Scientific Abstract Presentations: Gender Affirmation Session 2 Friday, October 10 Fri, Oct 10 2:00-3:30 p.m. CDT

Purpose Phalloplasty addresses both functional and aesthetic aspects of penile reconstruction, contributing to improved quality of life for many individuals. Selection of recipient vessels is challenging due to the absence of adequate vessels in the immediate proximity. Despite technical refinements in microsurgical penile reconstruction, flap-related complications, often due to vascular complications, remain high at 25.9% (1). Currently, there is no consensus on the appropriate vessel selection. This systematic review consolidates research on recipient vessels in phalloplasty and examines their correlation with postoperative outcomes. We hypothesized that the selection of recipient vessels in phalloplasty significantly impacts surgical outcomes, including complications and flap survival. Methods A systematic review of literature was performed according to PRISMA guidelines, from 1949 to January 2024, across Ovid-MEDLINE/PubMed, Embase, and CENTRAL, yielding 958 articles after removal of duplicates. Forty -six articles met the inclusion criteria, detailing recipient vessels, surgical outcomes, and complications. Collected data included patient demographics (age, sex, BMI), surgical details (indications, techniques, free flap type, and flap size), donor and recipient vessels, anastomosis technique, number of venous anastomoses, postoperative outcomes (complications and treatments), and follow-up duration. A random effects model was employed to calculate pooled proportions of complications. Subgroup analysis was conducted to explore the effects of recipient artery, anastomosis technique, recipient vein(s), number of venous anastomoses, flap type, and surgical indications on surgical outcomes. Results The included articles represent 1,976 phalloplasty cases (1,585 gender-affirming and 391 non-gender-affirming). The predominant flap configuration was the tube-within-a-tube design, utilized in 52.4% of cases. Radial forearm flap was the most common free flap, used in 1,008 cases (51.1%). The most common recipient artery was the deep inferior epigastric artery (DIEA) (71.5%, 1,413 cases), followed by the superficial femoral artery (9.2%, 181), common femoral artery (7.8%, 154), circumflex femoral artery (1.4%, 28), and deep femoral artery (0.8%, 15). The most common transposed recipient vein was the deep inferior epigastric vein (DIEV) & Great Saphenous vein or branches (GSV) (34.4%, 679), followed by the DIEV alone (34.3%, 677), and the GSV alone (26.6%, 526). The overall rates of arterial and venous thrombosis were 2.1% and 2.3%, respectively. The use of interpositional vein grafts with the femoral artery resulted in significantly higher thrombosis at 16.7% compared to 0.1% for the femoral artery with direct anastomosis and 1.2% for DIEA with direct anastomosis (p<0.001). The overall rates of partial and total flap necrosis were 6.7% and 1.5%, respectively. Direct anastomosis with the femoral artery demonstrated significantly lower partial flap necrosis at 0.5% compared to 5.4% for DIEA (p=0.026). Conclusions The choice of recipient vessels plays a crucial role in the success of phalloplasty. Current literature indicates that the deep inferior epigastric vessels exhibit the lowest proportion of vascular complications and anastomosis revisions. However, the higher proportion of arterial thrombosis observed with the femoral artery may be significantly attributable to the incorporation of an interpositional vein graft. Despite their lower thrombosis rates, the use of the deep inferior epigastric vessels was associated with higher rates of partial flap necrosis when the vessels remained patent.

References (1) Falcone M, Preto M, Timpano M, et al. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: single-centre experience and systematic review of the current literature. Int J Impot Res. 2021;33(7):737-745. doi:10.1038/s41443-021-00414-x

Background: Marijuana use has been increasing due to changes in legal status and growing social acceptance. However, its effect on surgical complications remains largely unknown. Some surgical subspecialties have reported an association between marijuana use and a modest increase in perioperative morbidity and mortality following major elective surgery (1). However, no studies have examined its impact on outcomes in facial feminization surgery (FFS). Therefore, this study aims to assess the prevalence of marijuana use in our institutional FFS cohort and evaluate its effect on postoperative complications.

Methods: A retrospective analysis of patients undergoing FFS at our institution between 2017 and 2024 examined demographics, comorbidities, marijuana use and other recreational drugs, and postoperative complications. Current marijuana users were included, excluding former users. Propensity score matching using 1:1 nearest neighbor matching was employed to minimize confounders, matching marijuana users and non-marijuana users based on age, race, body mass index, comorbidities, and other drug use. Bivariate statistical analyses were performed using Mann-Whitney U and Chi-square tests. Multivariate logistic regression was conducted to evaluate the independent association between marijuana use and postoperative complications in both cohorts.

Results: A total of 300 patients underwent FFS, including 85 current marijuana users (28.3%) and 193 non-users (64.3%). The cohort median age was 33.0 years, with a median follow-up of 3.0 months. Overall complication rates were low, with infection at 3.3%, hematoma at 3.0%, and dehiscence at 0.70%. No significant differences were observed between users and non-users across all complications. Multivariate logistic regression also found no significant association between marijuana use and increased likelihood of postoperative complications. Propensity score matching was performed, yielding 162 patients, including 76 marijuana users (46.9%). Similar to the unmatched cohort, no significant associations were observed between cannabis users and non-users across all variables. Multivariate logistic regression further confirmed no increased likelihood of postoperative complications.

Conclusion: This study demonstrated that current marijuana use does not significantly impact FFS surgical outcomes, with comparable complication rates between users and non-users. Propensity score matching controlled for confounders, enhancing the study's generalizability. These findings support the safe inclusion of marijuana users undergoing FFS and provide evidence to help guide perioperative counseling. However, further research is warranted to develop more comprehensive guidelines for this patient population.

