Scientific Abstract Presentations: Gender Affirmation Session 3 Saturday, October 11 Sat, Oct 11 8:00-9:30 a.m. CDT

Purpose Feminizing hormone therapy (HT) is an important adjunct to surgical intervention in the treatment of gender dysphoria for transfeminine individuals. While the effects of hormone therapy on the breast and body are well-described, the early hormone therapy impact on craniofacial anatomy has not been explored in the literature. Frontal sinus anatomy is particularly pertinent in patients presenting for frontal bone setback and contouring as part of facial feminization surgery (FFS). This anatomical study is the first of its kind to quantify the multidimensional differences in frontal sinus anatomy associated with early hormone therapy exposure.

Methods A retrospective review of all patients presenting for FFS from 2018 to 2024 in a multi-institutional integrated healthcare system was performed. Patient history including age at HT initiation, duration of HT, surgical history, and demographic data were obtained. Patients were categorized into early and late HT groups and matched by duration of HT, with early defined as initiation of estrogen before 21 years old and late defined as HT started at 21 years of age or older. Multidimensional preoperative CT scan measurements of the facial bone anatomy was performed by two independent investigators. Measurements included nasofrontal angle, nasofrontal suture to mid-sellar distance, anterior table thickness/depth/projection of left and right frontal sinuses, height, and width. Statistical analysis included Multivariable Regression Analysis, Chi-Square tests, Independent Samples t-test, and Mann-Whitney U test as appropriate.

Results A total of 104 patients were included in the study, with 52 patients per group. Mean age at CT scan was 24.6 ± 8.1 years for the early group and 41.1 ± 13.2 for the late group. Median duration of HT was 2.6 years in the early group vs 3.0 years in the late group. Late HT patients demonstrated significantly greater left anterior table thickness (3.1 ± 1.1 mm early vs 3.8 ± 1.6 mm late, p=0.02), left sinus projection (17.6 ± 3.8 mm early vs 21.6 ± 6.7 mm late, p<0.001), right sinus depth (14.6 ± 4.5 mm early vs 12.2 ± 3.2 mm late, p=0.004), and right sinus projection (17.7 ± 4.3 mm early vs 19.9 ± 4.9 mm late, p=0.01). There was no significant difference in nasofrontal angle, nasofrontal suture to mid-sellar distance, left sinus depth, right anterior table thickness, sinus height, or sinus width between the two groups. Frontal sinus aplasia was observed in 10 (19.2%) patients in the early group and 4 (7.7%) patients in the late group (p=0.09). Regression analysis demonstrated that age at CT was not an independent predictor of frontal sinus depth or projection.

Conclusion Early feminizing hormone treatment was significantly associated with decreased bilateral frontal sinus projection, right sinus depth, and left sinus anterior table thickness in patients presenting for FFS. This may result in less indications for or a smaller degree of frontal sinus setback in patients seeking gender-affirming facial surgery. These data support the early initiation of feminizing hormone treatment prior to 21 years of age in transfeminine individuals as a way to minimize the development of masculine frontal sinus characteristics.

Purpose: As gender-affirming surgeries (GAS) become more common, recommendations for perioperative hormone management remain unclear, with many advising discontinuation due to thromboembolic risk. However, acute cessation of hormones can cause undesirable effects and exacerbate gender dysphoria in the perioperative period. This systematic review aims to evaluate the outcomes of continuation versus cessation of gender-affirming hormone therapy (GAHT) before gender-affirming surgeries to inform guidelines and improve patient care. Methods: A systematic review was conducted in December 2024 following PRISMA guidelines. Articles were screened through a two-stage process, with inclusion criteria focusing on studies related to perioperative hormone therapy before GAS. Exclusion criteria included non-English articles, commentaries, reviews, and conference abstracts. A difference in proportion meta-analysis was performed to compare the occurrence of postoperative complications such as hematoma, seroma, wound dehiscence, graft necrosis, infection, granulation tissue, and venous thromboembolism. Results: Of 3,829 citations screened, 8 studies were included, analyzing 2,382 patients and 1,067 cases. In this cohort, 1,392 patients and 576 cases continued GAHT, 681 patients and 483 cases discontinued, and 112 patients and 8 cases had dose reductions. Five studies focused on estrogen, and three focused on testosterone. The reported rate of complications was similar between cohorts, regardless of hormone therapy continuation or cessation. A difference in proportion meta-analysis showed no significant difference in complications between groups who continued and those who ceased hormone therapy for both estrogen and testosterone groups. Hematoma, the most common complication, had a rate of 2.6% in the cessation group and 1.1% in the continuation group, with an average lower limit of -0.052 and an average upper limit of 0.044 in the estrogen use articles, with a 95% confidence interval. Some Pdiff values trended negatively for most articles, showing no difference or a slight preference toward discontinuation, with the exception of venous thromboembolism, where Pdiff for the majority of articles showed a slight positive trend, indicating a small risk in the discontinuation group. However, the differences in all complication categories were not statistically significant. Conclusion: Overall, meta-analysis demonstrates there is no significant difference in risk between patients who cease hormone therapy and those who continue it. In light of the known detrimental effects of disrupting hormone therapy in patients with gender dysphoria, these findings suggest that continuation of hormones in the perioperative setting should be strongly considered.

Background: Artificial intelligence (AI) is transforming patient education in all areas of medicine, and its potential applications in the field of plastic surgery are being increasingly reported. Patient education plays a significant role in enabling individuals to make informed decisions about their healthcare, particularly in sensitive and specialized areas such as gender-affirming surgery. Traditionally, patient education for such surgeries has relied on consultations, brochures, and digital resources. However, the emergence of conversational AI, such as Chat Generative Pre-training Transformer (ChatGPT), opens a new avenue for personalized patient education, while potentially alleviating provider burden.

