Scientific Abstract Presentations: Gender Surgery Session 3 Saturday, October 17 Sat, Oct 17 2:00-3:30 p.m. CDT

Background- Although gender-affirming mastectomy (GAM) is technically similar to gynecomastia surgery, it is performed in a distinct clinical and hormonal context, and whether these differences translate into unique complication patterns remains underexplored in large cohorts. We hypothesized that complication profiles would be comparable between transgender and cisgender patients.

Methods- Following IRB approval, a retrospective review of patients undergoing GAM or gynecomastia mastectomy (2003–2024) was performed, including adults undergoing bilateral procedures with ≥30-day follow-up. Complications included hematoma, seroma, infection, wound dehiscence, nipple–areolar complex necrosis, scar asymmetry, and pathologic scarring. Revision procedures and clinic- or operating room–based interventions were also analyzed. "Acute complications" were defined as the occurrence of ≥1 event within 30 days. Continuous variables were reported as median [Q1, Q3] and categorical variables as percentages. Chi-square, Fisher's exact, and Mann–Whitney U tests were used. Multivariable logistic regression was used to identify independent predictors of complications. Based on reported complication rates of 19.7% and 8.7%, a conservative power analysis demonstrated that 391 patients per group were required with 80% power at α=0.05.

Results- A total of 634 patients underwent GAM and 458 underwent gynecomastia surgery. GAM patients were younger (24 [20,29] vs. 27 [20,40] years, p<0.01) with a higher BMI (29.7 [24.94, 35.19] vs. 28.2 [25.79, 31.64], p<0.01). Preoperative testosterone use was more common in GAM (85% vs. 4.8%, p<0.01). Fifty-two percent of GAM patients discontinued therapy preoperatively compared with 23% in the gynecomastia cohort. Periareolar incision was more frequent in gynecomastia (74% vs. 12%, p<0.01), whereas double incision with free nipple graft (DIFNG) was the predominant technique in GAM (73% vs. 12%, p<0.01). Concurrent liposuction was performed in 1.1% of GAM and 41% of gynecomastia cases.

Acute complications occurred in 16.4% of patients in gynecomastia group compared with 12.9% in GAM group (p=0.11). Seroma (11% vs. 5.5%, p<0.01) and seroma requiring aspiration (9.2% vs. 5.7%, p=0.03) were higher in the gynecomastia cohort. Rates of pathologic scarring were similar between groups for both the periareolar (1.3% vs. 0.9%, p=0.56) and DIFNG (4.3% vs. 1.9%, p=0.41). Other complications were not significantly different.

On multivariable analysis, increasing age (aOR 1.03, CI 1.01–1.04, p<0.01) and preoperative testosterone use (aOR 1.79, CI 1.15–2.80, p<0.01) were independently associated with higher odds of acute complications. Preoperative testosterone use was also associated with increased odds of hematoma (aOR 2.11, CI 1.26–3.53, p<0.01). Increasing age was an independent predictor of seroma (aOR 1.025, CI 1.008–1.042, p<0.01). Periareolar incision was associated with lower odds of revision surgery (aOR 0.40, CI 0.20–0.79, p<0.01). Among patients receiving testosterone, preoperative hormone cessation was not significantly associated with acute complications (aOR 0.52, CI 0.20–1.31, p=0.17) or hematoma (aOR 0.66, CI 0.34–1.23, p=0.20).

Conclusions- Complications after GAM were comparable to those after gynecomastia surgery despite significant differences in patient characteristics and operative technique. Seroma was more common in the gynecomastia cohort. Increasing age and preoperative testosterone use were independently associated with higher odds of acute complications and hematoma. Preoperative cessation did not change acute complications or hematoma rates.