1. Potnuru PP, Jonna S, Williams GW. Cannabis Use Disorder and Perioperative Complications. JAMA Surg.2023;158(9):935–944. doi:10.1001/jamasurg.2023.2403

Purpose Many surgeons require patients to undergo twelve consecutive months of gender-affirming hormone therapy (GAHT) before certain gender-affirming surgeries. Surgical stress and general anesthesia can provoke perioperative migraines, and sex hormones significantly influence primary headaches. Migraines are more prevalent in cisgender women than cisgender men, and changes in estrogen and testosterone levels can influence migraine prevalence. This study aims to describe a cohort of transgender and nonbinary patients with primary headaches who are utilizing GAHT. Headache symptoms and health care resource utilization are compared one year before versus one year after GAHT initiation. Methods A single-institution, retrospective review of adult patients with a history of a primary headache disorder who initiated GAHT between January 2017 and October 2023 was conducted. The primary outcomes were prevalence of headache symptoms and seeking care for headaches. The McNemar, Fisher's exact, and Wilcoxon signed rank tests were used to compare these outcomes one year before versus one year after GAHT initiation. Results This study includes 64 patients with a median age of 23 (IQR 18-30). The prevalence of headache in this population regardless of GAHT initiation is 7.7% (n=307). Migraine is the most common headache type (n=47, 73%) and 13 patients (20%) have a history of aura. Most are transmasculine, or assigned female at birth (n=48, 75%). There is no significant difference in the proportion of patients with headache symptoms one year before versus one year after initiating testosterone (n=19, 40% versus n=22, 46%; p=0.48) or estrogen (n=5, 50% versus n=11, 69%; p=0.55) and no significant difference in the proportion of individuals who sought outpatient or hospital care for headaches one year before versus after initiating testosterone (n=16, 33% versus n=18, 37%; p=0.45) or estrogen (n=5, 31% versus n=5, 31%; p=1). There is no significant difference in the average (standard deviation [SD]) number of health care visits for headache one year before versus after initiating GAHT in transmasculine or transfeminine patients (0.67 [1.3] versus 0.73 [0.43], p=0.81; 0.63 [1.0] versus 0.44 [0.73], p=0.55). There is no significant difference between transdermal, oral, subcutaneous, or intramuscular GAHT administration and incidence of symptoms or healthcare resource utilization for headaches for transmasculine or transfeminine patients. However, transfeminine patients with aura are more often started on transdermal estrogen compared with transfeminine individuals without aura (p < 0.01). The median follow-up after initiation was 36 (IQR 22-58) months and no thromboembolic events occurred. Conclusion This is the first study of headache prevalence and progression following initiation of GAHT in adults with pre-existing primary headaches. These findings suggest that GAHT may have limited impact on headache symptoms and healthcare resource utilization in both transmasculine and transfeminine individuals. However, the route of GAHT administration may play a role in the development of migraine characteristics. Therefore, transfeminine patients who develop migraines with aura after the initiation of transdermal patches should consider other routes of GAHT administration. These findings can help guide patient-physician decision-making for patients with primary headaches and concern for exacerbation of symptoms following initiation of GAHT.

Purpose: Current challenges in creation of the neophallus include significant scarring, high urethral complication rates, and anatomic fidelity. The aim of this study is to report on the use of tissue expander (TE) placement in single-scar ALT phalloplasty, demonstrate the validity of this novel approach, and highlight its potential to address these clinical challenges.

Methods: A 29 year-old patient underwent a two-stage shaft-only phalloplasty. During the first stage in June 2022, the tissue expander was placed and filled with 150 cc. Following this procedure, the expander was filled to a total of 805 cc over the course of several post-operative visits. We proceeded with stage 2 four months later, in which the neophallus was created, the nerve was coapted, and the donor site was closed. A little under one year later, the patient underwent glansplasty and scrotoplasty. Follow-up is ongoing.

Results: No major complications were observed at any stage of reconstruction. Following stage one, the patient endorsed minor nerve pain likely due to stretching of the lateral femoral cutaneous nerve. This pain resolved prior to the second stage. Currently, patient reports improving sensation and ability to orgasm through stimulation of the phallus. In addition, the patient is able to urinate without issue. The patient is pleased with the appearance of a single-scar and the aesthetic outcome of the phallus. Next steps include implantation of inflatable erectile prosthesis and scrotal implant.

Conclusion: We successfully performed a single-scar ALT phalloplasty with TE placement in this case. The TE placement allows for primary closure which can alleviate the scar burden faced by patients seeking gender-affirming phalloplasty. Furthermore, tissue expansion can allow for thinner flaps and flap hypervascularization which may improve flap survival rates as well as aesthetic outcomes. Combination of this procedure with laminating urethroplasty and delay of urethral anastomosis should also be explored as a method to reduce urethral fistula and stricture rates.

Purpose: Feminizing bottom surgery encompasses various techniques aimed at aligning physical anatomy with gender identity for transgender women and gender-diverse individuals. Despite the importance of these procedures in gender-affirming care, there remains limited research comparing the priorities and experiences of individuals before and after undergoing these surgeries. Understanding these perspectives is essential for improving patient education, surgical decision-making, and postoperative satisfaction. Therefore, this study sought to identify potential gaps between preoperative expectations and postoperative realities by directly comparing these two populations.