Objectives: This study investigates the utility of ChatGPT as a tool for patient education in the context of gender-affirming surgery, examining its ability to provide accurate and comprehensive information.

Methods: ChatGPT 4.0 was used to generate a Frequently Asked Questions (FAQ) sheet for seven common gender-affirming surgery procedures. The FAQ sheets were inputted into a survey and distributed to five plastic surgeons that practice the full spectrum of gender-affirming surgery. Each question of every FAQ sheet was then assessed for accuracy and comprehensiveness using a standardized five-point Likert scale. Continuous variables were reported as means and standard deviations.

Results: The ChatGPT-generated FAQ sheets were more accurate than comprehensive across all surgical procedures. The mean overall accuracy was 68.4% (standard deviation [SD] = 5.8%) and the mean overall comprehensiveness was 56.8% (SD = 5.6%). All FAQ sheets were at least 'somewhat accurate,' with all mean scores exceeding 3 on the Likert scale. In terms of comprehensiveness, all FAQ sheets were deemed 'adequate,' with scores above 3 on the Likert scale.

Conclusions: Our study demonstrates the likely utility of ChatGPT in introductory and, in some cases, comprehensive patient education. However, ChatGPT's limitations stem from its reliance on existing internet resources; therefore, information provided by the AI should be verified and supplemented by gender-affirming surgeons. ChatGPT can serve as a foundational tool, streamlining the creation of educational materials and potentially increasing office visit efficiency. By leveraging conversational AI as a supplementary resource, physicians may provide tailored patient education in gender-affirming care, particularly as the technology continues to evolve.

Purpose Feminizing hormone therapy (HT) is an important adjunct to surgical intervention in the treatment of gender dysphoria for transfeminine individuals. While the effects of hormone therapy on the breast and body are well-described, the early hormone therapy impact on craniofacial anatomy has not been explored in the literature. Frontal sinus anatomy is particularly pertinent in patients presenting for frontal bone setback and contouring as part of facial feminization surgery (FFS). This anatomical study is the first of its kind to quantify the multidimensional differences in frontal sinus anatomy associated with early hormone therapy exposure.

Methods A retrospective review of all patients presenting for FFS from 2018 to 2024 in a multi-institutional integrated healthcare system was performed. Patient history including age at HT initiation, duration of HT, surgical history, and demographic data were obtained. Patients were categorized into early and late HT groups and matched by duration of HT, with early defined as initiation of estrogen before 21 years old and late defined as HT started at 21 years of age or older. Multidimensional preoperative CT scan measurements of the facial bone anatomy was performed by two independent investigators. Measurements included nasofrontal angle, nasofrontal suture to mid-sellar distance, anterior table thickness/depth/projection of left and right frontal sinuses, height, and width. Statistical analysis included Multivariable Regression Analysis, Chi-Square tests, Independent Samples t-test, and Mann-Whitney U test as appropriate.

Results A total of 104 patients were included in the study, with 52 patients per group. Mean age at CT scan was 24.6 ± 8.1 years for the early group and 41.1 ± 13.2 for the late group. Median duration of HT was 2.6 years in the early group vs 3.0 years in the late group. Late HT patients demonstrated significantly greater left anterior table thickness (3.1 ± 1.1 mm early vs 3.8 ± 1.6 mm late, p=0.02), left sinus projection (17.6 ± 3.8 mm early vs 21.6 ± 6.7 mm late, p<0.001), right sinus depth (14.6 ± 4.5 mm early vs 12.2 ± 3.2 mm late, p=0.004), and right sinus projection (17.7 ± 4.3 mm early vs 19.9 ± 4.9 mm late, p=0.01). There was no significant difference in nasofrontal angle, nasofrontal suture to mid-sellar distance, left sinus depth, right anterior table thickness, sinus height, or sinus width between the two groups. Frontal sinus aplasia was observed in 10 (19.2%) patients in the early group and 4 (7.7%) patients in the late group (p=0.09). Regression analysis demonstrated that age at CT was not an independent predictor of frontal sinus depth or projection.

Conclusion Early feminizing hormone treatment was significantly associated with decreased bilateral frontal sinus projection, right sinus depth, and left sinus anterior table thickness in patients presenting for FFS. This may result in less indications for or a smaller degree of frontal sinus setback in patients seeking gender-affirming facial surgery. These data support the early initiation of feminizing hormone treatment prior to 21 years of age in transfeminine individuals as a way to minimize the development of masculine frontal sinus characteristics.

Purpose: Compared to the general population, transgender and gender-diverse individuals exhibit a higher prevalence of tobacco and drug use (1,2). Despite the well-established negative impact of tobacco smoking on wound healing and surgical outcomes (3,4), limited research has analyzed its effects in the context of gender-affirming surgery. This study evaluates the association between tobacco, marijuana, and vape use on postoperative outcomes following chest masculinization surgery (CMS).

Methods: We conducted a retrospective cohort study of transgender and non-binary patients who underwent CMS with double incision mastectomy and free nipple grafting between March 2022 and January 2025 by the senior author. The primary predictors were tobacco and marijuana smoking, defined as cigarette/cigar/joint smoking and vaping. Primary outcomes were defined as surgical complications requiring intervention (venous thromboembolism (VTE), sepsis, acute kidney injury (AKI), urinary tract infection, infection requiring antibiotics or surgical washout, wound dehiscence, hematoma or seroma requiring intervention, skin necrosis, nipple graft failure) and adverse aesthetic outcomes (scar widening or hypertrophy, revision surgery for standing cone deformity or scars). The association between smoking behaviors and postoperative outcomes were analyzed using bivariate statistical analysis.

