Scientific Abstract Presentations: Gender Affirmation Session 1 Thursday, October 9 Thu, Oct 9 1:30-3:00 p.m. CDT

Background: Research across surgical subspecialties has demonstrated inconsistent results regarding the effectiveness of the antifibrinolytic agent tranexamic acid (TXA) in reducing hematoma and seroma rates, with few studies focusing on gender-affirming mastectomies. With no consensus on routine usage, this study evaluates gender-affirming mastectomies with and without TXA and reviews postoperative complications.

Methods: A retrospective cohort study, using the TrinetX 20-year database of 133 million U.S. medical records, identified patients undergoing gender-affirming mastectomies. Patients were separated according to the intraoperative use of TXA. Demographics and postoperative outcomes were evaluated including seromas, hematomas, infections, and thromboembolisms.

Results: There were 951 gender-affirming mastectomies performed with TXA and 7,929 without. After propensity-score matching, 951 patients remained in each cohort. The mean age was 26.6, and mean body mass index was 29.1. The TXA cohort had a lower rate of hematoma (1.8% versus 2.3%, respectively; p=0.4) and seroma (0.8% versus 1.4%, respectively; p=0.1) but with no significant difference. TXA use was not associated with an increased risk of thromboembolisms (p=0.9) or infections (p=0.6). The TXA cohort had a significantly lower incidence of emergency room visits within three months post-mastectomy (4.0% versus 6.0%, respectively; p=0.046).

Conclusion: Gender-affirming mastectomies are safe and effective treatment options. TXA usage was not associated with an increased risk of hematomas, seromas, or thromboembolisms, but had a lower incidence of emergency room visits post-mastectomy, which may be due to the lower rate of overall postoperative complications. Surgeons may consider prescribing TXA in gender-affirming mastectomies in specific individuals based on clinical judgment.

Purpose Top surgery, which is one of the most common gender-affirming procedures, has been shown to increase body image satisfaction, improve gender congruence, decrease gender dysphoria, and is rarely regretted. Reinnervation techniques have been shown to improve sensation outcomes for the NAC and throughout the chest wall. Historically, Body Mass Index (BMI) has been a challenging topic amongst TGD patients and gender-affirming surgeons as existing research has shown mixed outcomes of BMI impact on postoperative outcomes. As such, some providers may hold stringent BMI cutoffs that limit access to life changing procedures. This is the first study to illustrate, in detail, the complications correlated with various BMI groups following reinnervation in female to male gender affirming mastectomy.

Methods A retrospective chart review was conducted on 122 total patients who underwent FTM gender-affirming mastectomy with targeted NAC innervation. BREASTQ was sent to patients post-operatively. Semmes-Weinstein monofilament testing was used to measure sensation in the nipple, areola, and breast skin within 2cm of the NAC to total 9 segments.

Results A total of 118 patients were included in our chart review. The average BMI of this cohort was 25.1±5.16 kg/m2 (range 18.2 - 49.0). Most patients fell into the healthy weight category (54, 45.8%) or had Class I Obesity (13, 11.0%). Our cohort showed no significant impact of BMI on restoration of sensation in the first 1-6 months, or 12-24 months in any breast region. Log regression results demonstrated that overweight(p=0.51), Class I(p=0.34), and Class 3 (p=0.997) patients did not have significantly lower restoration of sensation than patients in the normal weight class. This trend held up to 24 months post operatively. Furthermore, multivariate regression analysis of BMI class revealed no statistically significant association between BMI class and postoperative complications within the first 30 days(p=0.56) or revision surgeries(p=0.32).

Conclusions This study demonstrated that BMI is not a significant predictor for restoration of sensation following gender affirming mastectomy with targeted NAC innervation regardless of post-operative time point. It is also consistent with prior research indicating that BMI may not be an accurate predictor of post-operative complications in the setting of adequate patient education. As investigations into optimizing outcomes for gender affirmation surgery continue, our group suggests a wholistic approach to patient evaluation for gender affirming mastectomy.

Background: Gender-affirming surgery, including phalloplasty and metoidioplasty, is an effective and necessary treatment for patients with gender dysphoria.(1-4) This study aims to better describe the needs and priorities of patients undergoing these procedures by using social media as a lens to analyze patient sentiment.

Methods: We utilized Pushshift.io, an archive of Reddit data, to extract all posts and comments from the r/Metoidioplasty and r/Phalloplasty subreddits since their inception. These posts were analyzed using natural language processing and VADER sentiment analysis. Posts with extreme sentiment scores were manually reviewed for theme classification and qualitative analysis.