Purpose: Lower face feminization represents a technically demanding component of facial feminization surgery (FFS). Although traditional approaches emphasize bony contouring, the relative contributions of skeletal, muscular, and glandular structures to lower facial squareness remain incompletely understood. This study aimed to develop a quantitative framework identifying the anatomical determinants of lower facial squareness. Methods: A retrospective cohort of 90 patients was analyzed. CT scans were segmented using Mimics and reconstructed in 3-matic. Measured parameters included mandibular flare distance, gonial and flare angles, chin width, bicondylar width, ramus height, and parotid and masseter thickness. Horizontal dimensions were normalized to interzygomatic width and vertical dimensions to lower facial height. Facial squareness was rated by seven blinded evaluators using a 0–3 Likert scale, and mean scores were calculated. Inter-rater reliability was assessed using the intraclass correlation coefficient (ICC). Predictors of squareness were examined using linear regression. To assess the relative importance of anatomical components, explained variance in squareness ratings was partitioned among mandibular, masseter, and parotid variables. Results: After normalization, males demonstrated significantly greater mandibular ramus height than females (p = 0.001) and larger parotid and masseter volumes (p = 0.025 and p < 0.001, respectively). No significant sex difference was observed in mandibular flare distance (p = 0.791), whereas the gonial angle was significantly smaller in males (mean difference −4.28°, p = 0.001). Inter-rater agreement for squareness classification was good bilaterally (right ICC = 0.68, 95% CI 0.58–0.77; left ICC = 0.77, 95% CI 0.68–0.83; both p < 0.0001). On linear regression, smaller gonial angle was the strongest predictor of increased squareness (β = −0.173, 95% CI −0.311 to −0.034, p = 0.015). Greater ramus height was also associated with increased squareness (β = 0.152, 95% CI 0.013–0.292, p = 0.03). Higher BMI was associated with lower squareness scores (β = −0.136, 95% CI −0.265 to −0.008, p = 0.037), whereas older age was associated with higher squareness scores (β = 0.143, 95% CI 0.015–0.271, p = 0.029). In multivariable analysis, ramus height and gonial angle remained significant predictors of squareness (p = 0.05 and p = 0.026, respectively), and cranio-caudal masseter thickness slope independently predicted squareness (β = 0.18, 95% CI 0.03–0.33, p = 0.018). Race and gender were not significant predictors. Variance partitioning demonstrated that mandibular morphology accounted for approximately 50% of the variance in squareness ratings, while the masseter and parotid together explained approximately 40%. Conclusion: The mandibular gonial angle is the strongest skeletal determinant of lower facial squareness. Age and BMI also significantly influence perceived squareness. Our findings provide a quantitative framework for surgical planning and support a multimodal FFS approach integrating bony contouring with targeted soft tissue modification to optimize aesthetic outcomes.

Purpose: The upper-third of the face is a key determinant of gender recognition, yet traditional facial feminization surgery (FFS) techniques focus primarily on central forehead contouring and brow elevation, often leaving residual temporal fullness and lateral brow descent. Over several years, the senior authors have progressively refined their approach to address these limitations. This study outlines the evolution of their upper-third feminization technique and reports clinical outcomes after adoption of the current comprehensive surgical protocol.

Methods and Materials: A retrospective review was performed of consecutive patients undergoing primary upper-third FFS by the senior authors between 2024 and 2025. All cases included one or more of the following refinements: (1) extended lateral frontal contouring from the midline to the frontozygomatic suture using burring and, when indicated, frontal sinus setback based on Ousterhout frontal sinus type; (2) horizontal periosteal scoring approximately 5 mm inferior to the supraorbital rim to increase brow mobility and allow a better lateral elevation; and (3) temporal cheek suspension with fascial plication after wide subgaleal and deep temporal dissection to release temporal retaining ligaments and reorient soft tissues along a superolateral vector. Demographics, hormone therapy status, comorbidities, and smoking history were recorded. Complications and postoperative course were extracted from the medical record. Standardized pre- and postoperative photographs were reviewed to assess changes in forehead contour, forehead–temple transition, lateral brow position, and periorbital–malar contour.

Results: Twenty-seven patients met the inclusion criteria. Mean age was 34 years; 89% were White, 7% Black, and 4% Hispanic or Latina. All patients were on gender-affirming hormone therapy. BMI spanned from underweight to class I obesity. Mean follow-up was six months. The refined techniques yielded consistent improvement in upper-third feminization. Extended lateral frontal contouring reduced lateral bossing and smoothed the curvature from the central forehead to the temporal region. Horizontal periosteal scoring enabled stable symmetrical elevation of the lateral brow with limited postoperative descent. Temporal cheek suspension with fascial plication softened the periorbital region and produced a more continuous transition from the temple to the lateral cheek. Complications were infrequent and minor. Two patients (7.4%) developed transient forehead or scalp sensory changes that resolved during follow-up. One patient (3.7%) had limited scar alopecia, one (3.7%) minor contour irregularity, one (3.7%) wound dehiscence, and one (3.7%) dissatisfaction with aesthetic outcome. No infections, hematomas, motor nerve injuries, or permanent sensory deficits occurred. Overall, 85.2% of patients had no documented complications. Postoperative clinic notes documented high patient satisfaction and durable contour changes within the available follow-up period.