Results: Of 92 patients meeting inclusion criteria, the average (standard deviation, SD) age was 27.3 (7.7). Over half (54.3%, n=50) had a history of smoking or vaping, including tobacco (37.0%, n=34) and marijuana (42.4%, n=39). At time of consultation, 38.0% (n=35) of patients were active smokers, with 17.4% (n=16) using tobacco and 32.6% (n=30) using marijuana. Despite smoking cessation counseling, preoperative nicotine and cotinine tests were positive in 10.9% of patients (n=10). The mean (SD) follow-up duration was 5.2 (4.1) months postoperatively.

Overall, surgical complications occurred in 25.0% (n=23), while 29.3% (n=27) experienced adverse aesthetic outcomes. There were no significant differences in frequency of surgical and adverse aesthetic outcomes between active, previous and never tobacco users. Similar results were obtained when tobacco users were stratified into cigarette smokers and nicotine vapers. There was no difference in complications between those with positive preoperative nicotine/cotinine tests and those without. Marijuana use (smoking or vaping) was also not significantly associated with adverse surgical or aesthetic outcomes. Within our cohort, there were no major surgical complications including sepsis, VTE or AKI. Other surgical complications included infection requiring antibiotics (16.3%, n=15), infection requiring washout (4.4%, n=4), wound dehiscence (4.3%, n=4), skin necrosis (2.2%, n=2), hematoma (2.2%, n=2), seroma (2.2%, n=2), and nipple graft failure (1.1%, n=1). Adverse aesthetic outcomes included scar widening/hypertrophy (29.3%, n=27), and revision surgery for standing-cone deformities or scarring (11.9%, n=11).

Conclusion: Active smoking or vaping of tobacco, nicotine or marijuana may not be associated with significant complications following CMS. While smoking should not be encouraged, we acknowledge the difficulty of quitting. Our findings suggest that smoking should not be a reason to deny or delay treatment. Future, larger cohort studies may further delineate the association between smoking and gender-affirming surgery outcomes.

References 1. Sawyer AN, Bono RS, Kaplan B, Breland AB. Nicotine/tobacco use disparities among transgender and gender diverse adults: Findings from wave 4 PATH data. Drug Alcohol Depend. 2022 Mar 1;232:109268. doi: 10.1016/j.drugalcdep.2022.109268. Epub 2022 Jan 10. PMID: 35038608; PMCID: PMC8885914.

2. Hughto JMW, Quinn EK, Dunbar MS, Rose AJ, Shireman TI, Jasuja GK. Prevalence and Co-occurrence of Alcohol, Nicotine, and Other Substance Use Disorder Diagnoses Among US Transgender and Cisgender Adults. JAMA Netw Open. 2021;4(2):e2036512. doi:10.1001/jamanetworkopen.2020.36512

3. Fan Chiang YH, Lee YW, Lam F, Liao CC, Chang CC, Lin CS. Smoking increases the risk of postoperative wound complications: A propensity score-matched cohort study. Int Wound J. 2023 Feb;20(2):391-402. doi: 10.1111/iwj.13887. Epub 2022 Jul 9. PMID: 35808947; PMCID: PMC9885463.

4. Sørensen LT. Wound Healing and Infection in Surgery: The Clinical Impact of Smoking and Smoking Cessation: A Systematic Review and Meta-analysis. Arch Surg. 2012;147(4):373–383. doi:10.1001/archsurg.2012.5

Background: Facial feminization surgery (FFS) is a specialized and complex gender-affirming procedure that has been shown to improve self-perception and social integration among those who identify as transgender or non-binary. Despite the growing popularity of FFS, data on patient demographics, surgical outcomes, and factors contributing to patient satisfaction and the pursuit of revision procedures remain limited. Thus, the purpose of this study was to identify factors associated with revision surgery in FFS to provide valuable insights to optimize surgical planning and improve patient-reported outcomes.

Methods: Data from 69 healthcare organizations included in the US Collaborative TriNetX network was analyzed. Fourteen facial feminization procedures were identified using CPT codes including blepharoplasty, rhytidectomy, genioplasty, frontal sinus setback, orbital contouring, facial bone contouring, malar augmentation, rhinoplasty, chondrolaryngoplasty, browlift, otoplasty, lipectomy, midface reconstruction, and autologous facial grafts. Cohorts were created based on a diagnosis of gender identity disorder and subsequent incidence of at least one of these cosmetic surgeries. Multiple cohorts were created including total incidence of FFS, total incidence of revision, and surgeries with greater than 10 instances of revision and analyzed using the Advanced Explore Cohort feature.

Results: A total of 1,171 adult patients were diagnosed with gender dysphoria and underwent at least one facial feminization procedure. The majority of patients were white (69%), non-hispanic or latino (73%) with a mean age of 36.2 ± 12.8 years. The most commonly performed surgeries were frontal sinus setback (n=547, 47%), rhinoplasty (n=536, 46%), chondrolaryngoplasty (n=411, 35%), and browlift (n=400, 34%). In total, the revision rate was 9% with 107 patients undergoing revision surgeries. Of these, facial bony contouring (n=30, 7.8%) had the highest rate of revision followed by genioplasty (n=20, 5.3%), chondrolaryngoplasty (n=21, 5.1%), and rhinoplasty (n=21, 3.9%). Pearson's chi-square test did not demonstrate statistically significant differences in these revision rates (p=0.08). The average time to revision facial feminization surgery was 0.95 years based on mean age at time of primary surgery and revision, which varied by procedure. Genioplasty (0.6 years), facial bone contouring (0.7 years), and chondrolaryngoplasty (0.9 years) were revised on average within the first year post-operatively, while rhinoplasty revisions took place at a mean 1.7 years post-operatively.

