Scientific Abstract Presentations: Gender Affirmation Session 4 Saturday, September 28 Sat, Sep 28 2:00-3:30 p.m. PDT

Introduction: Gender Affirmation Top Surgery (GATS) has been found to promote wellbeing for transgender (TGD) adults; yet, very limited research exists on TGD minors who receive GATS. This study investigates post-operative surgical and psychological outcome variables (i.e., appearance congruence, gender identity acceptance, chest dysphoria, anxiety, depression, and social support) for TGD people who received top surgery as minors. Methods: The N=46. The sample was acquired from a single surgeon who has a high volume top surgery practice. All patients received GATS between 2016-2023. TGD people who were at least 6 months post-operation (range 6 mo-7 years) and minors when they received top surgery were invited to complete the online survey consisting of demographics/clinical characteristics and validated measures (i.e., Transgender Congruence Scale (TCS), Chest Dysphoria Measure (CDM), Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS), and Multidimensional Scale of Perceived Social Support (MSPSS)). Analyses consisted of descriptive statistics of validated measures. The results were compared to published pre-operative surveys of TGD adults and minors, as well as studies of anxiety and depression in cis minors. Surgical outcomes were compared to an equivalent number of adult GATS performed by the same surgeon during the same time frame. Results: All patients underwent GATS as an outpatient. 36 patients underwent double incision mastecomy with free nipple grafting and 10 patients underwent sub-cutaneous mastectomy via a peri-areolar approach. There were no serious adverse events that required blood transfusion, IV antibiotics, re-admission to the hospital or an overnight stay. 1 hematoma that required a secondary evacuation procedure in clinic was encountered. There was no complete loss of free nipple grafts. The TCS average post-op composite score was 53 (SD5.97; range=38-60). The TCS appearance congruence average composite score was 40 (SD4.93; range=27-45). The TCS gender identity acceptance average composite score was 12.81 (SD2.37; range=3-15). The CDM average composite score was 1.80 (SD1.66; range=0-6). The PHQ-ADS average composite score was 9.68 (SD8.94; range=1-41). The PHQ anxiety subscale average composite score was 4.84 (SD4.72; range=0-21). The PHQ depression subscale average composite score was 4.84 (SD4.63; range=0-20). The MSPSS average was 5.78 (SD1.23 range=1-7). Conclusions: The surgical results in minors was equivalent to that of adults. The procedures were well tolerated with very low levels of complications. When comparing these results to published norms of pre-operative psychological outcomes for TGD minors, our post-operative outcomes show higher levels of appearance congruence (40 versus 26.80), lower levels of chest dysphoria (1.80 versus 30.50), and milder levels of anxiety and depression. Recently, top surgery in minors has been deemed controversial. At this time 19 states have implemented laws banning such surgery. Our findings show TGD minors who receive GATS experience good surgical post-operative outcomes that can significantly improve their psychological well being. These results are a step towards challenging the laws that currently ban the procedure.

Purpose: Hypertrophic scarring represents a significant concern in gender-affirming mastectomy (GAM) procedures, crucial for aligning patients' physical appearance with their gender identity. Despite extensive literature on factors contributing to hypertrophic scarring, research quantifying its incidence in GAM recipients remains limited. This systematic review aims to address this gap by summarizing rates of hypertrophic scarring following GAM reported in the literature.

Methods: A PROSPERO-registered systematic review adhering to PRISMA guidelines was conducted. Keyword searched including 'hypertrophic scarring' and 'gender affirming mastectomy' in PubMed, Web of Science, and Embase databases yielded 631 articles. Inclusion criteria focused on studies reporting hypertrophic scarring rates in GAM patients, excluding conference abstracts, meta-analyses, systematic reviews, and articles lacking quantitative measures of hypertrophic scars. Meta-analysis was conducted using Stata version 17.0 (College Station, TX, USA).

Results: Thirteen studies, comprising 2,327 cases of GAM, were included, predominantly single-center retrospective cohort studies (92%) with one cross-sectional survey study. Follow-up duration varied, with 30% of patients followed for less than one year. The pooled rate of hypertrophic scarring was 10% (95% confidence interval [CI] 7-14%). Silicone tape application, recommended in three articles, aimed to mitigate scarring. Revision rates for hypertrophic scarring were reported in eight articles, with an overall rate of 3% (95% CI 1-4%). Comparing between patients receiving preoperative testosterone and those who did not showed no difference in the rates of hypertrophic scarring in one study.

Conclusion: Hypertrophic scarring occurs in approximately 10% of GAM patients, with a 3% rate of hypertrophic scar revisions. Limited follow-up duration may under-represent hypertrophic scarring incidence, necessitating extended follow-up to accurately detect its development. Standardized classification systems for hypertrophic scarring in this context are crucial. Future research should focus on prolonged follow-up to accurately capture the hypertrophic scarring incidence and explore effective management and prevention strategies.

