Scientific Abstract Presentations: Gender Affirmation Session 3 Saturday, September 28 Sat, Sep 28 8:00-9:30 a.m. PDT

Background: Although many studies report on the suppressing effects of estrogen therapy on facial and body hair in transgender and nonbinary (TGNB) individuals, few studies have elucidated its effects on hairline stability on the scalp. In this work, we assessed the influence of estrogen therapy on forehead length. Methods: All TGNB patients assigned male at birth (AMAB) seeking facial feminization surgery aged 30 years or older were included in the study. Central and forehead length were collected at initial consultation visits. Variables that potentially influence hair growth were collected by chart review, including age, duration of hormone replacement therapy (HRT), presence of spironolactone, and presence of other hair treatments, including finasteride, dutasteride, or minoxidil. Multivariable generalized linear models were constructed with relevant predictor variables, while also incorporating global mental health scores as a proxy for psychological effects on hair loss. Results: 171 patients were included in this study, with a median age of 36.0 [interquartile range (IQR): 32.0-46.0] years and a median HRT duration of 2.0 [1.0-6.0] years. Multivariable generalized linear models revealed no significant predictors for central forehead length. On the other hand, lateral forehead length was positively predicted by age (B=0.06, 95% confidence interval (CI) [0.03-0.08], p<0.001) and hair treatment (B=0.62, 95%CI [0.11-1.13], p=0.02), but negatively predicted by HRT duration (B=-0.07, 95%CI [-0.10- -0.03], p<0.001). Conclusions: Although older age is a predictor of lateral hairline recession in TGNB AMAB individuals, lateral forehead length was also predicted to decrease by 0.07 cm with each year of feminizing hormone therapy.

Introduction: Nonbinary people are increasingly accessing gender-affirming mastectomy procedures, and their desired chest appearance can differ from that of transgender or cisgender individuals. However, little is specifically known about surgical outcomes in nonbinary patients, as research in gender-affirming chest surgery has primarily compared cisgender versus transgender and gender-diverse people, without specifically addressing nonbinary people. This study will assess surgical and post-operative complications between cisgender, transgender, and nonbinary adults undergoing mastectomy procedures.

Methods: ACS-NSQIP database was used to identify transgender and nonbinary patients who underwent mastectomy between 2018 and 2021 (CPT Codes 19300, 19301, 19303, and 19304), as well as cisgender patients who underwent mastectomy for cosmetic or cancer prophylaxis purposes. Baseline characteristics and surgery-related complications among cisgender, transgender, and nonbinary patients were assessed using analysis of variance tests, Fisher's exact test, unpaired t-tests, and multivariable regression models.

Results: 3,110 patients met inclusion criteria: 1,521 (48.9%) were cisgender, 1,536 (49.4%) were transgender, and 53 (1.7%) were nonbinary. More nonbinary mastectomies were performed in 2021 than in 2018-2020 combined. The cisgender cohort was older, had greater medical comorbidities, and experienced longer operative times than the other groups (p<0.001).

A total of 98 cisgender (6.4%), 34 transgender (2.2%), and none of the nonbinary patients underwent reoperation (p<0.001). Hematoma and seroma were the most common indications for reoperation (39.0%). With regards to infections, 72 cisgender patients had surgical site infections (4.8%), compared to 1 nonbinary (1.9%) and 16 transgender (1.1%) patients. Additionally, 16 cisgender patients had bleeding requiring transfusion (1.1%), compared to 2 transgender (0.1%) and none of the nonbinary patients (p=0.003). Other systemic complications had low incidence, and no statistical differences were identified between the cohorts. Overall, cisgender patients had the highest all-cause complication incidence (p<0.001).

After adjusting for confounding variables such as age, BMI, ethnicity, smoke, diabetes, transgender patients had a lower likelihood of reoperation (OR: 0.271; 95% CI: 0.164-0.449; p<0.001) or all-cause complications (OR: 0.218; 95% CI: 0.124-0.385; p<0.001) compared to cisgender patients. No significant wound or all-cause complications differences were identified between nonbinary and cisgender patients.

Conclusions: Gender-affirming mastectomy can be safely performed in nonbinary and transgender adults. Even when controlling for various comorbidities, transgender and nonbinary patients had better or equivocal complication outcomes compared to cisgender patients. Factors beyond the scope of the database, such as different surgical techniques, social determinants of health, and hormone exposure, may explain these differences, and future research should elucidate these complication disparities.

