Scientific Abstract Presentations: Gender Surgery Session 2 Friday, October 16 Fri, Oct 16 8:00-9:30 a.m. CDT

Purpose: Gender-affirming surgery is medically necessary care for many patients, yet access barriers in the United States, including insurance denials, high costs, and limited surgeon availability, may drive patients to seek care abroad.1 International travel for surgery carries well-documented risks, including complications requiring post-return management by surgeons unfamiliar with the index operation.2,3 The aim of this study was to quantify trends in international gender-affirming surgery discussions on Reddit across a period of U.S. policy change to inform preoperative counseling and continuity-of-care planning. Methods: All posts from r/TransgenderSurgeries and r/asktransgender from January 2022 to February 2026 were analyzed using rule-based natural language processing. Posts were obtained from a publicly available Reddit archive (Arctic Shift). Posts were classified as STRICT (destination/travel language and a gender-affirming procedure term) or BROAD (destination/travel language only). Policy inflection point was defined as January 28, 2025, the date of a federal executive order affecting access to gender-affirming care. A transition period (December 2024 to January 2025) was excluded. We compared pre- and post-policy (November 2023 to November 2024; February 2025 to February 2026). Monthly STRICT rates were evaluated using interrupted time-series analysis with binomial regression (time, post-policy indicator, and time-after-policy), consistent with recommended social media research practices.4 Procedure categories and destinations were assigned by prespecified keyword rules. For r/TransgenderSurgeries, we extracted dollar-denominated amounts from posts voluntarily reporting costs and identified complication- and aftercare-related language using term lists. For comparator analyses, we evaluated procedure posts without destination/travel language. Group differences in proportions were tested using chi-square tests. Results: Analysis included 280,827 posts spanning January 2022 to February 2026, aggregated into monthly observations for interrupted time-series modeling. In the pooled sample, STRICT discussion increased from 2.20% to 2.37% (+7.7% relative, p=0.030) with post-policy acceleration (OR/month=1.036, p=0.00029). In r/Transgender_Surgeries, STRICT discussion increased from 8.45% to 9.71% (+14.9% relative, p<0.001) with significant post-policy acceleration (OR/month=1.030, p=0.011). Vaginoplasty comprised approximately half of STRICT posts, increasing from 4.05% to 4.92% of all posts (p<0.001), while facial feminization remained stable (~2.0%). Destination mentions concentrated in Thailand, Canada, Mexico, Spain, and South Korea with a post-policy shift toward Thailand. In r/asktransgender, STRICT mentions remained low (~0.7%) but interrupted time-series analysis estimated a post-policy level increase (OR=1.60, 95% CI 1.17–2.18, p=0.003). Among posts reporting costs (n=98), median amounts varied substantially by destination (Thailand $20,000, Mexico $14,250, Canada $32,500, Spain $37,000, South Korea $11,000) and were lower than published U.S. median spending estimates.5 Complication-related language appeared in 13.6% of international-travel posts versus 8.0% of procedure posts without travel language (p<0.001), and aftercare-related language in 14.5% versus 9.5% (p<0.001). Differences were largest for vaginoplasty (20.8% vs 13.6%, p<0.001) and facial feminization (7.6% vs 4.9%, p<0.001). Conclusions: International travel discussions related to gender-affirming surgery increased significantly, driven by vaginoplasty-related posts concentrated in a few destinations with lower stated costs compared with published U.S. medians. These findings support need for structured preoperative counseling and standardized protocols for U.S. providers managing post-return complications after surgery abroad. Online communities may serve as early surveillance sources for anticipating patient care needs.

References: 1. Pletta DR, Quint M, Radix AE, et al. Gender-Affirming Surgical History, Satisfaction, and Unmet Needs Among Transgender Adults. JAMA Netw Open. Sep 2 2025;8(9):e2532494. doi:10.1001/jamanetworkopen.2025.32494 2. Foley BM, Haglin JM, Tanzer JR, Eltorai AEM. Patient care without borders: a systematic review of medical and surgical tourism. J Travel Med. Sep 2 2019;26(6)doi:10.1093/jtm/taz049 3. Deivasigamani S, Khaw KL, Bonawitz SC. Passport Not Required: A Comparison of Plastic Surgery Complications From Domestic and International Medical Tourism. Ann Plast Surg. Jan 26 2026;doi:10.1097/SAP.0000000000004651 4. D'Souza RS, Hooten WM, Murad MH. A Proposed Approach for Conducting Studies That Use Data From Social Media Platforms. Mayo Clin Proc. Aug 2021;96(8):2218–2229. doi:10.1016/j.mayocp.2021.02.010 5. Downing J, Holt SK, Cunetta M, Gore JL, Dy GW. Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the US. JAMA Surg. Sep 1 2022;157(9):799–806. doi:10.1001/jam

Purpose: There is a high burden of Ehlers-Danlos syndrome (EDS) among transgender and gender diverse (TGD) patients (1). EDS and other structural collagen defects increase risk of surgical complications such as bleeding, delayed wound healing, and excess scarring (2-5). Understanding the impact of EDS on gender-affirming surgery (GAS) outcomes, perioperative complications, and patient satisfaction is of growing importance to better inform preoperative counseling, surgical planning, and postoperative management. This study investigates the association of EDS with complications and adverse aesthetic outcomes of chest masculinization surgery (CMS).