Methods: An IRB-approved survey was distributed through Reddit gender-based forums to collect data on demographics, surgical preferences, priorities, and experiences related to feminizing bottom surgery. Participants were categorized into two groups: those interested in but who had not yet undergone feminizing bottom surgery (preoperative) and those who had already received such procedures (postoperative). Group differences were assessed using t-tests and chi-squared tests with significance set at p<0.05.

Results: The study included 211 respondents who met inclusion criteria, with 164 (77.73%) in the preoperative group and 47 (22.27%) in the postoperative group. The majority of participants identified as transgender women (88.41% preoperative, 95.74% postoperative). Both groups demonstrated similar demographics across age, BMI, education level, and income, with the only significant difference being that postoperative individuals were more likely to have undergone other gender-affirming surgeries (38.30% vs. 12.72%, p<0.001). Regarding surgical preferences, both groups favored penile inversion and peritoneal vaginoplasties over intestinal or minimal-depth techniques. Functional outcomes-specifically orgasmic capability and preservation of erotic sensation were consistently prioritized above aesthetic and anatomical considerations across both cohorts. However, significant differences emerged in two areas: preoperative individuals placed higher priority on self-lubrication (p<0.05), while postoperative individuals assigned greater importance to vaginal width (p<0.001). Among the 73 participants who had consulted with surgeons, only 60% reported that their surgeons discussed different surgical techniques and their respective advantages and disadvantages. Penile inversion was the most commonly discussed technique (84.78%), while intestinal vaginoplasty was the least discussed (26.09%, p<0.001). Notably, minimal-depth vaginoplasty was discussed in only 55.17% of preoperative and 40.43% of postoperative consultations.

Conclusions: This study reveals shifting priorities between preoperative and postoperative patients in feminizing bottom surgery. While functional outcomes remain a priority, specific anatomical priorities shift. Additionally, discrepancy in surgical counseling, particularly the limited discussion of minimal-depth and intestinal approaches, indicates an opportunity to enhance preoperative education. Such improvements could optimize decision-making with a broader discussion and enhanced counseling between patients and providers.

Purpose: Preferences for gender-affirming chest masculinization or top surgery vary among gender-diverse patients. As the demand for top surgery continues to grow, it is increasingly crucial to foster discussions that promote tailored care and collaboration among patients and surgeons to achieve desired surgical outcomes. A previous study introduced an institutional pictorial algorithm, with visual representations of both standard and non-standard top surgery options, to help gender-diverse patients better understand their choices (1). The present study aimed to evaluate the use of this published pictorial algorithm on patient perspective regarding top surgery surgical options and preferences.

Methods: A survey was administered to patients pursuing or who had previously undergone top surgery at a plastic surgery clinic. The survey consisted of demographic information, top surgery experiences, top surgery preferences, and an algorithmic questionnaire. Group differences among transmasculine, non-binary, and other gender-diverse (OGD) groups (defined as prefer not to say, genderfluid, genderqueer, agender, or other) were analyzed using chi-squared tests, Fisher's exact test, and ANOVA, with statistical significance set at p<0.05.

Results: We had a total of 107 respondents, including 46 transgender males, 47 non-binary, and 14 OGD. Compared to transgender males, non-binary and OGD individuals had higher education levels (p<0.005) without any significant differences among household income levels. Before reviewing the pictorial algorithm, 100% of transmasculine individuals sought only standard top surgery options, while OGD (42.86%) and non-binary individuals (19.15%) were more likely to seek "non-standard" options for top surgery, including near total mastectomy or radical breast reduction (p<0.0001). However, after viewing the pictorial algorithm, a greater proportion of transmasculine individuals stated they were "unsure" of their exact preferences for NAC, compared to non-binary and OGD groups (p=0.002). Regarding communication with surgeons, there was a trend toward non-binary and OGD respondents feeling less comfortable discussing "non-standard" options with their surgeons and discussing nipple position. Overall, transmasculine individuals found the algorithm more helpful than OGD and non-binary individuals (4.30±0.76 vs. 3.79±0.58 vs. 3.59±1.07, p=0.001). Written feedback from respondents included more representation of scar contour, nipple size and placement, and NAC-free surgical options.

Conclusion: These findings highlight the diverse surgical preferences among patients seeking gender-affirming top surgery. "Non-standard" options appear to be more relevant for non-binary and OGD individuals than for transmasculine patients, while transmasculine patients initially expressed strong preferences for standard top surgery. The more specific questions in the pictorial algorithm appeared to result in transmasculine individuals expressing more uncertainty regarding their preferred surgical approach, particularly regarding NAC preferences. This underscores the need for more-in depth preoperative discussions, with the pictorial algorithm serving as a valuable tool. Future efforts should focus on refining the algorithm to better address the needs of non-binary and other gender-diverse populations, ensuring a more-inclusive approach to top surgery counseling.

References: Garvey SR, Friedman R, Nanda AD, Boustany AN, Lee BT, Lin SJ, et al. Along the continuum from reduction to mastectomy: An algorithmic approach to the gender diverse top surgery patient. J Plast Reconstr Aesthet Surg. 2023;83:246-9.

Purpose Facial feminization surgery (FFS) often includes forehead procedures, such as forehead setback and/or contouring. The original Ousterhout classification used lateral cephalograms to define frontal sinus anatomy into 4 types and plan the frontal bone procedure. References to these types are commonly used by the literature, patients, and surgeons when planning FFS. However, since the original publication in 1987, no study has used CT scan to validate these, nor determine frequency of each and whether it correlates with surgical procedure. The aim of our study is to investigate whether specific CT scan measurements validate the differences in frontal sinus anatomy originally described by Ousterhout, with what frequency each occurs and whether the frontal bone surgical procedures indicated correlate with such measurements.

