Scientific Abstract Presentations: Gender Affirmation Session 1 Thursday, September 26 Thu, Sep 26 1:00-2:30 p.m. PDT

Purpose Patients increasingly access online resources for information about various treatment modalities, including Gender Affirming Surgery (GAS) patient populations. The present study intends to provide a readability, content quality, and technical quality assessment of online patient educational materials (OPEM) related to GAS.

Materials and Methods An online search using 12 key search phrases "gender affirming surgery", "feminizing top surgery", "masculinizing top surgery", "bottom surgery", "phalloplasty", "vaginoplasty", "gender reassignment surgery", "gender confirmation surgery", "facial feminization", "facial masculinization", "sex reassignment surgery", and "tracheal shave" was performed. Previous user data was disabled to prevent bias from prior search history. The first 20 unique search results for each search term were screened and further assessed if identified as an OPEM. The readability of the online material was assessed with validated readability formulas. The content quality was assessed with DISCERN (comprised of 16 questions, each rated on a scale of 1-5) and JAMA benchmark criteria (scale of 0-4 with assessed components: authorship, attribution, disclosure, and currency). Technical quality of the collected websites was assessed using WebsiteGrader. Other characteristics including mention of World Professional Association for Transgender Health (WPATH) guidelines and discussion of insurance coverage were recorded. Statistical analyses included ANOVA, Chi-Squared tests, and T-tests across website type.

Results Overall, 231 OPEM were identified (Academic/Hospital: 124, Private Practice: 47, Online Health Reference: 43, Other: 17). Across website types, there was no significant difference in readability consensus grade level. The average consensus grade level across analyzed websites was 12.7 which was found to be significantly higher than the NIH-recommended sixth grade level (p<0.001). With regards to content quality, the average DISCERN score was 40.5 for academic/hospital website types, 44.3 for online health reference websites, and 34.7 for private practice websites. Both online health reference websites and academic/hospital websites had significantly higher DISCERN scores than private practice websites (p<0.05). The JAMA Benchmark Criteria was analyzed across website types and average scores were 0.69 for academic/hospital, 2.01 for online health reference websites, and 0.15 for private practice websites. Private practice websites had significantly lower JAMA scores than academic/hospital websites (p=0.009) and online health reference websites (p<0.001).

The average technical quality score was 66.0 for academic/hospital websites, 68.1 for online health reference websites, and 72.5 for private practice websites. Pairwise comparisons found that private practices had a significantly higher technical quality score than academic/hospital websites (p<0.001) and online health reference websites (p=0.023). Academic/hospital websites mentioned WPATH guidelines at a significantly higher rate than online health reference (46% vs 19%, p=0.017) and private practice websites (46% vs 21%, p=0.027).

Conclusions A significant discrepancy in readability was identified between analyzed websites and the NIH recommendation of a 6th grade level. Significant variability was found in content and technical quality based on website type with private practice websites having lower content quality but higher technical quality. It is crucial for OPEM to be accessible and of appropriate quality for patients seeking information about GAS as overly complicated or low quality information can serve as a hindrance to patients making informed healthcare decisions.

Purpose: This study investigates facial satisfaction, gender dysphoria and their associated correlation in transgender patients before and after receiving feminizing gender-affirming surgery (FFS).
Methods: Our institution participates in an international initiative to field-test the GENDER-Q survey, a novel instrument designed to measure the outcomes of gender-affirming care. In conjunction with the GENDER-Q, we utilized the Gender Preoccupation and Stability Questionnaire (GPSQ) to evaluate gender dysphoria. We collected data from patients both preoperatively and at a minimum of 6 months post-operatively. We compared the overall GPSQ score and GENDER-Q item responses using both unpaired and paired t-tests. Furthermore, Spearman's correlation coefficients to assess the relationship between individual GENDER-Q items and GPSQ scores were calculated. Results: Survey data from 35 transgender patients are included, with 8 patients providing data both pre- and postoperatively, resulting in 29 preoperative and 14 postoperative surveys The mean follow-up time was 6.5 months (SD=1.5) All patients received FFS procedures in their upper, middle and lower face. The average age of patients was 33.0 years (SD= 8.2). Unpaired analysis of the Gender Q for overall satisfaction showed significantly higher values post-operatively than pre-operatively for all parts of the face. The highest pre and post-operative difference in mean Likert scores (out of a maximum of 6) was observed for upper face by 2.6 points (p<0.001) and the lowest for cheeks by 1.12 (p=0.02). This trend held for paired analysis with significant differences between pre and post-operative satisfaction scores; with largest and smallest pre and post-operative mean of differences belonging to upper face (2.8, p<0.001) and cheeks (0.11 , p=0.85), respectively. GPSQ scores (out of a maximum of 56) were significantly lower, indicating improved gender dysphoria, with both paired and unpaired comparisons showing a decrease of 7.12 points (p<0.05). The negative correlation between gender dysphoria interference with mental health and postoperative satisfaction was strongest for the upper face (r=-0.63, p=0.02) and eyebrows (r=-0.66, p=0.01). While age did not significantly correlate with pre- and post-operative facial satisfaction scores individually, it was positively correlated with an increase in eyebrow (r=0.77, p=0.03) and nose (r=0.84, p=0.01) scores after FFS. Conclusion: The findings of this study underscore a significant enhancement in facial satisfaction and a concomitant reduction in gender dysphoria among transgender patients, post-facial feminization surgery. Notably, satisfaction with the upper face and eyebrows was closely linked to improvements in gender dysphoria, aligning with existing literature that emphasizes the importance of these features in perceptions of femininity. These results endorse the implementation of a comprehensive outcomes evaluation framework for facial feminization procedures and underscore the aesthetic and psychological benefits conferred by these surgeries to the transgender community.