Methods: A single-institution, retrospective review of TGD adults with EDS who presented from January 2017 to September 2024 was conducted. Descriptive statistics were calculated on demographics, health histories, and GAS experiences. Complications and adverse aesthetic outcomes were described for those who underwent CMS. Patients with EDS were compared to those without EDS who underwent double-incision CMS between March 2022 and July 2024 to assess the association of EDS with postoperative outcomes. Bivariate and multivariable logistic regression were conducted with the potential confounders of age, body mass index, testosterone use, and past smoking history as covariates.

Results: The prevalence of EDS among TGD patients who accessed gender-affirming care during this period was 1.9% (n=177/9316). Among individuals with EDS, 63.8% (n=113/177) were nonbinary and assigned female at birth and 26.6% (n=47/177) were transgender men. Fourteen underwent CMS with a mean (standard deviation) age of 25.1 (6.0) years old and mean body mass index (BMI) of 30.6 (6.9). Most (78.6%, n=11) used exogenous testosterone for an average of 17.6 (13.6) months before surgery, and 71.4% (n=10) had a concurrent diagnosis of postural orthostatic tachycardia syndrome (POTS). The median CMS follow-up time was 4.0 months.

Patients with EDS had a significantly greater odds of experiencing wound dehiscence, wound washout or debridement, and revision surgery for excess tissue removal after CMS (adjusted odds ratio [95% confidence interval] 5.9 [1.2-27.4], p=0.02; 9.5 [1.0-102.9], p=0.04; 7.0 [1.5-33.7], p=0.01). Patients with EDS did not have a significantly greater odds of experiencing wound infection, scar widening, or standing cone deformities postoperatively. There was no significant difference in age, BMI, past smoking history, or testosterone use between patients with versus without EDS. No intraoperative or major postoperative complications such as sepsis, deep vein thrombosis, or pulmonary embolism occurred for any CMS patients with or without EDS.

Conclusions: This study demonstrated that CMS remains a safe and effective procedure in patients with EDS. While over one-third of EDS patients experienced wound healing or aesthetic concerns, none experienced intraoperative or major postoperative complications. Although there was no significant difference in the development of skin redundancy, scar widening, or infection postoperatively, EDS patients were more likely to require interventions such as revision surgery for excess skin and wound washout or debridement. These findings suggest that while EDS may not increase the occurrence of wound healing or aesthetic concerns, it may increase the severity of these concerns, necessitating intervention. Patients with EDS should be counseled accordingly during preoperative consultation for CMS and monitored postoperatively.

Purpose Access to gender-affirming surgical care remains fragmented, requiring patients to independently navigate multi-specialty referrals, insurance barriers, and variable provider transparency [1,2]. We previously introduced Transcend, a centralized digital navigation platform designed to streamline surgical planning and provider verification. This study reports final data from the beta launch evaluating early real-world implementation outcomes and patient-reported impact among platform users. Methods Transcend was deployed during beta launch within an academic gender-affirming care setting between January 2025 to March 2026. Forty-nine patients utilized the platform and completed structured survey evaluation. Users were introduced to the platform during consultation or preoperative planning and followed longitudinally across stages of care, with follow-up durations ranging from preoperative planning to 2 years postoperatively. Surveys assessed perceived care barriers, usability, trust in provider verification, decision confidence, and likelihood to recommend. Platform analytics evaluated engagement patterns and utilization of provider search, insurance filtering, and surgical planning tools. Only finalized beta data are presented. Results Among 49 respondents, 95% identified as transgender women and 60% were actively planning surgery, while 43% were postoperatively pursuing additional procedures. All participants (100%) reported cost as a barrier to care; 82% cited difficulty finding providers and 65% reported prior insurance denial. All respondents (100%) agreed that a centralized transition-planning platform would be helpful, would reduce time required to coordinate care, and would improve identification of appropriate providers. All participants reported increased feelings of empowerment after viewing the platform. Eighty percent expressed trust in the provider verification system and preferred the platform over independent online searches. Eighty percent reported that the interface was easy to navigate and organized. Mean likelihood to recommend the platform was 9.0 on a 0–10 scale, with 90% categorized as promoters (score 9–10). Emotionally, 85% reported feeling more hopeful after viewing the platform, while 20% reported continued feelings of overwhelm. Conclusions Final beta-launch data from 49 users demonstrate feasibility, strong patient engagement, and perceived improvements in care coordination within gender-affirming surgical pathways. Across users with follow-up ranging from preoperative planning to 2 years postoperatively, Transcend improved perceived empowerment, provider identification, and planning efficiency. These findings support the role of centralized, verification-based digital infrastructure in addressing systemic fragmentation within gender-affirming surgical care. Ongoing expansion will evaluate scalability, longitudinal outcomes, and provider-side adoption across institutions.

1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
2. Reisner SL, Poteat T, Keatley J, et al. Global health burden and needs of transgender populations: A review. Lancet. 2016;388(10042):412-436.

Purpose Many transfeminine patients seeking feminizing breast augmentation surgery report tuberous breast deformity in one or both breasts, which presents as breast tissue herniation through the nipple-areolar complex. While this condition is prevalent in the general breast augmentation patient population, it may be correlated with estrogen replacement therapy in transgender patients. Breast augmentation in this anatomical context requires tailored surgical planning to achieve optimal aesthetic outcomes. Adjunctive techniques including radial scoring, circumareolar mastopexy or combination of both can be performed at the time of breast augmentation. Nine included cases resulted in satisfactory aesthetic outcomes and significant reduction in postoperative gender dysphoria. These techniques are increasingly relevant as demand for gender-affirming breast and chest surgeries continues to rise.