Conclusions: A comprehensive upper-third facial feminization protocol can correct limitations of traditional, centrally focused techniques. The described approach yields reliable improvements in forehead–temple contour, lateral brow position, and periorbital–malar harmony with low morbidity. Future studies incorporating quantitative morphometric analysis and patient-reported outcomes will further define its long-term efficacy.

Background: Perioperative management of gender-affirming hormone therapy (GAHT) is controversial due to concerns regarding estrogen-mediated thrombotic risk. Evidence is needed to determine if preoperative estrogen increases the incidence of thrombotic events in gender-affirming augmentation mammoplasty. Methods: A retrospective cohort study was performed using the TriNetX global federated health research network to identify adult (18+) patients undergoing augmentation mammoplasty with prior diagnosis of gender identity disorder. Patients were stratified by preoperative estrogen prescription (including oral, transdermal, and injectable formulations) within one year of surgery. Cohorts were balanced for age, BMI, nicotine dependence, and type 2 diabetes using 1:1 propensity-score matching. Primary outcomes included 30-day and 365-day incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE). Secondary outcomes included postoperative infection, implant removal, capsular contracture, capsulectomy and capsule revision, and mortality. Results: A total of 1,206 matched patients were included. 30-day analysis demonstrated no incidence of pulmonary embolism or mortality in either cohort. At 365 days, pulmonary embolism incidence remained zero. Capsular contracture incidence was identical (n=14, RR 1.0; 95% CI 0.48–2.08). Capsulectomy or capsule revision rates were comparable (RR 0.859; 95% CI 0.4–1.841). All other outcomes, including deep vein thrombosis, were ≤ 10 per cohort at 30 and 365 days, representing a maximum absolute incidence of 1.66%. Conclusions: These findings suggest a low absolute risk for thrombotic events after gender-affirming augmentation mammoplasty with and without GAHT. However, given the lack of data on held doses, further evaluation into the routine perioperative discontinuation of GAHT is merited to determine clinical necessity.

Purpose: To quantify and compare the incidence and severity of hypertrophic and keloid scarring following gender-affirming chest surgery (GACS) versus reduction mammoplasty (RM).

Methods: A retrospective review was performed of adult patients undergoing GACS or RM at Mayo Clinic–Jacksonville from January 2020 to December 2024. Inclusion criteria required age ≥18 years and standardized clinical photographs obtained ≥3 months postoperatively. Of 56 GACS and 354 RM patients identified, propensity score matching (1:3 ratio) based on age, BMI, race, ethnicity, smoking status, diabetes, and surgeon experience yielded 24 GACS and 26 RM patients for final analysis. Scars were graded independently by two blinded reviewers using the observer component of the Patient and Observer Scar Assessment Scale (POSAS; range 5–50) and a modified Manchester Scar Scale (MSS; range 5–16). Hypertrophic scars were defined as MSS contour ≥3 and keloids as contour =4. Continuous variables were compared using Wilcoxon rank-sum testing and multivariable linear regression adjusting for residual imbalance.

Results: Mean follow-up was 3 months for all patients. Mean POSAS score was significantly higher in the GACS cohort (24 ± 8) compared with RM (16 ± 5). Mean MSS score was also higher in GACS (10 ± 2) versus RM (8 ± 2). Hypertrophic scarring occurred in 7 of 24 GACS patients (29%) and 12 of 26 RM patients (46%). Keloid formation was more frequent in GACS (8 of 24, 33%) than RM (1 of 26, 4%). Overall unfavorable scarring (hypertrophic or keloid) was observed in 15 of 24 GACS patients (62.5%) and 13 of 26 RM patients (50%). Multivariable regression confirmed significantly greater scar severity in the GACS group. Non-Caucasian ethnicity was associated with higher scar scores. Among GACS patients not receiving hormone therapy (n = 2), scar scores approximated the cohort median.

Conclusions: Patients undergoing GACS demonstrated significantly greater scar severity and a higher prevalence of keloid formation compared with matched RM controls. These findings align with emerging literature identifying hypertrophic scarring as a notable complication after gender-affirming mastectomy (1,2). Our study contributes to the literature gap by documenting a higher incidence of keloid scars in GACS patients compared to RM controls, emphasizing the need for heightened awareness and tailored management strategies. Hormonal influences may contribute to altered wound healing, as prior prospective data suggest an association between exogenous testosterone and increased scar palpability (3). Recognition of elevated scar risk in GACS patients is essential for preoperative counseling, surgical planning, and implementation of targeted scar mitigation strategies. Larger prospective studies are warranted to clarify contributory mechanisms and optimize management in this population.