Introduction: Access to gender affirmation surgery (GAS) is contingent on availability of procedures, affordability, legality, and social norms. In regions with higher accessibility to GAS – typically high resourced, high-income countries - there may be corresponding higher generation of empirical evidence related to GAS. This is problematic on a global health policy level because surgical and patient-reported outcomes (PRO) data may not align with what is observed in low- or middle-income countries (LMICs). To-date, limited research has characterized the type of GAS, patient population, surgical outcomes or PROs associated with GAS in LMICs. This systematic review addresses this gap by examining GAS-related outcomes literature in LMICs.

Methods: Electronic databases of MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO databases were searched with the help of a medical librarian. The World Bank classifications were used to determine a country's income group, i.e., middle income (MI) or lower income (LI). Peer-reviewed articles or conference abstracts that were published in any language, reported surgical or patient-reported outcomes of GAS, and were conducted in MI or LI countries were included. Studies reporting exclusively on surgeries for congenital disorders of sexual differentiation, reviews, case studies, editorials, letters to the editor, and animal studies were excluded. Title and abstract screening and full-text review were completed in duplicate, and 30% data extraction was checked by a second author to ensure rigor. Non-English studies were translated in English. A priori designed data extraction form was piloted (n=25) and data elements extracted included study and sample characteristics, surgery, surgical outcomes and complications, and PROs.

Results: A total of 139 studies were included (63.3% peer-reviewed articles and 36.7% conference abstracts) from 14 LMIC countries. Most studies were in English (95%), and non-English studies were published in Chinese (n=3, 2.2%), Russian (n=2, 1.4%), and Persian (n=2, 1.4%). Most of the studies were conducted in Serbia (n=43, 31%), followed by Brazil (n=25, 18%), Iran (12%), Turkey (n=13, 9%, China (n=13, 9%), and Thailand (n=10, 7%). The most common procedure reported was vaginoplasty (n=53, 25%), followed by phalloplasty (n=40, 19%), metoidioplasty (n=30, 14%), mastectomy (n=26, 12%) and other surgeries (n=29, 14%). For vaginoplasty and phalloplasty, common complications included vaginal stenosis (incidence rate 0%-50%) and fistula formation (0%-11%), and urinary strictures (0%-37%) and fistulas (0%-52%), respectively. Among all studies, overall complication rates ranged from 0%-63%, revision surgery rates ranged from 0%-43%, and infection rates ranged from 0%-31%. Most studies reported PROs (n=91, 66%), however, out of the studies that reported PROs, more than half (n=60, 66%) did not use a validated PRO measure. Commonly reported PROs included satisfaction with aesthetic appearance, sexual well-being, sensation, and physical function (e.g., ability to urinate).

Conclusion: The GAS outcomes reported in LMICs differ from those in high- or upper middle-income countries. Substantial heterogeneity in surgical technique, outcomes measured, and complication rates was noted, precluding a meta-analysis. Future GAS research, especially in LMICs, will benefit from standardizing surgical outcomes data collected and using validated PRO measures.

Introduction
Successful nipple areolar complex (NAC) reconstruction greatly influences patient outcomes for transgender patients undergoing chest masculinization. Despite the recent rise in case volume, little is known on designing the ideal NAC that maintains its aesthetics in dynamic settings. This study aims to examine the characteristics of male NACs and their dimensional variability to help develop guidelines on designing neo-NAC to improve surgical and patient outcomes in transgender chest masculinization.

Methods Thirty cis-gender male participants were enrolled. NAC height and width, sternal notch to nipple distance (SNND), and inter-nipple distance (IND) were measured in standing and supine positions with stable room temperature to prevent measurement bias. Other variables recorded included chest circumference, NAC angulation, body mass index, weight, height, age, and ethnicity. All measurements were taken in a private room with stable temperature (~22° C) to prevent variability in data secondary to cold-induced NAC contraction.

