Scientific Abstract Presentations: Gender Affirmation Session 5 Sunday, October 12 Sun, Oct 12 8:00-9:30 a.m. CDT

Introduction: A key component of facial feminization surgery (FFS) is the frontal bone setback procedure to decrease supraorbital bar prominence. Intraoperative transillumination of the frontal bone is a commonly-accepted technique to delineate frontal sinus borders for osteotomy. Cranial bone hyperpigmentation is a rare finding associated with tetracycline use, malignancy, infection, or metabolic disorders. Its occurrence in FFS and effects on transillumination remained largely undocumented. We present two cases of frontal bone hyperpigmentation found during FFS and subsequent impact on surgical management.

Case Reports: A 26-year-old Caucasian transgender female with no history of bone disease or tetracycline use presented for FFS. Her preoperative CT facial scan was unremarkable. During cranial dissection, dark pigmentation of the frontal bone was identified, permeating full thickness through all bone layers. Frontal sinus transillumination through the hyperpigmented bone was not possible. Sinus measurements from the CT were used to guide osteotomies, with conservative markings. A fissure burr was utilized to perform anterior table osteotomies without violation of the intracranial space. The anterior table was contoured and repositioned posteriorly in the usual fashion. The bone was secured with low-profile mini-plates and screws before additional contouring of the orbital rims and zygomaticofrontal prominence. Bone dust was used to fill gaps and cover the fixation hardware. A second case involved a 58-year-old Asian transgender female with history of hypertension, gout, and asthma without prior tetracycline use or bone disease. Her preoperative CT scan was unremarkable. Intraoperatively, darkened cranial bone was encountered, also preventing frontal sinus transillumination. The surgical team proceeded with osteotomies with an ultrasonic aspirator device using standard anatomic landmarks and guided by preoperative CT measurements. The harvested bone was reshaped and repositioned using two X-plates and screws to achieve a deprojected forehead contour. Both patients tolerated the procedures well without complications.

Discussion: Bone hyperpigmentation has been associated with chronic tetracycline use and metabolic conditions like alkaptonuria especially. Previous reports of cranial hyperpigmentation were linked to tetracycline therapy, often decades prior. Sequestrum, or dead bone caused by osteomyelitis, may also present with discoloration. Additionally, metallosis, caused by prosthesis or implant material deposition, can lead to bone staining. However, neither patient in this series had any of these associated conditions. The absence of exam findings or radiographic evidence predicting the presence of hyperpigmented bone preoperatively emphasizes the need for an alternative to transillumination in these rare circumstances. In both cases, CT-based frontal sinus measurements proved critical in determining safe parameters for osteotomies, although their application is more complex compared to transillumination. Alternatively, virtual surgical planning (VSP) with cutting guides can be utilized to delineate the osteotomy sites, but with additional cost.

Conclusion: Cranial bone hyperpigmentation is a rare, poorly described anatomical variation that presents a unique intraoperative challenge for surgeons performing frontal bone setback using transillumination. Due to the unpredictable nature of cranial bone hyperpigmentation, having an alternative method of frontal sinus identification is recommend, either with CT-based measurements or VSP. Further research should explore bone hyperpigmentation etiologies and possible predictive factors.

Background

The field of gender-affirming surgery is rapidly evolving, with plastic surgery units worldwide increasingly offering these services. Phalloplasty is a critical component of female-to-male (FTM) transition, providing significant psychological and functional benefits. However, there is no clear consensus on the optimal surgical technique for phalloplasty in this patient population. This systematic review examines the existing literature on the use of pedicle flaps and the free radial forearm flap in FTM gender-affirming surgery.

Methods

A systematic review was conducted following the PRISMA guidelines and was registered a priori (CRD42023479414) [1] . The search strategy adopted the Peer Review of Electronic Search Strategy (PRESS) guidance, searching PubMed/Medline, Scopus, Web of Science, ProQuest, and EBSCO for eligible studies [2]. Two independent reviewers screened and selected studies, resolving discrepancies by consensus. Flap survival and patient satisfaction were the primary outcome measures. Secondary outcomes included standing voiding ability, penetrative sexual function, number of operative stages, surgical duration, anesthetic techniques, and donor site morbidity or acceptance. Risk of bias was assessed using ROBINS-I, and evidence quality was evaluated using GRADE [3, 4].

Results

A total of 19 studies comprising 769 patients (614 radial forearm flaps, 155 pedicled anterolateral thigh flaps) were included. Both techniques demonstrated comparable outcomes, though the pedicled flap required significantly less operative time (290 vs. 516 minutes). Flap failure rates were low for both groups (1.9% radial forearm, 0.6% anterolateral thigh)(p = 0.348) and patient satisfaction was high (78% vs. 76.2%) (p = 1.0). Risk of bias assessment indicated serious selection bias due to the observational nature of studies. GRADE evaluation rated the evidence as low, reflecting the absence of randomized trials in this field.

Conclusion

The radial forearm flap remains the most reliable technique for phalloplasty, with the anterolateral thigh flap serving as a secondary option when the radial forearm flap is not feasible. However, the limited number of studies and the lack of standardized outcome reporting in gender-affirming surgery make it difficult to draw definitive conclusions or establish evidence-based recommendations. While both flap types are considered safe for female-to-male phalloplasty, the small patient cohorts and absence of randomized data contribute to the ongoing uncertainty in determining the optimal approach.

