procedure(s), while HIV status (p = 0.207) did not affect odds of experiencing complications.

Conclusion: HIV was not associated with increased odds of experiencing complications following GAS, suggesting the safety of GAS within the HIV-positive patient population. As GAS becomes more common, including among people with HIV, future investigations should continue to evaluate trends and outcomes within GAS with a broader scope involving genital gender-affirming surgery.

Purpose: An estimated 1.3 million adults in the United States identify as transgender and approximately 276,000 or 21.2% are enrolled in Medicaid. In 2022, 52.9% of states offer legal protections in Medicaid policies for gender-affirming care. However, provisions for types of gender-affirming surgeries vary significantly by state and are constantly evolving with the establishment of new laws. The aim of this study was to systematically review Medicaid coverage for gender-affirming surgeries state-by-state.

Methods: We previously reported on the categorization of each state's health policy as protective, restrictive, or unclear for gender-affirming care overall under Medicaid plans. Building upon our previous work, we systematically assessed the 27 states with protective policies to determine coverage of gender-affirming surgeries. Policies that were in effect as of August 2022 were reviewed. Surgical procedures were categorized as chest, genital, craniofacial and neck, or miscellaneous reconstruction. Coverage for individual procedures was subsequently classified as explicitly covered, explicitly non-covered, or not described.

Results: Among the 27 states with protective Medicaid policies for gender-affirming care, explicit coverage was found for chest (n=17, 62.9%), genital (n=17, 62.9%), and facial (n=7, 25.9%) reconstruction, albeit coverage for specific types of surgeries within these categories varied. Several states did not explicitly specify the types of reconstruction covered. Twelve states (44.4%) gave no indication for breast augmentation or implant coverage, 15 states (55.6%) gave no indication for labiaplasty/vulvoplasty coverage, and 18 states (66.7%) gave no indication for penile prosthesis coverage. Sixteen states (59.3%) did not describe coverage for gender-affirming facial surgery. Coverage for surgical revision was not described by 19 states. For states that did explicitly specify coverage of surgery, the availability for gender-affirming chest and genital reconstruction was similar. Breast reduction or mastectomy was explicitly covered by 17 states (63.0%) and breast augmentation or implants were explicitly covered by 15 states (55.6%). Penectomy was explicitly covered by 15 states (55.6%) and phalloplasty was explicitly covered by 14 states (51.9%). However, gender-affirming facial reconstruction was only explicitly covered in six states and D.C. (25.9%). Additional procedures covered for facial reconstruction were limited. Five states (18.5%) explicitly covered thyroid chondroplasty while three states (11.1%) explicitly covered blepharoplasty, brow lifts, cheek implants, lip enhancement/reduction, and scalp advancement/reduction. Typical explicitly non-covered services included pectoral implant (n=6, 22.2%), mastopexy (n=6, 22.2%), collagen injections & other fillers (n=8, 20.6%), neck lifts (n=9, 33.3%), laryngoplasty (n=8, 29.6%), liposuction (n=8, 29.6%), and reversal surgery (n=12, 44.4%).

Conclusions: Among the 26 states and D.C. (52.9%) that cover gender-affirming care under Medicaid, many had explicit coverage for the major gender-affirming chest and genital procedures. In contrast, gender-affirming facial reconstruction is limited in its coverage. Additionally, states are often non-descriptive in their gender-affirming policies, thus complicating interpretation of coverage for numerous surgical procedures. Given that many states did not describe coverage, final rates are indeterminate as it is left up to subjective interpretations of policy and individual reviews of medical necessity.