Methods A retrospective chart review was conducted of patients undergoing FFS from 2018-2024 within a large integrated healthcare system. Data collected included relevant CT scan measurements and type of forehead procedure received. CT scans of facial bones were analyzed in axial, coronal, and sagittal view to obtain frontal sinus measurements relevant to the Ousterhout descriptions. Two independent reviewers (AA and ID) captured measurements, which were then applied to Ousterhout descriptions and each patient was designated an Ousterhout type. Statistical analysis included chi-square Test of independence to examine relationship between Ousterhout classification and type of FFS forehead procedure, as well as One-Way ANOVA to determine if there was statistically significant difference between the frontal sinus measurements between Ousterhout classifications.

Results A total of 155 patient charts were reviewed. One-Way ANOVA showed statistically significant difference between Ousterhout classifications in the following CT scan frontal sinus measurements: left anterior table thickness, left depth (p < 0.001), left projection (p < 0.001), right anterior table thickness (p < 0.001), right depth (p < 0.001), right projection (p = 0.002), height (p < 0.001), and width (p < 0.001). Frequency of each Ousterhout classification type assigned compared with the original description are as follows: 18% type 1 (compared to 9%), 7% type 2 (compared to 8%), 40% type 3 (compared to 82%), no type 4, and 34% that did not easily fall under an Ousterhout classification. In evaluating the procedure performed, most patients with type 3 underwent setback while most patients with combined type 1 and 2 underwent contouring only. Chi-square test of independence showed statistical significance (p < 0.001) between Ousterhout classification and type of procedure.

Conclusion Our study concludes that CT scan measurements of relevant frontal sinus anatomy including anterior table thickness, projection, depth, height, and width validate the significant differences in frontal sinus types originally described by Ousterhout. It also validates that the frontal bone surgical procedure indicated and performed correlates with Ousterhout original classification. However the frequency with which each type occurs deviates significantly with his original description as well as many that do not fit in any type described. Based on this, we propose that contouring only may be a valid option in more patients than originally described, which is helpful in discussions with patients and surgical planning.

Purpose: While gender-affirming vaginoplasty (GAV) has become more common, optimal postoperative length of stay (LOS) remains unclear, with recommendations ranging from 3 to 9 days. Prolonged hospitalization can increase healthcare costs and expose patients to hospital-related complications, yet, the safety of early discharge is not well established. As access to gender-affirming care expands, establishing standardized postoperative care is critical. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, this study examines predictors of prolonged length of stay in gender-affirming vaginoplasty and evaluates the safety of discharging patients within 2 days.

Methods We identified patients who underwent gender-affirming vaginoplasty from 2012 to 2022 in the ACS-NSQIP database using procedure-specific CPT codes. Patients were stratified into two groups based on length of stay: early discharge (≤2 days) and prolonged (>2 days). Group differences were assessed using Chi-square or Fisher's exact tests for categorical variables and Student's t-test or Wilcoxon Rank-Sum for continuous variables. Multivariate analysis with logistic regression and propensity adjustment was performed to identify independent predictors of prolonged LOS. Statistical significance was set at p<0.05.

Results A total of 663 patients were included. Patients with early discharge were significantly older (38.22±11.22 vs. 35.90±12.73, p=0.03). Significant differences between groups were also observed for race, surgical specialty, and American Society of Anesthesiologists (ASA) classification (p=0.03, 0.001, and 0.02, respectively). Patients with prolonged LOS had higher preoperative hematocrit values (41.04±3.50 vs. 39.99±3.26, p=0.01) and longer operative times (289.87±108.22 vs. 164.40±103.61, p<0.0001). Notably, early discharge had fewer total complications (5.68% vs. 13.74%, p=0.03), with trends toward reduced readmissions (2 vs. 25), and reoperations (4 vs. 25), although the latter two did not reach statistical significance. On univariate analysis, preoperative hematocrit, operative time, and surgical specialty predicted prolonged LOS. However, after multivariate adjustment, only operative time remained a significant predictor. In the propensity-adjusted model, prolonged LOS was associated with a threefold increase in the odds of complications (OR 3.28, CI: 1.24-8.75, p=0.02).

Conclusion: Among patients undergoing gender-affirming vaginoplasty, longer operative time was the strongest predictor of prolonged hospitalization. Significant associations with age, race, surgical specialty, ASA classification, and hematocrit levels highlight key areas for targeted intervention in perioperative optimization. Discharge within 2 days was associated with significantly fewer complications and showed trends toward lower readmission and reoperation rates, supporting early discharge as a safe and feasible option in selected patients.

PURPOSE: Preoperative gabapentin has shown promise in reducing postoperative pain, opioid requirements, and nausea and vomiting in breast cancer surgery. (1) The use of preoperative gabapentin has also been explored in other domains, including facial plastic surgery, orthopaedic surgery, general surgery, and urology, to variable results. However, its efficacy in transgender, non-binary, and gender-expansive (TNG) patients undergoing gender-affirming surgery has not been established. This study seeks to examine the effect of preoperative gabapentin and intraoperative acetaminophen, alone and in combination, as part of a multimodal, opioid-sparing analgesic approach to gender-affirming mastectomy.

METHODS: A retrospective chart review was conducted of patients undergoing gender-affirming mastectomy with a single plastic surgeon between 2022 and 2024. Charts were reviewed for age at surgery, body mass index (BMI), and records of perioperative medication administration. Specifically, receipt of a single 1200-mg dose of gabapentin in the preoperative holding area, receipt of acetaminophen intraoperatively, and receipt of antiemetics and opioid analgesics in the postanesthesia care unit (PACU) were noted.