References 1. Page, M. J., McKenzie, J. E., Bossuyt, et. al. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, n71. https://doi.org/10.1136/bmj.n71

2. McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS peer review of electronic search strategies: 2015 guideline statement. J Clin Epidemiol. 2016;75:40-46. doi:10.1016/j.jclinepi.2016.01.021

3. Sterne J A, Hernán M A, Reeves B C, SavoviÄ J, Berkman N D, Viswanathan M et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions BMJ 2016; 355 :i4919 doi:10.1136/bmj.i4919

4. Brozek JL, Akl EA, Alonso-Coello P, et al. Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions. Allergy. 2009;64(5):669-677. doi:10.1111/j.1398-9995.2009.01973.x

Introduction

Gender-affirming mastectomy (GAM) is the most common gender-affirming surgical procedure, with cases increasing by 200% in recent years. While double-incision GAM is the standard technique, it involves long horizontal incisions across the chest which may be prone to hypertrophic scarring (HS)-the most common postoperative complication. HS can cause significant physical and psychosocial morbidity, and effective treatment options are limited. However, few studies have investigated the occurrence of HS in patients undergoing GAM. This study aimed to evaluate the incidence and risk factors of HS following GAM to provide insight on underlying pathophysiology and to improve evidence-based patient counseling.

Methods

A retrospective cohort study was conducted of patients who underwent double-incision GAM from 2020 to 2024 from two institutions under the care of six surgeons. Data included patient demographics, comorbidities, perioperative androgen replacement therapy, testosterone blood levels, postoperative complications requiring surgical intervention, HS occurrence (based on documentation in follow-up clinic notes), corticosteroid injections, and scar revision. Patients with less than 4 weeks follow-up were excluded. Bivariate as well as univariable and multivariable logistic regression analyses were performed.

Results

A total of 241 patients were included with a mean age of 26.7 (±9.0) years, a mean BMI of 27.9 (±5.4) kg/cm2 and a mean mastectomy weight of 614.0 (±389.6) grams. HS occurred in 16.6% of patients, corticosteroid injections were administered in 8.3% and 0.8% underwent scar revision. Non-Caucasian race (higher Fitzpatrick skin type levels) was significantly associated with higher rates of HS (32.4% versus 13.4%, p=0.004; OR 4.0, 95% CI 1.7-9.4, p=0.001), corticosteroid injections (19.4% versus 6.1%, p=0.007) and scar revision (5.6% versus 0.0%, p=0.023). Androgens were used perioperatively by 67.2% of patients, with a mean preoperative testosterone level of 485.4 (±302.1) ng/dL compared to non-users 35.1 (±17.4) ng/dL (p<0.0001). Perioperative androgen use was significantly associated with higher rates of HS (20.4% in users versus 8.9% in non-users, p=0.024; OR 3.4, 95% CI 1.3-8.4, p=0.001). Age, BMI, comorbidities, nicotine use, previous breast surgery, mastectomy weight, and the development of other postoperative complications, such as wound dehiscence, were not significantly associated with HS. The average follow-up duration was 5.3 (±4.5) months.

Conclusion

HS occurred in 16.6% of GAM patients, with race/Fitzpatrick skin type and perioperative androgen replacement therapy identified as significant risk factors (four-fold and three-fold increased risk, respectively). Patients should be counseled preoperatively regarding their individual risk profile. Future research should investigate perioperative androgen management or testosterone thresholds for optimal balance between scarring outcomes and overall patient treatment goals.

Purpose: Feminizing gender-affirming genital surgery seeks to align genital appearance with gender identity in transfeminine individuals. Multiple surgical techniques exist and involve the creation of a vulva and oftentimes a vaginal canal. While access to feminizing gender-affirming genital surgery is growing adjacent to demand, limited empirical evidence exists on the patient-reported outcomes (PROs) of these procedures. Aim: To examine construct validity of GENDER-Q scales measuring satisfaction with the vagina, labia, clitoris, and dilation and health-related quality of life (HRQL) in feminizing gender-affirming genital surgery. Methods: Between 2022 and 2024, an international field test of the GENDER-Q was conducted with transgender and gender diverse (TGD) adults fluent in English, Danish, Dutch, or French Canadian. Participants who reported having feminizing gender-affirming genital surgery completed scales measuring satisfaction with the vagina, labia, clitoris, and dilation and five HRQL scales that measure body image, gender dysphoria, social acceptance, psychological well-being, and psychological distress. Scale scores were transformed from 0 (worst) to 100 (best). Construct validation was assessed by testing pre-defined hypotheses, with acceptance of at least 75% of hypotheses providing evidence of validity. Results: In the GENDER-Q field-test sample, 581 participants wanted to have feminizing genital surgery and 1236 had received it. Participants were mostly white (80%), had a mean age of 40±14 years, and lived in Canada (51%) or the United States (37%). Surgical techniques that participants underwent included: penile inversion vaginoplasty (77%), minimal depth vulvoplasty (9%), peritoneal pull through vaginoplasty (8%), or colon/small bowel vaginoplasty (1.9%). Hypothesis-based construct validity was demonstrated for both genital feminization and HRQL scales, with ≥75% of hypotheses accepted. For HRQL scales, those who wanted surgery scored lower (p<0.001) than those who underwent surgery (Body Image: 51±23 vs 61±23; Gender Dysphoria: 54±18 vs 68±21; Social Acceptance: 70±17 vs 77±19; Psychological Distress: 57±19 vs 69±21; Psychological Well-being 58±18 vs 67±20). Those who needed more surgery scored lower on the HRQL scales than those who had completed surgery (p<0.001). Less satisfaction was observed for those who reported that their vagina was not as deep as they would have liked (Vagina: 44±16 vs 63±20; Dilation: 50±20 vs 65±19) (p<0.001). Those who reported their vagina was narrower than they would have liked (Vagina: 43±15; Dilation: 46±17) scored lower than those who reported their vagina was the right width (Vagina: 62±20; Dilation: 66±19) (p<0.001). As expected, satisfaction with dilation incrementally decreased as participants reported greater pain during dilatation (p<0.001). Less satisfaction with the vagina was reported for those who currently experienced a wound complication (40±19 vs 58±20) or vaginal stenosis (41±17 vs 61±20) (p<0.001). Needing a revision to the clitoris, inner/outer labia, or vaginal width or depth was associated with lower scores on the genital feminization scales (p<0.001). Conclusion: GENDER-Q scales that measure satisfaction with the vagina, labia, clitoris and dilation and HRQL can be used to measure outcomes in feminizing gender-affirming genital surgery from the patient perspective. These scales can be used in comparative effectiveness research, in clinical care or in quality improvement efforts, to inform patient-centered care.