Background Masculinizing top surgery (MTS) can help align a patient's chest appearance with their gender identity. Most commonly it is performed using a bilateral inferior mammary fold incision with free nipple grafting (FNG). Nipple areolar complex (NAC) reconstruction is a critical component, however there is a lack of information surrounding the technique of NAC reconstruction. We review patients undergoing MTS with FNG using a novel technique of FNG, known as the "Man-Go Method". Methods This retrospective study included patients 18 or older, who underwent MTS with FNG between 2020-2022. Those who underwent MTS without FNG were excluded. A single surgeon performed all operations. Results Of the 166 patients, 31.3% were smokers. Most patients (97.6%) did not experience partial or total graft lost, and 2 patients experienced partial unilateral nipple necrosis, and 2 experienced total unilateral graft loss. In total 8.4% of patients incurred a complication with the most common being seroma, which occurred in 7 patients (4.2%). Interestingly, patients undergoing combo cases with OBGYN for hysterectomy followed by MTS were more likely to incur chest wall infection (7.5% vs 1.1%, OR = 7.50). There was no difference in hematoma or seroma formation, dehiscence, partial or complete nipple loss, or revision rates between groups. than those who underwent only MTS (p=0.012). Conclusions The Man-Go Method is a safe and effective method to optimize NAC appearance for FNG in MTS. The procedure is straightforward, does not require harvest or creation of a separate composite graft, and does not require excessive preparation of the de-epithelialized site for graft inset. This reduces operative time and complexity in comparison to some of the current modifications of NAC reconstruction. Additionally, patients appear to be satisfied with their reconstructive outcomes.

Purpose: Although the transgender and gender diverse (TGD) community has gained more visibility and respect in recent years, the TGD community continues to experience diminished quality of life and increased mortality. At least partially due to barriers to health care, factors contributing to a decreased quality of life include increased rates of HIV, sexually transmitted infections (STI's), cancers caused by HPV, depression, anxiety, substance use, and suicide. While gender affirming hormone therapy and surgery is associated with enhanced physical and mental health, significant cost and access barriers block these life-saving services. The purpose of this study was to investigate the cost-effectiveness of gender-affirming chest feminization and masculinization in transgender and gender diverse adults. Methods: A cost-effectiveness analysis was conducted using two Markov models with a willingness to pay (WTP) threshold of $50,000/Quality Adjusted Life Year (QALY). In both the model investigating chest masculinization as well as that of feminization, the two amin arms of the Markov models were undergoing surgery or no surgery with additional sub-arms of negative or positive health events, such as post-operative complications and adverse health or successful surgery and access to hormone therapy. Data on health event probability, quality of life, and cost were extracted from the 2015 US Transgender Survey (USTS) Report, the Froedtert & Medical College of Wisconsin Health Network, and available literature. Analysis was performed using TreeAge Pro Healthcare (2022) and Microsoft Excel (2022). Results: For transfeminine patients, gender-affirming chest feminization is cost-effective with a cost of $9,478.33 and effectiveness of 0.77 QALY's, respectively, in the first year of the model. The incremental cost-effectiveness ratio (ICER) of $610.55 is below the WTP threshold, demonstrating the cost-effectiveness of the procedure. For transmasculine patients, gender-affirming chest masculinization is also cost-effective with surgery having a cost and effectiveness of $14,928.15 and 0.77 QALY's, respectively, compared to a lack of surgery ($9,521.521, 0.43 QALY's) in the first year of the model. The ICER was $14,302.74/QALY which is below the WTP thereby demonstrating the cost-effectiveness of the procedure. Moreover, this model predicts the ICER gradually decreasing to $11052.05/QALY at five years, $9262.93/QALY at ten years, and $8,128.20/QALY at fifteen years. Conclusions: We are one of the first groups utilizing the 2015 USTS Report to establish the cost-effectiveness of both chest feminization and masculinization procedures. Our Markov Model uniquely considers a variety of possibly health events experienced by transgender patients, such as post-operative complications, access to gender-affirming hormone therapy or lack thereof, and adverse mental health. These results suggest hormonal and surgical gender-affirming care for both transmasculine and transfeminine patients should be offered as the quality of life for transgender individuals is enhanced. Moreover, enhancing the health of the TGD community limits the expenses of health institutions long-term as the TGD patients experience less complications from adverse physical and mental health commonly associated with a lack of gender-affirming care.

Objective: To evaluate decisional conflict among individuals considering Metoidioplasty and Phalloplasty Gender Affirming Surgery (MaPGAS).

Methods: We administered a cross sectional survey to adult, English speaking participants assigned female at birth considering MaPGAS recruited via social media platforms and community health centers. Data collected included demographics, medical and surgical history MaPGAS type considered, and the Decisional Conflict Scale (DCS). DCS domains measure uncertainty, informed status, personal values clarity, perceived support, and decision effectiveness. Scores range from 0-100; a score > 37.5 indicates greater decisional conflict. Participants were also asked to provide open ended feedback related to MaPGAS uncertainty. Demographic characteristics and DCS scores were compared between surgical subgroups using descriptive and chi-square statistics using one-factor ANOVAs with Bonferroni adjustments and post hoc Tukey's tests to compare mean DCS scores between groups.