Purpose Transgender and gender-diverse (TGD) individuals experience disproportionate rates of mental health challenges, including anxiety, depression, and suicidality compared to cisgender individuals. Gender-affirming hormone therapy (HT) has been associated with improved psychosocial symptoms in TGD individuals. However, our understanding of the impact of HT on psychosocial functioning is limited based on studies with subjective assessments and short follow-up periods of 2 years or less. Here, we evaluate the utilization of mental health resources before and after HT, to assess long-term changes in suicidality, acute mental health care, and medication usage. Methods We conducted a retrospective chart review of TGD individuals who pursued HT at a single institution from January 2017 to July 2023. Patients were included if they had a history of suicidal ideations, suicidal attempts (SA), or acute mental health visit (ED visit or hospitalization). For each patient, outcomes were analyzed within equal before and after HT follow-up periods. Suicidality, non-suicidal self-injury (NSSI), acute mental health care visits, and psychotropic medication use were compared. The McNemar test, Wilcoxon signed rank test, and Chi-squared test were used to compare outcomes before versus after HT. A subgroup analysis of adolescent individuals (<26 years) was also performed. Results A total of 91 TGD individuals were analyzed with a median (interquartile range [IQR]) age of 18 (17-24) years. Within this population, 72 (79%) were adolescent individuals. The median [IQR] matched follow-up period was 2.9 [2.3-5.3] years before and after HT. A smaller percentage of patients in the total cohort reported SA (10 [11%], 22 [24%], P=0.012) after HT. Among adolescents, there was a smaller proportion who reported SA (9 [13%]; 25 [25%], P=0.039) and NSSI (13 [18%], 25 [35%], P=0.019) after versus before HT. The number of prescribed psychotropic medications and acute mental health visits did not change between the two follow-up periods in the overall cohort. Among adolescents, however, the frequency of acute mental health visits declined from 0.47 visits/year (standard deviation [SD]: 0.48) to 0.25 visits/year (SD: 0.86) (p=0.017). Patients who sought acute mental health care after HT initiation, compared with those who did not, were significantly more likely to have history of abuse (20 [50%], 11 [22%], P=0.004) and unstable housing e.g., homelessness or transitioning between foster placements (12 [30%], 5 [12%], P=0.01). Conclusion Our findings demonstrate improvements in psychosocial well-being after nearly three years of HT, which corroborates and expands upon the findings of prior studies with shorter-term follow-up. This study also provides the first report of the positive impact of HT on NSSI in adolescents. Characterization of patient and psychosocial factors associated with increased risk of poor mental health outcomes is needed to better support TGD people throughout their transition.

Introduction: Transgender and gender non-conforming patients with a high BMI (>35 kg/m2) are often denied gender-affirming mastectomy (GAM) due to concerns related to body habitus and increased risk of complications (1). Factors such as weight bias and concern for poor aesthetic outcomes may further dissuade surgeons from working with patients with high BMI (2). This study aims to evaluate the impact of BMI on surgical complications following GAM, comparing outcomes in patients with high BMI (≥35 kg/m2) to those with normal BMI (18.5-24.9). Additionally, we introduce a tailored surgical approach aimed at reducing the risk of undesirable "dog-ear" deformities in overweight and obese patients.

Methods: A retrospective review was conducted to identify all GAM performed between January 2011 and September 2023 by a single surgeon. Patients were stratified by BMI to compare medical and surgical outcomes within 90 days postoperatively. Demographics, comorbidities, and complications, including hematoma, seroma, dehiscence, unplanned observation, and other complications were analyzed. BMI groups were compared using an analysis of variance (ANOVA) F test for continuous variables and a Chi-square test for categorical variables. Multiple logistic regression analyses were conducted to examine the association between BMI cohorts and complications, adjusting for significant covariates on univariate analysis (age, race, hypertension, type II diabetes, sleep apnea, and asthma).

Results: Among 519 GAM patients, BMI cohorts included normal (n=118), overweight (n=134), class I obesity (n=110), class II obesity (n=79), and class III obesity (n=78). Significant differences were observed between BMI groups for unplanned observation (p=0.0323) and other complications (p< 0.001). "Unplanned observation" involved extended post-operative admissions and emergency encounters, while "other complications" encompassed issues such as cellulitis, edema, hypersensitivity, keloids, and paresthesias. There were no differences between BMI groups for hematoma, seroma, or dehiscence. After adjusting for significant covariates, patients with class III obesity had more unplanned observations than patients with normal weight (p=0.0193). Other complications were significantly greater in overweight and obese cohorts compared to normal weight (p<0.05).

Conclusions: Patients with a high BMI (>35 kg/m2) undergoing GAM did not exhibit an increased risk of common complications, such as hematoma, seroma, or dehiscence, within the first 90 days postoperatively compared to individuals with a normal BMI. However, they did have a greater likelihood of unplanned observation and other complications, including cellulitis, edema, and paresthesias. Given that patients were not at higher risk for serious complications, this study advocates for accepting patients seeking GAM at their existing weight without mandating preoperative weight loss. Furthermore, it emphasizes the importance of a customized surgical approach that addresses the entire chest contour, including the removal of excess lateral thoracic tissue, to achieve a flatter, squared-off appearance.