Background: Breast reconstruction with implants is the gold standard in transfeminine gender-affirming chest surgery (1). To date there are few reported cases evaluating microsurgical free flap tissue transfer as a viable option in gender-affirming surgery and there is a paucity of data on surgical outcomes (2-4). Here we review two cases of free flap breast reconstruction in transgender women and discuss technical considerations and early outcomes.

Methods: We performed retrospective chart review of identified patients. Patient demographics, surgical characteristics, and post-operative outcomes were documented. Patient demographics included age, body mass index, and pertinent past medical history. Surgical characteristics include operative time, flap weight, and details on vascular perforators. Post-operative outcomes included surgical complications such as infection, fluid collection, and wound dehiscence, as well as medical complications.

Results/Cases: Patient 1 has a history of BRCA1 mutation and underwent prophylactic bilateral skin-sparing mastectomies and implant-based breast reconstruction in 2020, which was complicated by symptomatic capsular contracture and animation deformity; she was deemed an optimal candidate for autologous reconstruction, thus she was converted to bilateral deep inferior epigastric perforator (DIEP) free flaps, with an uneventful postoperative course aside from minor recipient site dehiscence that was managed conservatively with local wound care. Patient 2 desired gender-affirming augmentation mammaplasty but did not want implants. She underwent bilateral breast augmentation with DIEP free flaps, with an uneventful postoperative course aside from donor site infection that was managed with short admission for intravenous antibiotics. Values regarding patient and surgical demographics for transgender patients undergoing autologous breast reconstruction fell within the standard expected ranges for their cisgender counterparts. Both patients remain satisfied with their aesthetic outcomes.

Conclusion: Abdominal-based free flaps are safe and effective options for both cosmetic and post-oncologic breast reconstruction in transgender and gender-diverse patients. More data is needed to better quantify outcomes and identify areas for improvement. Our preliminary data suggests similarities in technical considerations and outcomes of autologous breast reconstruction / augmentation in cisgender patients.

References 1. Claes KEY, D'Arpa S, Monstrey SJ. Chest Surgery for Transgender and Gender Nonconforming Individuals. Clin Plast Surg. 2018;45(3):369-380. doi:10.1016/j.cps.2018.03.010 2. Murariu D, Holland MC, Gampper TJ, Campbell CA. Illegal silicone injections create unique reconstructive challenges in transgender patients. Plast Reconstr Surg. 2015;135(5):932e-933e. doi:10.1097/PRS.0000000000001192 3. Majdak-Paredes EJ, Shafighi M, Fatah F. Unilateral hypoplastic breast in a male-to-female transsexual with Poland syndrome after gender reassignment--reconstructive considerations. J Plast Reconstr Aesthet Surg. 2009;62(3):398-401. doi:10.1016/j.bjps.2008.01.017 4. Chun Fat S, Ray E. Gender-affirming microvascular breast reconstruction. Gland Surg. 2023;12(7):982-988. doi:10.21037/gs-23-133

Background: For small-breasted individuals with gender dysphoria, concentric periareolar mastectomy (CPM) is often the preferred surgical approach. However, traditional techniques carry a significant risk of hypertrophic scarring and changes in areolar dimensions. This study presents a novel method combining periareolar interlocking suture (PIS) and waterjet-assisted liposuction (WAL), aimed at minimizing scarring, reducing complications, and improving aesthetic outcomes.

Methods: Between April 2017 and December 2023, a total of 2312 mastectomies were performed in 1156 patients with gender dysphoria. Of these, 410 breasts underwent CPM combined with PIS and WAL in 205 individuals. Eligible patients had small breasts (A to B-Cup), minimal ptosis (grade 0-I), and good skin elasticity. The primary outcome measures included complication rates, patient satisfaction (evaluated using the BODY-Q Chest and Nipples Scale), nipple sensitivity, and secondary revision rates. Statistical analyses included paired t-tests and categorical variable comparisons using Chi-square or Fisher's exact test (significance level p < 0.05).

Results: The mean age of the study population was 23 years, with a hospital stay of 4 days and an average surgical duration of 96.1 minutes. The overall complication rate was 7.8%, with 4.6% experiencing acute hematoma requiring surgical intervention. Minor complications included seroma (1%), partial NAC necrosis (1%), and wound dehiscence (1%), all of which were managed conservatively. Secondary aesthetic corrections were necessary in 2.2% of cases.

Patient satisfaction was exceptionally high. On the BODY-Q scale, chest satisfaction scores increased from 15.6 ± 12 preoperatively to 94.78 ± 7.78 postoperatively (p < 0.001), and nipple satisfaction improved from 32.8 ± 19 to 94.3 ± 9.23 (p < 0.001). Postoperative nipple sensitivity was preserved in 88.9% of cases, with 58.5% rating their sensitivity as "very sensitive" and 30.4% as "sensitive." The average areolar diameter decreased significantly from 34.12 ± 6.49 mm preoperatively to 26.12 ± 2.88 mm postoperatively (p < 0.001).