Results: A total of 362 participants completed the survey, mean age 30.3 years; 41% (n = 149) non-binary, 76% (n = 276) White, 75% (n = 274) non-rural, 45% (n = 164) privately insured, 37% (n = 135) completed ≥ 4 years of college, 23% (n = 84) considering metoidioplasty, 24% (n = 87) considering phalloplasty, 26% (n = 93) considering both metoidioplasty and phalloplasty, and 27% (n = 98) not considering/already had MaPGAS. DCS total scores were lowest (least conflict) for those not considering MaPGAS and highest for those considering both MaPGAS options, though not statistically significant. Those considering both MaPGAS options had higher uncertainty subscale scores 64.1 (SD25.5, p < 0.001) than respondents in the other three groups (43.5 (SD 29.7), 36.7 (SD 30.4), 22.8 (SD 23.1). Concerns surrounding MaPGAS complications emerged as the top feedback factor contributing to uncertainty and decisional conflict.

Conclusions: In a cross-sectional national sample of individuals seeking MaPGAS, decisional uncertainty was highest for those considering both MaPGAS options as compared to metoidioplasty or phalloplasty alone. This suggests this cohort may benefit from focused decision support.

BACKGROUND: Feminizing genioplasty warrants modification of the chin to achieve a feminine appearance. This study aims to compare female and male skeletal chin dimensions to provide guiding principles for surgical planning of feminizing genioplasty.

METHODS: Dry skulls stored at the Cleveland Museum of Natural history were included for analysis. Sex, age, and ethnicity were documented. Lower facial height, chin height, width, projection, and shape were assessed. Chin height was measured from B Point to Menton. Chin width was measured in the parasagittal plane (distance between vertical lines drawn between the canine and first premolar) and as the distance between the mental foramina. Chin projection was measured from the anterior nasal spine through the B point to the menton. Chin width was normalized to zygomatic and gonial widths. Independent-sample t-tests were carried out to detect significant differences between observed values of chin dimensions between both groups. Multivariate analysis of variance (MANOVA) was used to detect significant differences in the shape and size of the chin between male and female chins and between African American and European American chins. Based on a desired power of 80%, a confidence level of 95%, and a pooled standard deviation of 3.77 mm, a sample size of 86 skulls was required to detect a difference of 2.30 mm between male and female chin heights.

RESULTS: Forty-three male (43.58±12.52-year-old) and 43 female (40.48±12.04-year-old) skulls were included. In each group, 25 skulls were of African origin and 18 were of European origin. Male chin height (24.44±1.96 mm) and lower facial height (LFH, 69.41±5.79 mm) were greater than females' (chin height: 21.53±2.25 mm; LFH: 64.03 ±6.07 mm) (p<0.0001). Male chin width was greater between parasagittal lines (male 33.08±2.12; female 31.30±2.26; p=0.0001) and inter-mental foramina (male 45.23±2.72 mm; female 44.00±2.59 mm; p=0.017). Intergonial width was significantly larger in men (men, 97.15±6.85mm; female, 90.57±5.20mm; p<0.0001), as was zygomatic width (male, 129.87±5.99mm; female, 123.57±8.07mm; p<0.0001). After parasagittal width was normalized to intergonial width (female: 0.35±0.030; male: 0.34±0.027; p=0.43) and zygomatic width (female: 0.25±0.024; male: 0.26±0.021; p=0.82), there were no significant differences noted between the sexes. Although normalization of interforaminal width to zygomatic width did not demonstrate significant differences between the sexes (female: 0.36±0.027; male: 0.35±0.026; p=0.15), normalization of interforaminal width to intergonial width (female: 0.49±0.034; male: 0.47±0.043; p=0.024) revealed a significant difference between male and female skulls. Chin projection (male, 75.40±7.96mm; female, 75.63±7.02mm; p=0.89) did not differ according to sex. Male chins displayed larger and more prominent lateral tubercles producing a square-shaped chin. In comparison, female chins were rounded. In males, African ethnicity was associated with significantly greater chin height (African, 24.89±2.02mm; European, 23.82±1.73mm; p=0.038) and chin width in the parasagittal plane (African, 33.70±2.30mm; European, 32.22±1.51mm; p=0.011) compared to European ethnicity. In contrast, female skulls did not demonstrate a significant effect of ethnicity on chin morphology.