Methods Between September 2024 and December 2025, nine transgender women with clinically diagnosed tuberous breast deformity underwent gender-affirming breast augmentation at a tertiary center specializing in transgender health care. The average patient age was 27 years with average body mass index of 27 kg/m². All patients had received gender-affirming hormone therapy for a minimum of two years (mean duration three years) at the time of surgery. Four patients underwent combined circumareolar mastopexy and radial scoring to correct tuberous breast anatomy. Circumareolar mastopexy alone was performed in three cases to address breast tissue herniated through the nipple-areolar complex. Radial scoring of the lower pole and release of the constricted inframammary fold alone was performed in two cases. Implant-based augmentation was performed in the subfascial or subpectoral plane using smooth, round implants with variable profiles, selected based on each patient's anatomy and feminization goals. Gender dysphoria was measured preoperatively and 1-month postoperatively using the Gender Dysphoria Index (GDI), a patient-reported 0-10 Likert scale where zero represents no dysphoria and 10 represents maximal dysphoria.

Results All patients reported satisfaction with surgical outcomes and aesthetics. The average preoperative GDI score among patients was 8.33 (±1.13) and was significantly reduced to 0.14 (±0.35) at the 1-month postoperative visit. Moderate implant profile was most common (44% of patients) with average implant size of 420.5 cc. Of the 9 patients and 18 breasts which received treatment, 1 breast in 1 patient demonstrated hematoma which was addressed during reoperation one day after primary procedure. There were no surgical complications, including capsular contracture, in the other 8 patient cases. These cases support circumareolar mastopexy and radial scoring as safe, viable techniques to address tuberous breast deformity in the transgender female patient population.

Conclusions The specific aesthetic goals and anatomical considerations of transfeminine patients with tuberous breast deformity must be carefully assessed in preoperative consultations for gender-affirming breast augmentation. In our study population, circumareolar mastopexy with radial scoring followed by implant-based breast augmentation effectively corrected tuberous breast deformity, achieved aesthetic outcomes aligned with patients' goals, and significantly reduced gender dysphoria. These techniques demonstrate a safe and effective approach for managing tuberous breast deformity in the context of gender-affirming breast augmentation. Future studies may further evaluate technique selection, implant type and choice, and assess possible adjunctive procedures to optimize aesthetic outcomes and patient satisfaction.

Purpose: Non-binary (NB) individuals represent a growing segment of the transgender population, yet their access to gender-affirming surgery (GAS) remains poorly characterized nationally. Existing literature on GAS largely focuses on binary pathways, potentially obscuring unique patterns of surgical desire, access, and barriers among NB individuals. This study aims to characterize national patterns of GAS utilization among NB respondents in the United States to identify demographic, socioeconomic, and psychosocial predictors of surgical receipt within this population.

Methods: A secondary analysis of the 2015 U.S. Transgender Survey (USTS) was conducted, including 9,769 non-binary respondents. Desire for and receipt of GAS were compared between NB and binary transgender respondents, and characteristics of NB respondents with unmet versus met surgical desire were analyzed. Weighted multivariable logistic regression identified predictors of ever undergoing at least one GAS procedure among NB respondents.

Results: Overall, 7.4% of NB respondents had undergone at least one GAS procedure, compared with 30.5% of binary transgender respondents (p<0.001). For all procedures except voice surgery, NB respondents who desired GAS were less likely to have undergone the procedure. Among assigned-female-at-birth NB respondents, mastectomy was the most desired procedure (48% expressing interest in or having undergone), but only 12% of those expressing desire had received the procedure, compared with 36% of binary transgender men (p<0.001). Among assigned-male-at-birth NB respondents, facial feminization surgery was the most frequently desired procedure (21% expressing interest in or having undergone), yet only 6% of those desiring it had received surgery, compared with 16% of binary transgender women (p<0.001). Within the NB cohort, Hispanic respondents (OR 0.32 [0.14–0.72]) and assigned-male-at-birth individuals (OR 0.18 [0.10–0.34]) had lower odds of surgical receipt relative to those who were White or assigned-female-at-birth. Higher educational attainment was associated with greater odds of surgery (graduate degree vs < high school: OR 5.01 [1.41–17.83]), as well as higher income (relative to no income, $100,000 or more: OR 7.79 [3.11–19.54], $50,000–$99,999: OR 2.42 [1.15–5.11], $25,000–$49,999: OR 1.86 [1.01–3.44]). Lack of health insurance was associated with higher odds of GAS (OR 2.56 [1.49–4.39]). Greater outness to others was associated with higher odds of GAS receipt (OR 4.73 [2.24–9.97] for those out to all others relative to those out to none or some people). Receipt of gender-related counseling (OR 2.39 [1.59–3.60]) and hormone therapy (OR 3.22 [2.27–4.57]) were both strongly associated with surgical receipt.

Conclusions: Non-binary individuals experience significant disparities in access to GAS relative to binary transgender populations. Structural barriers, socioeconomic inequities, and psychosocial factors play central roles in shaping access. These findings underscore the need for reforms in insurance coverage and surgical training that move beyond binary transition pathways to achieve equitable, patient-centered gender-affirming care.

Background
Facial feminization surgery (FFS) encompasses a broad range of craniofacial procedures aimed at aligning facial features with a patient's gender identity. Procedures such as cranioplasty and frontal sinus setback involve complex skeletal remodeling in proximity to critical neurovascular structures, raising distinct safety considerations. Despite the increasing utilization of upper and mid-face FFS, existing literature is largely limited to single-center series and lacks large-scale characterization of perioperative and postoperative complications. A population-level assessment of the complication profile of upper and mid-face face procedures is therefore needed to inform better surgical planning, risk stratification, and patient counseling.