Conclusion: The integration of PIS and WAL with CPM represents an effective technique for gender-affirming top surgery in small-breasted individuals. This approach provides superior aesthetic outcomes, high patient satisfaction, and a low revision rate while preserving nipple sensitivity. Given the increasing demand for minimally scarring surgical procedures in this patient group, this technique offers a valuable alternative to traditional methods. Further research is warranted to assess long-term outcomes and optimize patient selection criteria.

References:

References:

Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgender Health. 2022;23:1-259. doi:10.1080/26895269.2022.2100644

Wolter A, Diedrichson J, Scholz T, et al. Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy. J Plast Reconstr Aesthet Surg. 2015;68(2):184-191. doi:10.1016/j.bjps.2014.10.016

Hammond DC, Khuthaila DK, Kim J. The interlocking Gore-Tex suture for control of areolar diameter and shape. Plast Reconstr Surg. 2007;119(3):804-809. doi:10.1097/01.prs.0000251998.50345.e9

Klassen AF, Kaur M, Poulsen L, et al. Development of the BODY-Q Chest Module Evaluating Outcomes following Chest Contouring Surgery. Plast Reconstr Surg. 2018;142(6):1600-1608. doi:10.1097/PRS.0000000000004978

Righi B, Robotti E. Successfully exploiting two opposing forces: a rational explanation for the "interlocking suture." Aesthetic Plast Surg. 2011;35(2):177-183. doi:10.1007/s00266-010-9580-0

Introduction In the Netherlands, gender-affirming surgery has a well-established history in Amsterdam. In 2020, our academic hospital in Nijmegen launched a new gender surgery program. Since its inception, the author has performed surgeries on over 400 patients. This abstract outlines our experiences in combining procedures to facilitate a smoother transition for transwomen, enhance outcomes, and minimize both waiting times and disruptions to their work and social lives. By combining the penile inversion vaginoplasty (SRS), breast augmentation, and facial feminization surgery (FFS), the patient benefits from a single rehabilitation period while maintaining a low risk of complications.

Methods We conducted a retrospective analysis of our transgender women population undergoing combined surgical procedures in 2024. We categorized individual procedures, including sex reassignment surgery, breast augmentation, and facial feminization surgery (FFS). In the FFS category, we employed a combination of techniques, including frontal bossing setback, brow suspension, hairline lowering, and surgeries involving the nose, lips, thyroid, angular bones, and genioplasty. Our analysis concentrated on operative duration, hospital admission times, and postoperative complications.

Results In 2024, we conducted nine penile inversion vaginoplasty procedures, either accompanied by augmentation, facial feminization surgery (FFS), or a combination of both. Notably, there were no complications reported in any of the patients. The average operative time for the combined surgery (3 in 1) was 5.5 hours, while the vaginoplasty combined with FFS took 4.5 hours, and the vaginoplasty paired with augmentation lasted 3.25 hours. Additionally, we performed one zero-depth vaginoplasty along with FFS, which required 4 hours, two orchidectomies with FFS that each took 2 hours, and one FFS procedure in conjunction with augmentation completed in 3 hours. Also without complications. A total of 30 patients underwent penile inversion vaginoplasty, with an average surgical duration of 2 hours and 15 minutes. No significant complications were reported, except for one case in which a patient required conversion to a zero-depth vaginoplasty due to necrosis of the neovaginal cavity caused by a bacterial infection.

Conclusion Our unified surgical approach has not led to a higher rate of complications and appears to enhance patient satisfaction, despite the lack of formal evaluation through questionnaires. Consequently, we are committed to maintaining this streamlined surgical plan, allowing transgender women to complete their surgical transition in a single step. We will not only continue to monitor our outcomes but also initiate a structured evaluation of patient satisfaction to further refine our practices. We believe it is essential to share our preliminary findings to introduce the innovative concept of a unified procedure, which aims to minimize downtime and facilitate a quicker return to work for our patients. This initiative underscores our dedication to improving the surgical experience and supporting the needs of the transgender community.

Purpose: There has been an increase in patients seeking gender-affirming surgeries. Assessing outcomes from the patient perspective can provide valuable information that can inform patient choice as well as effectiveness of surgical techniques. A new gender-affirming care-specific patient-reported outcome measure (PROM), GENDER-Q, has been developed to measure multiple appearance and quality of life outcomes. However, to support implementation of GENDER-Q in research and clinical practice it is important to ensure that the tool is acceptable to people who identify as transgender or gender diverse. Aim: To examine acceptability of the GENDER-Q in a large, international sample of transgender and gender diverse (TGD) adults. Methods: A multi-phase, mixed methods study was conducted (February 2019 to March 2024). Part one involved concept elicitation interviews with data used to develop a set of PROM scales measuring key concepts. Participants from Canada, the United States (US), Denmark, and the Netherlands were recruited. Scales were developed and refined iteratively with feedback from patient participants and experts. In part two, an international field-test was conducted. Participants were recruited through social media and 21 clinical sites across Canada, the US, the Netherlands and Spain, and community groups (e.g., crowdsourcing platform). After completing the GENDER-Q, a subsample of participants was asked to complete questions to evaluate acceptability (e.g., was easy to understand, was thorough, asked important questions, felt safe to complete). Results: Concept elicitation interviews with 84 participants (mean age 34 ± 14 years) resulted in the development of scales to measure health-related quality of life, sexual, urination, gender practices, voice, hair, face and neck, body, breasts, genital feminization, chest, genital masculinization, and experience of care. Of the 5,497 field-test survey participants, 1285 completed the additional questions to measure acceptability and content validity. Most participants were from the US (32%), Canada (28%), and the United Kingdom (12%). In terms of treatment, 65% were currently taking hormones, 56% had undergone chest surgery, 31% vaginoplasty, 21% breast surgery, 8% had some form of facial feminization, 3% body contouring, and 6% had surgery to create a penis. GENDER-Q was found to be highly acceptable by the majority of participants. Most respondents either mostly or strongly agreed that GENDER-Q asked questions in a respectful way (90%), felt safe to complete (87%), was thorough (87%), was easy to understand (83%), and it made them feel that their voice would be heard (65%). A small subgroup of participants endorsed feeling upset (8%) or uncomfortable (8%) after completing GENDER-Q. Conclusion: A cross-sectional sample of 1285 individuals agreed to the acceptability and useability of the GENDER-Q. Although it is important to note that completing this PROM can cause a small sample of patients to feel upset or uncomfortable. GENDER-Q can now be incorporated in clinical care and research to collect evidence that will help to inform patient care, surgical practice and quality improvement efforts.