1. Spiegel JH. Facial determinants of female gender and feminizing forehead cranioplasty. The Laryngoscope. 2011;121(2):250-261. doi:10.1002/lary.21187

Introduction A necessary component of postoperative care in gender-affirming vaginoplasty is consistent dilation of the neovaginal canal. The process of dilation is time-consuming and requires significant patient instruction and understanding. Patients can experience pain and difficulty with dilation, decreasing compliance and causing distress. This, in turn, can cause inconsistent dilation, leading to partial or complete closure of the neovaginal canal, and necessitate revisional surgery. This study sought to evaluate many patient and intraoperative factors that may contribute to dilation difficulty in patients, from social determinants of health indicators to operative characteristics.

Methods After approval from the Institutional Review Board at the Icahn School of Medicine, a retrospective review of patients undergoing gender-affirming vaginoplasty between January 2016 and December 2021 at The Mount Sinai Center for Transgender Medicine and Surgery was carried out. Demographics, comorbidities, preoperative genital characteristics, intraoperative details, postoperative complications, and follow up information was collected. National and state Area Deprivation Index (ADI) scores, reclassified by quintiles, were collected for each patient. ADI represents a multifaceted evaluation of a region's socioeconomic conditions, which have been linked to health outcomes. The primary outcome was the presence of consistent dilation difficulty reported during follow-up clinic visits for any reason, including discomfort, pain, or understanding of instructions. Pearson's Chi Square and Fisher's Exact Tests were used for categorical values, and Student's T-tests were carried out for continuous variables. Multiple logistic regression was carried out to identify significant predictors of dilation difficulty. Statistical significance was set at p<0.05.

Results Four hundred twenty-seven (427) patients were included in the study, 325 (72.7%) patients had no dilation difficulty, and 98 (22.9%) had dilation difficulty. Mean follow-up time was 12.3 months. On univariate analysis, Medicare insurance status (p<0.001), unemployment (p=0.007), any psychiatric diagnosis besides gender dysphoria (p=0.049), longer preoperative penile length (p=0.041), prior pelvic surgery (p=0.035), peritoneal vaginoplasty (p<0.001), longer operative time (0.023), and any unplanned readmission (p=0.004) were associated with postoperative dilation difficulty. Follow-up time was significantly longer in the dilation difficulty cohort (p<0.001), and significantly more patients with dilation difficulty required revision surgery (p<0.001). Multiple logistic regression revealed higher odds of dilation difficulty in patients with Medicare (OR 6.35, CI 1.55-26.07, P=0.010), in the fourth quintile of state-level ADI (OR 4.56, CI 1.30-15.98, p=0.018), with a history of keloids (OR 4.59, CI 1.42-14.85, p=0.01), with any non-gender dysphoria psychiatric diagnosis (OR 2.0, CI 1.11-3.58, p=0.021), and who received a peritoneal vaginoplasty (OR 5.01, CI 1.68-14.95, p=0.004). Lower odds of dilation difficulty were associated with patients in the second quintile of national-level ADI (0.356, 0.138-0.918, p=0.033), and in employed patients (OR 0.443, CI 0.221-0.930, p=0.031).

Conclusions This is one of the first studies to examine the impact of sociodemographic, preoperative, and intraoperative factors on postoperative dilation difficulty in a large cohort of gender-affirming vaginoplasty patients. The risk of dilation difficulty may be associated with multiple aspects of the care spectrum, including social factors, psychiatric comorbidity, and operative technique. Understanding these risks are crucial for early intervention and ensuring patient postoperative dilation success.

Purpose: Superolateral orbit reshaping, aimed at reducing the prominence and softening of the superolateral orbital rim, is integral to forehead feminization surgery. However, there is limited literature providing objective anatomical evidence on the sexual dimorphism of orbital features. This study aimed to investigate orbital characteristics between cis-males and females and their implications for forehead feminization.