Results: A total of 4,236 r/Metoidioplasty posts, 37,347 r/Metoidioplasty comments, 12,837 r/Phalloplasty posts, and 122,489 r/Phalloplasty comments were analyzed. The number of posts and comments in both subreddits increased significantly over time. The mean sentiment score for r/phalloplasty comments was significantly higher than the mean sentiment score for r/metoidioplasty comments. The average monthly sentiment score for r/Phalloplasty posts and comments has decreased significantly since the subreddit's inception. 1,347 posts (340 from r/Metoidioplasty and 1,007 r/Phalloplasty) with extreme sentiment scores above 0.95 or below -0.95 were identified. A total of 42 overarching themes were identified. The most frequent themes included the healing/recovery process, sensation and sexual function, and preoperative planning and consultation.

Conclusions: Our findings reveal an increase in online engagement over time within the r/Metoidioplasty and r/Phalloplasty Reddit communities. This suggests a growing interest in these gender-affirming surgeries and the need for increased patient support. The decrease in phalloplasty sentiment scores may reflect rising concerns or negative experiences among patients. Frequent topics of discussion with extreme sentiment scores identify potential target areas for increased education and patient-physician discussion. Ultimately, this study offers valuable insights into the real-time concerns and priorities of patients undergoing gender-affirming surgery. While Reddit offers a rich source of qualitative data, the limitations of using social media, such as selection bias and the potential for extreme viewpoints to dominate discussions, must be acknowledged. Future studies integrating social media data with traditional clinical outcomes and patient reported outcomes could help develop a more comprehensive understanding of patient experiences, improving both surgical practices and support systems for transgender individuals.

1. McNichols CHL, O'Brien-Coon D, Fischer B. Patient-reported satisfaction and quality of life after trans male gender affirming surgery. Int J Transgend Health. 2020;21(4):410–417. https://pubmed.ncbi.nlm.nih.gov/34993519/. Accessed Oct 20, 2024. doi: 10.1080/26895269.2020.1775159.
2. Standards of care for the health of transsexual, transgender, and gender nonconforming people. The World Professional Association for Transgender Health. . https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf. Accessed Oct 14, 2024.
3. Black CK, Fan KL, Economides JM, Camden RC, Del Corral GA. Analysis of chest masculinization surgery results in female-to-male transgender patients: Demonstrating high satisfaction beyond aesthetic outcomes using advanced linguistic analyzer technology and social media. Plast Reconstr Surg Glob Open. 2020;8(1):e2356. https://pubmed.ncbi.nlm.nih.gov/32095382/. Accessed Oct 20, 2024. doi: 10.1097/GOX.0000000000002356.
4. Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National estimates of gender-affirming surgery in the US. JAMA Network Open. 2023;6(8):e2330348. https://pmc.ncbi.nlm.nih.gov/articles/PMC10448302/. Accessed Oct 20, 2024. doi: 10.1001/jamanetworkopen.2023.30348.

Background Most research on body mass index (BMI) in plastic surgery focuses on general reconstructive procedures, with limited data available on its impact on facial aesthetics and gender-affirming surgeries. Facial feminization surgery (FFS) is a set of procedures designed to modify facial features to appear more feminine. Given that obesity is a well-established risk factor for complications in various surgical fields, this study investigates whether similar risks apply to FFS to better inform surgical decision-making and reduce unnecessary barriers to care.

Methods A retrospective analysis was conducted on transfeminine patients who underwent FFS at our institution to evaluate the relationship between BMI and postoperative complications. A parallel analysis was performed using the National Surgical Quality Improvement (NSQIP) database from 2009 to 2023, identifying patients with International Classification of Diseases-10 (ICD-10) codes for gender dysphoria and Concurrent Procedural Terminology (CPT) codes related to FFS. In both cohorts, BMI was classified as normal weight (18.5 to 24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2). Multivariate logistic regression, with comorbidities as covariates, was used to assess associations between BMI category, overall postoperative complications, and specific complication types.