Methods A retrospective cohort study was conducted using the TriNetX database. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients undergoing gender affirming care. Upper and mid-face FFS procedures included frontal cranioplasty, hairline advancement, browlift, upper and lower blepharoplasty, rhinoplasty, malar implants, and fat grafting. Primary outcomes included post-operative complications – including cellulitis, abscess, sepsis, swelling/edema, bleeding, and infection – stratified into early (<30 days) and late (>30 days) events. Complication rates were assessed using cohort-level analyses and Kaplan-Meier survival methods to estimate complication-free survival.

Results A cohort of 2,747 patients undergoing gender affirming surgery, of whom 890 (32.4%) underwent cranioplasty, 1,963 (71.5%) hairline advancement, 875 (31.9%) browlift, 77 (2.8%) upper blepharoplasty, 10 (0.4%) lower blepharoplasty, 789 (28.7%) rhinoplasty, 90 (3.3%) malar implants, and 394 (14.3%) fat grafting. Overall complication rates were low across all procedures, with consistently high Kaplan-Meier estimates of complication-free survival (>93% at the end of follow-up). Frontal cranioplasty demonstrated low early swelling (1.60%) and infection (1.94%) rates, with similarly low late swelling (2.10%) and infection (1.86%). Hairline advancement was associated with early bleeding (2.39%) and infection (4.22%), while late complications included sepsis (0.56%), swelling (1.83%), bleeding (1.60%), and infection (3.59%). Browlift procedures showed low early swelling (1.40%) and infection (1.86%) with late swelling (2.60%), bleeding (1.17%), and infection (2.13%). Rhinoplasty demonstrated low early infection (1.55%), low late swelling (1.99%), and infection (1.71%). No complications were documented following upper blepharoplasty, and a small sample size limited the assessment of lower blepharoplasty outcomes. Late swelling following fat grafting occurred in 3.45% of cases.

Conclusion
Upper and mid-face FFS procedures demonstrated low rates of postoperative complications at both early and late follow-up. By providing population-level estimates across a broad procedural spectrum, these findings help contextualize surgical risk and support informed perioperative decision-making for patients undergoing upper and mid-face FFS. Further work is needed to delineate nuanced early-versus-late complication patterns and to evaluate the outcomes of commonly combined upper face procedures in real-world practice settings.

Background: State-level legislation restricting gender-affirming care for transgender youth has expanded rapidly across the United States in recent years. According to the Williams Institute, approximately 724,000 transgender youth ages 13–17 reside in the United States. Nearly half live in states with bans on gender-affirming medical care for minors, and more than half reside in states with laws restricting participation in sports consistent with gender identity or limiting access to gender-affirming facilities. These restrictive policies are disproportionately concentrated in the South and Midwest(1). As transgender youth age into adulthood, the geographic distribution of gender-affirming surgery (GAS) plastic surgeons may play a critical role in determining access to surgical care. This study evaluates the regional distribution and migration patterns of GAS plastic surgeons in the context of contemporary legislative climates affecting transgender youth. Methods: A cross-sectional analysis was performed identifying U.S.-based plastic surgeons providing gender-affirming surgical care. Surgeons were identified through institutional gender-affirming care programs, state-based centers advertising comprehensive transgender services, professional society resources, and publicly available directories. Fellowship training history and current practice location were obtained from institutional websites, faculty profiles, and professional biographies. Geographic classification was performed using U.S. Census regions. Regional retention was assessed by comparing fellowship location with current practice location. Distribution was descriptively compared with regions identified by the Williams Institute as having high prevalence of restrictive legislation affecting transgender youth. Results: Twenty-six GAS plastic surgeons met inclusion criteria. Fellowship training occurred most frequently in the West (Pacific) (35%), followed by the Midwest (East North Central) (19%), South (20%), and Northeast (26%). Current practice locations were concentrated in the West (46%) and Northeast (22%), with fewer surgeons practicing in the South (18%) and Midwest (15%). Sixty-two percent of surgeons remained within the same U.S. Census region after fellowship training, while 38% migrated interregionally. Notably, several surgeons trained in Midwest and Southern fellowship programs relocated to West Coast practice settings. Regions identified as having the highest proportions of transgender youth living under restrictive legislation, particularly the South and Midwest, had comparatively fewer practicing GAS surgeons relative to the West. Conclusion: The distribution of GAS plastic surgeons does align with regions where transgender youth are most affected by restrictive legislation. The South and Midwest regions have the highest proportion of transgender youth living in a state with at least one restrictive policy at 94.5% and 51.3%, according to the Williams Institute(1). This study showed a smaller proportion of GAS surgeons relocating to these regions, and showed more surgeons moving away after fellowship. Concentration of surgeons in Western metropolitan areas, combined with migration away from certain Midwest regions, may exacerbate existing disparities in access to gender-affirming surgical care as youth transition into adulthood. References

1. The impact of 2025 anti-transgender legislation on Youth. Williams Institute. (2026, January 29). https://williamsinstitute.law.ucla.edu/publications/anti-trans-legislation-youth/

Background: Gender-affirming phalloplasty (GAP) is a complex reconstructive undertaking typically performed over multiple surgical stages, with the combination and sequencing of stages varying based on patient goals and surgeon preference. Clitoral burial (CB) is a commonly performed procedure in which the clitoris is repositioned beneath the base of the neophallus. CB serves both a functional and aesthetic purpose: allowing for erogenous sensation through direct stimulation of the neophallus, while concealing the clitoral body. Although CB is a routine step in GAP, its independent contribution to postoperative morbidity has not been characterized. Therefore, the objective of this study was to evaluate whether CB is associated with postoperative complications.