Methods: An IRB-approved retrospective review of maxillofacial CT scans was conducted on ethnicity- and age-matched groups of cis-male and female patients (2003-2022). Patients were excluded if they had prior sinus surgery, facial skeletal fracture, or craniofacial abnormalities. Three-dimensional reconstruction of the skulls was performed and processed using Mimics and 3-matic software. Data collected included patient sex, age, ethnicity, orbit dimensions, superolateral orbit angle, superolateral orbit rim prominence, and the extent of supraorbital bar protrusion. Inter-orbital and bi-orbital distances were defined as the lengths between right and left dacryons, and between the right and left ectoconchions, respectively. Mann-Whitney test and Pearson correlation were performed to analyze the association between variables.

Results: A total of 186 patients (106 males and 80 females) with a mean age of 51.2±20.3 years were included. Compared to the female group, male patients exhibited significantly taller orbits (male: 35.8±2.7 mm, female: 34.3±2.2 mm, p=0.0001), wider orbits (male: 41±2.4 mm, female: 38.8±2.2 mm, p<0.0001), longer bi-orbital distances (male: 100.8±4.5 mm, female: 95.2±7.9 mm, p<0.0001), a more prominent superolateral orbit rim (male: 14±1.9 mm, female: 11.1±1.5 mm, p<0.0001), a narrower superolateral orbit angle (male: 133.7°±6.7, female: 145.7°±5.1, p<0.0001), and greater supraorbital bar protrusion (male: 3.6±1.5 mm, female: 1.7±0.8 mm, p<0.0001). However, the ratios of orbital height/width (male: 0.9±0.08, female: 0.9±0.06, p=0.28) and inter-orbital distance (male: 18.7±3.4 mm, female: 19.4±2.7 mm, p=0.13) were not significantly different between the 2 groups. The prominence of the superolateral orbit rim correlated positively with supraorbital bar protrusion (r=0.45, p<0.0001), orbital height (r=0.22, p=0.003), orbital width (r=0.37, p<0.0001), and bi-orbital distance (r=0.42, p<0.0001), and correlated negatively with superolateral orbit angle (r=-0.56, p<0.0001).

Conclusions: For effective forehead feminization, prioritize proportional adjustments in superolateral orbit rim prominence, superolateral orbit angle, and supraorbital bar protrusion relative to orbit dimensions, rather than absolute values, to ensure balanced aesthetics, acknowledging size variations between cis-male and female skulls.

Background: Gender diverse patients, including those identifying as non-binary, genderqueer, and genderfluid, may have different preferences for top surgery, often undergoing multiple procedures compared to transgender men (1). There is little discussion in the literature on the options available to these patients that differ from well-described techniques for surgery in binary transgender men. The purpose of our study was to assess the differential experiences, preferences, and needs of transgender men and non-binary individuals, soliciting feedback on a pictorial algorithm to facilitate discussions in surgical decision-making (2).

Methods: An IRB-approved survey was distributed through various Reddit gender-based platforms. A total of 799 responses were collected, of which 647 met inclusion criteria for gender diversity. Respondents were grouped by transgender males, non-binary, and others on the transmasculine spectrum. The survey consisted of demographic information, experiences with top surgery care, and an algorithmic questionnaire for top surgery. Group differences were assessed using t-tests and chi-squared tests (p<0.05 for significance).

Results: Non-binary and other transmasculine respondents were significantly more likely to desire "non-standard" chest wall reconstruction (p=0.002), including desiring a breast mound (13.94 and 8.40%) compared to transgender men (2.95%, p=0.006) and the standard approach was selected 15-22% more by transmasculine respondents. Non-binary and other transmasculine respondents were less likely to desire nipple and areolar complex (NAC) reconstruction, but 10-20% amongst all three groups were "unsure." Non-binary and other transmasculine respondents were more likely to have seen a surgeon (p=0.002), feel like they were educating their surgeons on various options (p=0.0001) with greater comfort (p=0.003). However, their understanding after meeting a surgeon for top surgery was significantly lower compared to transgender men (4.55 and 4.51 vs 4.71, p=0.04). Compared to transgender men, non-binary and other gender respondents were older and had higher levels of education (p<0.0001).

Conclusions: Non-binary and other transmasculine individuals had different preferences and experiences compared to binary transgender men in this survey. In addition to more often desiring a breast mound or foregoing NAC reconstruction, non-binary respondents reported that more often they were educating surgeons on options for aesthetic outcomes. Surgeons performing "standard" top surgery have the requisite technical skills to achieve a spectrum of aesthetic results for non-binary patients. The pictorial algorithm examined in the present study may assist patients and surgeons establish a shared vision for their top surgery outcomes. While most transmasculine individuals across the spectrum prefer a standard top surgery approach, the desire for "non-standard" options was evident across all genders in this survey, indicating that a more open discussion will benefit binary transgender men as well.

References 1. McTernan M, Yokoo K, Tong W. A Comparison of Gender-Affirming Chest Surgery in Nonbinary Versus Transmasculine Patients. Ann Plast Surg. 2020;84(5S Suppl 4):S323-S8.