CONCLUSIONS: The most important factor in feminizing genioplasty appears to be the correction of the chin shape; height and width reduction are not necessary for most subjects.

Purpose: Nonbinary (NB) transgender individuals are those who do not identify with their assigned gender at birth and do not identify solely as men or women. NB people have existed cross-culturally throughout history. Despite being exceptionally diverse, within the healthcare system, these patients are often overlooked or amalgamated with binary trans (BT) patients with whom they often have considerably different experiences and healthcare needs. This may manifest in barriers to gender-affirming surgery (GAS), such as requirements for hormone replacement therapy and psychosocial assessment, which have been developed for BT populations and are often less relevant for NB patients. Utilizing GENDER-Q, a novel patient-reported outcome measure, this study aimed to clarify the impact of GAS generally, and gender-affirming mastectomy (GAM) in particular, for nonbinary patients.

Methods: Following IRB approval the GENDER-Q questionnaire was sent to adults who previously consulted for GAS at our institution, including those who did not move forward to surgery here. Participants who responded to relevant questions and reported their age and gender identity were included. Respondents who indicated that "man" or "woman" best described their gender identity were compared with those who selected any other gender identity. A subgroup analysis of GAM patients was conducted comparing NB patients with binary trans men (BTM). To enable univariate comparisons (Chi-square and Fisher's exact tests) of ordinal Likert scale responses, answers above and below the middle of the scale were grouped and compared.

Results: Three-hundred fourteen respondents were included, 219 (69.7%) identified as BT (101 trans men, 118 trans women) and 95 identified as NB. NB respondents reported statistically higher rates of being misgendered (NB:35.06% vs. BT:11.56%, P-value < 0.001), more often reported feeling unsafe in public (NB:44.74% vs. BT:27.75%, P-value = 0.008) and were less satisfied with the way their body aligned with their gender (NB:58.14% vs. BT:75.39%, P-value = 0.004). Auspiciously, both binary and NB respondents reported GAS affirmed their gender (NB:98.39%, BT:96.77%, P-value = 0.513) and was one of the best decisions they've made (NB:98.39% vs BT:97.37%, P-value = 0.655). GAM was found to be the most common procedure among both BTM (79.2%, 80/101) and NB respondents (76.5%, 65/85). Isolating for GAM demonstrated both BTM and NB patients had comparably high satisfaction with the way their chests looked (93.55% vs. BTM:91.76%, P-value = 0.761) and affirmed their gender postoperatively (NB:95.16% vs. BTM:98.72% P-value = 0.322). Overall, both groups agreed the outcome was what they wanted (NB:98.28% vs. BTM:95.08% P-value = 0.334) and that it was worth what they went through (NB:98.28% vs. BTM:96.72% P-value = 0.589).

Conclusion: Both binary and nonbinary respondents reported exceptionally high satisfaction following gender-affirming surgery. The most common procedure among nonbinary respondents was mastectomy. When isolating for mastectomy patients, binary trans men and nonbinary respondents demonstrated comparably high satisfaction with the way their chest affirmed their gender identity postoperatively and looked overall. Further, both groups agreed they got the outcome they wanted, and that it was worth what they went through. This data supports increased access to mastectomy for nonbinary individuals.

INTRODUCTION Gender affirming surgery, notably gender-affirming mastectomy (GAM), has become increasingly common. Available surgical techniques include periareolar or dual incision with or without free nipple grafting. Dual incisions range from straight to curved, which often follows the contour of the pectoral muscle. Though patient factors may necessitate a specific surgical approach, patient preferences for chest contouring, scar pattern, and the nipple-areolar complex also inform technique. To augment surgeon-rated aesthetic outcomes of such procedures, our study sought to characterize the public perceptions of aesthetic outcomes for gender-affirming mastectomy.