Results Our institutional cohort included 350 FFS patients with the following BMI distribution: 72 obese (20.6%), 119 overweight (34.0%), and 135 normal weight (38.6%). The overall postoperative complication rate was 10.0%. Multivariable logistic regression showed no significant association between BMI category and overall complications or specific complications, including infection, dehiscence, and hematoma. To validate these findings, we analyzed an NSQIP cohort of 597 FFS patients with a similar BMI distribution: 150 obese (25.1%), 175 overweight (29.3%), and 247 normal weight (41.4%). The overall complication rate was low at 3.11%. Consistent with our institutional data, multivariate analysis of the NSQIP cohort found no significant association between BMI and any postoperative complication, including superficial surgical site infection (SSI), deep incisional SSI, or dehiscence.

Conclusion Our findings provide robust, multi-institutional evidence that BMI should not be a contraindication for FFS, and that FFS is safe in each category of BMI. Reducing BMI-related barriers can improve access to gender-affirming care. Further research is needed to explore additional factors influencing postoperative outcomes in this population.

Purpose: Preoperative body mass index (BMI) cut-offs for chest masculinization surgery (CMS) are institution-specific and based on limited data. Our prior NSQIP research showed that while higher BMI increased the odds of minor surgical complications, no patients experienced severe morbidity or mortality. This study re-evaluates this association at a single institution to inform preoperative planning and patient counseling for transgender and non-binary individuals.

Methods: We conducted a retrospective cohort study of patients who underwent CMS with double incision mastectomy and free nipple grafting between March 2022 and January 2025 by the senior author. Patients undergoing other CMS techniques were excluded. The primary outcome was incidence of postoperative surgical complications and adverse aesthetic outcomes. Surgical complications included infection requiring antibiotics or washout, hematoma or seroma requiring drainage, wound dehiscence requiring intervention, skin necrosis, nipple graft failure, pulmonary embolism or venous thromboembolism, blood transfusion, acute kidney injury, urinary tract infection, pneumonia, or sepsis. Adverse aesthetic outcomes included scar widening and/or hypertrophy, dog ear revision, and scar revision surgery.

BMI (kg/m²) was analyzed as a continuous and categorical variable per WHO guidelines: healthy weight (18.5–24.9), overweight (25.0–29.9), Class I obesity (30.0–34.9), Class II obesity (35.0–39.9), Class III obesity (40.0–49.9), and Class IV obesity (≥50). Associations between BMI and complications were assessed using bivariate and regression analyses, controlling for past medical history, anticoagulant use, and connective tissue disorders.

Results: Among 92 patients who fulfilled inclusion criteria, the average (standard deviation) age was 27.3 (7.7) years old, and mean (SD) BMI was 32.2 (7.3) kg/m². BMI distribution was: 14.1% healthy weight (n=11), 28.3% overweight (n=26), 25.0% class I obesity (n=23), 16.3% class II obesity (n=15), 13.0% class III obesity (n=12), and 3.3% class IV obesity (n=3). The mean (SD) follow-up duration was 5.2 (4.1) months postoperatively.

BMI was not significantly associated with any surgical complications except wound dehiscence. Patients with a BMI >50 kg/m2 were significantly more likely to experience wound dehiscence compared with patients with a BMI 25 - 29.9 kg/m2 (1/3 [33.3%], 0/26 [0%], P=0.01). Adverse aesthetic outcomes occurred in 29.3% (n=27) of patients. BMI was not significantly associated with any individual aesthetic outcome. However, BMI was significantly associated with the composite outcome of experiencing at least one aesthetic complication. Patients with BMI ≥40 kg/m² had significantly greater odds of at least one aesthetic complication than those with BMI <25 kg/m² (BMI 40–49.9 kg/m²: aOR 16.800, 95% CI 1.617–>100, P=0.018; BMI ≥50 kg/m²: aOR 24.000, 95% CI 1.028–>100, P=0.048).

Conclusions: Higher BMI was associated with greater odds of wound dehiscence and experiencing an adverse aesthetic complication following CMS. However, the incidence of major postoperative complications was negligible.

Purpose: Access to reliable, high-quality, and inclusive information and resources is crucial for individuals considering gender-affirming surgery, as it directly impacts their ability to make informed decisions about their care. Many patients turn to a broad range of resources, including online forums, social media, medical websites, and academic literature, to gather information about surgical options, risks, and recovery expectations, and long-term outcomes. However, the quality and accessibility of these resources can vary widely, creating potential gaps in patient education. This study examines the types of information patients seek regarding gender-affirming bottom surgery, their preferred sources, and the perceived quality of available resources.