Conclusion: This large-scale TriNetX study demonstrates that revisionary surgery following facial feminization occurs in 9% of patients, with facial bony contouring having the highest rate of revision. This characterization of FFS can help guide the surgeon-patient discussion regarding post-operative expectations following facial feminization. Further research is warranted to determine the patient and surgical factors which lead to revision in facial feminization surgery.

Background: Facial feminization surgery (FFS) describes a set of procedures that alter the craniofacial skeleton to reduce incongruence between self-identified gender and physical appearance. Given the complex bony alterations, three-dimensional virtual surgical planning (VSP) has become increasingly utilized for these procedures to create personalized and accurate postoperative results. However, few studies have evaluated the similarity between these plans and assigned-female-at-birth (AFAB) skulls.

Methods: Patients who underwent FFS procedures including frontal sinus setback, suprabrow contouring, genioplasty, and gonial angle reduction at a single academic institution were identified. Materialise (Leuven, Belgium) 3D virtual surgical plans were designed prior to the operation, and computed tomography (CT) scans for AFAB subjects were provided upon request by the New Mexico Decedent Imaging Database (NMDID). These subjects were randomly selected and approximated the age distribution of the patient cohort.

Craniofacial landmarks to isolate the forehead, chin, and gonial angle regions were placed using Mimics (Materialise, Leuven, Belgium). Surface area, volume, and region-specific morphometric values were calculated. Measurements of planned osseous changes were compared to benchmark values derived from the group of five AFAB subjects to determine the degree of similarity between the surgical plan and anthropomorphically feminine features. Inherent differences in skull size between AFAB subjects and transgender female patients were investigated by comparing the bizygomatic width of each group using a two-sample t-test.

Surface area and volume AFAB similarity for each region were compared using an ANOVA analysis. Statistically significant differences between groups were subsequently determined using pairwise t-tests with a Bonferroni correction.

Results: A total of 80 patients and 188 FFS procedures (69 forehead operations, 74 genioplasties, 45 bilateral gonial angle reductions) were included in this study. The cohort had a mean age at surgery of 34.3 ± 10.1 years old compared to a mean age at time of imaging of 34.0 ± 6.1 years for the five AFAB control subjects. The mean bizygomatic width of the AFAB subjects was 128.9 ± 9.9 millimeters in comparison to 134.1 ± 5.2 millimeters for the patient cohort. This difference was statistically insignificant (p=0.3118).

Regarding surface area changes, both forehead (86.5% ± 11.0%, p<0.05) and genioplasty procedures (88.4% ± 10.9%, p<0.005) were found to have a greater AFAB similarity score than gonial angle reduction (81.0% ± 11.7%). Conversely, planned genioplasty volume (85.5% ± 11.5%) had a significantly greater similarity to anthropomorphically feminine measurements than forehead procedures (74.7% ± 20.7%, p<0.0005) or gonial angle reduction (70.3% ± 16.7%, p<0.0001).

Conclusions: Virtual surgical plans are an increasingly utilized tool during facial gender-affirming surgery to provide patients with more feminine characteristics. This study presents, to our knowledge, the largest and most comprehensive analysis of how well these plans approximate AFAB craniofacial features. By introducing this framework for analysis, this study provides insight into improving FFS preoperative planning and patient counseling.

Background: Information regarding current breast cancer screening guidelines for the transgender population is scarce and often contradictory within the medical literature, leading to inconsistent recommendations from healthcare providers. Additionally, the knowledge that transgender patients possess regarding their breast health and their understanding of current breast cancer screening recommendations remains widely unknown.

Methods: A survey-based study was designed to assess the level of understanding that transgender patients have about their future breast cancer screening needs. The survey was distributed to patients receiving gender-affirming care in a single institution's Department of Plastic Surgery and medical-student-run free clinic. Patients were surveyed about their use of hormone replacement therapy, interest in or prior exposure to top surgery, and understanding of breast cancer screening guidelines. Patients were also asked about their reported level of education regarding their future breast cancer screening needs.

Results: Of the 68 survey respondents, 70% indicated either previously having top surgery or future interest in pursuing top surgery. However, only 26.67% of transgender females, 9.52% of transgender males, and 9.09% of non-binary or gender-fluid respondents reported that they felt educated regarding their future breast cancer screenings. Notably, only 32.3% of respondents reported receiving education about breast cancer screening from a healthcare professional. In contrast, 77.4% of all respondents reported being educated about breast cancer screenings from another source (e.g., social media, Google search, etc.).

Conclusions: Our study demonstrates the gaps in knowledge that exist among transgender individuals regarding their breast health and highlights the urgent need for healthcare providers to educate their patients about breast cancer screening recommendations. This knowledge can be used to develop educational resources that aim to decrease the incidence of breast cancer within the transgender population and to raise awareness of appropriate screening measures.

Background: Chest and breast procedures are the most common form of gender-affirming surgery (GAS) performed in the U.S.. Current literature varies widely on the shape and placement of the incision and nipple-areola complex (NAC). As such, our group developed a new web-based decision-making tool that allows the patient to choose a skin tone, body type, scar incision pattern, and NAC placement based on size, shape, and position on the chest. The purpose of this study is to assess the implementation and feasibility of a virtual tool for GAS in a clinical setting.