Methods: A retrospective chart review was conducted of all patients who underwent GAP at a single academic institution between June 2017 and January 2026. Patients who underwent CB in any stage were part of the CB group, and patients who did not undergo CB in any stage were part of the non-CB group. Patient demographics (age, BMI) and relevant comorbidities (hypertension, diabetes mellitus, smoking status) were collected. All surgical stages within each patients' phalloplasty course were characterized by the type of reconstruction performed (index phalloplasty, metoidioplasty, or revision) and any concurrent procedures, including CB, vaginectomy, urethral lengthening, urethral hookup, scrotoplasty, and glansplasty. Flap complications included hematoma, dehiscence, surgical site infection, delayed wound healing, partial necrosis, and complete necrosis. Urologic complications included urinary tract infection (UTI), fistula, stricture, and urinary retention. Composite outcomes included any complication, any major complication (complication resulting in urgent return to the operating room), any flap complication, and any urologic complication. Patient-level comparisons were performed using Wilcoxon or Welch t-tests to compare continuous variables between the two groups, and χ² or Fisher's exact tests were used to compare categorical variables. Firth-penalized generalized estimating equations (PGEE) were used to account for multiple surgeries per patient and estimate the independent association between CB and postoperative complications, adjusting for patient demographics, comorbidities, number of prior surgeries, and concurrent procedures. Statistical significance was set at p<0.05.

Results: A total of 67 patients and 196 surgical stages were included in the analysis. 20 (29.9%) patients were in the CB group and 47 (70.1%) were in the non-CB group. Patients in the CB group had significantly higher rates of urethral lengthening, urethral hookup, and a greater total number of surgical stages per patient (p<0.05); all other characteristics were similar between groups. Surgical stages in which CB was performed were associated with significantly higher odds of any flap complication (aOR 4.82, p=0.018), delayed wound healing (aOR 5.60, p=0.008), and UTI (aOR 3.63, p=0.006). Dehiscence was more frequent in stages with CB than stages without (40.0% vs. 27.5%), but was not significantly different (aOR 3.08, p=0.092).

Conclusions: CB is independently associated with increased rates of delayed wound healing and UTI in GAP. Surgeons may consider staging CB separately from other complex, high-risk reconstructive steps in multistage phalloplasty to mitigate complication risk, and counsel patients on potential added morbidity when CB is performed.

Introduction Approximately 2.8 million people in the U.S. identify as transgender and/or gender diverse (TGD), of which 54.2% are 13-24 years old.(1) TGD youth face suicide rates 4-7 times higher than their cisgender peers, with just under half endorsing suicidal ideation.(2,3) Gender-affirming care, including gender-affirming chest surgery (cGAS), has demonstrated clinically significant mental health benefits and plays a critical role in addressing these disparities.(4) The present prospective study builds on existing literature by assessing surgical and mental health outcomes of cGAS in a large TGD youth population.

Methods A total of 196 patients undergoing cGAS between 2019-2025 at a pediatric academic institution were reviewed. All patients were referred for cGAS following extensive screening and counseling through a multidisciplinary gender-affirming care team, including mental health, endocrinology, and surgical providers. Patients pre-cGAS (n=136) were enrolled prospectively; patients post-cGAS (n=60) were retrospectively reviewed, with 32(53%) consenting to further prospective survey collection. All prospective patients completed pre- and post-cGAS surveys, including GAD-7, PHQ-2, Gender Dysphoria (17 possible items, 10-point Likert scale), and Chest Dysphoria (17 possible items, 4-point Likert scale).(5) Higher scores indicated greater symptom burden.

Results Of the 168 prospective patients, 126(75%) identified as transmasculine, 34 (20%) nonbinary or gender diverse, and 8(5%) transfeminine. 137(82%) patients were post-cGAS (mean age(SD): 18.4(1.8) years), with 96 patients (58%) undergoing double incision mastectomy with free nipple grafts and 6(4%) without; 26(16%) keyhole mastectomy; 5(3%) breast augmentation; and 2(1%) breast reduction. Complications requiring intervention were seen in 25(18%) patients, including 10(7%) patients with postoperative surgical site infection requiring antibiotics, 9(7%) with hypertrophic scarring warranting laser therapy, and 5(4%) requiring reoperation. Reoperation indications included revision for uneven chest contouring and/or large nipple areolar complex (NAC) (n=3), intraoperative management of wound dehiscence (n=1), and NAC ischemia (n=1).

All four mental health domains showed significant improvement after cGAS. Gender dysphoria decreased significantly overall (preop vs. postop mean(SD)= 78.9(32.2) vs. 57.4(27.7), p<0.05), with patients reporting the largest reductions in their post-cGAS gender dysphoria when showering, looking in the mirror, wearing bathing suits, and navigating being misgendered. Chest dysphoria showed a marked reduction (29.1(8.6) vs. 6.9(7.7), p<0.05), as well as depression scores via PHQ-9 (1.8(1.8) vs. 1.02(1.3), p<0.05) and anxiety scores via GAD-7 (7.6(4.9) vs. 5.2(4.4), p<0.05).

Conclusions cGAS is associated with significant improvements in gender dysphoria and body image, chest dysphoria, depression, and anxiety in this prospective TGD adolescent and young adult cohort. The high prevalence of pre-existing mental health comorbidities in this cohort underscores the harm of restricting cGAS in young TGD patients. These findings support the psychological and functional benefits of cGAS and highlight the importance of ensuring equitable access to gender-affirming care.