Results The mean years of age and BMI was 27.40 (range 19-76) and 24.78 (SD 3.05), respectively. Mean chest circumference and NAC angulation measured at 100.3 cm (SD 8.9 cm) and 27.8° (SD 8.48°), respectively. Mean standing and supine measurements were as follows: NAC height 21.2mm (SD 3.9) vs. 23.4mm (SD 4.7), NAC width 29.0mm (SD 5.1) vs. 29.7mm (SD 5.6), SNND 20.8cm (SD 2.1) vs. 19.3cm (SD 1.8), and IND 22.4cm (SD 2.3) vs. 23.5cm (SD 2.5). NAC height-to-width ratio decreases from supine to standing, as well as IND, indicating a medialization of the NACs when upright. A multiple linear regression model did not find any significant confounding effects of age, BMI, chest circumference, or NAC angulation on NAC HWR with position changes.

Conclusion Our findings suggest that during chest masculinization surgery, the design of male neo-NAC has a risk of being positioned too medial and elliptical with upright positioning. Care must be taken intraoperatively to account for changes in neo-NAC dimensions that occur with body position changes. We strongly recommend that surgeons determine the final position of the neo-NAC intraoperatively while having the patient in upright sitting position.

Purpose: Body mass index (BMI) is often used to determine surgical eligibility for gender-affirming mastectomy (GAM) (1). However, there is limited empirical data informing these criteria (2). Moreover, prior studies evaluating BMI and GAM complications have been limited to single-institution data. This is the first meta-analysis to evaluate the relationship between BMI and surgical complications after GAM across multiple institutions and surgical techniques.

Methods: A systematic review and meta-analysis was performed for all studies in the databases PubMed, Embase, and Web of Science that evaluated the relationship between BMI and surgical outcomes after GAM. Our institution's GAM cohort (n = 443) was also included in this analysis. Obesity was defined as BMI ≥ 30 kg/m2. Outcomes of interest included hematoma and seroma formation, surgical site infections, and wound and nipple-areola complex (NAC) complications. The fixed-effects Mantel-Haenszel method was used to synthesize results across studies.

Results: Of the 604 studies screened, 10 met the inclusion criteria. There were a total of 1339 patients, of which 519 (39%) were obese and 820 (61%) were non-obese. There were significantly higher odds of seroma formation (odds ratio [OR] = 2.2, 95% CI = 1.3–3.8, P = 0.01), NAC complications (OR = 2.0, 95% CI = 1.3–3.3, P < 0.01), and wound complications (OR = 4.4, 95% CI = 1.4–14.6, P = 0.01) in patients with obesity compared to those without obesity. There were no significant differences in hematoma formation (OR = 1.1, 95% CI = 0.6–1.9, P = 0.73) or surgical site infections (OR = 1.7, 95% CI = 0.8–3.6, P = 0.19).

Conclusion: While some GAM complications were more common in patients with obesity, serious complications like hematoma and infection were as likely to occur among patients with and without obesity. Patients with higher BMIs should be counseled about their increased risk for these complications. However, BMI cutoffs alone should not be used to determine surgical eligibility especially given GAM's significant improvement in gender dysphoria and the low morbidity associated with these complications. Future studies evaluating patient-reported outcomes are critical to understanding the true impact of these potentially increased complications in patients with obesity. Additionally, more data is needed to understand differences in surgical risk among higher BMI classes.

References: 1. Martinson TG, Ramachandran S, Lindner R, Reisman T, Safer JD. High body mass index is a significant barrier to gender-confirmation surgery for transgender and gender-nonbinary individuals. Endocr Pract. 2020;26(1):6-15. 2. Castle E, Kimberly L, Blasdel G, Parker A, Bluebond-Langner R, Zhao LC. Should BMI Help Determine Gender-Affirming Surgery Candidacy? AMA J Ethics. 2023 Jul 1;25(7):E496-506. doi: 10.1001/amajethics.2023.496. PMID: 37432002.

Background: Facial feminization surgery (FFS) is a collection of procedures of the head and neck aimed at achieving softer features to establish a more "feminine" appearance. While most commonly performed in transgender women, FFS applies to cis-gendered women as well. Ranging from coronal brow lifts, rhinoplasty and cheek implants, to frontal bossing reductions and tracheal shavings, FFS is a unique set of craniofacial procedures that address gender dysphoria, a debilitating mental health condition. Despite notable quality of life (QOL) improvements secondary to FFS, there is yet to be a standardized framework for evaluating patient-reported outcome measures (PROMs). This remains a major barrier in the field of gender affirming care. The purpose of this study is to examine the different PROMs reported in the literature and advocate for the optimization of QOL metrics for post-FFS patients.