Methods: A pilot study was conducted of patients undergoing initial pre-operative consultation for chest masculinization surgery at our institution. Patients were surveyed regarding their experience using the tool. Surgeons and staff members were asked to use the tool to create multiple possible chest configurations and were surveyed on the implementation and perceived usefulness of the tool in a clinical setting.

Results: A total of 8 clinicians and 43 patients used the tool and completed the survey. 6 (75%) of the clinicians strongly agreed that the tool would improve their understanding of a patient's desired outcomes while 4 (50%) agreed that this tool would be more useful for pre-surgical planning than patient-brought photos. Patient assessments were generally positive. 29 (67%) of patients strongly agreed that the tool could help patients make decisions about their desired top surgery results, and 28 (65%) strongly agreed that the tool was easy to use. Clinician feedback expressed concern that the tool may cause patients to expect results unachievable with the patient's pre-surgical anatomy and recommended a modifiable lateral view of the chest to determine desired tissue volume. Both clinicians and patients requested more diversity in body shapes and skin color.

Conclusion: Both patients and clinicians found the visualization tool for GAS to be helpful and feasible in a clinical setting. Further refinements of the tool with additional views, body types, and skin colors are necessary to optimize its use.

Purpose: Recent legislative advancements for gender-affirming surgery (GAS) coverage have led to a significant increase in patients undergoing vaginoplasty. Although less commonly selected compared to full-depth vaginoplasty, minimal-depth vaginoplasty presents benefits, including fewer complications, quicker recovery, high patient satisfaction, and reduced postoperative demands. A notable gap exists in the literature regarding motivations behind patient decision-making in this context. Social media platforms have emerged as sources of support and information sharing among patients considering GAS. This study aims to explore public perception and discourse surrounding gender-affirming vaginoplasty by systematically analyzing discussion boards to understand the information needs, motivations, concerns, and outcomes of patients choosing between minimal-depth and full-depth vaginoplasty.

Methods: The Python Reddit API Wrapper (PRAW) was employed to identify original threads (posts and comments) from December 2015 to August 2024 containing the terms "vaginoplasty," "vulvoplasty," or "depth" on six subreddits: "Nonbinary," "translator," "MtF," "transgender," "ask_transgender," and "asktransgender." Threads were filtered by keywords related to minimal-depth and full-depth vaginoplasty procedures, followed by a two-stage screening process. In stage one, two screeners independently reviewed all threads for inclusion. In stage two, two screeners manually coded relevant threads into themes, including dysphoria, immediate post-operative concerns, long-term considerations, sexual preferences, support systems, healthcare access, financial concerns, cosmetic considerations, comorbidities, and information barriers regarding procedure options. Any discordance was resolved through discussion.

Results: 219 out of the 450 screened threads met inclusion criteria. The most frequently cited themes include immediate post-operative recovery and complications (73 threads), bottom dysphoria (59), healthcare access (51), sexual preferences (44), long-term considerations (43), financial concerns (34), future surgical flexibility (25), cosmetic considerations (22), individual comorbidities (18), support systems (16), and information barriers (9). Reasons for considering minimal-depth included lack of interest in penetration (9.7%) and medical contraindications (2.4%). Barriers included concerns regarding possible depth augmentation (8.3%) and lack of information (4.4%). Full-depth preferences were driven by alleviating dysphoria (15.0%) and the desire for penetrative intercourse (7.3%). Concerns cited postoperative dilation/douching (15.1%), risk of infection (2.4%), and surgical complexity (2.4%). Additionally, 6.8% of patients cited the ability or quality of orgasm as an important factor. Among patients who underwent minimal-depth or full-depth vaginoplasty, 74% reported positive sentiments regarding their experience.

Conclusions: This study offers the first evidence of public perception and discourse on minimal-depth versus full-depth vaginoplasty, emphasizing the influence of platforms on patient decision-making. Understanding the information present on social media is critical for plastic surgeons navigating patient consultations. These insights can help tailor preoperative counseling, enhance patient education, correct misconceptions, and promote informed, patient-centered decision-making, ultimately improving surgical outcomes.

Background: Robotic sigmoid colon vaginoplasty (SCV) and peritoneal flap vaginoplasty (PFV) are increasingly utilized in transgender and non-binary (TGNB) individuals seeking genital reconstruction. These procedures offer self-lubricating mucosa, sufficient neovaginal depth, and enhanced sexual function while potentially lowering the risk of neovaginal stenosis and reoperation. Despite their growing popularity, data on how body mass index (BMI) influences outcomes after SCV and PFV remain sparse. This study aims to investigate the effects of elevated BMI on postoperative results in patients undergoing SCV versus PFV. Methods: We conducted a single-center retrospective review of TGNB individuals who underwent SCV and PFV between December 2020 and February 2024. Patients with a BMI ≥30 kg/m² were categorized into SCV or PFV cohorts. Demographic information, surgical details, and postoperative outcomes were analyzed and compared. Short-term complications were defined as those occurring within 30 days postoperatively, while long-term complications were classified as those emerging after 30 days.