Patients were grouped based upon types of non-opioid pain medication received: 1) neither preoperative gabapentin nor intraoperative acetaminophen (NONE), 2) intraoperative acetaminophen alone (ACE), 3) preoperative gabapentin alone (GABA), and 4) preoperative gabapentin and intraoperative acetaminophen (BOTH). Binary logistic regression was employed to compare analgesia modalities in assessing the likelihood of requiring opioid therapy in the PACU while controlling for age and BMI. Additionally, multivariable linear regression was conducted, using the same covariates, to compare modalities for the outcome of postoperative opioid requirement, in morphine milligram equivalents (MME).

RESULTS: A total of 167 patients met inclusion criteria, with 30 patients (18.0%) receiving preoperative gabapentin. A binary multivariate logistic analysis demonstrated that, relative to the NONE group, the GABA group was significantly less likely to require opioid therapy in the PACU (OR=0.148, 95% CI: 0.035 – 0.531, p=0.005). The ACE group (OR=0.082, 95% CI: 0.029 – 0.203, p<0.001) and BOTH group (OR=0.043, 95% CI: 0.002 – 0.261, p=0.004) were also significantly less likely to need opioids in the PACU. There was no association between analgesia modality and postoperative nausea and vomiting, as measured by requiring an antiemetic in the PACU.

Multiple linear regression, controlling for age and BMI, revealed that the GABA group (β= - 5.21, 95% CI -0.16 – -10.26, p=0.043), ACE group (β= - 7.25, 95% CI -3.80 – -10.70, p<0.001), and BOTH group (β= - 10.07, 95% CI -3.72 – -16.43, p=0.002) all required significantly fewer MMEs in the PACU.

CONCLUSIONS: Our results demonstrate a synergistic relationship between preoperative gabapentin and intraoperative acetaminophen as part of a multimodal, opioid-sparing analgesic approach in gender-affirming mastectomy. Of note, a significant effect on postoperative nausea and vomiting was not demonstrated. Further research into the efficacy of standardized, multimodal analgesia practices for patients undergoing gender-affirming surgery is needed.

(1) Jiang Y, Li J, Lin H, et al. The efficacy of gabapentin in reducing pain intensity and morphine consumption after breast cancer surgery: A meta-analysis. Medicine (Baltimore). 2018;97(38):e11581. doi:10.1097/MD.0000000000011581

PURPOSE: Preoperative gabapentin has shown promise in reducing postoperative pain, opioid requirements, and nausea and vomiting in breast cancer surgery. (1) The use of preoperative gabapentin has also been explored in other domains, including facial plastic surgery, orthopaedic surgery, general surgery, and urology, to variable results. However, its efficacy in transgender, non-binary, and gender-expansive (TNG) patients undergoing gender-affirming surgery has not been established. This study seeks to examine the effect of preoperative gabapentin and intraoperative acetaminophen, alone and in combination, as part of a multimodal, opioid-sparing analgesic approach to gender-affirming mastectomy.

METHODS: A retrospective chart review was conducted of patients undergoing gender-affirming mastectomy with a single plastic surgeon between 2022 and 2024. Charts were reviewed for age at surgery, body mass index (BMI), and records of perioperative medication administration. Specifically, receipt of a single 1200-mg dose of gabapentin in the preoperative holding area, receipt of acetaminophen intraoperatively, and receipt of antiemetics and opioid analgesics in the postanesthesia care unit (PACU) were noted.

Patients were grouped based upon types of non-opioid pain medication received: 1) neither preoperative gabapentin nor intraoperative acetaminophen (NONE), 2) intraoperative acetaminophen alone (ACE), 3) preoperative gabapentin alone (GABA), and 4) preoperative gabapentin and intraoperative acetaminophen (BOTH). Binary logistic regression was employed to compare analgesia modalities in assessing the likelihood of requiring opioid therapy in the PACU while controlling for age and BMI. Additionally, multivariable linear regression was conducted, using the same covariates, to compare modalities for the outcome of postoperative opioid requirement, in morphine milligram equivalents (MME).

RESULTS: A total of 167 patients met inclusion criteria, with 30 patients (18.0%) receiving preoperative gabapentin. A binary multivariate logistic analysis demonstrated that, relative to the NONE group, the GABA group was significantly less likely to require opioid therapy in the PACU (OR=0.148, 95% CI: 0.035 – 0.531, p=0.005). The ACE group (OR=0.082, 95% CI: 0.029 – 0.203, p<0.001) and BOTH group (OR=0.043, 95% CI: 0.002 – 0.261, p=0.004) were also significantly less likely to need opioids in the PACU. There was no association between analgesia modality and postoperative nausea and vomiting, as measured by requiring an antiemetic in the PACU.

Multiple linear regression, controlling for age and BMI, revealed that the GABA group (β= - 5.21, 95% CI -0.16 – -10.26, p=0.043), ACE group (β= - 7.25, 95% CI -3.80 – -10.70, p<0.001), and BOTH group (β= - 10.07, 95% CI -3.72 – -16.43, p=0.002) all required significantly fewer MMEs in the PACU.

CONCLUSIONS: Our results demonstrate a synergistic relationship between preoperative gabapentin and intraoperative acetaminophen as part of a multimodal, opioid-sparing analgesic approach in gender-affirming mastectomy. Of note, a significant effect on postoperative nausea and vomiting was not demonstrated. Further research into the efficacy of standardized, multimodal analgesia practices for patients undergoing gender-affirming surgery is needed.