Methods: An electronic database search of Ovid MEDLINE was completed according to PRISMA guidelines for articles pertaining to FFS and QOL. Study characteristics, QOL survey information, and patient demographics were collected. Specifically, we considered QOL to be assessed by postoperative satisfaction, revisions, regrets, and subjective surveys.

Results: In total, seventeen articles that met inclusion criteria were selected and reviewed from the 2,032 studies identified from our literature search. There was a total of 1,193 patients that underwent a variety of FFS procedures, including rhinoplasty, forehead reconstruction, cranioplasty, and lip-lift procedures, among others. Four studies exclusively used non-validated satisfaction rating questionnaires and four studies exclusively used non-validated QOL surveys. Seven studies exclusively used validated surveys, including the Nose feminization scale, SNOT-22, SWLS, SHS, PROMIS, and FACE-Q. Two studies used both a non-validated QOL survey and validated surveys, SF-36v2 and ANA.

Conclusion: Overall, there remains a massive discrepancy in surveys across studies assessing QOL in patients who have undergone FFS. The standardization and optimization of QOL metrics for this population is a necessary step towards improved outcomes and the inclusion of FFS as a reconstructive surgery under insurance. Questionnaires such as GENDER-Q are promising tools in addressing the aforementioned limitations. Garnering patient-reported outcomes in a standardized manner is particularly important due to the varying perspectives and procedures in gender affirming care, thereby providing invaluable feedback for surgeons.

Background

Gender-affirming facial surgery (GAFS) can be performed as a full, single-staged procedure (F-GAFS) or in multiple, partial stages (P-GAFS). P-GAFS addresses either the upper, middle, or lower facial thirds while F-GAFS includes procedures on multiple facial regions during a single anesthetic event. Potential advantages of P-GAFS include less operative time and allowing the face to fully heal before reconstructing a different facial region. Furthermore, patients can acclimate to their new appearance before a decision is made to pursue additional surgery. A key advantage of F-GAFS is that only one anesthetic event and postoperative recovery period are necessary, limiting patient-life disruptions. One small single-center study found no statistically significant difference in surgical complications between F-GAFS and P-GAFS.(1) The purpose of our study is to compare safety profiles of F-GAFS and P-GAFS, including the relationship between sociodemographic and surgical characteristics with various complications.

Methods

The 2012-2022 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) databases were queried for International Classification of Diseases, 9th Revision and 10th Revision codes specifying "gender dysphoria" or "transgenderism." Using Current Procedural Terminology (CPT) codes, patients were categorized as having facial surgeries on the upper face, middle face, and lower face.(2) Patients who had surgery on two or more regions (e.g., upper and middle face) were classified as F-GAFS. Patients were excluded if they underwent a concurrent procedure unrelated to facial surgery. Surgical complications included return to the operating room, hospital readmission, urinary tract infection, surgical site infection, and wound disruption. Two-sample t-tests and chi-squared tests compared patient characteristics and surgical outcomes. Logistic regression was used to assess the adjusted risk of F-GAFS.

Results

A total of 552 patients underwent GAFS, including 193 P-GAFS (35.0%) and 359 F-GAFS (65.0%) patients. F-GAFS patients, on average, had higher BMIs, and the mean operative time of F-GAFS was more than double that of P-GAFS (p<0.001). An increasing number of patients underwent GAFS during the study period: 5 patients in 2013, 27 in 2017, and 134 in 2022. Nineteen patients (3.4%) had surgical complications. Fifteen patients had surgical site infections, three had bleeding requiring transfusion, and one had a pulmonary embolism. There were complications in 2.1% of P-GAFS patients (n=4) and 4.2% of F-GAFS patients (n=15). However, this difference was not statistically significant in bivariable analyses (p=0.23) nor in a multivariable regression controlling for baseline characteristics (odds ratio: 1.15, 95% confidence interval: -1.21 - 1.49, p=0.84).

Conclusions

Our findings underscore the increasing popularity of GAFS while also highlighting the safety of both F-GAFS and P-GAFS for transgender and gender-diverse patients. These results support informed decision-making to optimize aesthetic goals and complication outcomes. Insurers should guarantee coverage for both approaches, providing surgeons and patients the most flexibility in choosing a surgical strategy.