Results: A total of 85 patients were included, with 46 (54.1%) undergoing SCV and 39 (45.9%) undergoing PFV. The median age was 35 years (IQR: 11), and the median BMI was 33.9 kg/m² (IQR: 4.5). There were no significant differences between the groups in terms of diabetes, hyperlipidemia, smoking status, or Charlson Comorbidity Index. The median duration of hormone therapy use was 52 months (IQR: 79). Among the 33 patients (38.8%) undergoing revision vaginoplasty, 22 (47.8%) had SCV and 11 (28.2%) had PFV (p=0.064). Revision rates may have influenced differences in operative duration, which was shorter for SCV (208 minutes, IQR: 91.2) compared to PFV (246.5 minutes, IQR: 80), p=0.001. Hospital length of stay (median 5 days, IQR:2) and time to mobilization (median 3 days, IQR:0) were similar between groups, but the time to first dilation was shorter for SCV (3 days, IQR: 1) than PFV (4 days, IQR: 1), p<0.001. In total, 23 (27.1%) patients experienced at least one short-term complication, including full-thickness dehiscence (14.1%), ileus (5.9%), and vaginal bleeding (3.5%). Five patients (5.9%) required reoperation within 30 days. Long-term complications were observed in 20 (23.9%) patients, including vaginal prolapse (5.9%), vaginal stenosis (8.2%), and full-thickness dehiscence (3.0%). Delayed healing with hypergranulation tissue occurred more frequently in the PFV cohort (12.8%) compared to none in the SCV group (p=0.018), though this was not significant on multivariate analysis. A total of 15 (17.7%) patients required reoperation, predominantly for vaginal prolapse or stenosis (14.1%). The median follow-up time was 10.2 months (IQR: 9.2). There were no significant differences between cohorts in terms of overall complication rates or other perioperative details.

Conclusion: Elevated BMI did not significantly influence postoperative outcomes between SCV and PFV. Both procedures demonstrated acceptable complication rates, providing sufficient neovaginal lubrication and depth, and are viable options for revision vaginoplasty. Understanding the role of BMI and obesity in these intra-abdominal surgeries is crucial, as our findings suggest that SCV and PFV are safe and effective for TGNB individuals with higher BMI.

Background: Robotic sigmoid colon vaginoplasty (SCV) and peritoneal flap vaginoplasty (PFV) are increasingly utilized in transgender and non-binary (TGNB) individuals seeking genital reconstruction. These procedures offer self-lubricating mucosa, sufficient neovaginal depth, and enhanced sexual function while potentially lowering the risk of neovaginal stenosis and reoperation. Despite their growing popularity, data on how body mass index (BMI) influences outcomes after SCV and PFV remain sparse. This study aims to investigate the effects of elevated BMI on postoperative results in patients undergoing SCV versus PFV. Methods: We conducted a single-center retrospective review of TGNB individuals who underwent SCV and PFV between December 2020 and February 2024. Patients with a BMI ≥30 kg/m² were categorized into SCV or PFV cohorts. Demographic information, surgical details, and postoperative outcomes were analyzed and compared. Short-term complications were defined as those occurring within 30 days postoperatively, while long-term complications were classified as those emerging after 30 days.

Results: A total of 85 patients were included, with 46 (54.1%) undergoing SCV and 39 (45.9%) undergoing PFV. The median age was 35 years (IQR: 11), and the median BMI was 33.9 kg/m² (IQR: 4.5). There were no significant differences between the groups in terms of diabetes, hyperlipidemia, smoking status, or Charlson Comorbidity Index. The median duration of hormone therapy use was 52 months (IQR: 79). Among the 33 patients (38.8%) undergoing revision vaginoplasty, 22 (47.8%) had SCV and 11 (28.2%) had PFV (p=0.064). Revision rates may have influenced differences in operative duration, which was shorter for SCV (208 minutes, IQR: 91.2) compared to PFV (246.5 minutes, IQR: 80), p=0.001. Hospital length of stay (median 5 days, IQR:2) and time to mobilization (median 3 days, IQR:0) were similar between groups, but the time to first dilation was shorter for SCV (3 days, IQR: 1) than PFV (4 days, IQR: 1), p<0.001. In total, 23 (27.1%) patients experienced at least one short-term complication, including full-thickness dehiscence (14.1%), ileus (5.9%), and vaginal bleeding (3.5%). Five patients (5.9%) required reoperation within 30 days. Long-term complications were observed in 20 (23.9%) patients, including vaginal prolapse (5.9%), vaginal stenosis (8.2%), and full-thickness dehiscence (3.0%). Delayed healing with hypergranulation tissue occurred more frequently in the PFV cohort (12.8%) compared to none in the SCV group (p=0.018), though this was not significant on multivariate analysis. A total of 15 (17.7%) patients required reoperation, predominantly for vaginal prolapse or stenosis (14.1%). The median follow-up time was 10.2 months (IQR: 9.2). There were no significant differences between cohorts in terms of overall complication rates or other perioperative details.

Conclusion: Elevated BMI did not significantly influence postoperative outcomes between SCV and PFV. Both procedures demonstrated acceptable complication rates, providing sufficient neovaginal lubrication and depth, and are viable options for revision vaginoplasty. Understanding the role of BMI and obesity in these intra-abdominal surgeries is crucial, as our findings suggest that SCV and PFV are safe and effective for TGNB individuals with higher BMI.

Background: Gender-affirming (GA) surgeries increased in the last decade, yet GA training remains limited for plastic surgery residents. A recent survey of plastic surgery program directors indicated greater resident exposure to facial and top (chest) GA surgery than bottom (genital) surgery (1). Despite the rising demand for GA procedures, plastic surgery residents receive minimal training in genital reconstruction. While plastic and reconstructive surgery is a cornerstone of GA care, urology also plays a critical role in GA genital reconstruction. This study compares the GA genital surgery training between urology and plastic surgery (PRS) programs, their GA clinics or patient services, the national distribution, and summarizes the emergence of GA fellowships in plastic surgery.