References (1) Herman JL, Flores AR. How Many Adults and Youth Identify as Transgender in the United States? Williams Institute; 2025. (2) Tordoff DM, Wanta JW, Collin A, et al. JAMA Netw Open. 2022;5(2):e220978. (3) Olson-Kennedy J, Warus J, Okonta V, et al. JAMA Pediatr. 2018;172(5):431-436. (4) Ewing E, Sendek G, Becker M, et al. Plast Reconstr Surg Glob Open. 2025;13(6):e6911.

Background: Gender-affirming mastectomy (GAM) is a key procedure in gender-affirming care. However, as demand grows and mastectomy volume continues to increase, trajectory of postoperative functional recovery remains poorly characterized. While surgical techniques are well-described, there is little evidence-based data regarding patient-reported functional disability. QuickDASH, a validated 11-item patient-reported outcome measure, is designed to aid in quantifying upper extremity disability and symptoms and has been utilized in many patient populations. Defining the expected functional recovery course following GAM is critical when counseling patients pre-operatively and guiding post-operative rehabilitation. Therefore, this study aimed to characterize upper extremity functional outcomes in patients undergoing gender affirming mastectomies using the QuickDASH outcome measure.

Methods: This was a single-center, retrospective analysis of patients undergoing GAM at an academic institution between January 2024 to November 2025. Patients were included if they were age 18 or older, had documentation of a pre-operative QuickDASH score, and at least three post-operative scores. QuickDASH scores were collected at four time intervals: pre-operative baseline, less than 3 weeks, 3-8 weeks, and greater than 8 weeks from the date of surgery. The primary outcome was the change in QuickDASH scores over time, analyzed using the Friedman test with Wilcoxon pairwise comparisons for non-parametric longitudinal data. Secondary analyses included linear and logistic regressions to examine BMI, resection mass, and operative time as predictors of functional recovery.

Results: Thirty-three patients (20 transgender male, 13 non-binary) met inclusion criteria. The cohort mean age was 26.21 ± 8.26 years with a mean BMI of 28.40 ± 6.62. Double incision mastectomy with free nipple grafting was the most common technique (n=22). Pre-operative QuickDASH scores were low (mean 3.72 ± 5.98), reflecting high baseline function. Post-operatively, functional disability peaked at <3 weeks (mean 36.43 ±17.78, p<.001) and remained elevated at 3-8 weeks (mean 17.35 ± 13.35, p<.001). By >8 weeks, 87.9% of patients returned within 10 points of their pre-operative baseline with no significant difference from pre-operative scores (mean 4.34 ± 6.78, p=0.909). Lastly, BMI, total resection mass, and operative time were not significant predictors of score change, though increased operative time showed a trend toward predicting functional recovery (p=0.059, R2 = 0.110).

Conclusion: This study establishes that patients undergoing GAM experience a significant but transient decline in upper extremity function that typically resolves within two months. These findings provide an evidence-based recovery timeline for GAM, allowing surgeons to better counsel patients preoperatively. Furthermore, this study suggests that functional recovery is independent of body habitus or resection mass, though the impact of operative time warrants further prospective investigation.

Background Double-incision mastectomy is the most common procedure for chest wall masculinization in transgender and gender non-binary individuals (1). Reconstruction of the nipple–areola complex (NAC) has traditionally been considered an essential component of masculinizing chest surgery (2,3). However, a growing number of patients elect to forego NAC reconstruction, challenging long-held assumptions regarding its importance. This study crowdsources perceptions of nipple importance and examines factors influencing preferences for or against NAC reconstruction following chest wall masculinization.

Methods A ten-item questionnaire assessing demographics, prior experience with top surgery, surgical counseling, perceived importance of nipples, and rationale for reconstructive preferences was distributed to U.S. adults via Amazon Mechanical Turk. Eligible respondents were ≥18 years old with a task approval rating ≥90% and ≥50 previously completed tasks. Responses were collected using QualtricsXM and analyzed using GraphPad Prism. Comparisons between cisgender, transgender, and non-binary respondents were performed using chi-squared testing with Bonferroni correction. Statistical significance was set at p<0.05.

Results A total of 560 respondents completed the survey. Most respondents were aged 25–34 years (69%), identified as cisgender male (54%), and reported current health insurance coverage (97%). Forty-five percent reported prior top surgery, 48% were considering top surgery, and 7% were not interested, with no significant differences between gender groups (p=0.164).

Among respondents who consulted a surgeon, only 50% reported that the option to forego NAC reconstruction was discussed, while 45% reported that this option was not discussed. Perceived importance of nipples varied: 29% considered nipples important, 41% reported indifference, and 23% considered nipples unimportant. Perceptions differed significantly between cisgender and transgender respondents (p<0.001).

Respondents who would choose NAC reconstruction cited aesthetics (39%), desire to reduce chest volume without altering appearance (37%), and concern for stigmatization without nipples (20%). Those who would forego NAC reconstruction cited observing others make the same choice (48%), reduced conformity to traditional gender constructs (41%), and concern for postoperative nipple discoloration (10%).

Conclusions Despite NAC reconstruction remaining the conventional standard in masculinizing chest surgery, fewer than one-third of respondents considered nipples important following surgery. Peer visibility and reduced gender conformity were key drivers influencing interest in foregoing NAC reconstruction. Notably, nearly half of respondents reported that this option was not discussed during surgical consultation. Surgeons should routinely include omission of NAC reconstruction in shared decision-making discussions to better align surgical planning with evolving patient preferences.