1. Tjeertes EKM, Hoeks SE, Beks SBJ, Valentijn TM, Hoofwijk AGM, Stolker RJ. Obesity–a risk factor for postoperative complications in general surgery? BMC Anesthesiol. 2015;15:112.
2. Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-326.

Background: As an element of facial feminization surgery (FFS), sliding genioplasty is considered the most effective approach for aligning chin morphology with more feminine ideals. While two-dimensional imaging analysis has previously been used to quantify soft-tissue changes after genioplasty, this study presents a novel three-dimensional (3D) morphometric assessment.

Methods: Patients who underwent feminization genioplasty at a large academic medical center were enrolled. To be included, patients needed to have a complete panel of 3D imaging pre- and post-operatively. 3D photogrammetric evaluation was performed to assess nasofacial angle, nasomental angle, facial angle, facial thirds, chin projection, chin height, chin width, and chin angles. For all measurements, standard anthropometric points were placed by two observers in a blinded fashion. Soft-tissue changes were correlated with hard-tissue changes measured through computerized tomography imaging analysis.

Results: Fourteen patients met the inclusion criteria. The mean time between the date of surgery and post-operative 3D imaging was 10.70 ± 8.93 months. All measurements had substantial to almost perfect inter-rater reliability between the two raters. Pre- to post-operatively, the mean facial angle increased by 2.07° (p = 0.003), chin height decreased by 1.16 mm (p = 0.033), right chin angle increased by 1.20° (p = 0.031), left chin angle increased by 1.40° (p = 0.017), and chin width decreased by 1.59 mm (p = 0.034). Soft- and hard-tissue chin projection changes were positively correlated (r = 0.524, p < 0.001).

Conclusion: The quantification and correlation of 3D soft- and hard-tissue changes following feminization genioplasty allow for a comprehensive evaluation of post-operative outcomes and the potential need for secondary, revision surgeries.

Purpose: Non-binary individuals who are assigned female at birth are increasingly presenting for gender affirming chest surgery (GACS) (Esmonde et al., 2019). Although GACS is known to positively impact psychosocial outcomes among binary transgender men (Lane et al., 2023), little is known about psychosocial outcomes following surgery in non-binary individuals. We compare patient reported and clinical outcomes of gender affirming chest surgery between non-binary individuals who were assigned female at birth and binary transgender men who underwent GACS at our institution. Methods: We performed an institutional retrospective chart review. Demographic information, medical comorbidities, history of gender-affirming medical care, operative details, and complications were collected and compared between non-binary and binary patients. To evaluate postoperative psychosocial outcomes, an online survey was administered using REDCap at least 6 weeks following GACS. The survey included two widely used patient reported outcomes measures: the Gender Congruence and Life Satisfaction (GCLS) scale and the Chest Dysphoria Measure (CDM). Bivariate analysis was used to compare demographics, surgical outcomes and patient-reported outcomes between the non-binary and transgender male cohorts, and multivariate linear regression was performed to identify factors associated with patient reported outcomes scores. Results: 281 patients were included in the study, of which 40.6% (n=114) identified as non-binary and 59.4% (n=167) identified as binary transgender men. Fewer non-binary patients used testosterone (p<0.001). A greater proportion of binary transgender men (22.2%, N = 37) identified as Black or African American compared to non-binary individuals (7.9%, N = 9). Non-binary patients underwent a wider variety of masculinizing chest operations than binary patients, with less non-binary patients electing for free nipple areolar complex grafts (NAC) (p<0.001) and more non-binary patients undergoing breast reduction (p=0.001). 137 (48.7%) patients responded to post-operative surveys. Non-binary and binary respondents had comparable scores on the overall GCLS (p=0.86), GCLS chest subscale (p=0.38) and CDM (p=0.40). Absence of NAC grafts was associated with higher GCLS chest scores (p=0.004) and non-binary identity was associated with decreased social gender recognition scores (p<0.001). Conclusion: Non-binary individuals have similarly positive outcomes following gender affirming chest surgery compared with binary individuals. Surgeons working with non-binary patients should be aware of increased heterogeneity in this population and seek to understand individual patients' goals and priorities. Future research is needed to understand the impact of intersectional racial identities on access to gender-affirming surgery for non-binary individuals.

References Esmonde N, Heston A, Jedrzejewski B, et al. What is "Nonbinary" and What Do I Need to Know? A Primer for Surgeons Providing Chest Surgery for Transgender Patients. Aesthet Surg J. 2019;39(5):NP106-NP112. doi:10.1093/asj/sjy166 Lane M, Kirsch MJ, Sluiter EC, et al. Gender Affirming Mastectomy Improves Quality of Life in Transmasculine Patients: A Single-center Prospective Study. Ann Surg. 2023;277(3):e725-e729. doi:10.1097/SLA.0000000000005158

Background/Purpose: As of 2022, an estimated 1.6 million Americans identify as transgender or gender non-conforming, constituting a significant patient population with unique health needs(1). Gender-affirming surgery, hormone therapy, and behavioral health interventions are among the most popular and well-represented areas of gender-affirming care, and a growing number of resources are available to aid in gender transition. Medical tattooing carries promising implications in aesthetic outcomes as well as accessibility. Healthcare teams, LGBTQ+ resource centers, and tattoo businesses integrate medical tattooing with gender-affirming care, yet standards are underdeveloped and infrequently proposed in the literature. This review discusses applications of medical tattooing within gender-affirming care and identifies areas of need for future research.

