Scientific Abstract Presentations: Gender Affirmation Session 2 Friday, September 27 Fri, Sep 27 8:00-9:30 a.m. PDT

Background: Targeted Nipple Areola Complex Reinnervation (TNR) is a nerve preservation and reconstruction technique shown to restore baseline sensation at the chest and nipple areola complex (NAC) after gender affirming mastectomy (GAM) with free nipple grafting (FNG). We describe the senior authors learning curve for nerve dissection allowing for primary use of direct coaptation instead of nerve graft over time. Further, this study explores the postoperative time to sensation and sensory outcomes between direct repair and use of nerve allografts.

Methods: 60 patients who underwent GAM/ FNG at two institutions were prospectively enrolled from November 2021 through September 2023. Three groups with 20 patients each were compared: GAM/FNG + TNR with nerve allograft reconstruction (group 1), GAM/FNG + TNR with direct coaptation (group 2), and a control group GAM/FNG - TNR (group 3). Demographics, mastectomy weight, operative time, intraoperative nerve anatomy and nerve reconstruction technique were collected. Semmes Weinstein filament testing was used preoperatively, and at one, three-, six-and twelve months postoperatively. Monofilament index values included 2.83, 3.61, 4.34, 4.56 and 6.65, with lower values indicate lower threshold for detection, and therefore higher sensitivity. Chi-square analysis was used to detect sensation return differences between groups.

Results: Average preoperatively sensation was 3.56 at the chest and 3.87 at the NAC. A learning curve was associated with nerve branch dissection and coaptation with only the first 20 patients requiring a nerve graft. Demographics were comparable between all groups (p > 0.05). Per mastectomy, an average of 2 ICN branches were used for direct coaptation. Median allograft length was 3.5 cm (1.5-4.0). Preoperative sensation was comparable between groups (p= 0.77). NAC and chest skin sensation were significantly worse as compared to baseline in all groups at the one-month post-operative visit (p < 0.01). At 3 months postoperatively, NAC and Chest skin sensation values in group 1 and group 2 were significantly improved as compared to group 3 (p< 0.05). At 6 months, 72.7% of patients within group 2 demonstrated NAC sensation equal or improved from baseline. In comparison only 28.1% group 1 had NAC sensation equal to or improved from baseline (p <0.05). Similarly, at 6 months postoperatively 72.7% of patients in group 2 had equal or returned chest sensation, compared to 38.9% of patients in group 1. By 12 months, all sensation level were comparable between groups 1 and group 2 (p>0.05): 70% of group 1 and 83% of group 2 had equal or improved chest sensation, and 79.2% of group 1 and 100% of group 2 had equal or improved NAC sensation. Group 3 continued to have less sensation than the other groups, with 18% having equal or improved NAC sensation and 58% having equal or improved chest sensation.

Conclusion: After a short learning curve to improve nerve dissection, TNR with direct coaptation is efficacious and cost effective in restoring chest wall sensation for patients undergoing GAM, with promising results for return of sensation. Both allograft reconstruction and direct repair are feasible options with similar sensory outcomes at 12 months postoperatively.

Purpose: Surgical contouring of the frontal bone and orbital rims are foundational components of facial feminization surgery, which can have a transformative impact on gender identity and quality of life in patients. There is minimal evidence with which an individual patient's anatomy can be objectively placed in the context of natural morphologic variations within a population. As a result, identifying surgical candidates and defining the optimal morphologic endpoints of intervention remain subjective decisions. Borrowing from the field of biological anthropology, this study uses three-dimensional geometric morphometrics to: (1) compare skeletal morphology of the frontal and orbital regions between cis-gender men and women, and (2) measure population averages and variability within genders. Methods: We retrospectively reviewed adults who underwent computerized tomography (CT) imaging of the cranium prior to orthognathic surgery. Patients with a history of craniofacial trauma, genetic syndromes, metabolic growth disorders, or exogenous hormone exposure were excluded. A standardized set of 501 digital landmarks was used to capture surface morphometrics of the forehead, supraorbital ridges, and orbital rims. All landmarked crania were aligned using Generalized Procrustes Analysis to assess for differences in shape without the influence of scale, and principal component analysis evaluated the contribution of gender to the overall variance in coordinates. Using Robust Rank Aggregation, a ranked list of important landmarks most predictive of gender was generated after integrating the relative and absolute differences in male and female mean values, linear discriminant analysis weights and magnitudes, and random forest feature importance scores. Results: A total of 154 patients were analyzed, including 70 (45%) males and 84 (55%) females who underwent imaging at a mean age of 23.6±7.7 and 26.0±11.1 years, respectively. A ranked list of 119 important features with significant aggregate rank scores (p<0.05) demonstrated that the highest degree of inter-gender variability concentrated around the following landmarks: (1) the glabella and adjacent points between the brows, (2) the orbitale and adjacent points along the lateral and infraorbital rim, and (3) the supraorbital notch and adjacent points along the medial supraorbital rim. Landmarks along the lateral infraorbital demonstrated the greatest absolute differences between male and female average values, with females displaying a 2.23 mm greater projection in the anteroposterior dimension. The degree of morphologic variability within genders was similar in the male and female populations. Conclusions: This study applies anthropometric methods of shape analysis to create a normative anatomical map with which skeletal dimorphisms can be quantitatively studied at the population level. An analysis of frontal and orbital dimorphism found the greatest degree of inter-gender variability surrounding the glabella, lateral infraorbital rim, and medial supraorbital rim, which may help inform preoperative evaluation and planning for feminizing procedures of the upper facial third.