METHODS To assess aesthetic ratings of surgical outcomes, de-identified postoperative patient images and digital illustrations were presented in a survey through Amazon Mechanical Turk. Participants were blinded to the type of surgery (GAM or gynecomastia) presented. Three surgical techniques were compared: dual incision (straight or curved) and periareolar. Respondents evaluated overall appearance, resemblance to a cisgender male chest, shape and position of scars, and shape, position, and size of nipples. Rating scale options were poor, fair, good, and excellent. Feminine vs masculine scale options were extremely feminine, slightly feminine, slightly masculine, and extremely masculine.

RESULTS 114 complete responses were obtained. Respondents were predominantly 25 – 34-year-old (40.4%), white (79.8%), heterosexual (59.6%), cisgender men (54.4%) with a normal BMI (51.8%). 7.9% of respondents had a past surgical history involving their chest. Straight and periareolar GAM incisions in postoperative patient photos were more often rated as excellent or good on overall appearance (straight: 61.4%, periareolar: 54.5%, curved: 40.4%; p=0.005), resemblance to a cisgender male chest (straight: 53.5%, periareolar: 54.4%, curved: 43.8%; p=0.223), and scar shape (straight: 47.3%, periareolar: 53.5%, curved: 37.8%; p=<.001) compared to curved incisions. Straight (81.6%) and periareolar (73.7%) GAM incisions were more often described as very masculine or slightly masculine compared to curved incisions (56.2%) (p=0.058).

For gynecomastia, periareolar incisions had the highest ratings for overall appearance (periareolar: 78.1%, curved: 51.7%, straight: 36.8%; p=<.001), resemblance to a cisgender male chest (periareolar: 78.9%, curved: 54.5%, straight: 38.5%; p=<.001), and scar shape (periareolar: 78.0%, curved: 42.9%, straight: 32.5%; p=<.001). Incision type preferences for the digital drawings were similar to those for gynecomastia surgery across these three factors. While periareolar and curved incisions were rated most masculine for gynecomastia (p=0.005), periareolar and straight were rated most masculine for the digital illustrations (p=<.001). For GAM photos, gynecomastia photos, and the digital drawings, periareolar incisions were consistently the preferred scar shape.

CONCLUSIONS Our characterization of public perceptions of aesthetic outcomes for gender-affirming mastectomy suggests that patients seeking to maximize resemblance to a cisgender male chest may prefer straight or periareolar incisions. Differences in preferences for GAM postoperative photos vs gynecomastia photos vs digital illustrations suggest theoretical preferences may not always translate in practice and between different surgeries. For some patients, however, the ideal gender-affirming mastectomy outcome may deviate from the ideal cisgender male chest as dual incisions can sometimes provide an illusion of chest contour. Surgeons offering gender-affirming mastectomy can incorporate these results during preoperative consultation for informed shared decision making with patients.

Purpose: Measuring craniofacial changes in facial feminization patients can elucidate ideal postoperative measurements and standardize feminine craniofacial features to achieve patient goals. This study aimed to examine changes in surface area and direct measurements of three of the commonly manipulated regions of the face in facial feminization surgery (FFS): the forehead/superior orbital rim, mandible, and chin.

Methods: Pre-operative and post-operative radiographic images were analyzed from 11 FFS patients using Mimics V25.0 software by Materialise. The forehead/superior orbital rim, right and left mandibles and chin were each individually isolated by utilizing anatomical landmarks to assess for surface area (SA). Direct measurements included the frontal nasal angle (FNA: glabella-nasion-sella), bossing angle (BA; glabella-nasion-anterior table), bigonial width (bilateral gonion distance), chin height (menton to root of central incisor) and chin width (distance between mental tubercles). Paired t-tests were utilized to assesses the degree of pre-and post-operative changes.

Results: All measurements significantly decreased post-operatively. The SA of the forehead/superior orbital rim had an average11.8% decrease (pre-operative:13600.7 mm2 vs post-operative: 11821.7 mm2, p=0.03). The chin had an average 9.4% average decrease in SA (pre-operative: 13018.8 mm2 vs post-operative: 11732.4 mm2, p=0.02). For the mandibles, the left mandible had an average decrease of 12.1% (pre-operative: 3327.9 mm2 vs post-operative: 2893.9 mm2, p=0.01), while the right mandible had an average decrease of 7.9% (pre-operative: 3102.9 mm2 vs post-operative: 2841.4 mm2, p=0.04). For the forehead/superorbital rim, the FNA significantly decreased from 116.62° to 107.68° (7.42% average decrease, p=0.01), while the BA decreased on average 40.70% (preoperatively 20.24° vs. postoperatively 12.02° p<0.001). For the direct chin measurements, the average chin height decreased from 23.68 mm to an average of chin height of 21.67 mm (8.47% average decrease, p= 0.005), while the average chin width decreased from 22.71 mm to 16.44 mm (27.60% average decrease, p<0.001). The average bigonial width decreased from 97.38 mm to an average post-operative width of 92.7 mm (4.7% average decrease, p=0.002).