References 1. Dai D, Charlton BM, Boskey ER, et al. Prevalence of gender-affirming surgical procedures among minors and adults in the US. JAMA Netw Open. 2024;7(6):e2418814. 2. Almazan AN, Hart R, Jacobson RA, Chung KC. Hypertrophic scarring and scar revision in gender-affirming mastectomy: a systematic review. Arch Dermatol Res. 2024. 3. Hill CJ, Wakamatsu KK, Flack SE, et al. Effects of exogenous testosterone on scarring in gender-affirming chest surgery: a prospective cohort study. Plast Reconstr Surg Glob Open. 2023;11(4):e5111.

Background

In facial feminization surgery (FFS), rhinoplasty is central to achieving gender congruence, yet patient-reported outcome measures (PROMs) data in this population remain limited. To date, no study has prospectively compared cisgender and transgender rhinoplasty using validated PROMs over time, highlighting the need for longitudinal, patient-centered outcomes.

Methods

From July 2023 to January 2026, FFS patients undergoing primary rhinoplasty and cisgender patients undergoing reconstructive primary rhinoplasty were prospectively enrolled to complete a pre-operative validated 12-item Appearance of Nose PROM instrument. FFS patients additionally completed the PROMIS Emotional Distress short form. These were repeated at 3–6 months post-op, and at 1-year post-op. Pre- and postoperative nasal appearance changes were compared within each cohort, and between cohorts. Change in anxiety and depression scores in the FFS cohort were also assessed. Statistical analysis was performed in SPSS.

Results

A total of 54 FFS and 47 cisgender rhinoplasty were enrolled. Twenty-four FFS patients and 12 cisgender patients completed the second survey, and 8 FFS patients and 4 cisgender patients completed the final survey. Baseline nasal appearance was similar between cohorts (Cis 32.4±12.7, FFS 30.5±8.6, p=0.398). Both cohorts demonstrated clinically meaningful improvement in nasal appearance by 3–6 months (Cis +26.62 [7.92-45.32], p=0.009; FFS +35.53 [20.89-50.18], p=0.00004); the adjusted FFS–Cis difference was small and non‑significant (+8.91 [−13.84 to +31.66], p=0.428). A repeated measures model using all visits showed strong improvement over time with no significant time × cohort interaction. In the FFS cohort, anxiety decreased significantly at 3-6 months (Δ −6.83 [−10.58 to −3.08], p=0.0010), and depression decreased significantly as well (Δ −5.00 [−8.42 to -1.58], p=0.006). Twelve-month estimates were imprecise due to smaller paired sample sizes, especially in the cisgender cohort.

Conclusion

Both groups showed significant improvements in nasal appearance, with a larger effect seen in FFS, supporting the effectiveness of reconstructive rhinoplasty across populations. FFS patients additionally demonstrated early reductions in anxiety and depression, illustrating the mental health benefits of FFS. Larger cohorts and longer follow-up are needed to confirm differences in efficacy across populations.

Double incision mastectomy with free nipple graft (FNG) is a common surgical procedure for chest masculinization. The most common technique for FNG is down-sizing the areola and then grafting the entire nipple-areola complex (NAC). This technique results in inability to change the size of the nipple in relation to areola and a less masculine appearance. We are presenting the results of a composite nipple graft technique that takes separate grafts of the areola and the nipple to reconstruct the NAC (Picture 1a) and compares their outcomes (hypopigmentation and cosmesis) directly to the standard technique (Picture 1b).

A retrospective chart review was performed of patients who underwent transgender mastectomies with FNG from July 2023 – October 2024. They were grouped into the composite grafts (CG) and current standard (CS). Inclusion criteria was age greater than 18 and having long-term post-op photographs. The main outcomes analyzed using ImageJ were percent of NAC area with hypopigmentation at about 3 and 6 months and nipple-to-areola ratio, as well as subjective scoring (1-5) of the NAC cosmesis.

There were 30 patients in CG group and 51 patients in the CS group, with each patient having separately analyzed right and left grafts. There was no difference in demographics or comorbidities between groups. The CG group had a less percentage hypopigmentation at 3 months post-op, 6.7% vs 14.1% in CS (p = .0001) but this difference was eliminated at 6 months, 11.3% vs 13.0% (p = .45). The nipple was smaller in relation to the total NAC area in the CG group when compared to CS, 9.8% vs 14.2% (p = 0.0003). The CG group scored higher on subjective cosmetic outcome at both 3 months (average of 4.1 vs 3.7, p = 0.003) and 6 months post-op (average of 3.9 vs 3.6, p.= 0.03).