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

Introduction: Gender dysphoria is defined as incongruence between expressed and assigned gender. Transfeminine individuals often undergo Gender-Affirming Surgery (GAS) and adopt Estrogen Therapy (ET) for effective gender alignment. Despite the transformative benefits of GAS, a potential increase in risk Venous Thromboembolism (VTE) may be associated with continuation of ET in the peri-operative period. This study aims to assess the rate of venous thromboembolism in GAS patients on ET. Methods: A retrospective review of transgender patients on ET who underwent GAS was conducted between January 1, 2018, and October 1, 2023. Exclusion criteria were defined as patients with thrombophilia or surgeries lasting less than 30 minutes. Demographics were presented using median and interquartile range or mean ± standard deviation. Sample normality was assessed using the Shapiro-Wilk test. Independent student T-test and Chi-Squared test were employed when appropriate. A p-value of less than 0.05 was set as statistically significant. All analyses were conducted in R (R Open-Source Software, version 4.1.3). Patients were followed up to eight weeks post-operatively. Results: A total of 195 GAS in 123 transfeminine patients were included (mean age: 37.06 ± 14.25 years). Primary vaginoplasty comprised 47% of procedures followed by Orchiectomy (56.4%) and Facial Gender Affirmative Surgery (28%). The most common ET was 17-β-estradiol (47%), whereas the predominant method of administration was oral (46.7%). Eighty-seven procedures (44.5%) were done on patients who stopped ET, and among these patients, 66 (75.86%) stopped ET two weeks prior to surgery. Mean operative times differed between those that continued ET (3.92 ± 2.04 hours) and stopped ET (5.02 ± 2.71 hours, p = 0.002). Thirty-six patients (18.46%) received postoperative VTE chemoprophylaxis, amongst which 13 (12.04%) were in the ET-continued group and 23 (26.43%) in the ET-stopped group. The average Caprini score of our sample was 3.4 (ET-stopped group 3.6 and ET-continued group 3.0). There was a total of 2 VTE events, one in each group, with an overall 1.03% incidence rate. The VTE incidence in patients continuing and discontinuing ET was 1.04% and 1.15%, respectively (p = 0.9447). All VTE events occurred in patients on oral ET, resulting in a 3.3% incidence in patients on oral ET. No statistically significant difference in VTE rate was found in subjects using other forms of administration when compared to oral ET (p = 0.19). Conclusion: Based on our cohort of 123 transgender patients, maintaining ET peri-operatively does not elevate the risk of postoperative VTE in patients with low baseline Caprini scores. Oral ET was associated with a relatively higher VTE risk. Further research with a randomized prospective design is imperative to validate these findings and provide comprehensive guidelines for peri-operative management of ET.

Introduction Gender-affirming surgery (GAS) is a vital component of care for many transgender and gender diverse (TGD) patients. At the onset of the COVID-19 pandemic, the American College of Surgeons recommended the delay of all elective and non-essential surgeries. Although GAS encompasses a swath of procedures that help mitigate gender dysphoria and the host of mental sequalae it is associated with, GAS was considered 'elective' and subjected to the delay. Prior research has described a significant rise in GAS volume in the past decade, but there is limited insight into how the COVID-19 pandemic has impacted caseload and clinical outcomes from 2020 onwards (1, 2).

Aim To describe the impact of COVID-19 on GAS case volume and complication rates.

Methods The American College of Surgeons' NSQIP database was queried to identify GAS cases completed between 2019-2021. ICD-10 codes were used to identify TGD patients by diagnosis of gender dysphoria (F64.x) due to limitations in gender-identity inclusion in the NSQIP database. Trends in GAS volume and procedure type were described, and chi-square tests assessing for differences in patient demographics and clinical outcomes were completed using IBM SPSS Statistical Software v24, with p<0.05 indicating significance.

Results Of the 2,708,874 surgical patients identified in the 2019-2021 NSQIP database, 4,298 (0.16%) were TGD. The proportion of masculinizing and feminizing GAS cases did not differ significantly between years: 44% masculinizing top surgery; 21% masculinizing bottom surgery; 15% feminizing top surgery; 12% feminizing bottom surgery; and 8% head/neck surgery (p=0.42). Quarter 2 of 2020 had a notable 53% decrease in GAS volume in comparison to quarter 2 of 2019. Compared to the annual GAS caseload in 2019, there was a 3% decrease in 2020 and a 34% increase in 2021. The rates of 30-day complications (x̄=3.6%, p=0.35); reoperations (2.0%, p=0.49); and readmissions (1.0%, p=0.10) did not significantly differ between years.