Conclusion: Each region manipulated in FFS underwent significant decreases in both surface area and direct measurements. These findings contribute to quantifying changes for FFS for identifying standards to further inform patient expectations. Future studies are needed to assess ideal measurements and percent changes craniofacial surgeons could aim to achieve depending on patient pre-operative characteristics.

Introduction: Detransitioning is defined as the return to native gender by an individual who previously underwent gender transition by means of social, medical, or surgical treatment. Over the last decade, multidisciplinary gender-affirming care and understanding of this patient population have expanded across the United States. While documented rates of surgical regret are reported to range between 1-2%, recent data shows that about 13% of patients detransition at one point in their lives. Alarmingly, 82.5% of people who had detransitioned reported at least one external factor such as social stigma as the major motivating factor.1 This study utilized Google Trends to analyze the recent search popularity of detransitioning.2

Methods: The term "detransitioning" was analyzed using Google Trends. Search popularity was assessed over a one-year time period in addition to regional search trends by state. Changes in search volume were compared according to popular news media detailing detransitioning and gender transition regret.

Results: There were fluctuating relative search volumes (normalized search volume in comparison to total search volume) for the term "detransitioning" with peaks in December 2022 and February 2023. Average relative search volume surged after a December 2022 media publication on a former Navy SEAL's detransitioning story. The state associated with the most search interest in detransitioning was Minnesota, followed by Colorado, Oklahoma, Oregon, and Missouri. Incidentally, a 2022 Minnesota Student Survey showed an alarming rise in suicide attempts in the transgender high school student population. Similarly, Oklahoma filed a "Don't Say Gay" bill in April 2022, Oregon introduced a bill criminalizing gender-affirming surgeries in minors, and Missouri filed four new bills in an attempt to ban all gender-affirming care.

Discussion: A rise in public interest around social phenomena as detransitioning seems to mirror high-profile media cases. Detransitioning is a yet poorly understood phenomenon by the plastic surgery community at large. Factors leading to patients reversing prior gender-affirming treatments have been linked to external factors such as societal stigma. Interestingly, states that have shown most search activity around detransitioning may have experienced concomitant social changes around LGBTQ issues.

References: 1. Turban JL, Loo SS, Almazan AN, Keuroghlian AS. Factors Leading to "Detransition" Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health. 2021 May-Jun;8(4):273-280. doi: 10.1089/lgbt.2020.0437. Epub 2021 Mar 31. PMID: 33794108; PMCID: PMC8213007. 2. Google Trends. Detransitioning. Accessed March 7, 2023. https://trends.google.com/trends/explore?date=today%205-y&geo=US&q=ozempic