(1) Jiang Y, Li J, Lin H, et al. The efficacy of gabapentin in reducing pain intensity and morphine consumption after breast cancer surgery: A meta-analysis. Medicine (Baltimore). 2018;97(38):e11581. doi:10.1097/MD.0000000000011581

PURPOSE: Preoperative gabapentin has shown promise in reducing postoperative pain, opioid requirements, and nausea and vomiting in breast cancer surgery. (1) The use of preoperative gabapentin has also been explored in other domains, including facial plastic surgery, orthopaedic surgery, general surgery, and urology, to variable results. However, its efficacy in transgender, non-binary, and gender-expansive (TNG) patients undergoing gender-affirming surgery has not been established. This study seeks to examine the effect of preoperative gabapentin and intraoperative acetaminophen, alone and in combination, as part of a multimodal, opioid-sparing analgesic approach to gender-affirming mastectomy.

METHODS: A retrospective chart review was conducted of patients undergoing gender-affirming mastectomy with a single plastic surgeon between 2022 and 2024. Charts were reviewed for age at surgery, body mass index (BMI), and records of perioperative medication administration. Specifically, receipt of a single 1200-mg dose of gabapentin in the preoperative holding area, receipt of acetaminophen intraoperatively, and receipt of antiemetics and opioid analgesics in the postanesthesia care unit (PACU) were noted.

Patients were grouped based upon types of non-opioid pain medication received: 1) neither preoperative gabapentin nor intraoperative acetaminophen (NONE), 2) intraoperative acetaminophen alone (ACE), 3) preoperative gabapentin alone (GABA), and 4) preoperative gabapentin and intraoperative acetaminophen (BOTH). Binary logistic regression was employed to compare analgesia modalities in assessing the likelihood of requiring opioid therapy in the PACU while controlling for age and BMI. Additionally, multivariable linear regression was conducted, using the same covariates, to compare modalities for the outcome of postoperative opioid requirement, in morphine milligram equivalents (MME).

RESULTS: A total of 167 patients met inclusion criteria, with 30 patients (18.0%) receiving preoperative gabapentin. A binary multivariate logistic analysis demonstrated that, relative to the NONE group, the GABA group was significantly less likely to require opioid therapy in the PACU (OR=0.148, 95% CI: 0.035 – 0.531, p=0.005). The ACE group (OR=0.082, 95% CI: 0.029 – 0.203, p<0.001) and BOTH group (OR=0.043, 95% CI: 0.002 – 0.261, p=0.004) were also significantly less likely to need opioids in the PACU. There was no association between analgesia modality and postoperative nausea and vomiting, as measured by requiring an antiemetic in the PACU.

Multiple linear regression, controlling for age and BMI, revealed that the GABA group (β= - 5.21, 95% CI -0.16 – -10.26, p=0.043), ACE group (β= - 7.25, 95% CI -3.80 – -10.70, p<0.001), and BOTH group (β= - 10.07, 95% CI -3.72 – -16.43, p=0.002) all required significantly fewer MMEs in the PACU.

CONCLUSIONS: Our results demonstrate a synergistic relationship between preoperative gabapentin and intraoperative acetaminophen as part of a multimodal, opioid-sparing analgesic approach in gender-affirming mastectomy. Of note, a significant effect on postoperative nausea and vomiting was not demonstrated. Further research into the efficacy of standardized, multimodal analgesia practices for patients undergoing gender-affirming surgery is needed.

(1) Jiang Y, Li J, Lin H, et al. The efficacy of gabapentin in reducing pain intensity and morphine consumption after breast cancer surgery: A meta-analysis. Medicine (Baltimore). 2018;97(38):e11581. doi:10.1097/MD.0000000000011581

Introduction:

Genioplasty is a crucial component of facial feminization surgery since feminine chins are noticeably narrower, with a more rounded appearance than masculine chins. This is traditionally achieved with a central wedge excision and two-piece ostectomy that is then fixated. However, implants can be niduses of infection, especially in the mouth. A reductive genioplasty with in-situ bilateral ostectomies to narrow the chin can eliminate the need for rigid fixation while still providing a feminine appearance. This study analyzes the outcomes of the two-piece reduction with plating versus in-situ reductive genioplasty under a single surgeon.

Methods:

The study analyzed 188 patients from January 2020 to July 2024. Patients were categorized into two-piece with plating or in-situ reductive genioplasties. Both techniques were performed according to virtual surgical planning guides. Patient age, BMI, HIV status, post-operative complications, and revision rates were collected and compared among the two groups utilizing an independent t-test with a significance value of 0.05.

Results:

There were 136 patients (72.3%) in the plating group and 42 patients (22.3%) in the reductive group. The mean age of the plating group was 31.4 years old compared to the 30.9 of the reductive group (p = 0.72) with a mean BMI of 25.7 for both groups. The plating group had 10 cases of abscess (7.4%) and 2 cases of osteomyelitis (1.5%), whereas the in-situ reductive group did not have any cases of abscess or osteomyelitis. HIV status was not a significant determinant of whether a patient developed infection. Both groups had one instance of hematoma. The plating group had 17 patients (12.5%) undergo revision surgery for asymmetry, hardware removal or other reason, while the in-situ reductive group had no patients undergo revision surgery (p = 0.008).

Conclusions:

In-situ reductive genioplasty may be a better alternative to the central wedge excision and two-piece ostectomy with fixation genioplasty for facial feminization surgery as it results in fewer post-operative complications and greater patient satisfaction.