References

1. Chaya BF, Boczar D, Rodriguez Colon R, et al. Comparative Outcomes of Partial and Full Facial Feminization Surgery: A Retrospective Cohort Study. J Craniofac Surg. 2021;32(7):2397-2400. doi:10.1097/SCS.0000000000007873
2. Coon D, Berli J, Oles N, et al. Facial Gender Surgery: Systematic Review and Evidence-Based Consensus Guidelines from the International Facial Gender Symposium. Plast Reconstr Surg. 2022;149(1):212-224. doi:10.1097/PRS.0000000000008668

Purpose Gender Affirming Surgery (GAS) comprises a spectrum of surgical procedures intended to align individuals' physical characteristics with their gender identities, including Facial Feminization Surgery (FFS). FFS can be staged or as a single comprehensive procedure, depending on patient factors and surgeon preference. Patients may also choose to undergo secondary FFS should the results of the index operation not be satisfactory. The rate of unplanned secondary FFS and its contributing factors have not been explored in the literature. This study aims to elucidate trends in FFS revisions to further improve care for transgender patients.

Methods All surgeries from a single institution from 2012 to 2023 that were associated with any one or more of 95 CPT codes related to GAS were filtered for patients who had a diagnosis of transsexualism (F64). Manual chart review was then conducted to confirm that these procedures were performed for gender-affirmation and to collect variables including patient demographics, age at social transition, age when starting hormone replacement therapy, and reason for each procedure. Secondary FFS was separated into staged and unplanned, with unplanned FFS defined as there being no mention of staging in any pre-operative visit note for the initial FFS, or that the patient presented for secondary FFS due to dissatisfaction with the index procedure. A cohort of 134 patients who underwent 280 surgeries was included in chi-square analysis.

Results 107 patients underwent FFS, and 37 (34.6%) of these patients underwent FFS surgery more than once for any reason. 21 (19.6%) underwent unplanned secondary FFS. Patients who received FFS as their initial GAS procedure were more likely to have revisions (43%) compared to those who first underwent top or bottom surgeries before FFS (24% and 14% respectively, p=0.0399). There was no significant association between the age at initial FFS and rate of FFS revision, or time between social transition or hormone initiation and rate of FFS revision.

Conclusion The socially, emotionally, and medically complicated process of transitioning looks different for each individual, based on their unique needs and desires. Notably, this study found that nearly one in five FFS patients underwent unplanned secondary procedures, which underscore the importance of refining the approach to FFS for transgender patients. Additionally, our findings reflect the evolving WPATH guidelines, which no longer mandate a defined period of social transition or hormone therapy before GAS, except for breast surgeries. Further investigation is warranted to identify factors influencing the need for revision FFS and to enhance surgical outcomes for patients undergoing gender-affirming procedures.

Introduction: Transgender and gender diverse (TGD) individuals may elect to undergo body contouring liposuction +/- fat grafting to the buttock and hip. Feminizing body contouring (FBC) aims to fill trochanteric depressions, enhance posterior projection, and decrease the waist-hip ratio (1). There is currently little-to-no literature describing patients or outcomes after undergoing FBC.

Methods: Retrospective chart review of 139 consecutive patients who underwent 159 FBC procedures at single surgical practice from December 2019 to February 2024. Inclusion criteria: patients ≥18 years old with ≥30 day follow-up. Primary variables of interest were past medical history, hormone use history, fat donor and recipient sites, complication rates, and revision rates.

Results: 139 patients underwent a total of 159 procedures: 87.4% were primary, 10.0% primary revision,1.8% secondary revision, and 0.6% tertiary revision. Procedures were completed by 3 surgeons within a single practice with the breakdown of 92, 50, and 17 cases respectively. Revision cases were performed by the same surgeon.

96.2% of patients had used hormones for an average 8.8 years (SD=8.7). Of those using hormones, 88.0% were taking estrogen, 46.5% taking spironolactone, and 20.1% taking progesterone. The average age at time of procedure was 36.9 years old (SD=10.0, range=21-67). Past medical history included depression (22.6%), anxiety (19.5%), positive HIV status (15.7%), HTN (11.9%), and asthma (9.4%). Average BMI was 29.1, SD= 4.7.

Donor sites included: abdomen (98.1%), back (95.9%), medial thighs (61.6%), lateral and/or medial thoracic area (37.7%), arms (31.4%), axillary (28.9%), mons pubis (10.7%), submentum (6.2%). Recipient sites included: hips (95.0%), buttocks (96.2%), breasts (3.1%), face (5.0%), labia majora (1.9%). Abdominoplasty was indicated for 12 patients (7.6%) and 5 (41.6%) received abdominoplasty. Average fat transferred per procedure was 2.2 L (SD=1.1, range: 0.3-4.5). Drains were used in 50.9% of patients.