Background: Twenty percent of the transgender population identifies as non-binary. Most of the current research on the surgical preferences, goals, and outcomes of transgender patients does not distinguish between trans-male and non-binary patients pursuing chest masculinization. The primary aim of this study was to compare the surgical practices for gender-affirming top surgery between non-binary and trans-male patients. We hypothesized that the prevalence of different chest masculinizing procedures in each group was significantly different between the two groups. Methods: This study included patients aged 18 years and older who underwent "top surgery" between January 2003 and December 2022. Surveys containing the BODY-Q chest module were sent to patients who met inclusion criteria. Demographics, medical comorbidities (smoking status, diabetes, hypertension, mental health conditions), procedure types, intraoperative and postoperative complications, and survey responses were compared using Fisher's exact test, Pearson's Chi-squared test, or Wilcoxon rank sum test, as appropriate. Results: Three hundred and twelve patients met inclusion criteria and were sent a survey. The survey response rate was 24% (76/312). Of the 76 respondents, twelve (16%) identified as non-binary and 64 (84%) identified as trans-male. Age (23 versus 25-year-old, p=0.3), BMI (28 versus 29, p=0.4), history of tobacco use (33% versus 33%, p>0.9), diabetes (0% versus 3.1%, p>0.9), hypertension (8.3% and 4.7%, p=0.5), and depression (50% and 42%, p=0.6) did not differ between our non-binary and trans-male cohorts. The most common procedure type was double incision mastectomy with nipple-areola graft for both groups (50% and 74%, p=0.2, non-binary and trans-male, respectively). Non-binary and trans-male patients had equivalent rates of intraoperative (0% versus 1.6%, p>0.9) and postoperative complications (8.3% versus 11%, p>0.9). Both groups reported that surgery improved their overall quality of life (75% versus 84% strongly agree, p=0.5, non-binary and trans-male, respectively). Both populations preferred their chest to be flat (98% versus 100%, p=>0.9, non-binary and trans-male, respectively) and to have smaller nipple-areola complexes (83% and 95%, p=0.085, non-binary and trans-male, respectively). Nipple sensation was reported to be important for 33% of non-binary patient and 41% of trans-male patients (p=0.8). Trans-male patients placed greater importance on having a male chest for their gender identity compared to non-binary patients (95% vs 83% very important, p=0.056). Two patients, both non-binary (17%), elected to not keep their nipple-areola complexes (NACs) and reported that no NACs were more congruent with their gender identity (p=0.023). Conclusions: Non-binary patients represent a significant proportion of patients seeking chest masculinization procedures. In this study, non-binary patients had distinctive surgical preferences regarding NACs. Thus, the non-binary population may require different surgical planning and have distinctive clinical needs compared to their trans-male counterparts.

Purpose: To date, no study has evaluated the psychosocial impact that gender transitioning has on partners of transgender nonconforming (TGNC) individuals. In this study, we assessed relationship dynamics, including psychosocial distress, quality of life, and internal resilience of partners of TGNC individuals.

Methods: Anonymous surveys were administered via the Amazon Mturk Platform. Eligible participants were ages 18-99, with a partner who underwent a gender transition. Relationship satisfaction and mental health was assessed via validated questionnaires, e.g., Self-Esteem and Relationship Questionnaire (SEAR), General Anxiety Disorder (GAD), and Personal Health Questionnaire Depression Scale (PHQ-8). Linear regression assessed associations between relationship satisfaction and status of partner transitioning (social vs. hormonal vs. surgical). Data analysis was performed using descriptive and analytical statistical methods, Welch's t-tests, multivariate linear regression models, and Spearman's coefficient correlations on SPSS (v28).

Results: Out of 337 participants who completed the study, 42.4% identified as male, with a mean age of 35.8. Nearly half (44.4%) had partners who transitioned from cis male to trans female (MTF), while a third (36.8%) had partners who transitioned from cis female to trans male (FTM). Most (72.4%) reported their partner underwent a surgical transition (15.1% top surgery, 5.6% bottom, 51.6% top and bottom), while 27.6% reported non-surgical partner transitioning (13.1% social, 14.5% hormonal). Sexual satisfaction and resilience scores were higher among respondents whose partners had undergone non-surgical transitioning (p<0.001). PHQ-8, GAD, and sexual satisfaction scores differed significantly among participants whose partners underwent top only surgery vs. bottom only surgery (p<0.001).

Conclusion: This is the first study to report the psychosocial impact of TGNC transitioning on their partners. We found that partner sexual satisfaction, depression, and anxiety scores were impacted by their TGNC partner's level of transitioning, with greater impact associated with surgical transitioning. Supportive services for partners of TGNC individuals should be considered during the work-up and transition process to better protect these romantic relationships for the benefit of both parties.

Background: Facial feminization surgery (FFS) encompasses multiple procedures in order to address gender dysphoria among transfeminine patients. Furthermore, the upper third of the face has several characteristics, including brow position, hairline shape, and forehead projection, that may confer cis-feminine identity. Depending on respective Ousterhout classification, the latter may be addressed through an anterior frontal sinus setback. Methods of its fixation may consist of metal or bioabsorbable plates. However, titanium mesh, often used in frontal sinus fracture repair, has not been described in the context of frontal bossing reduction in FFS. The purpose of this study was multifold: 1) to study clinical outcomes associated with use of titanium mesh for stabilization of bone following anterior frontal sinus setback; and 2) to compare its efficacy with other fixation methods including bioabsorbable plates.