Methods: An IRB-approved survey assessing the availability and perceived difficulty of educational resources for gender-affirming bottom surgery was distributed across Reddit gender-based platforms. Participants were categorized based on their interest in either vaginoplasty or phalloplasty/metoidioplasty. Depending on their stated surgical preferences, survey respondents received an information sheet on vaginoplasty or phalloplasty/metoidioplasty and were asked to rate their difficulty and key aspects. Group differences were analyzed using t-tests and chi-squared tests, with statistical significance at p<0.05.

Results: A total of 348 individuals were included. Online forums and departmental websites were the most utilized resources for both vaginoplasty and phalloplasty/metoidioplasty. YouTube was rated the easiest to understand for vaginoplasty-related information, while academic journals and textbooks were perceived as the most challenging for both procedures. Notably, participants interested in phalloplasty reported significantly greater difficulty understanding educational websites than those seeking vaginoplasty (p<0.0001). When evaluating the provided information sheets, respondents generally found the sheet very easy to understand and relatively helpful in deciding preferred surgical techniques. Patients interested in vaginoplasty found the procedure description most helpful, while those interested in phalloplasty found the comparative tables most useful.

Conclusions: While online forums and educational sites were the most accessible resources, their usability varied with phalloplasty-related materials presenting greater accessibility challenges than vaginoplasty resources. YouTube was identified as an easy-to-understand medium. These findings highlight the need to develop patient-friendly educational materials like the provided information sheets that effectively communicate gender-affirming bottom surgery options. Future research should focus on enhancing the usability of educational materials to support informed decision-making across all gender-affirming bottom surgery types.

Purpose Nonbinary people, who identify outside the traditional gender binary, are estimated to comprise 38% of the gender diverse population in the United States . However, the specific transition goals of nonbinary individuals remain largely unexplored. Preliminary data indicates that nonbinary people may have distinct preferences regarding medical and surgical transition options compared with their transgender counterparts, but there are no studies that directly compare transition goals between these groups. This study aims to characterize differences in medical and surgical transition goals between transgender and nonbinary individuals. Methods Individuals who completed an initial intake form at our gender-affirming health center between January 2017- December 2019 were included. Our primary outcome was the frequency of desired and undertaken medical and surgical transition options. Demographic information, desired procedures, medical and surgical history were extracted from the intake form and medical chart. Chi-squared tests were used to compare outcomes between transgender and nonbinary individuals. Results Among 1402 patients, 1275 (91%) were binary and 127 (9%) were nonbinary. The median (IQR) follow-up duration after intake was 3 (1-4) years. Of 807 (58%) patients who were assigned female at birth, 709 (88%) were transgender men and 98 (12%) were transmasculine nonbinary individuals. Of 595 (42%) patients who were assigned male at birth, 566 (95%) were transgender women and 29 (4.8%) were transfeminine nonbinary individuals. Compared with transgender men, transmasculine nonbinary individuals were significantly less likely to be on gender-affirming hormone therapy (GAHT) (621/709 [87%] versus 62/98 [63%], p<0.001) and desire future GAHT (69/88 [78%] versus 17/36 [47%], p<0.001). They were also significantly less likely to request phalloplasty compared with transgender men (23/98 [24%] versus 374/694 [54%], p<0.001). Interest in chest masculinization surgery, however, was similar between the two transmasculine cohorts. Both binary and nonbinary transfeminine individuals expressed similar interest in GAHT. However, transfeminine nonbinary individuals were significantly less likely than transgender women to request vaginoplasty (8/29 [27%] versus 376 [69%], p<0.001). Conclusion Significant differences in transition goals exist between nonbinary and binary transgender individuals presenting to our gender-affirming health center. Nonbinary individuals were found to pursue GAHT less frequently than transgender individuals. While there was a similar interest in top surgery between transmasculine nonbinary individuals and transgender men, bottom surgery was more often requested by transgender men and transgender women compared to their nonbinary peers. These findings emphasize that nonbinary individuals may have unique transition goals, and providers should recognize that gender identity is an important component of patient-centered care.

Purpose Dehiscence of the posterior introitus following primary vaginoplasty is serious and disfiguring, resulting in visually unappealing scars and loss of labia minora definition. Dehiscence is also common, with rates reported up to 33% in previous studies.(1) Despite its frequency, the underlying causes remain poorly understood. We sought to assess the proportion of patients with dehiscence at our center and to identify characteristics that may be associated with this significant complication.