Conclusion While annual GAS volume has steadily increased since 2010, 2020 marks the first ever decrease in caseload due to the significant decline in cases during the first few months of the pandemic. GAS caseload has since resumed its rising trend, with no significant difference in distributions of patient demographics, GAS procedure types, and clinical outcomes between pre- versus post-pandemic years. These findings highlight potential issues in accessibility of GAS during the pandemic, which comes in addition to the already existing GAS barriers of lengthy waitlists, navigating insurance coverage, obtaining required mental health letters, and completing preoperative hair removal- all of which have a direct impact on the mental health and well-being of TGD patients.

References (1) Lane M, Ives GC, Sluiter EC, et al. Trends in Gender-affirming Surgery in Insured Patients in the United States. Plast Reconstr Surg Glob Open. 2018;6(4):e1738. Published 2018 Apr 16. doi:10.1097/GOX.0000000000001738

(2) Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. Published 2023 Aug 1. doi:10.1001/jamanetworkopen.2023.30348

Introduction One of the more common and disruptive complications of gender-affirming vaginoplasty is postoperative bleeding, typically presenting as a hematoma or hemorrhage. These complications often require readmission and reoperation. Interventions targeted at reducing the risk of postoperative bleeding include the use of hemostatic agents, such as intravenous tranexamic acid (IV-TXA), which has been found in multiple surgical disciplines to have some effect on postoperative bleeding events. The present study aims to evaluate the impact of intraoperative IV-TXA administration on postoperative bleeding events in a large sample of gender-affirming vaginoplasty patients.

Methods Following approval from the Institutional Review Board at the Icahn School of Medicine, patients receiving gender-affirming vaginoplasty at the Mount Sinai Center for Transgender Medicine and Surgery between January 2018 and December 2021 were evaluated retrospectively. Demographics, comorbidities, intraoperative details, and postoperative outcomes were collected. Intraoperative details included hemostatic agents, estimated blood loss, anticoagulation, operative time, transfusion, and intraoperative complications. Preoperative and postoperative hemoglobin levels were also collected. Postoperative complications included minor hematomas, defined as hematomas requiring conservative treatment; major hematomas, defined as hematomas requiring intervention such as return to the operating room and readmission; postoperative hemorrhage; and readmission and reoperation related to bleeding. Non-plastic surgery patients, patients who did not receive heparin anticoagulation, and patients with bleeding disorders were excluded. Pearson's Chi Square and Fischer's Exact tests were used for categorical variables, and analysis of variance was used for continuous variables. Statistical significance was set at p<0.05

Results Three-hundred-forty-two (342) patients were included in the study, 189 of whom did not receive IV-TXA and 153 of whom received IV-TXA. Mean follow up time was 9.5 months. Surgeon preference alone dictated IV-TXA use. All patients received some form of local hemostatic agent, including topical thrombin and Gelfoam. Significantly fewer patients in the IV-TXA group had a minor hematoma (13.2% vs. 0.6%, p<0.001). Estimated blood loss was significantly less in the IV-TXA group (121±51 mL vs. 172±77 mL, p<0.001). Postoperative hemoglobin was higher in the IV-TXA group (10.5±2.3 g/dL vs. 9.75±1.6 g/dL, p=0.05). Major hematomas (3% vs. 2.6%, p=0.511), postoperative hemorrhage (7% vs. 4%, p=0.235), bleeding requiring reoperation (3.7% vs. 3.2%, p=0.828), and bleeding requiring readmission (3.7% vs. 1.9%, p=0.268) were not significantly different between the two groups. Venous thromboembolic events were not different between the two groups (0% vs. 1.3%, p=0.115). Subgroup analysis of readmissions and reoperations for major hematomas or postoperative hemorrhage in each group did not achieve statistical significance, although readmissions for major hematomas were 50% less in the IV-TXA cohort.

Conclusions The use of IV-TXA significantly reduces minor hematomas in patients receiving gender-affirming vaginoplasty, a complication that causes patient distress and pain in the postoperative period. IV-TXA is also useful in decreasing blood loss, and does not significantly impact the rate of venous thromboembolic events, a feared complication of IV-TXA use. Despite no statistically significant difference in major bleeding events, the trend towards fewer readmissions for major hematomas in the IV-TXA cohort may suggest this intervention is worthwhile in preventing serious postoperative bleeding complications.

Introduction The Long Thoracic Nerve (LTN) lies immediately deep to the serratus anterior fascia on the lateral chest wall,1 rendering it vulnerable to iatrogenic injury in surgery.2 LTN injury leading to scapular winging is a well-described complication in the breast oncology and thoracic surgery literature.3,4 Expansion of insurance coverage for gender-affirming surgical care has led to rapid increases in the number of gender-affirming mastectomies being performed by plastic surgeons.5 This operation typically involves significant lateral chest contouring placing the LTN at a high risk of injury along the chest wall. In this study, the course of the LTN relative to the lateral border of the pectoralis major muscle was mapped to delineate and define a danger zone for iatrogenic LTN injury in gender-affirming mastectomy.