Methods: A retrospective cohort study of transfemale and non-binary patients undergoing primary FFS by our senior author between January 2021 and February 2023 was performed. Variables collected include demographics, Ousterhout classification, operative details, including temporal augmentation, method of fixation, use of bone dust, hairline advancement, as well as complications, and duration of follow-up. Patients with history of prior FFS were excluded. Data was analyzed using SPSS, (IBM; Armonk, NY).

Results: A total of forty-three transfeminine patients were included in this study. The cohort had an average age of 33.0 years (SD = 8.7) and a median follow-up time of 1.0 month (IQR = 1.0 to 7.0). Amongst our cohort, 26 patients (60.5%) received titanium mesh, 1 (2.3%) patient received metal plates, and 16 patients (34.8%) underwent burring only for forehead contouring. There were no reported complications or need for revision surgery to the forehead amongst the entire cohort despite frontal sinus reconstruction material used and number of additional feminizing procedures performed during the primary FFS.

Conclusions: Complication rates and patient satisfaction were favorable among patients receiving titanium mesh for fixation of the anterior table during FFS. Titanium mesh can be considered as an additional technique for frontal bossing reduction and anterior table fixation in FFS.

Purpose: Gender-affirming procedures can reduce gender dysphoria, decreasing rates of depression and suicidality among transgender patients.1 Surgical candidacy can be limited by obesity, due to concern for complications.2 Due to limited research on gender-affirmation surgery among the pediatric population, this study investigates chest-masculinization surgery outcomes in transgender and gender-nonconforming adolescents and young adults.

Methods: All transmasculine patients undergoing top surgery between March 2020 and June 2022 by a single surgeon at a children's hospital were retrospectively reviewed. Patient demographics, body mass index (BMI), surgical technique, and outcomes were collected. Revisions included any elective OR return to modify chest appearance. Patients with BMI above or below 30 kg/m2 were compared. Analysis was completed using chi-squared analysis and independent T-test.

Results: Upon review, 135 patients underwent top surgery (113 double-incision mastectomies (DI) with or without nipple grafts, 21 Keyhole mastectomies, 1 breast reduction), of which 41 had BMI>30kg/m2, with a range of 15.8-48.4 kg/m2. The average length of follow up was 4.4 ± 4.4 months (range 0-18.3 months) for this cohort. Overall complication and revision rates were 11.1% and 5.2%, respectively. Complications included hematoma (6.7%), seroma (4.4%), and surgical site infection (0.7%). Complications did not significantly vary based on surgical technique (DI: 9.7% vs Keyhole:19.1%, p=0.386) or BMI (>30kg/m2: 9.8% vs <30kg/m2: 11.7%, p=0.974). Additionally, revision rates did not significantly differ based on surgical technique (DI: 4.4% vs Keyhole: 9.5%, p=0.667) or BMI (>30kg/m2: 4.9% vs <30kg/m2: 5.3%, p=0.752). Thirty-day readmission rates also did not significantly vary between BMI cohorts (>30kg/m2: 4.9% vs <30kg/m2: 7.5%, p=0.861). Patients with seromas had a lower average BMI than those without (23.3 kg/m2 vs. 27.26 kg/m2, p=0.008).

Conclusion: Our results suggest top surgery can be safely performed among transmasculine youth and adolescents with BMI ≥30kg/m2, and patients with lower BMI may have an increased risk of seroma formation. While preoperative weight loss may be preferred, high BMI should not be a barrier in proceeding with chest-masculinization surgery.

References 1. Akhavan AA, Sandhu S, Ndem I, Ogunleye AA. A review of gender affirmation surgery: What we know, and what we need to know. Surgery. 2021;170(1):336-340. doi:10.1016/j.surg.2021.02.013 2. Rothenberg KA, Gologorsky RC, Hojilla JC, et al. Gender-Affirming Mastectomy in Transmasculine Patients: Does Obesity Increase Complications or Revisions?. Ann Plast Surg. 2021;87(1):24-30. doi:10.1097/SAP.0000000000002712