Methods Wound dehiscence was documented in post-operative appointment notes from October 2016 to July 2023 and recorded as a binary response variable. We performed univariate and multivariate binary logistic regression with the following variables: age, BMI, chronic disease (HTN, DM, cardiac disease, peripheral vascular disease, and renal disease), type of closure used at the posterior incision, "tucking" habit, number of flights of stairs at home, pre-operative penile length, pre-operative skin elasticity, pre-operative scrotal skin excess, post-operative wounds (any), vaginal dilator size being used at 1 month, 3 months, and after 3 months post-operation, post-operative Body Congruence Index (BCI; formerly Gender Dysphoria Index), difference between pre- and post-operative BCI, post-operative hematoma, revision surgery, and revision labiaplasty. All statistics were performed in IBM SPSS (v28.0.1.1).

Results A total of 667 patients who underwent primary vaginoplasty at our center were included in this study. Of these we found 16.2% (n = 108) of patients had postoperative dehiscence. We found that wound dehiscence was strongly associated with revision surgery (p=0.004, OR=2.095, 95%CI:1.268-3.462) and peripheral vascular disease (p=0.029, OR=13.316, 95%CI:1.306-137.78). Conversely, wound dehiscence was strongly inversely associated with 1.5" diameter dilator size at 3 months post-op (p=0.006, OR=0.304, 95%CI:0.130-0.715) and 1.5" diameter dilator size after 3 months post-op (p=0.004, OR=0.332, 95%CI:0.158-0.699). The use of simple running 3-0 Chromic closure (p=0.026, OR=0.376, 95%CI:0.160-0.888), and flights of stairs at home (p=0.011, OR=0.694, 95%CI:0.523-0.921) were also associated with a lower incidence of dehiscence. To account for differences in surgeon documentation, we combined dehiscence with wound (any) and found the combined variable was strongly associated with revision surgery (p<0.001, OR=2.335, 95%CI:1.465-3.721) and post-operative hematoma (p=0.016, OR=1.838, 95%CI:1.121-3.014). No other variables were strongly associated with or against dehiscence.

Conclusions Our results highlight that patients with dehiscence are more likely to seek revision surgery, more likely to have hematomas, and less likely to increase their dilator size. The strong association between PVD and dehiscence also suggests that adequate blood flow to the vaginal introitus is imperative for minimizing dehiscence. Interestingly, patients with stairs at home were less likely to experience dehiscence. This may be reflective of stricter counseling and bedrest adherence or benefits of mild physical activity and warrants further investigation.

Sources 1. Rossi Neto R, Hintz F, Krege S, Rubben H, Vom Dorp F. Gender reassignment surgery--a 13 year review of surgical outcomes. Int Braz J Urol. 2012;38(1):97-107. doi:10.1590/s1677-55382012000100014

Background: Penile inversion vaginoplasty is a widely performed gender-affirming procedure aimed at constructing a functional neovagina. Postoperative vaginal dilation is essential to prevent stenosis, but many patients report challenges related to discomfort, inconvenience, and adherence to dilation protocols. This study aims to characterize patient-reported experiences with vaginal dilation, identifying barriers and trends over time.

Methods: Patients who underwent penile inversion vaginoplasty at a single institution between March 2024 and June 2024 were invited to complete weekly postoperative surveys over a seven-month period. Survey questions addressed dilation frequency, depth, duration, and any encountered challenges. Univariate analyses were conducted to assess temporal trends in patient-reported challenges.

Results: Eighteen out of 24 patients responded to the survey (71% response rate), providing a total of 202 weekly responses. The average reported dilation frequency was 6.95 ± 0.17 days per week, with an average of 2.97 ± 0.46 sessions per day. Dilation sessions lasted 35.9 ± 9.7 minutes on average. The mean depth achieved was 4.2 ± 0.49 on a standard dilator set, with a small but statistically significant decrease over the seven-month period (4.9 vs. 4.1; p=0.003). All respondents reported at least one challenge with dilation during the study period, including pain (83%), tightness (83%), bleeding (72%), discharge (61%), and time or personal constraints (56%). On univariate analysis, the frequency of reported complications did not significantly differ throughout the study period.

Conclusion: This study is the first to longitudinally assess patient-reported experiences with vaginal dilation following penile inversion vaginoplasty. While adherence to dilation protocols remains high, patients face significant challenges, particularly pain, tightness, and bleeding, which should be addressed during preoperative counseling. Tailored dilation regimens and targeted pain management strategies are critical to improving postoperative outcomes and patient satisfaction.