Methods: A literature search was conducted electronically through PubMed database. The search included literature written in the English language and published within the date range February 2014 through 2024. The search terms "medical" and "tattoo" were combined with the "AND" operator, and the "NOT" operator was used to specify against literature on tattoo "removal" or "complications". Articles written on decorative tattooing, complications, or applications irrelevant to gender affirmation were excluded.

Results: The initial search yielded 668 publications, which were further subjected to exclusion criteria. After exclusion criteria were applied, 54 relevant articles were selected for review. Of the selected 54 articles, 42.6% covered surgical and tattooing techniques as well as clinical guidelines, 24.1% were review papers, 11.1% were studies on patient satisfaction, and 7.4% were case reports. When categorizing articles according to applications of medical tattooing, 40.7% were written on breast and nipple-areolar complex tattooing, 20.4% on head and neck tattooing or microblading, 3.7% on scar camouflage, 3.7% on tattoos used for health informatics, and 7.4% on a combination of applications. There were not any articles identified in the search that focused exclusively on the transgender patient population.

Conclusions: There are numerous applications of medical tattooing that promote gender affirmation, including nipple-areolar complex tattooing, scar camouflage, scalp microblading, permanent makeup, and health information storage. Although a growing number of gender-affirming healthcare providers refer patients to tattoo artists, medical tattooing specific to transgender patients has not been discussed in the literature. Given the nuances of gender dysphoria and its management, future studies must be conducted specifically within this population in order to evaluate the success of medical tattooing in addressing gender dysphoria, as well as the extent to which it is utilized. Further, due to its widespread and interdisciplinary uses, medical tattooing and related standards of care should continue to develop within the realm of healthcare, rather than as an afterthought.

References: 1. Flores A, Herman J, Gates G, Brown T. How many adults identify as transgender in the United States? Williams Institute. Published June 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/

Purpose: Transgender and gender-diverse (TGD) individuals face frequent barriers to gender-affirming care (GAC), including insurance obstacles, financial and legal constraints, inadequate access to mental health services and poor social support. Our study aimed to identify the most prevalent barriers to GAC, focusing on those contributing to loss of follow-up and examining how these barriers differ with age.

Methods: We performed a retrospect review of patients who sought GAC at our multidisciplinary center for TGD care from September 2018 to September 2019. For patients who underwent intake, we evaluated patient charts and staff messages to ascertain reasons for lack of follow-up, and impediments to surgical or non-surgical services. Descriptive statistics were calculated. Bivariate analyses and univariate linear regression were performed.

Results: Of 577 patients who had an intake, the majority identified as transmasculine (n=319 [55%]), followed by transfeminine (n=205 [36%]), and non-binary (n=47 [8%]). Half the individuals who had an intake attended a clinic visit (n=284 [49%]) and were followed for a median (interquartile range [IQR]) duration of 16 (3-38) months. The most common barrier to GAC was insurance (159 [28%]), followed by obtaining behavioral health letters (84 [15%]), followed by weight loss (76 [13%]). Of 104 patients with available insurance information, most patients had private insurance (n=76 [73%]). Patients with insurance as a barrier to care were more likely to have a shorter follow up (less than one year) (n=124 [62%]) as compared to a longer (more than one year) follow up (n=41 [48.8%]) compared with patients who had cited other barriers. Patients who had weight loss as a barrier were less likely to attend a clinic visit following intake (n=47 [61.8%]) as compared to those who did not have weight loss as a barrier (n=246 [49%], P=0.048). For every additional year of age, there was a corresponding 2% increase in the odds of having insurance as a barrier (1.023Age - 1.64, 95% confidence interval [CI] [1.006, 1.040], P=0.009) and a 3% increase in the odds of having weight loss as a barrier (1.026Age - 2.67, 95% CI [1.005, 1.048], P=0.016).

Conclusion: Weight loss and insurance coverage represent substantial impediments to access of GAC, particularly among older patients. Our study is the first to investigate how barriers to GAC vary across age and how common barriers to GAC affect patient's continuity of care.