All patients received IV antibiotics, lovenox, and sequential compression devices at time of operation and were placed in jackknife position for infiltration using 4mm cannulas. All cases used power assisted liposuction. 89.3% of patients were instructed to suspend hormone use 2 weeks prior to surgery. All patients with an abdominal donor site (98.1%) were placed in abdominal compression postoperatively. 28.9% of patients attended at least one session of hyperbaric oxygen chamber therapy.

Complications included: contour deformity (6.3%), cellulitis (5.0%), seroma (2.5%), fat necrosis (1.9%), PE (0.6%). The readmission rate was 2.5%. 1.8% of patients required a blood transfusion.

Conclusion: FBC is a safe, efficacious, and customizable procedure for TGD patients. TGD patients may require higher volumes of fat transfer compared to cisgender women, as one study reported an average of 1.8 L (2) per procedure. Clinical counseling should emphasize potential need for revision due to fat loss or contour deformity.

References: 1) Asokan A, Sudheendran MK. Gender Affirming Body Contouring and Physical Transformation in Transgender Individuals. Indian J Plast Surg. 2022;55(2):179-187. doi:10.1055/s-0042-1749099 2) Everett M, Morales R, Newall G, Fortes PF, Hustak KL, Patronella CK, Mentz HA. Safest Practices for Autologous Buttock Augmentation With Fat Grafting Using a Roller Pump Injection Technique. Aesthetic Surgery Journal, 2018;38(7): 751–762. doi:10.1093/asj/sjx113

Purpose: Penile inversion vaginoplasty (PIV) is among the most common genital gender-affirming surgeries (GAS) (Wright et al., 2023). Patient-reported outcomes are increasingly important in the assessment of GAS (Oles et al., 2022), however few studies have rigorously assessed outcomes of PIV. In this prospective study, we assessed satisfaction, body image and social function following PIV using the BODY-Q.

Methods: Individuals who underwent PIV at our institution between September 2018 and February 2023 were eligible for the study. The study was approved by our institution's IRB. All patients were over 18 years at the time of surgery. Surveys were administered preoperatively and postoperatively at 3.5 and 12 months. Clinical data, including complication and revision rates, were collected from the medical record preoperatively and 12-months postoperatively. The BODY-Q is a validated patient-reported outcome measure with subscales that measure quality of life (Poulsen et al., 2019). The body image and social function subscales were administered at all timepoints, and the satisfaction subscale at both postoperative timepoints. Outcomes were scored according to scoring guidelines and each bivariate analysis was performed using paired, non-parametric testing. Multivariable linear regression was performed to identify associations between satisfaction scores and demographic and clinical variables.

Results: Of the 76 patients who enrolled, 66 underwent surgery and 46 completed all 3 surveys. Body image scores were significantly higher postoperatively at both 3.5 months (Body Image: 61 IQR: [54;74], p<0.001) and 12 months (Median: 65 IQR: [54;85], p<0.001) compared with preoperative scores (Median: 38 IQR: [22;54]), but did not change significantly between 3.5 and 12 months (p=0.32). Similarly, social function scores were significantly higher at 3.5-month (Median: 57 IQR: [46;71], p=0.008) and 12-month (Median: 61 IQR: [48;74], p<0.001) timepoints compared with the preoperative timepoint (Median: 52 IQR: [40;60]) and did not change significantly from 3.5 to 12 months (p=0.24). Patients had high satisfaction scores postoperatively which did not change significantly (p=0.80) between the 3.5-month (Median: 95 IQR: [75;100]) and 12-month (Median: 100 IQR: [82;100]) timepoints. After controlling for age, BMI, comorbidities and revisions, major complications (requiring reoperation or readmission) were negatively associated with satisfaction at both 3.5 months (p=0.005) and 12 months (p<0.001).

Conclusions: Gender-affirming vaginoplasty positively impacts body image and social function, which stabilizes by 3.5 months. Overall, participants had high satisfaction following the procedure although satisfaction was negatively associated with major complications. In this prospective study, we affirm previous retrospective studies demonstrating the positive psychosocial impact of PIV, however longer-term prospective and multi-center studies remain important.