Methods Patients undergoing gender-affirming mastectomy by a single surgeon at a single institution were prospectively enrolled. The course of the LTN along the lateral chest wall was mapped using intraoperative nerve stimulation. The distance between the nerve and the lateral border of the pectoralis major muscle was measured and adjacent rib level was determined to define the zone in which the LTN is vulnerable to iatrogenic injury.

Results Twelve individuals met study criteria and were prospectively enrolled. Study participants were, on average, 23 years old, had an average BMI of 27.8, and 92% had Fischer Grade 3 or 4 ptosis. The LTN was mapped bilaterally and was most reliably located directly lateral to the intersection of the 4th rib and the lateral border of the pectoralis major muscle. The LTN was found an average of 4.3 cm lateral to the pectoralis major at the 3rd rib level, 5.4 cm lateral to the pectoralis border at the 4th rib level, and 6.9 cm lateral to the pectoralis border at the 5th rib level.

Conclusions This study defines a danger zone for injury to the LTN in gender-affirming mastectomy. Although proximal LTN injury can cause debilitating shoulder dysfunction, more distal LTN injury can cause chronic postoperative shoulder pain and dysfunction without frank scapular winging, making diagnosis and treatment difficult. Therefore, iatrogenic LTN injury is best avoided. With recent increases in the number of plastic surgeons performing gender-affirming mastectomies, awareness of this LTN danger zone is critical to avoid morbidity.

References 1. Tubbs RS, Salter EG, Custis JW, Wellons JC, Blount JP, Oakes WJ. Surgical anatomy of the cervical and infraclavicular parts of the long thoracic nerve. J Neurosurg. May 2006;104(5):792-5. doi:10.3171/jns.2006.104.5.792 2. O J, Kwon HJ, Cho TH, Won SY, Yang HM. Analysis of the positional relationship of the long thoracic nerve considering clinical treatment. Clin Anat. May 2021;34(4):617-623. doi:10.1002/ca.23647 3. Belmonte R, Monleon S, Bofill N, Alvarado ML, Espadaler J, Royo I. Long thoracic nerve injury in breast cancer patients treated with axillary lymph node dissection. Support Care Cancer. Jan 2015;23(1):169-75. doi:10.1007/s00520-014-2338-5 4. Salazar JD, Doty JR, Tseng EE, et al. Relationship of the long thoracic nerve to the scapular tip: an aid to prevention of proximal nerve injury. J Thorac Cardiovasc Surg. Dec 1998;116(6):960-4. doi:10.1016/S0022-5223(98)70047-9 5. Lane M, Ives GC, Sluiter EC, et al. Trends in Gender-affirming Surgery in Insured Patients in the United States. Plast Reconstr Surg Glob Open. Apr 2018;6(4):e1738. doi:10.1097/GOX.0000000000001738

Purpose

Both primary and revisional vaginoplasty are correlated with significantly improved patient-reported gender dysphoria. Moreover, the authors have observed clinically that some patients report zero ("fully resolved") gender dysphoria post-surgically. The present study aims to quantify the extent to which patients report zero Gender Dysphoria Index after primary vaginoplasty and to identify patient demographic, historical, and soft tissue characteristics that may influence this outcome.

Methods

Gender dysphoria was measured using Gender Dysphoria Index (GDI), a patient-reported measure of gender dysphoria on a 0-10 Likert scale (where zero is no gender dysphoria), at a single center from October 2016 to September 2021. The GDI is in the process of validation. Data central tendency and dispersion were measured using mean ± standard deviation (SD). Univariate and multivariable logistic regression modeled zero GDI as the dependent outcome. Results are reported as odds ratios (OR) with 95% Confidence Intervals (CI) and significance was defined as p<0.05. Variables of interest included age, race, body mass index (BMI), medical and psychiatric comorbidities (hypertension, diabetes mellitus, cardiac disease, peripheral vascular disease, renal disease, HIV status, and psychiatric history), alcohol and tobacco use history, pre-operative penile length, and presence of keloid or hypertrophic scarring.

Results

212 patients who underwent primary vaginoplasty and reported postoperative GDI were included in the study. The average preoperative GDI was 5.80 (±2.87), with a significant reduction to 2.86 (±2.40) in the postoperative period (p<0.001). 44 patients (20.8%) reported a postoperative GDI equal to zero. In this zero postoperative GDI subgroup, the average preoperative GDI was 5.29 (± 3.51); similarly to the overall patient cohort, GDI reduction was significant (p<0.001).

Univariate binary logistic regression revealed that White patients were significantly less likely to report a GDI of zero postoperatively (unadjusted OR=0.28, 95% CI=0.14 to 0.56, p<0.001). Patients identifying as Black or Hispanic had approximately four times higher odds of reporting zero GDI postoperatively (unadjusted OR=4.32, 95% CI=1.73 to 10.8, p=0.002; unadjusted OR=4.54, 95% CI=1.69 to 12.2, p=0.003). These odds further increased when adjusting for other covariates and when compared to White patients (adjusted OR=5.52, 95% CI=2.11 to 14.4, p<0.001; adjusted OR=5.83, 95% CI=2.07 to 16.4, p<0.001). Multivariable logistic regression revealed hypertension as the only comorbidity to significantly impact the likelihood of reporting zero GDI postoperatively (adjusted OR=4.35, 95% CI=1.32 to 14.3, p=0.015).