Purpose

Breast augmentation techniques have evolved to optimize aesthetic and functional outcomes. The subfascial plane has received attention for its ability to provide a natural aesthetic with the potential to minimize capsular contracture and malposition. However, studies have yet to compare the clinical outcomes of the subfascial approach in cisgender and transgender patients. The aim of this study is to compare the surgical outcomes of subfascial plane breast augmentation between these two patient populations.

Methods

A single institution retrospective review of cisgender and transgender patients that underwent subfascial primary breast augmentation by two surgeons between July 2017 and August 2024 was performed. Two cohorts of patients were matched using propensity scores to ensure comparable baseline characteristics. Short-term outcomes such as seroma/hematoma, return to the OR, surgical site infection, wound dehiscence, and long-term complications such as capsular contracture, malposition, and poor aesthetic outcomes were collected and compared between the two cohorts using unpaired t-test and Fisher's Exact test. Data analysis was conducted using IBM SPSS 24 and a p-value of < 0.05 was considered significant.

Results

A total of 41 patients were included in the study: 19 cisgender and 22 gender affirming patients. The cisgender cohort had a mean age of 38.3 years compared to 34.1 in the gender-affirmation cohort (p = 0.21). The cisgender cohort had a mean BMI of 22.9 compared to 34.1 in the gender- affirmation cohort (p = 0.13). Standardized mean differences for both age and BMI were 0.50 and 0.55 respectively, revealing imbalance. Two patients within the cisgender cohort experienced complications. One patient required surgical evacuation of a hematoma on post-operative day one and another required surgical intervention for grade IV capsular contracture 584 days after the initial procedure. Two patients within the gender-affirmation cohort developed synmastia and underwent surgical revision. No statistical significance in short or long-term complication rate between the cisgender (10.5%) and gender-affirmation (9.1%) cohorts was observed (p = 0.99).

Conclusion

Despite imbalances in mean age and BMI between the cisgender and transgender cohorts, no statistically significant difference in complication rates was found. The low overall complication rates in both groups suggests that subfascial breast augmentation is a safe and effective technique regardless of gender identity. However, the observed variations in complications-hematoma and capsular contracture in cisgender patients versus synmastia in gender-affirming patients-warrant further investigation to optimize surgical planning and patient outcomes in gender-affirming care.

References

1. Nicole Sanchez Figueroa, Doga Kuruoglu, Vahe Fahradyan, Nho Tran, Basel Sharaf, Jorys Martínez-Jorge, Feminizing Gender Affirming Breast Surgery: Procedural Outcomes at a Single Academic Institution, Aesthetic Surgery Journal Open Forum, Volume 6, 2024, ojae032, https://doi.org/10.1093/asjof/ojae032
2. Kanjoor, J.R., Khan, T.M. Chest Feminization in Transwomen with Subfascial Breast Augmentation-Our Technique and Results. Aesth Plast Surg 48, 2447–2458 (2024). https://doi.org/10.1007/s00266-023-03726-z
3. Bekeny JC, Zolper EG, Manrique OJ, Fan KL, Del Corral G. Breast augmentation in the transgender patient: narrative review of current techniques and complications. Ann Transl Med 2021;9(7):611. doi: 10.21037/atm-20-5087

Introduction: Robotic-assisted surgery has significantly advanced the field of reconstructive procedures, offering greater precision, reduced recovery times, and improved patient outcomes. One area where this technology has shown particular promise is in peritoneal flap vaginoplasty (PFV), a gender-affirming surgery for transgender women. Both single-port and multi-port robotic systems have been employed to perform this complex procedure. However, there remains ongoing debate regarding the comparative efficacy, safety, and overall patient benefits of these two approaches. This paper aims to evaluate the outcomes of single-port versus multi-port robotic systems in PFV, focusing on operative efficiency and patient safety.

Methods: This study was designed as a retrospective review of all patients who underwent robotic-assisted peritoneal flap vaginoplasty (PFV) at a single institution between September 2021 and May 2024. All procedures were led by the same surgical team, consisting of one plastic surgeon and one urologist, who worked together during each procedure. Demographic and postoperative data were collected from patient medical records. Data on operative details, such as the type of robotic system used (single-port vs. multi-port), procedure length, and total OR cost were also recorded. The primary outcomes of interest were the comparison of total operative time and total cost between the single-port and multi-port robotic procedures. Statistical analysis was conducted using IBM SPSS software and p-values of <0.05 were considered statistically significant for all analyses.

Results: A total of 48 patients underwent full-depth PFV. Average age of this cohort was 35 with an average BMI of 28.96 (SD=6.56). 25 patients underwent PFV with the assistance of a multiport robot and 23 patients underwent PFV with the assistance of a single-port robot. Demographic analysis showed no statistical difference between groups (p>0.05). Mean operative time of our multiport cohort was 269 minutes compared to a mean procedure length of 204 minutes in the single-port cohort (p<0.001). Average cost of the multiport robot vaginoplasty procedures was $31,268.96 and the average cost of the single-port robot procedures was $23,709.39 (p<0.001) There was no statistically significant difference in acute postoperative complications between cohorts.

Conclusion: This retrospective review demonstrates that single-port robotic-assisted peritoneal flap vaginoplasty (PFV) is associated with significantly shorter operative times and lower total costs compared to multi-port procedures. These findings suggest that the single-port approach may offer enhanced surgical efficiency without compromising patient safety.