References 1. Wilson SC, Morrison SD, Anzai L, et al. Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes. Ann Plast Surg. 2018;80(6):679-683. 2. Bustos SS, Forte AJ, Ciudad P, Manrique OJ. The Nipple Split Sharing vs. Conventional Nipple Graft Technique in Chest Wall Masculinization Surgery: Can We Improve Patient Satisfaction and Aesthetic Outcomes? Aesthetic Plast Surg. 2020;44(5):1478-1486. 3. Nipple areolar complex reconstruction is an integral component of chest reconstruction in the treatment of transgender and gender diverse people. International Journal of Transgenderism. 2019;20(1):1-3.

Background: Microsurgical phalloplasty requires reliable recipient vessels to maintain flap perfusion and minimize thrombosis and flap loss. The common femoral artery (CFA) and superficial femoral artery (SFA) are frequently selected for end-to-side anastomosis due to their caliber and accessibility within the femoral triangle. Intraoperative thrombosis during attempted end-to-side anastomosis may require abandonment of the recipient site and primary closure of the arteriotomy. The degree of stenosis following repair of femoral arteriotomy has not been well characterized. This study evaluates luminal stenosis after simulated arteriotomy repair of the CFA and SFA.

Methods: Nine adult cadavers (18 femoral segments) underwent femoral artery dissection using established anatomic landmarks. Arteriotomies were created in the CFA and SFA using 2.7-mm or 3.5-mm vascular punches and repaired under operating microscope magnification with 7-0 polypropylene suture. External vessel diameters were measured pre-repair using digital calipers. Following repair, vessels were transected transversely at the site of repair, and internal and external diameters were measured using digital calipers. Percent stenosis was calculated as the reduction in luminal diameter relative to the proximal and distal vessel segments. Bilateral (left versus right limb) and punch size comparisons were performed.

Results: Eighteen femoral segments (9 left, 9 right) were analyzed. Median age was 69 years (IQR 69–85), and median BMI was 22 kg/m2 (IQR 21–22). Arteriotomy repair resulted in significant luminal narrowing of the CFA (mean stenosis 9.25%, 95% CI 3.7 to 14.8, p = 0.003) and SFA (mean stenosis 13.8%, 95% CI 6.2 to 21.5, p = 0.0015). There were no significant differences between left and right limbs in percent stenosis for either vessel (CFA mean difference 3.61%, 95% CI –8.50 to 15.72, p = 0.49; SFA mean difference –3.83%, 95% CI –18.24 to 10.59, p = 0.55). Punch diameter (2.7 mm vs. 3.5 mm) did not significantly affect stenosis (CFA 10.1% vs. 7.9%, p = 0.74; SFA 14.9% vs. 12.7%, p = 0.82).

Conclusions: In this cadaveric study, repair of femoral arteriotomies resulted in statistically significant luminal narrowing of the CFA and SFA. However, the magnitude of stenosis (9.25% in the CFA and 13.8% in the SFA) remains well below the ≥50% diameter reduction commonly used to define significant lower extremity arterial stenosis. (1) These findings indicate that primary repair following an aborted end-to-side anastomosis is unlikely to result in clinically meaningful flow limitation. This has implications for recipient vessel selection and operative planning in phalloplasty. Similar considerations may extend to other complex microsurgical reconstructions involving end-to-side arterial anastomoses.

References: 1. Macharzina RR, Schmid SF, Beschorner U, et al. Duplex ultrasound assessment of native stenoses in the superficial femoral and popliteal arteries: a comparative study examining the influence of multisegment lesions. J Endovasc Ther. 2015;22(2):254-260. doi:10.1177/1526602815576094

Background: Gender-affirming mastectomy improves body satisfaction, and gender dysphoria in transmasculine and non-binary individuals. Higher rates of obesity in this population make BMI-based restrictions particularly impactful. Evidence linking obesity to postoperative outcomes after top surgery remains limited and heterogeneous particularly across BMI subgroups.

Methods: We conducted a systematic review and meta-analysis. (1) PubMed, Embase, and Cochrane were searched in January 2026 for studies comparing postoperative outcomes in obese versus non-obese patients undergoing chest masculinization. Primary endpoint was overall postoperative complications, secondary endpoints included hematoma, seroma, surgical site infection, revision surgery, and patient-reported outcomes. Data were pooled using random-effects models to calculate risk ratios (RR) with 95% confidence intervals (CI) for all dichotomous outcomes. Heterogeneity across studies was assessed with I², and prediction intervals were calculated using R software.

Experience: Eleven studies were included: 9 to the meta-analysis, and 2 were included in qualitative synthesis (12,220 patients). BMI was categorized according to WHO criteria, and studies additionally reported comorbidities such as diabetes, hypertension, smoking, and hormone therapy. Surgical techniques were heterogeneously reported, most used double-incision approaches with free nipple grafting (5 studies), while smaller proportions underwent periareolar or alternative techniques.

Results: Obese patients had a higher risk of surgical infection (RR 2.50, 95% CI 2.03–3.08, p < 0.01, I² = 0%) and secondary revision (RR 1.71, 95% CI 0.77–3.8, p = 0.19, I² = 49%) compared with non-obese. No significant differences were observed for hematoma (RR 1.40, 95% CI 0.87–2.26, p = 0.17, I² = 0%), seroma (RR 1.67, 95% CI 0.61–4.61, p = 0.32, I² = 56%), wound dehiscence (RR 1.91, 95% CI 0.83–4.40, p = 0.13, I² = 59%), or nipple–areolar complex (NAC) necrosis (RR 2.18, 95% CI 0.67–7.07, p = 0.19, I² = 0%). Subgroup analyses demonstrated a dose–response relationship, with a higher infection among patients with BMI 35.0–39.9 kg/m² (RR 1.77, 95% CI 1.26–2.48) and BMI ≥40.0 kg/m² (RR 3.39, 95% CI 2.37–4.85). NAC necrosis did not differ significantly across BMI, though BMI ≥40.0 kg/m² events were too sparse to yield stable estimates. Secondary revision risk increased in BMI 35.0–39.9 kg/m² (RR 3.34, 95% CI 1.15–9.75) and class BMI ≥40.0 kg/m² (RR 3.93, 95% CI 1.40–11.02), whereas overweight and BMI 30.0–34.9 kg/m² showed no significant difference. Seroma risk remained non-significant across all classes. Wound dehiscence increased significantly in BMI ≥40.0 kg/m² (RR 2.43, 95% CI 1.29–4.57, P < 0.01), with lower classes showing non-significant differences.