Methods: U.S.-based accredited integrated PRS and urology residency programs were identified using ACGME and American Urology Association (AUA) databases. Residency and institutional websites were reviewed to confirm program presence, rotation schedules, GA fellowship opportunities, and mentions of GA surgical services related to genital reconstruction. Unaccredited fellowships in urogenital or genitourinary reconstruction were included if they trained plastic or urologic surgeons in genital reconstruction. Fellowships without genital reconstruction or those excluding plastic or urologic surgeons were excluded. Geographic distribution was categorized into four U.S. regions: West, Midwest, South, and Northeast. Descriptive and inferential analysis was conducted using SPSS version 28.0.1. Results: 232 U.S.-based, accredited, residency programs were confirmed, 88 PRS and 144 urology. 8 PRS residency institutions provided GA fellowship (9.1%) versus and 9 with urology residency programs also offered a GA fellowship (6.3%) (p = 0.42). PRS residency programs that offered a microsurgery fellowship were 33 times more likely to have an associated GAS fellowship. A subanalysis of urology programs that offer genital reconstruction fellowships was assessed and nearly 41% (n=59) offered a fellowship that encompasses genital reconstruction and this was significantly greater than PRS GA fellowships (p<0.001). Geographically, no significant difference between region and origin of genital reconstruction fellowships (PRS versus urology) was observed. 28 (41.2%) programs that had a GAS fellowship did not advertise offering GA surgical services. Programs that didn't have a GA fellowship were more likely to advertise providing GA surgical services (n=79, 46.7%) (p<0.001). GA fellowships in PRS have expanded since 2017, beginning with Mount Sinai's program. Key milestones include OHSU (2018), Cleveland Clinic (2019), RUSH (2020), Michigan and Brigham & Women's (2022), and Johns Hopkins (2023). Upcoming programs include Utah, UCLA and Kansas Medical Center reflecting continued growth.

Conclusion: While PRS residency programs provide foundational reconstructive skills, only a limited number of programs provide exposure to GA genital reconstruction, and urology training opportunities in genital reconstruction exceed PRS. There remains a need for more training opportunities in genital reconstruction for plastic surgeons.

References: 1.Magoon KL, LaQuaglia R, Yang R, Taylor JA, Nguyen PD. The Current State of Gender-Affirming Surgery Training in Plastic Surgery Residency Programs as Reported by Residency Program Directors. Plast Reconstr Surg. 2020;145(2):567-574. doi:10.1097/PRS.0000000000006426

Introduction: Uterus transplantation (UTx) has emerged as a groundbreaking surgical solution, allowing conception for individuals with absolute uterine factor infertility (AUFI). To date, UTx has been performed primarily for patients with Mayer-Rokitansky-Kuster-Hauser syndrome or hysterectomy (1). However, UTx may also be an upcoming frontier in gender affirming surgery, as conception is often affirming of female gender. Previous systematic reviews of UTx have focused on surgical, maternal, and perinatal outcomes. This review updates previous syntheses of published UTx cases worldwide, emphasizing recipient characteristics and pregnancy outcomes.

Methods: A systematic review was conducted utilizing PubMed, Embase, and Cochrane CENTRAL according to PRISMA 2020 guidelines. Search terms related to "uterine transplantation," or "uterine graft" or "organ transplantation" were used. Studies reporting surgical outcomes, obstetric outcomes, or neonatal outcomes in the context of UTx were included. Review articles combining multiple studies and studies that did not include patient outcomes were excluded.

Results: Our search yielded 2,387 citations, of which 64 met the inclusion criteria. Across all studies, 86 cases of UTx for hysterectomy (n=5), MRKH (n=80), and Asherman's Syndrome (n=1) were reported. Uterine grafts were procured from living donors (LD) in 68/86, while deceased donors (DD) accounted for 18/86 of the transplants. There were a total of 16 graft failures, 11 being from LD (16% of LD) and 5 from DD (28% of DD). Graft rejection was also reported in 32 cases, 26 (38% of LD) and 6 from DD (33% of DD). Graft thrombosis occurred in 13 cases, 11 (16% of LD) and 2 from DD (11% of DD). The average time between UTx and menstruation was 5.3 weeks (SD = 3.4), and time between UTx and embryo implantation was 8.9 months (SD = 3.9). Out of 42 patients who became pregnant, a total of 49 live births were reported. Average birth weight was 2506.8g (SD = 556). The most common pregnancy complications included preterm labor (11, 22%), gestational hypertension (6, 12%), gestational diabetes (6, 12%), and PPROM (6, 12%). The most common neonatal complications were respiratory complications (6, 12%), jaundice (1, 2%), and hypoglycemia (1, 2%).

Conclusion: This study provides the most comprehensive synthesis of global data on UTx and associated live births. Programs offering UTx have achieved notable success and have offered individuals without childbearing potential an enhanced quality of life. However, the implementation and accessibility of UTx are primarily constrained by the resources and clinical infrastructure required to perform these complex procedures (2). Continued advancements and resource allocation are essential to broaden access to this innovative treatment.