Introduction: A key component of facial feminization surgery (FFS) is the frontal bone setback procedure to decrease supraorbital bar prominence. Intraoperative transillumination of the frontal bone is a commonly-accepted technique to delineate frontal sinus borders for osteotomy. Cranial bone hyperpigmentation is a rare finding associated with tetracycline use, malignancy, infection, or metabolic disorders. Its occurrence in FFS and effects on transillumination remained largely undocumented. We present two cases of frontal bone hyperpigmentation found during FFS and subsequent impact on surgical management.

Case Reports: A 26-year-old Caucasian transgender female with no history of bone disease or tetracycline use presented for FFS. Her preoperative CT facial scan was unremarkable. During cranial dissection, dark pigmentation of the frontal bone was identified, permeating full thickness through all bone layers. Frontal sinus transillumination through the hyperpigmented bone was not possible. Sinus measurements from the CT were used to guide osteotomies, with conservative markings. A fissure burr was utilized to perform anterior table osteotomies without violation of the intracranial space. The anterior table was contoured and repositioned posteriorly in the usual fashion. The bone was secured with low-profile mini-plates and screws before additional contouring of the orbital rims and zygomaticofrontal prominence. Bone dust was used to fill gaps and cover the fixation hardware. A second case involved a 58-year-old Asian transgender female with history of hypertension, gout, and asthma without prior tetracycline use or bone disease. Her preoperative CT scan was unremarkable. Intraoperatively, darkened cranial bone was encountered, also preventing frontal sinus transillumination. The surgical team proceeded with osteotomies with an ultrasonic aspirator device using standard anatomic landmarks and guided by preoperative CT measurements. The harvested bone was reshaped and repositioned using two X-plates and screws to achieve a deprojected forehead contour. Both patients tolerated the procedures well without complications.

Discussion: Bone hyperpigmentation has been associated with chronic tetracycline use and metabolic conditions like alkaptonuria especially. Previous reports of cranial hyperpigmentation were linked to tetracycline therapy, often decades prior. Sequestrum, or dead bone caused by osteomyelitis, may also present with discoloration. Additionally, metallosis, caused by prosthesis or implant material deposition, can lead to bone staining. However, neither patient in this series had any of these associated conditions. The absence of exam findings or radiographic evidence predicting the presence of hyperpigmented bone preoperatively emphasizes the need for an alternative to transillumination in these rare circumstances. In both cases, CT-based frontal sinus measurements proved critical in determining safe parameters for osteotomies, although their application is more complex compared to transillumination. Alternatively, virtual surgical planning (VSP) with cutting guides can be utilized to delineate the osteotomy sites, but with additional cost.

Conclusion: Cranial bone hyperpigmentation is a rare, poorly described anatomical variation that presents a unique intraoperative challenge for surgeons performing frontal bone setback using transillumination. Due to the unpredictable nature of cranial bone hyperpigmentation, having an alternative method of frontal sinus identification is recommend, either with CT-based measurements or VSP. Further research should explore bone hyperpigmentation etiologies and possible predictive factors.

Introduction: A key component of facial feminization surgery (FFS) is the frontal bone setback procedure to decrease supraorbital bar prominence. Intraoperative transillumination of the frontal bone is a commonly-accepted technique to delineate frontal sinus borders for osteotomy. Cranial bone hyperpigmentation is a rare finding associated with tetracycline use, malignancy, infection, or metabolic disorders. Its occurrence in FFS and effects on transillumination remained largely undocumented. We present two cases of frontal bone hyperpigmentation found during FFS and subsequent impact on surgical management.

Case Reports: A 26-year-old Caucasian transgender female with no history of bone disease or tetracycline use presented for FFS. Her preoperative CT facial scan was unremarkable. During cranial dissection, dark pigmentation of the frontal bone was identified, permeating full thickness through all bone layers. Frontal sinus transillumination through the hyperpigmented bone was not possible. Sinus measurements from the CT were used to guide osteotomies, with conservative markings. A fissure burr was utilized to perform anterior table osteotomies without violation of the intracranial space. The anterior table was contoured and repositioned posteriorly in the usual fashion. The bone was secured with low-profile mini-plates and screws before additional contouring of the orbital rims and zygomaticofrontal prominence. Bone dust was used to fill gaps and cover the fixation hardware. A second case involved a 58-year-old Asian transgender female with history of hypertension, gout, and asthma without prior tetracycline use or bone disease. Her preoperative CT scan was unremarkable. Intraoperatively, darkened cranial bone was encountered, also preventing frontal sinus transillumination. The surgical team proceeded with osteotomies with an ultrasonic aspirator device using standard anatomic landmarks and guided by preoperative CT measurements. The harvested bone was reshaped and repositioned using two X-plates and screws to achieve a deprojected forehead contour. Both patients tolerated the procedures well without complications.