Conclusions: Our findings support that obesity may be associated with higher rates of infection, wound dehiscence in higher BMI, and secondary revision, while rates of hematoma, seroma, and NAC necrosis appear largely comparable between groups. Evidence suggests a potential increase in the risk of complications among patients with obesity, however, patient satisfaction and gender-affirming outcomes seem to remain favorable.

1. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Journal of Clinical Epidemiology. 2009;62(10):1006-1012. doi:10.1016/j.jclinepi.2009.06.005

PURPOSE: Physicians and trainees feel unprepared to care for transgender and gender diverse (TGD) patients, a gap largely attributed to limited formal education in gender-affirming care (GAC) (1,2). Deficiencies in training can contribute to discomfort, lack of confidence, and suboptimal care interactions, perpetuating TGD health disparities (3,4). While gender-affirming surgery (GAS) is an essential component of GAC for many patients, coverage of GAS in medical education remains limited (5). Educational interventions at the medical student level could address this gap. We aimed to assess baseline student knowledge, attitudes, and confidence regarding GAS and evaluate the impact of a GAS-focused educational intervention integrated into a core surgery clerkship.

METHODS: A cross-sectional pre- and post-intervention survey study was conducted among medical students during their core surgery clerkship from October 2025 to January 2026. The intervention consisted of a required didactic lecture on gender-affirming chest, genital, and facial reconstruction. Lecture content addressed surgical readiness, fertility preservation, perioperative management, common complications, quality-of-life outcomes, and the interdisciplinary framework of GAS. Participants completed anonymous pre- and post-lecture surveys that included demographics, self-reported comfort and confidence across 16 items, an original 12-item knowledge assessment, and intervention evaluation questions. Paired t-tests, Wilcoxon signed-rank tests, and multivariate linear regression were used to evaluate outcomes. Covariates included age, year, number of prior clerkships, number of prior TGD patients, hours of prior GAC training, and presence of TGD friends or family.

RESULTS: Surveys were obtained from two clerkship cohorts: 42 medical students completed pre-intervention surveys and 38 completed post-intervention surveys, yielding 38 paired responses (response rate: 83%); 30% were interested in pursuing surgical residencies. Over 95% reported previously encountering TGD patients. Respondents reported strong perceived importance of GAS education: 97% agreed that GAS is an important part of medical education and 63% strongly agreed. All respondents reported wanting to be able to effectively care for TGD patients in their future practice, with 78% strongly agreeing. Despite this, 50% reported inadequate prior education on GAS during medical school.

Following the intervention, respondents reported increased confidence in clinically relevant knowledge and skills, including significant improvements in: comfort communicating with TGD patients, familiarity with available GAS procedures, ability to counsel on fertility preservation, ability to discuss surgical readiness and complications, understanding of mental health and quality-of-life impacts of GAS, and understanding of the interdisciplinary nature of GAC. Mean total knowledge assessment scores increased by 28% post-intervention; in an adjusted multiple linear regression model, lecture participation was the only covariate independently associated with significantly higher knowledge assessment scores (p<0.001). Notably, there was a significant increase in students considering plastic and reconstructive surgery as a future career post-intervention, and 83% reported increased motivation to learn more about GAC.

CONCLUSION: This study demonstrated that medical students value education on GAS yet report inadequate exposure. Integration of a targeted GAS lecture into a core surgery clerkship was associated with significant acquisition of knowledge and confidence. Early exposure to GAS may enhance trainee competence, confidence, and interest, potentially expanding the workforce interested in and capable of providing GAC.

References 1. Mousavian M, Ranganathan K, Keuroghlian AS, Park YS, Kumar A. What are the barriers to health professionals' training on gender-affirming care from patients' and clinicians' perspectives? Soc Sci Med. 2024 Jun;351:116983. doi: 10.1016/j.socscimed.2024.116983. 2. Streed CG Jr, Hedian HF, Bertram A, Sisson SD. Assessment of Internal Medicine Resident Preparedness to Care for Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning Patients. J Gen Intern Med. 2019;34(6):893-898. doi:10.1007/s11606-019-04855-5. 3. Call DC, Challa M, Telingator CJ. Providing Affirmative Care to Transgender and Gender Diverse Youth: Disparities, Interventions, and Outcomes. Curr Psychiatry Rep. 2021;23(6):33; doi:10.1007/s11920-021-01245-9. 4. Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):168-171; doi:10.1097/MED.0000000000000227. 5. Ha M, Ngaage LM, Finkelstein ER, Simon C, Hricz N, Zhu K, Yoon J, Liang F, Berli J, Rasko Y. Gender-Affirmation Surgery Training in United States Academic Plastic Surgery Residency Programs. Transgend Health. 2025 Feb 10;10(1):44-51. doi: 10.1089/trgh.2022.0206