BACKGROUND: Gender affirmation surgery (GAS) has gained traction in recent years due to increased acceptance of transgender individuals and has shown therapeutic benefits for patients. Unfortunately, the literature is sparse on the causes of postoperative complications and re-operation rates post-bottom surgery. Evaluating surgical outcomes of male-to-female (MtF) bottom surgery remains an important step towards improving care for transgender patients undergoing GAS. Our study aims to evaluate postoperative complications with potential risk factors and re-operation rates following MtF surgery, with the ultimate goal of improving surgical outcomes in the transfeminine population. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2020 was utilized to identify patients undergoing GAS with the relevant CPT and ICD 9 and ICD 10 codes. Multivariate regression analysis was performed to identify risk factors for unplanned reoperation using the IBM SPSS statistical system. A risk-adjusted multivariate regression analysis controlling for BMI, age, race, smoking status, and diabetes was also performed to identify other risk factors using odds ratio (OR). RESULTS: 651 cases of MtF bottom surgeries were identified. The adverse event that posed the highest risk for reoperation in this study was wound disruption/dehiscence (OR=73.85, p<0.001). History of steroid use for a chronic condition (OR=11.56, p=0.05) and longer operation times (OR=1.27, p=0.04) were also shown to be risk factors. Patients who needed a red blood cell transfusion intraoperatively or 72 h postoperatively were 6.40 times more likely to undergo an unplanned reoperation compared to those who did not need a transfusion (p=0.05). CONCLUSION: Our results suggest that the choice of appropriate surgical technique, minimizing blood loss and operation length, and postoperative wound care are crucial in decreasing unplanned reoperation. These ideas can aid plastic surgeons to minimize the risk of postoperative complications and improve surgical outcomes in the MtF transgender population.

Introduction/Background: Publicly available artificial intelligence (AI) in healthcare may transform patient education and reshape patient-provider relationships. Machine-learning language models such as ChatGPT are being increasingly applied to medical education (1). Gender-affirming surgery (GAS) refers to surgical procedures to help people transition to their self-identified gender. Given its extremely personal and emotionally-charged nature, GAS recipients may have a variety of questions and concerns related to the procedure (2). Thus, plastic and reconstructive surgeons may rely on AI-driven chatbots as an accessible, accurate, and patient-driven educational model.

Specific Aim(s): This research investigates whether ChatGPT-3.5 can provide comprehensive, accurate, safe, and emotionally sensitive information about gender-affirming surgery (GAS) mastectomy. This research will determine whether AI-driven chatbots can serve as supplementary resources for patient education through the lens of GAS.

Methods/Analysis: Ten frequently-asked questions (FAQs) concerning pre- and post-operative topics were sourced from online forums and physician websites, then inputted into ChatGPT-3.5. The generated responses were assessed using validated readability score systems, including the Flesch-Kincaid Score, Coleman-Liau Index, and SMOG Score. ChatGPT-3.5 responses were evaluated by plastic and reconstructive surgeons (n=7) that perform GAS mastectomy to assess accuracy, comprehensiveness, and potential danger to patients via a Likert Scale from 1 (e.g., least accurate) to 10 (e.g., most accurate). Each physician also commented on the responses' strengths and weaknesses.

Results: A normal distribution of the responses' readability scores collectively displayed an average reading score of 16.0 ± 1, indicating a college or graduate level in comparison to the national average of an eighth-grade reading level. Collectively, the mean accuracy, comprehensiveness, and danger scores were 8.8 ± 0.5, 7.8 ± 0.7, and 2.2 ± 0.4, respectively. Qualitatively, most physicians responded favorably to ChatGPT's practical advice, informative responses, even and considerate tone, acknowledgement of the variety of surgical techniques, emphasis on patient autonomy in surgeon selection, need to see a healthcare provider, and mention of mental health support. However, physicians also acknowledged instances of generic and unhelpful information, missing procedural details, incorrect and misleading assessments of post-operative estimates, support of debated or dangerous techniques, concern about labeling gender dysphoria as a psychological condition, and failure to emphasize mental help follow-up post-surgery.

Conclusions: While physicians acknowledge that ChatGPT-3.5 can sometimes provide generally accurate, comprehensive, and safe responses to FAQs pertaining to GAS mastectomy, certain concerns and generic answers warrant serious investigation of its future utility in patient education. While considering its potential limitations, ChatGPT-3.5 could serve as a useful supplementary education tool to patients in addition to physician consultation.

References: 1. Sallam M. ChatGPT Utility in Healthcare Education, Research, and Practice: Systematic Review on the Promising Perspectives and Valid Concerns. Healthcare. 2023; 11(6):887. https://doi.org/10.3390/healthcare11060887 2. Tirrell, A.R., Chang, B.L., Perez-Alvarez, I.M. et al. Selecting a chest masculinization plastic surgeon: a survey of transgender patients. Eur J Plast Surg 46, 563–571 (2023). https://doi.org/10.1007/s00238-022-02020-6