References (Up to 5):

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

Oles N, Darrach H, Landford W, et al. Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 2: Genital Reconstruction). Ann Surg. 2022;275(1):e67-e74. doi:10.1097/SLA.0000000000004717

Poulsen L, McEvenue G, Klassen A, Hoogbergen M, Sorensen JA, Pusic A. Patient-Reported Outcome Measures: BODY-Q. Clin Plast Surg. 2019;46(1):15-24. doi:10.1016/j.cps.2018.08.003

Purpose: Surgeons often use body mass index (BMI) cutoffs of 35 kg/m2 for gender-affirming chest surgery (GACS) based on the longstanding belief that high BMIs are associated with greater surgical risk.(1) This disproportionately affects transgender and gender diverse (TGD) individuals who may be unable to exercise due to chest dysphoria or use their weight to hide their chest. Current research suggests no significant association between BMI >35 kg/m2 and complications related to GACS in adults.(2,3) However, studies have limited data on adults with BMI >40 kg/m2.(4) This study investigates the impact of high BMIs on GACS complications and revision rates.

Methods: A retrospective chart review of individuals undergoing GACS at our institution from January 2016 to October 2023 was performed. Individuals 18 years and over who were at least 90 days post-operation from either bilateral gender-affirming mastectomies or bilateral gender-affirming chest reductions were included. Demographic information, relevant operative records, post-operative complications (i.e. hematoma, seroma, infection, dehiscence, tissue necrosis) and revision history were collected and analyzed via descriptive statistics and bivariate analysis.

Results: A total of 159 individuals were included in the study. The mean age at time of GACS was 28.7 (SD=9.1). The mean BMI was 31.2 kg/m2 (range=16.0 to 87.6, SD=10.1), with 13.8% (N=22) having a BMI >40 kg/m2. A total of 15 (9.4%) individuals had a complication within 90 days, 7 (4.4%) of which were a major complication that required return to the operating room. 12 (7.5%) individuals underwent a revision. Lastly, none of the cohort had a reversal (breast reconstruction) procedure. Having a BMI >40 kg/m2 was associated with the risk of developing a complication in general (P=0.04), however, it was not associated with the risk of developing a major complication that required reoperation (p=0.25) or necessitating a revision (p=0.67). No other factors appeared to be associated with complications or revisions.

Conclusions: The rate of post-operative major complications and revisions for individuals who underwent GACS is similar regardless of BMI. Obesity alone may not be sufficient to limit access for individuals seeking GACS. Future studies evaluating patient reported outcomes in high BMI adults following GACS are necessary.

References: 1. Madsen HJ, Gillette RA, Colborn KL, et al. The association between obesity and postoperative outcomes in a broad surgical population: A 7-year American College of Surgeons National Surgical Quality Improvement analysis. Surgery. 2023;173(5):1213-1219. doi:10.1016/j.surg.2023.02.001 2. Pittelkow EM, Duquette SP, Rhamani F, Rogers C, Gallagher S. Female-to-Male Gender-Confirming Drainless Mastectomy May Be Safe in Obese Males. Aesthet Surg J. 2020;40(3):NP85-NP93. doi:10.1093/asj/sjz335 3. Roblee C, Topple T, Hamill JB, et al. BMI is Not Associated with Chest-Specific Body Image, Complications or Revisions in Gender-Affirming Mastectomy: A Single-Center Cross-Sectional Study. Ann Surg. Published online October 23, 2023. doi:10.1097/SLA.0000000000006143 4. Rothenberg KA, Gologorsky RC, Hojilla JC, et al. Gender-Affirming Mastectomy in Transmasculine Patients: Does Obesity Increase Complications or Revisions? Ann Plast Surg. 2021;87(1):24-30. doi:10.1097/SAP.0000000000002712

Purpose: The study investigates the influence of intraoperative and perioperative blood pressure management on the occurrence of hematomas in gender-affirming bilateral mastectomy in transmasculine individuals. Prior research indicates that hematomas are a prevalent complication of mastectomy procedures. In 2001, Hussien et al. proposed that post-op hematoma forms due to intraoperative hypotension potentially concealing active bleeding, which becomes apparent once normotension is restored post-surgery. In this study, we aim to elucidate the relationship between blood pressure during intraoperative and perioperative period and hematoma formation, thereby guiding better perioperative care.