Our described technique of composite graft appears to provide less transient hypopigmentation post-op with greater control of the re-sizing of the nipple in addition to the areola by taking them as completely separate grafts. This leads to better subjective cosmetic outcomes when compared to the current standard technique.

Introduction: Chest feminization surgery (CFS) aims to alleviate gender incongruence and improve satisfaction with chest appearance. While anecdotally, CFS improves these important and distinct psychosocial measures, quantitative confirmation of this is still lacking to date, particularly regarding gender incongruence (1-3). This study sought to objectively assess the effects of CFS on gender incongruence and chest satisfaction using validated surveys.

Methods: Patients undergoing CFS were prospectively recruited from a single institution between 2022 and 2025. Surveys were administered preoperatively and up to 12 months postoperatively, with the latest survey score used as the postoperative value. Gender incongruence was measured via the validated Gender Minority Stress and Resilience (GMSR-NonAff/IntTrPh) survey with higher score indicating greater gender incongruence (5-point Likert scale, range 0-56). Satisfaction was measured via the validated Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM) survey with lower score indicating greater satisfaction (5-point Likert scale, range 4-20). Shapiro-Wilk test confirmed non-parametric distribution, and Wilcoxon signed-rank test assessed paired score differences. Statistical significance was set at p<0.05.

Results: A total of 38 patients who underwent CFS and completed a preoperative and postoperative survey were included. Median GMSR score decreased from 21 to 14 (n=36, Z=-2.52, p=0.012), indicating alleviation of gender incongruence after CFS. Median AFFIRM satisfaction score decreased from 13 to 5 (n=37, Z=-5.31, p<0.001), indicating improved chest satisfaction after CFS.

Conclusion: Chest feminization surgery is associated with objective alleviation of gender incongruence and improvement in satisfaction with chest appearance using validated surveys.

References: (1) Schoffer AK, Bittner AK, Hess J, Kimmig R, Hoffmann O. Complications and satisfaction in transwomen receiving breast augmentation: short- and long-term outcomes. Arch Gynecol Obstet. 2022 Jun;305(6):1517-1524. (2) McCranie AS, Desjardins HE, Allenby TH, Mathes DW, Wong CJ. Patient Satisfaction Using BREAST-Q and Breast Implant Illness after Breast Reconstruction in Transwomen. Plast Reconstr Surg Glob Open. 2024 May 13;12(5):e5787. (3) de Blok CJM, Staphorsius AS, Wiepjes CM, Smit JM, Nanayakkara PWB, den Heijer M. Frequency, Determinants, and Satisfaction of Breast Augmentation in Trans Women Receiving Hormone Treatment. J Sex Med. 2020 Feb;17(2):342-348.

Background: Facial feminization surgery (FFS) plays a critical role in alleviating gender dysphoria by aligning craniofacial morphology with gender identity. Although computer-aided design and manufacturing (CAD/CAM) has improved surgical precision and reproducibility in craniofacial procedures, objective intraoperative validation of skeletal contouring remains limited. This study evaluates the feasibility and clinical value of integrating CAD/CAM-assisted FFS with intraoperative computed tomography (CT) in a hybrid operating room (HOR) setting.

Methods: Between July 2025 and February 2026, two patients underwent comprehensive FFS using CAD/CAM-assisted virtual surgical planning. Preoperative three-dimensional facial photography and computed tomography were used for osteotomy design, cutting-guide fabrication, and skeletal simulation. Procedures included frontal bone setback and contouring via bicoronal approach, hairline advancement, zygomatic reduction through combined intraoral and temporal approaches, mandibular angle reduction, and genioplasty. Intraoperative CT was performed immediately after skeletal contouring to verify symmetry and contour accuracy, allowing real-time refinement within the same surgical session.

Results: All procedures were completed without intraoperative complications. Postoperative recovery was uneventful, with no facial nerve injury, hematoma, or infection. Intraoperative CT confirmed high concordance between planned and achieved skeletal contours, enabling immediate correction of minor contour irregularities. Postoperative imaging demonstrated symmetrical craniofacial structures consistent with preoperative simulation.

Conclusions: The integration of CAD/CAM-assisted FFS within a hybrid operating room enhances surgical precision by enabling real-time radiologic validation and immediate contour refinement. This approach may reduce revision rates and improve aesthetic predictability in complex gender-affirming craniofacial surgery. Larger studies are warranted to determine long-term outcomes and cost-effectiveness.