Introduction

Ehlers-Danlos Syndrome (EDS) is a family of connective tissue disorders that includes 13 subtypes. EDS largely affects the joints, skin, and vasculature and is known to cause surgical complications like poor wound healing. According to DSM-5, gender dysphoria (GD) is characterized by incongruence between one's gender and sex, and a strong desire for the primary and/or secondary sex characteristics of the other gender. At our institution, there seemed to be a high prevalence of patients seeking gender affirming chest surgery that have EDS diagnoses, but there is paucity in the literature characterizing this association. Thus, we aimed to study both prevalence and differences in surgical outcomes of this dual diagnosis through retrospective chart review and the Data, Inclusion, Collaboration, and Excellence (DICE) Ehlers-Danlos Syndrome and Hypermobility Syndrome Global Registry.

Methods

A retrospective chart review was performed from April 2018 to September 2024 of patients with GD at a single institution and reviewed for EDS diagnosis. Data on patients undergoing chest masculinization surgery were collected regarding demographics, past medical history, surgical details, and surgical outcomes. Patients with Hypermobility Spectrum Disorder (HSD) and surgical indications beyond GD were excluded. Recorded biological sex, gender identity, and diagnosis information were collected from the Registry. Incomplete survey responses and non-clinical and/or HSD diagnoses were excluded. Analyses of prevalence and all Registry analyses were done using descriptive statistics. Surgical outcome related statistical analysis was conducted in R Studio 4.4.1 and included Shapiro-Wilk's Normality, Mann-Whitney U, t-test, and Fisher's Exact.

Results

A total of 775 charts of patients with GD were identified, of which 19 (2.45%) were diagnosed with EDS, and 8 patients (1.03%) were diagnosed with Hypermobility Spectrum Disorder. Of those 775 with GD, 437 underwent chest masculinization and were included in outcome analysis. All baseline characteristics between groups were found to be equal (p>0.05), except for the incidence of Postural Orthostatic Tachycardia Syndrome (POTS), which was significantly higher amongst those with EDS (p=0.01; 95% CI 1.53, 146.93). Regarding negative surgical outcomes, there were no statistically significant differences between patients regarding EDS diagnosis (p>0.05). A total of 4132 patients in the Registry met criteria, with 343 (8.3%) identified as having GD.

Conclusions

The national prevalence of EDS ranges depending on subtype with the most common being Hypermobile EDS at 1:50-320. We observed a greater prevalence of EDS amongst those with GD (1:40). This is confirmed by the observed GD prevalence amongst those with EDS compared to national averages (8.30% vs 0.5% nationally). We hypothesize that these results reflect the unique awareness of one's body amongst gender non-conforming people, and their more frequent and earlier interactions with healthcare that might lend to more clinical diagnoses. We identified no significant differences in surgical outcomes per EDS diagnosis. These findings highlight that patients with EDS should not be excluded from accessing gender-affirming surgeries. Gender non-conforming patients already face significant barriers to receiving this life-saving care. Future research is needed to identify underlying genetic and molecular factors in EDS patients that are associated with GD.

Background In gender-affirming bottom surgery, sensory outcomes significantly impact postoperative well-being, greatly contributing to surgical choice of donor site. Yet sensory assessment methods vary widely without standardization. This study aimed to characterize the techniques for assessing sensation following trans-masculinizing and trans-feminizing gender-affirming bottom surgery by describing available methods, evaluating outcomes across sensory modalities and patient-reported outcome measures (PROMs), and identifying optimal assessment timelines.

Methods A comprehensive search of PubMed, Embase, and Cochrane Library was conducted in January 2025 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis Scoping Review (PRISMA-ScR) guidelines. Articles were screened in a two-stage process. Inclusion criteria were randomized control trials, observational studies, surveys, and interviews that evaluated sensory outcomes with provider-administered sensory testing after gender-affirming bottom surgery. Abstracts, commentaries, editorials, systematic reviews, and non-English studies were excluded.