Materials and Methods: A retrospective analysis was conducted on a cohort of 109 transgender individuals who underwent bilateral mastectomy by the same surgeon at our institution between 2016 and 2020. Patients who developed postoperative hematomas were identified, and a comprehensive dataset of all patients was compiled. Patients with incomplete data were excluded, yielding for 96 patients in total, with hematoma group n=8, non-hematoma group n=88. Data extracted includes demographics, baseline blood pressures from office visits, preoperative measurements an hour before procedure, all intraoperative blood pressure readings per anesthesia printed records, the maximum fluctuation of MAP, and immediate postoperative pressures. Preoperative comorbidities and hormonal treatment histories were also documented. An independent T-test assessed differences in average blood pressures between hematoma and non-hematoma groups, while logistic regression evaluated the influence of blood pressure variations on hematoma risk.

Results: From the 96 patients analyzed, 8 experienced hematomas requiring surgical evacuation. Baseline and preoperative blood pressures were similar between the non-hematoma (average BP 122.7/79.1, MAP 93.7) and hematoma groups (average BP 127.3/77.3, MAP 93.9), with no significant differences observed (p>0.05 for all). Intraoperative data revealed the hematoma group had a significantly lower average diastolic pressure (p=0.014) and MAP (p=0.027). Postoperative measurements showed this group also had a significantly higher average diastolic pressure (p=0.028) and MAP (p=0.026). Logistic regression analysis revealed that a low intraoperative mean arterial pressure (MAP) significantly predicted hematoma occurrence (p=0.029, OR=0.863, 95% CI [0.755, 0.989]). In hematoma group, patients had MAP decreased greater than 20mmHg (21.7%) from baseline. In addition, increase in immediate postoperative MAP was also a significant predictor for hematoma formation (p=0.013, OR=1.140, 95% CI [1.028, 1.264]). Hematoma group had an average of 34.8% increase in immediate post-op from intraoperative levels. In contrast, the non-hematoma group showed a smaller intraoperative MAP decrease of 13.2% and a postoperative increase of 9.3%. Lastly, age, BMI, baseline, and preoperative blood pressures did not significantly predict hematoma formation (p>0.1 for all).

Conclusion: The study reveals that lower intraoperative MAP and higher immediate postoperative MAP are associated with an increased risk of hematoma formation after bilateral mastectomy in transgender patients. These findings highlight the critical importance of maintaining stable intraoperative and immediate postoperative blood pressure levels to mitigate the risk of this complication. Notably, age, body mass index (BMI), and baseline blood pressure were not correlated with the incidence of hematoma, underscoring the importance of vigilant perioperative blood pressure management over these static patient factors.

Hussien M, Lee S, Malyon A, Norrie J, Webster M. The impact of intraoperative hypotension on the development of wound haematoma after breast reduction. Br J Plast Surg. 2001;54(6):517-522. doi:10.1054/bjps.2001.3662

Introduction: Gender-affirming surgery (GAS) aligns physical appearance with gender identity. While clinical outcomes of GAS are well-documented, understanding patient-reported experiences is vital. (1,2) This study uses the validated VMP-G, Mini Patient Reported to assess patient reported outcomes (PROs) after GAS to the chest. VMP-G assesses quality of life, self-concept, satisfaction, and gender dysphoria.

Methods: Participants seeking chest GAS from 2022 to 2023 completed the VMP-G preoperatively, at one-, six- and twelve- months post-surgery using the Research Electronic Data Capture survey tool (REDCap). VMP-G scores, range from 20 to 100 (higher scores indicating superior PROs). We compared outcomes and identified factors associated with higher scores at the each timepoint.

Results: Seventy-nine chest GAS patients (median age: 27; predominantly male) completed pre-operative surveys. One-, six-, and twelve-month post-surgery responses showed significant improvement in VMP-G scores compared to baseline (all p<0.0001), across all categories assessing quality of life, self-concept, satisfaction, and gender dysphoria. Regression analysis revealed younger age associated with higher VMP-G scores across both GAS groups. In the post-operative period, there was a significant difference between mean VMP-G scores at the one month and each of the six- and twelve-months period yet there was no difference between the average scores between the last two timepoints.

Conclusion: PROs using the validated VMP-G significantly improved at one-, six- and twelve months post-GAS to the chest, with stabilization of outcomes beyond the six-month recovery period.