Introduction: Chest masculinization ("top surgery") represents one of the most commonly performed gender-affirming procedures, most often utilizing either a double-incision mastectomy with free nipple grafting or periareolar approach. Surgical drains have been routinely placed to reduce seroma formation and preserve chest contour. However, evidence from drain-free oncologic mastectomy and increasing adoption of adjunctive closure strategies, including negative-pressure wound therapy, have challenged this paradigm. We aimed to perform a systematic review to evaluate whether drain placement meaningfully reduces seroma and related postoperative complications.

Methods: A systematic review was conducted according to PRISMA guidelines. Literature searches combined MeSH and free-text terms related to seroma, gender-affirming mastectomy, and transgender health. Eligible studies included randomized trials, cohorts, and case series reporting seroma outcomes after masculinizing chest surgery. Data extracted included drain status, surgical technique, BMI, and seroma incidence. Crude rates were summarized, and random-effects meta-regression was performed to assess associations between drain use, technique, and BMI.

Results: Twenty-six studies met inclusion criteria: 2 comparative, 2 historical comparison, and 22 single-arm studies (yielding 40 analytic arms). Two comparative studies provided direct evidence. Cordero et al. (n=359) found no significant difference in seroma rates between drain and no-drain groups (4.9% vs 5.1%), and multivariate analysis confirmed no protective effect of drains. Timmermans et al., in a randomized trial (n=85), reported higher seroma incidence with incisional negative-pressure wound therapy compared to suction drains (54% vs 31%; OR 0.15 favoring drains), indicating that drains were superior to incisional negative pressure wound therapy but not compared to standard closure without drains. Historical drain-free cohorts using progressive tension sutures reported seroma rates of 0–9.3% and lower revision rates compared with drain-inclusive series. Across single-arm cohorts, crude seroma incidence was 1.5% in drain-free arms versus 13.4% in drain arms (RR ≈ 8.9), though this difference is confounded by indication and heterogeneity. Meta-regression adjusting for technique did not show a consistent protective effect of drains; confidence intervals were wide and residual heterogeneity high (I² >80%). BMI was not significantly associated with seroma risk in adjusted models. Infection and wound dehiscence rates were similar between strategies, while nipple–areola complex necrosis appeared slightly less frequent in drain cohorts, though data were limited.

Conclusion: Drain-free techniques in gender-affirming chest surgery demonstrate comparable safety to traditional drain use and may reduce patient discomfort, antibiotic exposure, and revision rates when meticulous dead-space management is applied. Current evidence challenges the routine use of drains, suggesting they are not essential for preventing seroma or hematoma. These findings support broader adoption of progressive tension sutures and other closure strategies as standard practice. Future prospective trials are critical to define patient-specific indications for drains and optimize outcomes in this rapidly growing surgical field.

PURPOSE: Chest-masculinization surgery (CMS) is the most frequently performed gender-affirming surgery (GAS). While some CMS patients opt for nipple-areola complex (NAC) reconstruction, others do not (noNAC). There is a significant gap in literature regarding patient motivations for this decision and the impact of NAC reconstruction on patient-reported outcomes.

METHODS: This single-center, cross-sectional study investigated patients who underwent CMS between December 2017-May 2024. Three validated patient-reported outcome measures, the Chest Dysphoria Measure (CDM) (range 0-51), Gender Congruence and Life Satisfaction (GCLS) scale (range 38-190), and Transgender Congruence Scale (TCS) (range 12-60), were administered electronically. Bivariate and multivariable linear regression were conducted with potential confounders (age, gender identity, race, BMI, testosterone use) as covariates.

RESULTS: In total, 46 CMS patients completed the surveys (n=36 NAC reconstruction, n=10 noNAC). Average time between surgery and survey completion was 2.5 years (SD 1.8, range 0.5-6.1). A significantly greater proportion of noNAC patients were nonbinary (n=7/10) compared to NAC reconstruction patients (n=12/36) (Z=2.083, P=0.037). There was no significant difference in age, gender identity, race, BMI, or testosterone use between groups. The most reported reasons for not pursuing NAC reconstruction were the unimportance of nipples (n=9, 90%), the aesthetic of a bare chest (n=7, 70%), and the desire for tattooing (n=5, 50%). Across cohorts, postoperative chest dysphoria was low and gender congruence and life satisfaction were high. Comparing NAC reconstruction and noNAC cohorts, there was no significant difference (mean [standard deviation]) in individual item scores or total CDM (4.9 [4.0] NAC vs. 3.0 [3.1] noNAC, p=0.07), GCLS (152.0 [17.8] NAC vs. 157.6 [16.8] noNAC, p=0.26), or TCS (51.8 [7.2] NAC vs. 52.5 [6.4] noNAC, p=0.69) scores. There was also no significant difference between NAC and noNAC cohorts for GCLS and TCS subscales, when adjusted for confounders. On average, outcomes were positive in both groups.