References 1. Wall AE, Johannesson L, Sok M, Warren AM, Gordon EJ, Testa G. The journey from infertility to uterus transplantation: A qualitative study of the perspectives of participants in the Dallas Uterus Transplant Study. BJOG. 2022 Jun;129(7):1095-1102. doi: 10.1111/1471-0528.17052. Epub 2021 Dec 27. PMID: 34889028. 2. Ayoubi JM, Carbonnel M, Racowsky C, de Ziegler D, Gargiulo A, Kvarnström N, Dahm-Kähler P, Brännström M. Evolving clinical challenges in uterus transplantation. Reprod Biomed Online. 2022 Nov;45(5):947-960. doi: 10.1016/j.rbmo.2022.06.020. Epub 2022 Jul 1. PMID: 35999148.

Introduction: The demand for gender-affirming surgery (GAS) has risen significantly over the past decade with an increasing number of people openly identifying as transgender or gender-diverse (TGD). However, the lack of available GAS providers is frequently cited as a barrier to accessing these procedures. The purpose of this study is to estimate the gap between those who will desire GAS and the surgical workforce capable of meeting this demand through 2035.

Methods: We constructed a model based on several assumptions. We utilized data from the 2023 U.S. Household Pulse Survey to estimate the size of the TGD population. We referenced findings from the 2015 U.S. Transgender Survey to assess interest in undergoing each procedure type, and held that interest level constant into the future. Additionally, we estimated that all individuals who have indicated they desire GAS will seek it within a decade. There were 660 gender-affirming surgeons in the U.S. in 2020, and we assumed an annual growth rate of 3% since and in the future. Our model assumed that GAS providers dedicated an average of one day per week to operating on TGD patients.

Results: The TGD population aged 13 years and older is projected to reach 1.9M by 2035. The total demand for GAS during this period is estimated to be 1.9M, including 434K vaginoplasty, 376K facial feminization, 348K breast augmentation, 309K chest masculinization, 89K metoidioplasty, and 65K phalloplasty procedures.

Over the study period, approximately 59.8% of demand of the total GAS demand will be met. Chest masculinizations stand out as the only procedures for which demand is entirely fulfilled. The majority of desired breast augmentations and tracheal shaves are anticipated to be feasible (88.7% and 71.2%, respectively). However, only 52.0% of metoidioplasty and 41.3% of phalloplasty procedures are expected to be met. Notably, 33.0% of the facial feminization and 8.3% of vaginoplasty demand is projected to be met.

Conclusions: The findings underscore a concerning misalignment between the growing demand for GAS and the surgical workforce capable of meeting these needs, especially for facial feminization and genital surgeries. This study did not take into account the skewed geographic availability of GAS providers, and the availability-demand mismatch is likely more drastic in many parts of the U.S. nondiscrimination protection policy reform, expanding telehealth opportunities, and increasing education and surgical exposure to GAS for surgical residents would continue to build the workforce capable of meeting the demand.

Background/Purpose: Body mass index (BMI) is a critical metric in assessing adiposity relative to height and weight, often useful in evaluating surgical risks. Obesity in the context of gender-affirming vaginoplasty can increase surgical complexity and risks such as wound healing complications and infection rates. However, no universally established cutoff for surgical candidacy or fully elucidated role of BMI in vaginoplasty currently exists. In this study, we seek to identify the relationship between BMI and postoperative outcomes following vaginoplasty in transgender patients.

Methods: A retrospective analysis was performed using the National Surgical Quality Improvement Program (NSQIP) datasets from 2005–2022. Adult patients with an ICD-9/10 code diagnosis of gender dysphoria who underwent gender-affirming vaginoplasty were included. Patients were stratified based on BMI as Underweight (BMI<18.5), Healthy Weight (BMI 18.5-24.9), Overweight (BMI 25.0-29.9), Obesity Class I–III (BMI 30-34.9, BMI 30-39.9, and BMI≥40). Primary outcomes included 30-day readmission, reoperation, and postoperative complication rates. Multivariable logistic regressions were performed to assess the impact of BMI on surgical outcomes. Covariates were selected using forward selection based on minimizing the Akaike information criterion and clinical relevance. All regression models demonstrated good fit with adjusted pseudo-R2 values ranging from 0.190–0.437 (all p<0.001).

Results: Among 11,574,114 patients in the NSQIP database, 312 patients underwent gender-affirming vaginoplasty. BMI cohorts included 13 (6.0%) Underweight, 78 (35.9%) Healthy Weight, 60 (27.6%) Overweight, 35 (16.1%) Obesity Class I, 18 (8.3%) Obesity Class II, and 13 (6.0%) Obesity Class III (BMI range: 15.6–49.5). Patients among the more severe obesity classes demonstrated higher rates of 30-day readmissions (p<0.001), 30-day reoperations (p<0.001), operating room takebacks (p<0.001), and wound dehiscence (p<0.001; Table 1). Upon multivariable regression analysis, Obesity Class II and Class III diagnoses significantly increased patients' risk of 30-day readmissions (OR 33.6, p=0.008; OR 69.1, p=0.001), 30-day reoperations (OR 25.3, p=0.011; OR 61.4, p=0.001), and operating room takebacks (OR 25.3, p=0.011; OR 61.4, p=0.001). The risk of wound dehiscence was significantly higher for Obesity Class III patients (19.5, p=0.004), but not for Obesity Class II (OR 3.3, p=0.377). All other BMI strata were not associated with any of these complications (p>0.05; Table 2).

Conclusion: Patients with class III obesity undergoing gender-affirming vaginoplasty have poorer postoperative outcomes, including higher rates of wound dehiscence, reoperation, and readmission. However, further research is warranted to confirm these findings, preferably in the form of prospective studies in larger cohorts. Plastic surgeons should consider these risks carefully and implement tailored strategies to mitigate complications in this patient population.