The use of a subfascial plane for breast augmentation offers significant advantages to both subglandular and subpectoral planes. (1) But subfascial augmentation is only popularized with cis women, and still remains novel and poorly described for breast augmentation in trans women. (2) Breast augmentation in trans women introduces additional anatomic considerations when compared to the same procedure in cis women. Differences include thicker pectoralis muscles, wider chests, shorter nipple to inframammary fold distances, and less breast tissue. These anatomic differences make a subglandular approach for augmentation challenging due to a lack of soft tissue coverage, while a submuscular approach carries a substantial risk of animation deformity. To address these differences we investigated the benefits of the subfascial plane for breast augmentation in trans women. (3) We conducted a retrospective review of patients that presented between 2021-2023 to a single site for gender affirming breast augmentation. Patients underwent a primary augmentation via inframammary fold incision and regular follow up at 1 week, 1 month, and 4 month intervals. Findings regarding patient complication rate and demographic factors were documented and compared to those in published literature. 35 patients were included in this study. The average age of included patients was 32 years old, with an average implant of 455ccs bilaterally. The average body mass index was 27, and every patient was on some degree of long term hormone therapy prior to surgery. Only a total of 3 complications required reoperation: 1 case of capsular contracture, 1 unilateral hematoma, and 1 clinically significant seroma. No patients necessitated reoperation for unfavorable aesthetic results or nipple malposition. Overall, subfascial augmentation in trans women offers the benefits of a subglandular implant placement while also offering rates of capsular contracture, hematoma, and seroma comparable to subpectoral augmentation. We conclude that subfascial is an overall safe and aesthetically pleasing plane of augmentation that ideally addresses the anatomical and medical differences associated with trans women.

[1] Graf RM, Junior IM, de Paula DR, Ono MCC, Urban LABD, Freitas RS. Subfascial versus Subglandular Breast Augmentation: A Randomized Prospective Evaluation Considering a 5-Year Follow-Up. Plast Reconstr Surg. 2021 Oct 1;148(4):760-770. doi: 10.1097/PRS.0000000000008384. PMID: 34550930.

[2] Mehra G, Kaufman-Goldberg T, Meshulam-Derazon S, Boskey ER, Ganor O. Use of the Subfascial Plane for Gender-affirming Breast Augmentation: A Case Series. Plast Reconstr Surg Glob Open. 2021 Jan 21;9(1):e3362. doi: 10.1097/GOX.0000000000003362. PMID: 33564588; PMCID: PMC7858195.

[3] Torres Perez-Iglesias CA, Heyman A, Koh DJ, Medina N, Roh DS, Slama J. Technical and Clinical Differences Between Transgender and Cisgender Females Undergoing Breast Augmentation. Ann Plast Surg. 2023 Nov 1;91(5):534-539. doi: 10.1097/SAP.0000000000003706. Epub 2023 Sep 23. PMID: 37823620.

Introduction: Midface augmentation and lower face fullness reduction is commonly performed in facial feminization surgery. Traditionally, approaches such as fillers, fat grafting, bone repositioning, and alloplastic implants have been performed. In the evolving landscape of FFS, we present a case series utilizing a pedicled buccal fat pad flap to augment the midface while reducing lower facial volume.

Methods: This case series consisted of 4 patients who elected to proceed with gender-affirming facial surgery to augment the midface and contour the lower face. Buccal fat transposition involves accessing the fat pad through an intraoral incision and resuspending the fat pad to the desired midface position. The fat pad is then secured to the periosteum in the desired position. Concomitant procedures performed included mandibular contouring and genioplasty, partial masseter muscle resection, and facial fat grafting.

Results: No postoperative complications were observed. Subjective improvement in midface fullness and a reduction in lower-face fullness were appreciated.

Conclusion: Our case series indicates that buccal fat pad transposition is a promising technique in gender-affirming facial surgery. Contrary to alternatives, such as fat grafting or implants alone, this method can simultaneously improve midface fullness while contouring the submalar and lower facial region. Careful patient selection, good fixation technique, and appropriate adjunctive procedure utilization are essential to achieve consistent results.

PURPOSE: Early in the covid19 pandemic, the College of Surgeons, Society of Plastic Surgeons and others advocated for broad changes in health care, including telemedicine and postponement of non-urgent procedures when feasible. Over time, several studies described increasing ambulatory discharges after oncologic mastectomy and implant-based breast reconstruction.(1) There is a paucity of literature exploring surgical outcomes of transgender and gender-diverse (TGD) patients during the pandemic;(2) we identified no studies focused on gender-affirming mastectomy. TGD patients experience implicit bias due to how electronic health records (EHR) report name, gender and pronouns. With direct release of EHR notes, patients may visualize documentation of their non-affirmed name or pronouns in health portals. Optimizing communication is a way to improve outcomes in gender-affirming surgery.(3) We sought to characterize the impact of ambulatory discharges after mastectomy, focused on a TGD cohort.

METHODS: This is a chart review of three years before/after institution of the covid19 state of emergency at our health system. Demographics include gender, affirmed name, incision type, infection, fluid collection. Unplanned healthcare-utilization (secure messaging or contact via after-hours triage line) was also analyzed. EHR was reviewed to infer whether patients may have been misgendered or deadnamed during hospitalization: analysis designed as 'cultural complications' (after Harris(4)), representative of putative harm from implicit bias. This de-identified study was deemed exempt by Institutional Review Board (IRB) of Duke University.