CONCLUSION: This study suggests that a higher proportion of nonbinary patients compared to transgender men seek CMS without NAC reconstruction, citing unimportance of nipples and aesthetics as the most common reasons. Half of noNAC patients plan to undergo postoperative chest tattooing. In both NAC reconstruction and noNAC patient cohorts, long-term postoperative chest dysphoria was low and gender congruence, overall satisfaction, and quality of life were high, suggesting both NAC reconstruction and noNAC are effective approaches to CMS, pending patient preference.

Background: The Johns Hopkins Sex and Gender Clinic (SGC), established in 1971, is the longest continuously running clinic in the United States providing gender-affirming care (GAC). With over five decades of clinical service, the SGC provides the unique opportunity to assess long-term treatment outcomes for transgender and nonbinary (TGNB) individuals. Here we characterize outcomes of individuals presenting for gender incongruence to capture durability of gender identity, treatment pathways, and regret.

Methods: We conducted a retrospective review of demographic and clinical data of 224 patients who presented to the SGC between 2005–2020 with a chief complaint related to gender presentation or incongruence. Exclusion criteria included intersex conditions, follow-up <6 months, or lack of patient expressed gender incongruence. Primary outcomes included incidence of gender dysphoria (GD) diagnosis at initial evaluation, rates of gender-affirming hormone therapy (GAHT) and surgery (GAS), persistence of TGNB presentation, reasons for maintaining sex assigned at birth (SAAB), and regret.

Results: The median age at presentation was 21 years (IQR: 17–30; range: 4–85). In total, 74.1% (n=166/224) individuals met inclusion criteria, and had mean follow-up of 7.7 years (7.3 months – 19.1 years). At most recent follow-up, 92.8% (n=154/166) lived openly as TGNB, while 7.2% (n=12/166) presented as their SAAB. Specifically, among the 12 patients who continued to present as their SAAB, three themes were identified as deterrents for transitioning: six cited family rejection or stigma, five cited medical contraindications to hormones or surgery, and two indicated evolving understanding of their gender identities. Six of the 12 patients had started and discontinued hormones, among which 1 patient had reversal of chest masculinization surgery. Notably, no patients expressed regret. 88.6% (n=147/166) of patients met diagnostic criteria for GD after the first clinical assessment by the SGC, of which 89.8% (n=132/147) initiated GAHT and/or GAS. The remaining 12.4% were initially diagnosed with alternate diagnoses such as mood disorders 47.4% (n=9/19), adjustment disorder 21.1% (n=4/19), or autism spectrum disorder 21.1% (n=4/19). Notably, 73.7% (n=14/19) patients who did not receive an initial GD diagnosis subsequently pursued GAHT or GAS. Patients who did not pursue medical transition most often attributed their decision to family opposition or ongoing exploration of their gender expression.

Conclusion: This study represents the largest U.S. cohort of patients receiving GAC with multi-decade follow-up. In this review, detransition, defined as discontinuing GAHT or reversing GAS to align with one's SAAB, occurred in 6 of 166 patients (3.6%), primarily due to lack of social acceptance or medical contraindications to care. No patient expressed regret and patients' self-identified gender incongruence remained durable over time.

Background:
Facial feminization surgery (FFS) plays a crucial role for patients with gender dysphoria as it improves congruence between an individual's physical appearance and their self-affirmed gender identity. As demand for FFS continues to rise, there remains a paucity of large-scale, single-team studies evaluating outcomes and complications over an extended period. This study aims to assess the surgical outcomes and complications of over 350 consecutive patients who underwent FFS performed by a single team of a craniofacial and a facial plastic surgeon over a five-year period.

Methods:
A retrospective review of patients who underwent multiprocedural FFS between September 2020 and November 2025 was conducted. All surgeries were performed by a single team of a craniofacial and a facial plastic surgeon. Patient demographics, operative variables, and postoperative complications were analyzed. Additionally, prevention methods, procedure types, management of complications, and revision surgeries were reviewed.