Results Among the 2234 articles screened, thirteen studies were included. Eight studies (61.5%) assessed phalloplasty, four (30.8%) evaluated vaginoplasties, and one (7.7%) examined both procedures. Semmes-Weinstein monofilaments were the most commonly used assessment tool employed in 7 studies (53.8%) to measure pressure and tactile perception. Other assessment methods included vibratory testing (38.5%), thermal sensitivity (23.1%), two-point discrimination (15.4%), and sharp blunt discrimination (7.7%). Testing locations varied by procedure type, with the neophallus measurement typically divided into proximal, distal, dorsal, ventral and quadrant-based measures, while the neovaginal assessment focused on the neoclitoris, labia, and vaginal entrance. Five studies (38.5%) included preoperative baseline measurements using a variety of different reference sites. Follow-up timing ranged between one week and seven years postoperatively, with most studies initiating assessment with the same testing modalities between one and three months after surgery. Eight studies (61.5%) initiated patient-reported outcomes alongside objective sensory testing. Compared to other types of sensation, tactile sensation was most easily perceived and also exhibited progressive improvement over the first year postoperatively. In phalloplasties, proximal regions recovered sensation earlier than more distal regions. Additionally, the effect of flap type on sensation remained unclear. In both phalloplasties and vaginoplasties, perceptual thresholds varied by sensory modality. Of the articles that reported PROMs, the most commonly assessed were the ability to orgasm (75% of studies) and sexual satisfaction (62.5% of studies). Among studies that assessed ability to orgasm, between 79.5-100% of phalloplasty patients and 80-86% of vaginoplasty patients reported success. Additional outcomes included satisfaction with aesthetic results of the neogenitalia, functional results, ability to have penetrative sexual intercourse, and current sex life. The correlation between sensation testing and PROMs remains unclear.

Conclusion This study highlights the heterogeneity of sensory assessment techniques following gender-affirming bottom surgery. Given the variation in results across modalities, sensory evaluation requires a comprehensive approach incorporating multiple modalities including pressure perception, vibratory testing, thermal sensitivity, and two-point discrimination. Baseline measurements, ideally in preoperative testing, are essential for interpreting postoperative sensory outcomes and evaluating changes across time. Finally, the correlation between provider-administered sensory testing and patient-reported outcomes remains necessary for understanding the relationship between quantifiable sensibility and functional satisfaction.

Background: Access to gender-affirming chest masculinization (top surgery) is a critical aspect of healthcare for transgender and gender-diverse individuals. Many individuals turn to online platforms like Reddit to seek support and navigate their journeys. As traditional research may not fully capture patient perspectives, some studies have used these platforms to understand how individuals discuss surgical decision-making outside clinical settings. Our study aims to compare top surgery preferences and perspectives between Reddit users and clinic patients.

Methods: A survey was distributed via Reddit gender-based platforms and a plastic surgery clinic, collecting demographics, experiences, and perspectives on top surgery care. A two-way chi-square test assessed interactions between platforms (Reddit vs. clinic) and gender identity. Three gender identity groups were studied: transgender males, non-binary individuals, and other gender-diverse groups, which consisted of those identifying as agender, genderfluid, genderqueer, prefer not to say, or other. Significance was set at p<0.05.

Results: A total of 537 respondents were included, with 428 online and 109 clinic responses. Non-binary individuals were more prevalent in the clinic (43.12% vs. 28.97%, p=0.04), while agender individuals were primarily captured in online responses (7.01% vs. 0.92%). Transgender men were the largest group (~42%) across both platforms. Older adults (>45) were nearly absent from clinic responses but present online (p<0.0001). Race and ethnicity did not differ between groups. BMI categories (<18.5 and >35) were more common online (p=0.003). Online participants had lower educational attainment (p=0.02), lower income (p=0.01), and greater socioeconomic diversity. Of 537 respondents, 509 were either seeking or had completed top surgery. Reddit respondents were less likely to discontinue surgery due to conflicts (p<0.001). Reddit users, particularly non-binary and OGD groups, felt that they needed to educate providers about non-standard options more often (non-binary 8.13% vs. 2.13%; OGD 10.48% vs 0%, p<0.001). Regarding surgical preferences, Reddit non-binary and OGD groups were more likely to desire a breast mound compared clinic non-binary and clinic OGD groups (p=0.02). Compared to Reddit non-binary and OGD groups, clinic non-binary and OGD groups were more likely to desire an NAC (~65% vs ~35%, p=0.02) and placed less priority on NAC sensation (p=0.01). Both groups reported similar patterns of resource utilization.