RESULTS: A cohort of 57 adults was identified, with two-thirds undergoing surgery post-pandemic. Overall, 35% identified as non-binary (NB) or genderfluid. Among NB patients, 20% chose to undergo mastectomy without nipple areolar complex (NAC) reconstruction. There were no statistically-significant differences in complications between ambulatory and overnight groups (hematoma, seroma, infection), nor when comparing incision type. Ambulatory patients may have a higher rate of unplanned healthcare utilization, but this was not statistically significant. Ambulatory and overnight patients were charted with non-affirmed name or pronouns (47% vs 62%): same-day-discharge did not increase likelihood (χ2=3.740, p=0.0531).

CONCLUSIONS: Ambulatory gender-affirming mastectomy can be a safe practice: we found no evidence of increased risk of post-surgical complications, unplanned healthcare utilization or misgendering. Even though EHR and surgical notes use affirmed names, patients can still be mis-documented during hospitalization. This emphasizes the value of verbal sign-outs, and suggests a mitigation strategy to be free-typing notes with patients' affirmed name and pronouns.

Areas for improvement included discharge instructions and ensuring patients could contact clinicians on-call after hours or share photographs should they be concerned. Gender-neutral terminology should be used whenever possible, especially with NB patients. An important finding is 20% of NB patients in our practice chose to undergo mastectomy without NAC. There is a paucity of research regarding best practices with NB or genderfluid patients. Several authors have called for increased attention to TGD patient-reported outcomes, involving those with lived experience.(5) Further studies are needed; ours represents the first report of gender-affirming mastectomy during the pandemic, providing insights on quality improvement.

1.Marxen et al.PRSgo.2022;10(7):e4448.

2.Kloer et al.Am J Surg.2023;225(2):367-373.

3.Makhoul et al.Ann Plast Surg.2022;88(5Suppl5):S478.

4.Harris et al.Ann Surg.2021;273(3):e97-e99.

5.Peters et al. PRSgo.2022;10(10):e4616.

Introduction: Topical nitroglycerin has been shown to improve wound healing and decrease flap necrosis after oncologic mastectomy. 1,2 Its impact after gender affirming mastectomy, however, has not been evaluated well. The purpose of this study is to investigate the effectiveness of topical nitroglycerin on patients undergoing double incision mastectomy with free nipple grafts (DIFNG), especially regarding nipple graft and wound related outcomes.

Methods: Adult patients undergoing DIFNG from August 2022 to December 2023 at a tertiary university hospital were recruited for the study. Study participants were randomized into a control and treatment group. All surgeries were performed by the two senior authors using the same surgical technique and perioperative regimen. Control group had one-time, intra-operative application of bacitracin ointment to the nipple graft and surrounding mastectomy flap, while the treatment group had topical nitroglycerin (15mg each side) applied. They were evaluated at 5 days, 2 weeks and 6 weeks post-operatively for partial or total graft loss. Wound complications were evaluated as well. An ordinal logistic regression was performed to control for smoking status.

Results: A total of 93 patients were recruited with 46 participants in the control group and 47 participants in the treatment group. The two groups did not show any significant differences in demographics, comorbidities, ptosis grade, pre-operative hormone therapy or chest binding. Overall, partial nipple graft loss rate was 36.6% without any total graft loss. The incidence of partial graft loss was significantly lower in the topical nitroglycerin group compared to that of control group (21.3% vs. 52.2%, p = 0.00481). There was no significant difference in wound complications (10.9% vs. 10.6%, p=1.0).

Conclusions: One-time application of topical nitroglycerin around free nipple grafts in DIFNG is associated with a significant decrease in rates of partial nipple graft loss. There were no significant differences in wound complications.

References

1. Gdalevitch P, Van Laeken N, Bahng S, et al. Effects of nitroglycerin ointment on mastectomy flap necrosis in immediate breast reconstruction: a randomized controlled trial. Plast Reconstr Surg. 2015;135(6):1530-1539.
2. Wang P, Gu L, Qin Z, Wang Q, Ma J. Efficacy and safety of topical nitroglycerin in the prevention of mastectomy flap necrosis: a systematic review and meta-analysis. Sci Rep. 2020;10(1):6753-6753.

Purpose: Gender-affirming mastectomy (GAM) is an integral aspect of transition process for transgender, gender-diverse, and nonbinary individuals, particularly those assigned female at birth. However, access to this vital healthcare intervention is often hindered by socioeconomic factors, among which the Area Deprivation Index (ADI), serving as a proxy of socioeconomic status (SES), holds significance. The ADI, a widely used measure in public health research, provides comprehensive understanding of social determinants influencing health outcomes and quality of life. It offers insight into SES within specific geographic areas. While lower SES have been associated with barriers to healthcare, its impact on postoperative outcomes in GAM remains understudied. This study aimed to assess the association between the ADI and postoperative outcomes in GAM patients.