Results:
A total of 363 transfeminine patients, with a mean age of 31 years (range 17 – 60; SD 7.7), were included in this study. A total of 2,047 procedures were performed with each patient undergoing an average of 5.6 procedures. Forehead and supraorbital reduction (n = 328) were the most common procedures, followed by osseous genioplasty (n = 270), fat grafting to the cheeks (n = 237), mandibular angle reduction (n = 223), brow lift (n = 210), septorhinoplasty (n = 198), frontal sinus setback (n = 178), lip augmentation (n = 151), thyroid cartilage reduction (n = 115), and masseter muscle resection (n = 47). No intraoperative complications occurred. Postoperative complications were observed in 19 patients (5.2%), most commonly infection (n = 15; 4.1%). Majority of complications occurred at intraoral operative sites: 10 patients (2.8%) developed an intraoral infection and/or abscess, and 4 patients (1.1%) developed an intraoral hematoma. All patients with an intraoral abscess were treated with antibiotics and underwent in-office incision and drainage; 4 patients (1.1%) required return to the operating for washout and debridement. Following the first 9 intraoral complications, the genioplasty surgical technique was modified from a three-piece genioplasty to an in situ reductive genioplasty that does not require hardware fixation. Since implementing this change in January 2025, 128 patients have undergone genioplasty and/or mandibular angle reduction and only one postoperative intraoral infection (0.8%) has occurred. Other postoperative complications included nasal infection and/or abscess (n = 4) and submental abscess (n = 1), all of which were managed with antibiotics and/or in-office incision and drainage. 20 patients (5.5%) underwent revision surgery, with revision septorhinoplasty being the most common revision procedure (n = 12).

Conclusion:
In this large single-team study, FFS was performed safely with no intraoperative complications, a low rate of postoperative complications, and a low revision rate. The most common postoperative complication was intraoral infection, which has decreased since adopting the in situ reductive genioplasty technique. These findings support the safety and reliability of FFS.

PURPOSE Access to gender-affirming vaginoplasty often requires patients to travel across state lines (1). Although prior studies have examined social determinants of health such as Area Deprivation Index (ADI), insurance status, and employment in relation to postoperative outcomes (2), the impact of geographic residence relative to the surgical center remains unclear. The present study sought to evaluate whether out-of-state residence is associated with differences in postoperative complication patterns compared with in-state patients.

METHODS A retrospective review was performed of all patients who had undergone primary vaginoplasty at a single academic center between 2016 and 2022. Patients were stratified by state of residence at the time of surgery as in-state or out-of-state relative to the surgical center. Patients with less than 30 days of documented postoperative follow-up were excluded from the analysis. Primary outcomes recorded were postoperative complications (including granulation tissue, wound dehiscence, stricture, stenosis, return to operating room, and readmission) recorded during follow-up appointments. Univariate analysis utilized Fisher's exact test and Chi-square tests. Multivariable logistic regression models were constructed to evaluate the association between out-of-state residence and each complication, adjusting for confounders. Statistical significance was set at p<0.05.

RESULTS A total of 625 patients were included, of which 423 (67.7%) were in-state and 202 (32.3%) were out-of-state. Median follow-up was shorter among out-of-state patients (7.5 months, IQR 3.0–12.0) compared to in-state patients (10.0 months, IQR 5.0–17.0, p<0.001). On multivariable analysis, in-state residence was associated with lower odds of experiencing any complication (OR 0.66, 95% CI 0.45–0.98, p=0.040). However, residence status was not independently associated with granulation tissue (p=0.399), wound dehiscence (p=0.379), stricture (p=0.492), stenosis (p=0.210), composite stricture/stenosis (p=0.182), return to the operating room (p=0.152), or readmission (p=0.223).

CONCLUSION Although in-state residence was associated with lower odds of experiencing any complication on multivariable analysis, geographic status was not independently associated with any individual complication. Out-of-state patients also had significantly shorter follow-up, which may have reduced the opportunity to detect postoperative events. The present findings suggest that the observed difference in the composite outcome may reflect unmeasured factors related to access, travel burden, or follow-up variability rather than discrete increases in specific surgical morbidity.

REFERENCES 1. Johnstone T, Thawanyarat K, Eggert GR, et al. Travel distance and national access to gender-affirming surgery. Surgery. 2023;174(6):1376-1383. doi:10.1016/j.surg.2023.09.008 2. Shamamian PE, Chen D, Wang A, et al. Predictors of dilation difficulty in gender-affirming vaginoplasty. J Plast Reconstr Aesthet Surg. 2025;101:178-186. doi:10.1016/j.bjps.2024.11.042