Conclusions

Zero postoperative GDI, which can be considered "fully resolved" gender dysphoria, was reported by one out of five patients who underwent primary vaginoplasty. GDI improvement following vaginoplasty was statistically significant regardless of patient demographic, historical, or soft tissue factors.

Though sample size was limited, Black identity, Hispanic identity, and history of hypertension were independently associated with increased likelihood of reporting zero GDI postoperatively. In contrast, White patients had decreased odds of reporting zero postoperative GDI. Future work should identify specific factors, including provider communication, patient education, and preoperative expectations, that affect these patients' experiences with gender dysphoria in the postoperative period.

BACKGROUND: Chest masculinizing double-incision mastectomy with free nipple grafts is a gender-affirming operation to create a masculine-appearing chest for transgender and non-binary patients. Two important considerations for the procedure include placement of the nipple-areola complex (NAC) and incision pattern. Despite the rapidly growing number of patients undergoing this procedure, there are currently no studies in the literature indicating the preferred NAC position or incision pattern among transmasculine individuals.

METHODS: A web-based survey instrument was designed to elicit the surgical preferences of transmasculine patients treated at a large-scale medical system. Digitally-altered line drawings of a male torso were generated to represent various nipple positions and incision patterns. Variations of vertical NAC position included 80%, 85%, and 90% of the distance from the suprasternal notch to the xiphisternal joint. Variations of horizontal NAC position included 50%, 67%, and 75% of the distance from the midline to the anterior axillary line. Additionally, four separate images were generated to represent different inframammary fold (IMF) scar patterns: straight, slant, curved, and hockey stick. Patients were asked to rate each image on a 7-point Likert scale from very undesirable to very desirable. Subjects were asked to self-report demographic information and gender identity. Data analyses were performed using the Kruskal-Wallis test, followed by the Dunn test with Bonferroni correction for individual comparisons.

RESULTS: Responses were elicited from 923 patients via electronic message with a total of 106 patients agreeing to participate. The mean age was 27 years (range=18-52, SD=7.9), with 51% identifying as "transgender man", 35% identifying as "man", 7.5% identifying as "non-binary," and 6.5% identifying as "other". Almost all (99%) subjects were assigned female at birth, with 1% reporting assigned intersex. Significant differences (p<0.001) were found between median scores for both NAC images and incision scar images. For NAC position, all images that placed the NAC at 80% or 85% in the vertical dimension AND 67% or 75% in the horizontal dimension were rated significantly higher than all other options (p<0.01) but were not statistically significant from each other. Conversely, all images that placed the NAC at 50% in the horizontal dimension were rated significantly lower than the other options (p<0.001) but were not statistically significant from each other. For incisional scar, the hockey stick pattern (median=6) was rated significantly higher (p<0.001) than the straight scar (median=5), which was rated significantly higher (p<0.001) than both the slant (median=3) and curved scars (median=2). There was no significant difference between slant and straight scars (p=0.17).

CONCLUSIONS: Transmasculine patients prefer NAC placement between 80%-85% of the distance from the sternal notch to xiphisternal joint and 67%-75% of the distance from the midline to anterior axillary line. Patients are particularly averse to nipples placed too medially on the chest. Additionally, patients prefer the hockey stick mastectomy scar pattern most, followed by straight horizontal scars, slanted scars, and curved scars. These results provide valuable context for surgeons offering masculinizing mastectomy to transgender patients.

Background
Feminizing genital surgery, vulvoplasty or vaginoplasty, is commonly performed as one way of relieving gender dysphoria in those assigned male at birth. As the landscape of gender affirming care expands to allow greater access to genital surgery, sexual health remains a pivotal aspect of quality of life for many patients. This study aims to report the long-term functional and overall satisfaction outcomes of primary feminizing genital surgeries performed on transgender and gender diverse individuals.

Methods All patients who underwent primary vulvoplasty or vaginoplasty from 2017 to 2022 at a single integrated healthcare system were administered two questionnaires at least 6 months postoperatively (range 9 months to 6 years). The first questionnaire focused on satisfaction, perception of gender and life, and ability to orgasm. The second questionnaire was a validated Decision Regret Scale regarding their choice to have genital gender affirming surgery. Multivariable logistic regressions were conducted to determine significant associations between relevant variables and sexual outcomes as well as survey responses.