Methods: A retrospective review of 415 patients who underwent GAM at a single institution between 2014 and 2023 was conducted. State-level ADI deciles were derived from the University of Wisconsin's Neighborhood Atlas, using patients' residential addresses. Lower ADI deciles indicated neighborhoods with the least deprivation, while higher ADI deciles indicated neighborhoods with the most deprivation. Patients were categorized into quintiles based on ADI. Univariate and multivariate analyses examined the impact of SES on postoperative outcomes.

Results: Of 415 patients who underwent GAM, 25.3% resided in the least deprived neighborhoods (ADI quintile 1), while 28.7% resided in the most deprived neighborhoods (ADI quintile 5). Patients from higher ADI quintiles faced greater geographical barriers to care, with longer distance to the hospital and increased travel time (203 miles and 217 minutes for quintile 5 versus 24 miles and 69 minutes for quintile 1). Additionally, patients from more deprived neighborhood showed a higher prevalence of major depressive disorder (MDD) (68.9% in quintile 5 vs. 54.3% in quintile 1). Surprisingly, postoperative complications did not significantly differ across socioeconomic groups. Multivariate analysis showed that the use of post-operative drains was associated with a significantly lower odds of experiencing complications after GAM (OR 0.07, 95% CI 0.006-0.8, p=0.036).

Conclusion: This study reveals that individuals undergoing GAM from socioeconomically deprived neighborhoods encounter significant geographic and mental health challenges. It echoes findings from published literature that have shown how socioeconomic disparities can impact various aspects of healthcare access and outcomes. For instance, studies in breast cancer patients have demonstrated that lower SES is associated with delayed diagnosis, less access to specialized care, and poorer overall survival rates. However, the findings from our study suggest that within the realm of gender-affirming surgeries the disparities in SES do not seem to manifest as disparities in postoperative outcomes. This aligns with broader discussions about the importance of equitable access to healthcare services, particularly for marginalized communities. Efforts to address these disparities have included interventions at multiple levels, such as improving access to insurance coverage, providing transportation assistance, and implementing culturally competent care practices. While our study did not find a direct link between SES and postoperative outcomes in GAM, it underscores the need for continued efforts to address socioeconomic disparities in healthcare access and outcomes.

Purpose: Gender-affirming mastectomy (GAM) is an integral aspect of transition process for transgender, gender-diverse, and nonbinary individuals, particularly those assigned female at birth. However, access to this vital healthcare intervention is often hindered by socioeconomic factors, among which the Area Deprivation Index (ADI), serving as a proxy of socioeconomic status (SES), holds significance. The ADI, a widely used measure in public health research, provides comprehensive understanding of social determinants influencing health outcomes and quality of life. It offers insight into SES within specific geographic areas. While lower SES have been associated with barriers to healthcare, its impact on postoperative outcomes in GAM remains understudied. This study aimed to assess the association between the ADI and postoperative outcomes in GAM patients.

Methods: A retrospective review of 415 patients who underwent GAM at a single institution between 2014 and 2023 was conducted. State-level ADI deciles were derived from the University of Wisconsin's Neighborhood Atlas, using patients' residential addresses. Lower ADI deciles indicated neighborhoods with the least deprivation, while higher ADI deciles indicated neighborhoods with the most deprivation. Patients were categorized into quintiles based on ADI. Univariate and multivariate analyses examined the impact of SES on postoperative outcomes.

Results: Of 415 patients who underwent GAM, 25.3% resided in the least deprived neighborhoods (ADI quintile 1), while 28.7% resided in the most deprived neighborhoods (ADI quintile 5). Patients from higher ADI quintiles faced greater geographical barriers to care, with longer distance to the hospital and increased travel time (203 miles and 217 minutes for quintile 5 versus 24 miles and 69 minutes for quintile 1). Additionally, patients from more deprived neighborhood showed a higher prevalence of major depressive disorder (MDD) (68.9% in quintile 5 vs. 54.3% in quintile 1). Surprisingly, postoperative complications did not significantly differ across socioeconomic groups. Multivariate analysis showed that the use of post-operative drains was associated with a significantly lower odds of experiencing complications after GAM (OR 0.07, 95% CI 0.006-0.8, p=0.036).

Conclusion: This study reveals that individuals undergoing GAM from socioeconomically deprived neighborhoods encounter significant geographic and mental health challenges. It echoes findings from published literature that have shown how socioeconomic disparities can impact various aspects of healthcare access and outcomes. For instance, studies in breast cancer patients have demonstrated that lower SES is associated with delayed diagnosis, less access to specialized care, and poorer overall survival rates. However, the findings from our study suggest that within the realm of gender-affirming surgeries the disparities in SES do not seem to manifest as disparities in postoperative outcomes. This aligns with broader discussions about the importance of equitable access to healthcare services, particularly for marginalized communities. Efforts to address these disparities have included interventions at multiple levels, such as improving access to insurance coverage, providing transportation assistance, and implementing culturally competent care practices. While our study did not find a direct link between SES and postoperative outcomes in GAM, it underscores the need for continued efforts to address socioeconomic disparities in healthcare access and outcomes.