Discussion: Bone hyperpigmentation has been associated with chronic tetracycline use and metabolic conditions like alkaptonuria especially. Previous reports of cranial hyperpigmentation were linked to tetracycline therapy, often decades prior. Sequestrum, or dead bone caused by osteomyelitis, may also present with discoloration. Additionally, metallosis, caused by prosthesis or implant material deposition, can lead to bone staining. However, neither patient in this series had any of these associated conditions. The absence of exam findings or radiographic evidence predicting the presence of hyperpigmented bone preoperatively emphasizes the need for an alternative to transillumination in these rare circumstances. In both cases, CT-based frontal sinus measurements proved critical in determining safe parameters for osteotomies, although their application is more complex compared to transillumination. Alternatively, virtual surgical planning (VSP) with cutting guides can be utilized to delineate the osteotomy sites, but with additional cost.

Conclusion: Cranial bone hyperpigmentation is a rare, poorly described anatomical variation that presents a unique intraoperative challenge for surgeons performing frontal bone setback using transillumination. Due to the unpredictable nature of cranial bone hyperpigmentation, having an alternative method of frontal sinus identification is recommend, either with CT-based measurements or VSP. Further research should explore bone hyperpigmentation etiologies and possible predictive factors.

Purpose: Transgender and gender-diverse people may undergo surgeries to align their chest/breast with their gender identity. Patient-reported outcome measures (PROM) are carefully developed tools that can measure outcomes such as quality of life and appearance from the patient perspective. The purpose of this study was to assess the validity of GENDER-Q scales for use in gender-affirming chest and breast surgery. Methods: Data was collected internationally between 2022 and 2024 where participants completed relevant scales from a new PROM for gender-affirming care (GENDER-Q). Participants completed appearance scales related to the breast/chest and nipples if they reported wanting or having gender-affirming chest or breast surgery. All participants completed a set of 5 quality-of-life scales (Social Acceptance, Body Image, Gender Dysphoria, Psychological Distress, Psychological Wellbeing), as well as the Treatment Outcome scale on their most recent surgery. Scales are scored on an interval-level of 0 (Worst) to 100 (Best). Clinical questions related to surgery included: time since surgery, type of surgery, surgical complications, and revision status. To test construct validity of the scales predefined hypotheses were created for known group differences and tested using ANOVA and T-test. Results: Of 5497 participants, 4031 reported wanting or having a masculinization (n=2849) or feminization (n=1182) gender-affirming surgical procedure for the chest/breast area. Participants ranged in age between 18 and 83 years of age, with a mean age of 32 (SD=12). Those who wanted surgery scored lower on the appearance scales for both feminizing (Breast (µ=46(13)), Nipples (µ=56(18)) and masculinizing (Chest (µ=23(15)), Nipples (µ=43(17)) chest surgery than those who had completed surgery (Breast µ=66(15), Nipples µ=69(20);Chest µ=77(18), Nipples µ=65(20)). For chest masculinization, those who needed revisions for chest contouring (µ=58(15)), dog ears (µ=67(18)) and removal of excess breast tissue (µ=57(17)) scored lower on appearance scales than those who didn't need (µ=83(16); µ=82(16); µ=80(17)) or had completed revisions (µ=79(17); µ=75(17); µ=74(19)) (p<0.001). Scores on all quality-of-life scales were greater for those who had surgery than those who wanted surgery for both feminization and masculinization procedures (p<0.001). Treatment Outcome scale scores were slightly greater for those who had masculinizing (n=1484; µ=80(19)) than those who had feminizing (n=192; µ=75(23)) chest surgery. Conclusion: GENDER-Q quality-of-life and appearance scales evidence construct validity to measure patient outcomes in gender-affirming chest and breast surgery.

Background- Patients seeking gender-affirming surgery are often on hormone therapy, yet there is no clear consensus on the effects of preoperative testosterone supplementation on chest masculinization surgery. A particular concern is whether testosterone should be continued or discontinued before surgery. We hypothesized that preoperative testosterone therapy and its continuation during surgery would not increase complications following chest masculinization surgery.

Methods- A meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies on chest masculinization surgery that reported perioperative hormone use and surgical outcomes based on hormone status were included. Data collected included patient numbers, age, testosterone supplementation status, procedure type, postoperative complications, and the American Society of Plastic Surgeons (ASPS) level of evidence. Data were compared between patients on testosterone before surgery (TT) and those not on hormone therapy (NTT), as well as between those who continued or discontinued testosterone perioperatively. Additionally, a subgroup analysis was performed to assess hematoma rates based on surgical technique (limited incision vs. extended incision). Statistical analysis included pooled comparisons using the chi-square test and Welch's t-test.

Results- Fifteen articles met inclusion criteria with level of evidence of III (8) and IV (7). Three thousand seven hundred sixty-two patients were on testosterone treatment and seven hundred twenty-six not on hormone therapy. The total acute complication rates, including hematoma, seroma, infection, wound dehiscence, and nipple areolar complex (NAC) necrosis, for the TT and NTT groups were 11.08% and 9.8%, respectively (p = 0.29). Preoperative testosterone increased the odds of developing a hematoma by 1.88 times (7.76% vs. 2.9%, p < 0.001). Seroma prevalence was significantly lower in the TT group compared to the NTT group (1.55% vs. 4.29%; p = 0.028). Infection and wound dehiscence rates were not significantly different between TT and NTT (1.35% vs. 1%, p = 0.32; and 1% vs. 1.45%, p = 0.94). Venous thromboembolism (VTE) rates were not significantly different (0.14% vs. 0%; p = 0.88).

No significant difference in hematoma rate was observed between patients who continued (8.73%) and who stopped testosterone perioperatively (8%; p = 0.63). Hematoma rates were also similar regardless of when hormone therapy was stopped: 2 weeks (7.37%, n = 434), 3 weeks (6.93%, n = 101), 4 weeks (9.48%, n = 232), or 6 weeks (9.90%, n = 202) preoperatively (p = 0.60).