Results Survey response rate was 71.5%, with a total of 118 patients included in the final analysis. An overwhelming majority of 111 patients (94.1%) reported clitoral sensation and 90 patients (90.9%) reported vaginal sensation. Of those interested in sexual activity, 93 patients (84.5%) achieved clitoral orgasm and 45 patients (53.6%) achieved vaginal orgasm. A total of 111 patients (94.1%) strongly agreed that the surgery was the right decision. Clitoral sensation and clitoral orgasm showed no significant clinical predictors. Patients with younger age (OR 0.90, 95%CI: 0.84-0.97, p=0.005) and higher BMI (OR 1.28, 95%CI: 1.00-1.63, p=0.05) were more likely to report vaginal sensation. Patients with urinary problems, including new-onset urinary incontinence, persistent stream difficulty, urinary tract infections, urethrovaginal fistula, or meatal stenosis, were less likely to report vaginal orgasm (OR 0.28, 95%CI 0.08-0.97, p=0.04). Vaginal orgasm was also found to be associated with higher life satisfaction (OR 2.41, 95%CI 1.16-4.98, p=0.02) and greater ease of life since surgery (OR 6.09, 95%CI 1.30-28.52, p=0.02).

Conclusion Gender affirming surgery in an integrated system allows comprehensive long-term follow-up of patients with interdisciplinary team-based care. Despite the limitations of these surveys, this study demonstrated a majority of TGD patients had high levels of satisfaction, adequate sexual function, and low decision regret after feminizing genital surgery.

Purpose: The Ousterhout-based approach to forehead feminization surgery categorizes the forehead into 4 distinct groups based on the degree of prominence and the size of the frontal sinus. However, this classification overlooks frontal sinus heterogeneity and asymmetry. This study aimed to investigate frontal sinus contribution to supraorbital prominence and the implications for forehead feminization.

Methods: An IRB-approved retrospective review of maxillofacial CT scans was conducted on ethnicity- and age-matched groups of cis-male and female patients (2003-2022). Patients were excluded if they had prior sinus surgery, mucous thickening within the sinus space, facial skeletal fracture, or craniofacial abnormalities. Three-dimensional reconstruction of the skulls and frontal sinuses was performed using Mimics and 3-matic software. Data collected included patient sex, age, ethnicity, frontal sinus dimensions and asymmetry index (smaller volume/larger volume*100), bi-temporal width, surface area of the frontal sinus and supraorbital prominence, extent of supraorbital protrusion and nasofrontal angle, and frontal sinus anterior wall thickness. Moderate to extreme asymmetry of the frontal sinus was defined as an asymmetry index below 60. To compare frontal sinus measurements between males and females, data normalization was performed using bi-temporal distance to account for the inherent skull size variation between the two sexes. Mann-Whitney test and Pearson correlation were performed to analyze associations between variables.

Results: 183 patients (106 males and 77 females) with a mean age of 50.9±20.3 years were included. Bilateral frontal sinus absence occurred in 5 patients (2.7%), unilateral absence in 15 patients (8.2%), and 74 patients (40.4%) exhibited moderate/severe asymmetry. There were no significant differences in the asymmetry index between the two sexes (p=0.2). The male cohort showed mean frontal sinus dimensions of 54.7±16.5 mm (width), 30.4±8.7 mm (height), and 12.2±4.5 mm (depth), while the female cohort exhibited measurements of 44±16.7 mm (width), 24.3±8.3 mm (height), and 7±2.9 mm (depth). Following data normalization, male patients demonstrated significantly wider (p=0.001), taller (p=0.0003), and deeper (p<0.0001) frontal sinuses compared to female patients. Supraorbital prominence area was 1255.2±390.2 mm2 and 1214.5±277.8 mm2 in male and female cohorts, respectively, with no significant differences after normalization (p=0.55), while the frontal sinus area was significantly larger in male patients (male: 1275.4±587.5 mm2, female: 834.8±495.5 mm2, p<0.001). Supraorbital prominence area aligned with frontal sinus in only 39.4% of patients (≤20% difference). Overall, male patients demonstrated significantly thicker anterior wall (male: 3.1±1.4 mm, female: 3.6±1 mm, p=0.002), steeper nasofrontal angle (male: 121.3±10.5°, female: 134.4±9.4°, p<0.0001), and greater supraorbital protrusion (male: 3.6±1.5 mm, female: 1.7±0.8 mm, p<0.0001) compared to female patients. The extent of supraorbital protrusion correlated positively with supraorbital prominence area (r=0.45, p<0.0001), frontal sinus surface area (r=0.39, p<0.0001), bi-temporal distance (r=0.51, p<0.0001), and frontal sinus volume (r=0.24, p=0.02), and correlated negatively with nasofrontal angle (r= -0.53, p<0.0001) and anterior wall thickness (r= -0.26, p=0.0005).

Conclusions: Modifications to Ousterhout's classification are warranted to account for frontal sinus asymmetry. Anterior wall osteotomy should be tailored to the protrusion area. A combination of limited anterior wall setback and bone remodeling should be used for asymmetric cases.