Conclusion: This study highlights the value of online platforms like Reddit as a tool for understanding gender-affirming surgery preferences and perspectives. While clinic-based surveys are limited by the demographics of the surrounding area, online platforms are more inclusive of individuals with lower income, lower education, and those in the earlier stages of their gender-affirming care. By reaching underrepresented individuals who may lack healthcare access, Reddit can provide insights into surgical decision-making and barriers to care. Notably, online discussions revealed non-binary and gender-diverse individuals report greater variability in surgical preferences, particularly regarding NAC and breast mound. Plastic surgeons should consider expanding conversations to encompass the preferences among these gender-diverse populations while incorporating insights from online discussions to improve gender-affirming care.

Introduction With the rising prevalence of obesity in the U.S., understanding its impact on postoperative outcomes in gender-affirming surgeries is critical. Despite evidence linking obesity with complications in transfeminine procedures, its effect on neovaginoplasty outcomes remains unclear. This study aims to assess the relationship between BMI and postoperative complications, including revision rates, in patients undergoing various neovaginoplasty techniques.

Methods A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was conducted to identify patients who had undergone neovaginoplasty from the years of 2018-2022. Diagnosis codes for gender identity disorders and male-to-female vaginoplasty were used to identify the cohort. Adverse events that occurred within 30-days postoperatively were identified, and multivariate regression was utilized to delineate statistically significant relationships that existed between BMI and complications of interest.

Results

A total of 499 patients met inclusion criteria. The mean age was 36.44 ± 13.45 and racial demographics were as follows: 77% White, 7.2% Black or African American, 4.4% Asian, and 8.6% Unknown/Not Reported. Average BMI was found to be 27.48 ± 6.78 kg/m2. After controlling for age, race, smoking status, and diabetes, multivariate analysis revealed that increased BMI was significantly associated with higher odds of postoperative complications, including dehiscence (OR: 1.10; p=0.0188), UTI (OR: 1.09; p=0.0105), reoperation within 30 days (OR: 1.05; p=0.0391), and readmission within 30 days (OR: 1.05, p=0.0011).

Conclusions

This study, the largest to date on the impact of BMI on neovaginoplasty outcomes, reveals a significant association between increased BMI and higher odds of complications, including dehiscence, UTI, reoperation, and readmission within 30 days. Given the conflicting literature on the effects of obesity in gender-affirming surgeries, our findings provide critical insight into optimizing care for this population. Preoperative counseling and tailored perioperative strategies for patients with higher BMI are essential to improving outcomes and reducing postoperative complications in neovaginoplasty.

Introduction Gender affirming vaginoplasty (GAV) provides significant benefits to those with gender dysphoria by creating a functional and sensate vaginal canal and external genitalia for improved self-esteem, body satisfaction, and gender congruence (1,2,3). Because elevated body mass index (BMI) is often associated with increased complications, some surgical centers limit offering GAV to patients with BMI of a certain upper limit, such as 30 or 35 (4,5). This study will investigate BMI as a risk factor for complications in GAV to determine whether patients with obesity can safely undergo the procedure. Methods This study is a retrospective cohort study from March 2019 to December 2022. Patients undergoing gender affirming vaginoplasty were collected from the electronic medical records and categorized by surgical approach. Data collected included demographics, surgical and medical history, operative information, and postoperative outcomes. Complications analyzed included urethral stenosis, strictures, flap necrosis, urethral fistulas, infections, and wound dehiscence. Results A total of 56 individuals were included in the cohort, with 42 (75%) undergoing penile inversion vaginoplasty (PIV), eight (14.3%) undergoing colonic vaginoplasty, and six (10.7%) undergoing peritoneal lining vaginoplasty. Twenty-two (39.3%) patients experienced postoperative complications with six (10.7%) patients of the total cohort requiring readmissions. In those with complications, the median body mass index (BMI) was higher than those without complications, but this difference was not statistically significant (30.0 vs 26.0, p=0.2). The range of BMI in the patient cohort was 18.0 - 44.0 with an interquartile range of 23.0 - 33.0. BMI, a past medical history of diabetes, hypertension, depression, and human immunodeficiency virus (HIV) were not significantly associated with complications on univariate and multivariate analysis. Race, insurance status, and age were also not significantly associated with complications. Conclusion This study suggests patients with higher BMI may still undergo GAV safely and with good outcomes. Our institution aims to offer gender affirming surgery to patients who seek it without using BMI as a strict cut-off. Surgeons who perform gender affirming surgery should have shared decision-making with their patients regarding their risk profile and individual goals. Because BMI was not significantly associated with GAV complications, we recommend expanding BMI cut-offs for the procedure or evaluating each patient on a case-by-case basis.

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