Hematoma rates were higher with limited incision techniques compared to extended incision mastectomy techniques (11.96% vs. 6.5%; p < 0.001).

Conclusion- Testosterone therapy is associated with a higher risk of postoperative hematoma in chest masculinization surgery. However, perioperative cessation of testosterone does not appear to reduce bleeding risk. Therefore, delaying the initiation of testosterone therapy in patients not already on hormone supplementation before surgery may be preferable. Conversely, for patients already on testosterone therapy, continuing treatment perioperatively may be a reasonable approach.

Introduction: Gender-affirming chest surgery, commonly referred to as "top surgery," is a vital procedure for transgender men experiencing chest dysphoria. This study evaluates a novel superthin flap technique for chest masculinization over a 10-year period. The aim is to determine its effectiveness in improving physical well-being, body image, and psychological health. Methods: A prospective study was conducted on 341 patients undergoing primary masculinizing chest surgery between January 2014 and December 2023. Patients adhered to the World Professional Association for Transgender Health (WPATH) Standards of Care. Demographic data, surgical technique, complications, and revisions were documented. Patient-reported outcomes were assessed using the BREAST-Q and CRES-4 questionnaires. Statistical analyses identified risk factors for complications and were also used to evaluate statistically significant differences in questionnaire responses. Results: A total of 710 mastectomies were performed. The mean patient age was 27.2 years, and 94.1% were on testosterone therapy. The most common complications included seroma (5.08%), hematoma (3.9%), and partial nipple necrosis (3.3%). Mastectomy volume exceeding 440 g was significantly associated with higher complication rates (p < 0.01). BREAST-Q and CRES-4 scores demonstrated substantial postoperative improvements in breast satisfaction, psychosocial well-being, and quality of life. Patient satisfaction increased significantly across all measured domains. Conclusions: The superthin flap technique provides favorable aesthetic and functional outcomes, preserving natural nipple-areola complex positioning while minimizing complications. Patient satisfaction and quality of life improved significantly. Future research should focus on refining techniques and exploring sensory nerve reinnervation to enhance postoperative outcomes.

References: (1) Deutsch MB. Making It Count: Improving Estimates of the Size of Transgender and Gender Nonconforming Populations. LGBT Health. 2016;3(3):181-185. doi:10.1089/lgbt.2016.0013. (2) Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 2018;15(4):582-590. doi:10.1016/j.jsxm.2018.01.016. (3) Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. doi:10.1080/26895269.2022.2100644. (4) Agarwal CA, Scheefer MF, Wright LN, Walzer NK, Rivera A. Quality of life improvement after chest wall masculinization in female-to-male transgender patients: A prospective study using the BREAST-Q and Body Uneasiness Test. J Plast Reconstr Aesthet Surg. 2018;71(5):651-657. doi:10.1016/j.bjps.2018.01.003. (5) Bustos VP, Bustos SS, Mascaro A, et al. Transgender and Gender-nonbinary Patient Satisfaction after Transmasculine Chest Surgery. Plast Reconstr Surg Glob Open. 2021;9(3):e3479. doi:10.1097/GOX.0000000000003479.

Introduction Body mass index (BMI) has been used as a metric for understanding a patient's health status across various medical spaces, especially to reduce risk of perioperative complications. Currently, many surgical centers have requirements for patients to have a BMI of less than 30 or 35 in order for them to receive surgery. This serves as a barrier to transgender and gender nonconforming individuals to undergo medical transition such as gender affirming mastectomy (GAM). The objective of this study was to determine whether BMI correlated with increased complications for individuals receiving GAM.

Methods This study is a retrospective chart review to analyze mastectomy outcomes in adult patients undergoing gender affirming care between February 2018 and May 2024. Patients were categorized into standard BMI groups: non-obese (<30), 30.0-34.9 for class 1 obesity, 35.0-39.9 for class 2 obesity, and 40 and above for class 3 obesity. Complications were defined as a composite variable including hematoma, seroma, infection, wound dehiscence, and nipple areolar complex necrosis. Demographic variables included age, race/ethnicity, primary language, and comorbidities. Differences in postoperative outcomes based on BMI were analyzed using Chi-squared, Fisher's, and Mann-Whitney U tests.

Results A total of 209 patients underwent GAM. The vast majority of mastectomies were performed using the double incision technique (181, 86.6%). The median age was 25 (IQR: 21-30). There was no difference in complication rate between age, race, or ethnicity. Smoking (12.9%, p=0.049) and diabetes mellitus (3.3%, p=0.043) were significant risk factors for complications. The range of BMI was 16.8 to 55.82 with a median of 28.4 (IQR: 24.4-34.5). The median BMI was 28.1 (IQR: 24.3-34.8) for patients who did not experience complications and 28.7 (25.0-31.2) for patients who did experience complications. In the cohort, 119 (56.9%) patients were non-obese, 38 (18.2%) were class 1 obese, 23 (11.0%) class 2 obese, and 26 (12.4%) class 3 obese. The overall complication rate was 12.4%, and the revision rate was 7.2%. The complication rate was 15.1% for non-obese, 7.9% for class 1 obese, 0% for class 2 obese, and 19.2% for class 3 obese. There were no significant associations with BMI and complication rate (p = 0.7). In addition, there were no significant associations or clear trends with categories of obesity and complication (p = 0.094) or revision rate (p = 0.3).

Discussion Although BMI is a well known risk factor to surgical complications, this study demonstrates that GAM can be safely performed for patients in all BMI categories. Over 40% of our patient population were obese, and the complication rate was similar across all groups. Increased BMI and obesity should not be a limiting factor for patients seeking GAM, and patients who seek to undergo surgery should be counseled on their individual risk profiles during shared decision-making.