Introduction: Penile inversion vaginoplasty (PIV) is a gender-affirming surgical procedure to construct a neovagina in transgender women. The procedure is associated with excellent patient satisfaction, but also high complication rates (1). Hypergranulation tissue - excess granulation tissue which causes bleeding and discomfort - is a common complication often requiring repeated in-clinic treatment with Silver Nitrate (SN) using a speculum to access the inside of the neovagina (2). Corticosteroids have been shown to reduce hypergranulation tissue by modulating fibroblast activity and inflammation (3). By creating a steroid suppository, it is possible for patients to insert the medication into the vagina canal at home and treat the hypergranulation in between clinic visits. In this study, we review a cohort of patients treated with supplemental Betamethasone (BTM) suppositories alongside SN and compare them to those treated with SN alone to determine if BTM is an efficacious tool to reduce clinic visits and promote comfort in patients experiencing hypergranulation tissue post-PIV.

Methods: A retrospective chart review was conducted on patients who received BTM suppositories formulated by the Mayo Clinic pharmacy in addition to standard SN treatment between January 2023 and December 2024. This cohort was compared to a cohort of randomly selected patients with identical procedure profiles during the same period who were treated with SN alone. Data collected included the number of treatments, outcomes, severity of the hypergranulation tissue (assessed by quantity and diffuseness), and the need for further surgical intervention. These factors were analyzed to determine the effectiveness of BTM in treating hypergranulation tissue.

Results: There were 18 patients in the Silver Nitrate only group (SN groups) and 18 patients in the BTM and SN group (BTM +SN group): 13 patients had primary PIV while 5 had revision vaginoplasty in each group. The mean follow-up was 8 months in the SN group and 7 months in the BTM + SN group. Both groups had the same median number of treatments per patient for hypergranulation tissue (median: 3). Patients with moderate hypergranulation tissue in the BTM + SN group needed less treatments than those in the SN group (median 2 vs 4). Patients with severe hypergranulation tissue in the BTM + SN group had higher resolution rates at last follow-up compared to the SN group (44% vs 25%). Patients prescribed BTM at the time of their first treatment with SN had higher resolution rates compared to patients prescribed BTM at a later appointment (88% vs 63%).

Conclusion: BTM is an effective addition to SN for the treatment of hypergranulation tissue. Patients with moderate hypergranulation tissue prescribed BTM suppositories had a fewer median number of treatments, and patients with severe hypergranulation tissue had higher resolution rates. Additionally, patients who were prescribed BTM early had improved outcomes. Our results indicate BTM is a helpful addition to treat hypergranulation tissue in patients who experience hypergranulation tissue post-PIV.

1. Hontscharuk R, Alba B, Hamidian Jahromi A, Schechter L. Penile inversion vaginoplasty outcomes: Complications and satisfaction. Andrology. 2021/11/01 2021;9(6):1732-1743. doi:https://doi.org/10.1111/andr.13030
2. Hirotsu K, Kannan S, Brian Jiang SI. Treatment of Hypertrophic Granulation Tissue: A Literature Review. Dermatol Surg. Dec 2019;45(12):1507-1516. doi:10.1097/dss.0000000000002059
3. Shalom A, Wong L. Treatment of Hypertrophic Granulation Tissue with Topical Steroids. The Journal of Burn Care & Rehabilitation. 2003;24(suppl_2):S113-S113. doi:10.1097/00004630-200303002-00141

Purpose: While various surgical options have been studied and documented in masculinizing bottom surgery, there is limited understanding of the diverse needs and preferences across different gender identities. Additionally, a lack of thorough communication between surgeons and patients about the range of available surgical techniques can complicate decision-making. This study therefore assesses the experiences and preferences of transmasculine and gender-diverse individuals in masculinizing bottom surgery.

Methods: An IRB-approved survey was distributed across multiple Reddit gender-based forums. Participants who had either undergone or expressed interest in masculinizing bottom surgery were included and categorized based on their self-reported gender identity as either transmasculine or gender-diverse (including genderfluid, genderqueer, agender, and other gender identities). Statistical analysis used t-tests and chi-squared tests with significance set at p<0.05 to assess differences between groups regarding demographics, surgical preferences, and experiences with healthcare providers.

Results: The study included 137 individuals (97 transmasculine, 40 gender-diverse) with comparable demographic profiles between groups. A significant difference was found in hormonal therapy usage, with 86.5% of transmasculine compared to 62.5% of gender-diverse participants concurrently receiving hormonal treatment (p<0.01).

Regarding surgical preferences, transmasculine individuals showed a stronger preference for phalloplasty (38.1% vs 27.5%), while gender-diverse participants more frequently selected "other" non-traditional options (7.5% vs 0%) or expressed uncertainty about their preferred surgical approach (32.5% vs 25.8%). Both groups prioritized tactile sensation and general appearance in their surgical goals, although transmasculine individuals placed higher importance on general appearance (p<0.05) and showed a trend toward greater emphasis on standing urination (p=0.06).

Among the 13 participants who consulted with surgeons, fewer than half (38.5%) reported that their surgeons discussed different surgical techniques and their advantages and disadvantages. Donor site options were inconsistently presented, with forearm and anterolateral thigh being the most commonly discussed (38.5% each).

Conclusion: While transmasculine and gender-diverse individuals share many surgical priorities, significant differences exist in their preferences and certainty regarding surgical options. Gender-diverse individuals demonstrate greater uncertainty and more interest in non-traditional approaches compared to transmasculine patients. These findings highlight the need for more comprehensive, individualized discussions between patients and surgeons that address the full spectrum of available options, acknowledge the influence of gender identity on surgical goals, and provide adequate resources to support informed decision-making in masculinizing bottom surgery.