BACKGROUND: Many states have enacted legislative bans on gender-affirming surgery for transgender and gender-diverse (TGD) persons <18 years on the basis of procedural irreversibility and the potential for decisional regret or dissatisfaction.(1) More recently, President Donald Trump signed a federal executive order unilaterally prohibiting gender-affirming care for TGD persons <19 years on similar grounds.(2) While existing data demonstrates high satisfaction and low regret amongst TGD adults (>18 years) undergoing gender-affirming chest surgery (GACS), prior studies of TGD youth have focused on medical interventions (e.g. puberty blockers, hormone therapy).(3,4) This study examines decisional satisfaction and regret amongst TGD persons undergoing GACS at <18 versus 18-26 years old.

METHODS: Assigned female at birth individuals who underwent GACS at our institution >1 year prior to survey distribution were eligible. Patient-reported outcomes were collected using the Holmes-Rovner Satisfaction with Decision (SWD) Scale and the Decision Regret Scale (DRS). Higher SWD scores (1-5) represent increased satisfaction, whereas higher DRS scores (0-100) represent increased regret. Descriptive statistics, and Fisher's exact and Wilcoxon rank sum tests or t-tests were used to compare TGD adolescents (<18 years) and young adults (18-26 years). Three participants with highly discordant SWD and DRS scores were excluded due to presumed reporting error.

RESULTS: 74 of 180 (41.1%) eligible patients completed the survey, 39 of which were <18 years old at time of surgery (52.7%). The majority were white (n= 50, 67.6%), male-identifying (n=56, 75.7%), on testosterone at time of surgery (n=66, 89.2%) and underwent double incision mastectomy (n=71, 95.9%). Only 2 patients (2.7%) experienced a complication requiring readmission or reoperation. Median [IQR] age at surgery amongst the adolescent cohort was 17 years [16.0-17.0] compared to 19 years [18.0-20.0] in the young adult cohort (p<0.001). There were no significant differences in mean (SD) or median [IQR] DRS scores for TGD adolescents <18 years (2.95(10.68), 0.0[0.0-0.0]) compared to TGD young adults aged 18-26 years (1.86(6.76), 0.0[0.0-0.0]) (p=0.606, p=0.436). Similarly, there were no significant differences in SWD scores between the adolescent and young adult cohorts (4.91(0.22), 5.0[5.0-5.0] vs 4.91(0.27), 5.0[5.0-5.0]) (p=0.997, p=0.662). Patients with discordant pre- and post-operative gender identities (n=13, 17.6%) did not demonstrate significant differences in satisfaction or regret when compared to those with concordant identities (SWD 4.88(0.29), 5[4.9-5.0] vs 4.92(0.24), 5[5.0-5.0], p=0.399; DRS 2.31(5.99), 0[0.0-0.0] vs 2.46(9.56), 0[0.0-0.0], p=0.89).

CONCLUSIONS: TGD adolescents and young adults demonstrate high decisional satisfaction and low regret following GACS at least one year after surgery, regardless of age at time of surgery or stability in peri-operative gender identity.

REFERENCES: 1.) Redfield E., Conron KJ, Mallory C. The Impact of 2024 Anti-Transgender Legislation on Youth. UCLA: The Williams Institute. Published April 23, 2024. https://escholarship.org/uc/item/6sd0q2d6. 2.) Exec. Order No 14187. 3 C.F.R. 8771. The White House. Published January 28, 2025. https://www.federalregister.gov/d/2025-02194. 3.) Bruce L, Khouri AN, Bolze A, et al. Long-Term Regret and Satisfaction with Decision Following Gender-Affirming Mastectomy. JAMA Surgery. 2023;158(10). PMID: 37556147. 4.) Olson KR, Raber GF, Gallagher NM. Levels of Satisfaction and Regret with Gender-Affirming Medical Care in Adolescence. JAMA Pediatrics. 2024;178(12). PMID: 39432272.

Background: BMI is a known risk factor of postoperative complications. Understanding the correlation between BMI and surgical outcomes is critical to improving surgical techniques, optimizing patient care, and tailoring perioperative management. However, its role in gender-affirming chest masculinization, also known as 'top surgery', has not been thoroughly studied. The aim of this study is to explore the impact of BMI on postoperative complications in gender-affirming mastectomies.

Methods: A retrospective review was conducted on patients who underwent gender-affirming mastectomy from 2020 to 2024 at a single academic institution. Demographic data and preoperative BMI were collected. Postoperative outcomes included hematoma, seroma, wound healing, infection, duration of drain placement and emergency room visits. Independent T-tests and multivariate analysis was conducted using SPSS.

Results: 266 patients underwent gender-affirming mastectomy between 2020 and 2024 with a mean BMI of 29.8 (SD 8.14). 47 (17.7%) patients had Class I obesity, 30 (11.3%) patients had Class II, and 32 (12.0%) patients had Class III. Patients with a BMI >35 had longer post-op drain duration (7.76 vs. 11.05 days, p<0.001) and increased rates of infection (p=0.014). There were no differences in hematoma, seroma, wound healing and emergency room visits. Multivariate analysis controlling for smoking and diabetes demonstrated that BMI>35 was associated with higher rates of post-op infections (p=0.045).

Conclusion: Our study demonstrates patients with a BMI>35 undergoing gender-affirming mastectomy had longer post-op drain duration and increased rates of infection. It is important to tailor perioperative management for individuals with obesity undergoing gender-affirming mastectomy to mitigate these risks and optimize surgical outcomes. Further prospective studies are warranted to inform clinical guidelines for enhanced patient care in this population.