Background: Hysterectomy is one of the most commonly performed genital gender affirmation surgeries in transmasculine and nonbinary patients and can be performed in a staged manner or at the time of masculinizing genital surgery (1, 2). Prior studies have suggested that adopting a combined approach carries an increased likelihood of complications (3, 4). However, relatively small patient cohorts with varying results were included. This study aimed to (1) define the cohorts of patients undergoing gender-affirming masculinizing genital surgery with and without concurrent hysterectomy and (2) to determine the additive risks of concurrent procedures.

Methods: Patients with a diagnosis of gender dysphoria who underwent masculinizing gender-affirming bottom surgery (GABS) from 2012 to 2022 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The following principal Current Procedural Terminology (CPT) codes: 55980 (metoidioplasty), 55175, 55180 (scrotoplasty, simple or complex) or 56805 (clitoroplasty) were included. Patients were stratified by having a concurrent hysterectomy. Univariate analysis was done to compare the wound, mild systemic, severe systemic, and all-cause complication rates between a single GABS and joint procedure with hysterectomy of any approach.

Results:
A total of 179 patients were included. Patients who had concurrent hysterectomy were, on average, seven years younger than patients who had single GABS (p<0.01). The two groups were similar in comorbid conditions, such as obesity classification, diabetes, and smoking status. The median total operative time nearly doubled in patients who had a combined hysterectomy (p<0.01). There were no differences in wound, mild, severe systemic, or all-cause complications between the two groups.

Conclusion: Our study's results suggest that hysterectomy at the time of masculinizing GABS can be safe when performed in appropriately selected patients. While these combined procedures take longer, as expected, their complication rates are similar. These findings can inform preoperative counseling, while also offering reassurance to surgeons. A combined approach can improve efficiency, access to care, and improve patient satisfaction.

References

1. Ha B, Morrill MY, Salim AM, Stram D, Weiss E. Differences in Surgical Complications for Stage 1 Phalloplasty With Concurrent Versus Asynchronous Hysterectomy in Transmasculine Patients. Perm J. 2022 Dec 19;26(4):49-55. doi: 10.7812/TPP/22.054. Epub 2022 Oct 17. PMID: 36245082; PMCID: PMC9761287.

2. Carbonnel M, Karpel L, Cordier B, Pirtea P, Ayoubi JM. The uterus in transgender men. Fertil Steril. 2021 Oct;116(4):931-935. doi: 10.1016/j.fertnstert.2021.07.005. Epub 2021 Aug 5. PMID: 34364678.

3. Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, Milosevic A, Korac G, Perovic SV. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009 May;6(5):1306-13. doi: 10.1111/j.1743-6109.2008.01065.x. Epub 2009 Oct 27. PMID: 19175859.

4. Bizic M, Stojanovic B, Bencic M, Bordás N, Djordjevic M. Overview on metoidioplasty: variants of the technique. Int J Impot Res. 2020 Nov;33(7):762-770. doi: 10.1038/s41443-020-00346-y. Epub 2020 Aug 21. PMID: 32826970.

Introduction Regret after gender affirming surgery (GAS) is a complex and controversial issue that has been extensively researched. Comparing regret after GAS to regret after plastic surgery operations and other major life decisions, both surgical and non-surgical, is a novel approach that can provide insight into the magnitude of this issue. Importantly, this paper does not seek to equate gender affirming surgery to other elective surgeries or life decisions, but instead aims to provide a framework to understand regret after gender affirming surgery.

Methods A systematic review of three databases was conducted to investigate the rate of regret after common plastic surgery operations. We queried Medline, SCOPUS, and Web of Science databases for relevant keywords ("regret" AND one of the following: breast reconstruction, breast reduction, breast augmentation, mastopexy, facelift, neck lift, abdominoplasty, blepharoplasty, brow lift, rhinoplasty, liposuction, thighplasty, and buttock lift) in accordance with PRISMA guidelines. Information regarding percentage of patients experiencing regret, Decision Regret Scale scores, and any quantitative information was extracted. Separately, three separate literature reviews on regret after GAS, regret after elective surgical operations, and regret after other major life decisions were performed.

Results 295 records were identified on initial query. After abstract screening and inclusion and exclusion were applied, a total of 55 articles examining regret after plastic surgery were included. The Decision Regret Scale was commonly used to report regret, and scores ranged from 3.8-41.9. The percentage of patients reporting regret after plastic surgery operations ranged from 0-72%. Rate of regret after GAS is widely reported to be approximately 1%. Other major life decisions, such as tubal sterilization surgery, elective hernia repair, having children, and getting a tattoo have regret rates of 28%, 11%, 7%, and 16.2%, respectively.

Conclusion Overall, when comparing regret after GAS to regret after other plastic surgeries and other major life decisions, the percentage of patients experiencing regret is minor. The next essential step in the study of regret after gender-affirming surgery is to implement interventions to minimize post-operative regret.

Introduction Racial and ethnic minority groups have historically had more difficulty in accessing healthcare. They have also had worse experiences interacting with the healthcare system. Access issues often stem from structural inequalities, financial difficulties, discrimination, and geography. Beyond race and ethnicity, gender identity often complicates healthcare access and equality for many patients, particularly for patients who identify as transgender and may be seeking gender-affirming surgery. The intersection of these two areas of healthcare inequality may result in deficient healthcare for patients of minority racial and ethnic groups seeking gender-affirming care and surgery. Using a large national inpatient dataset, the present study sought to explore differences in gender-affirming genital surgery characteristics and safety measures by race.

Methods The 2019 Healthcare Utilization Project (HCUP) National Inpatient Survey (NIS) was queried using previously published gender dysphoria ICD-10-CM codes for selected gender-affirming genital surgeries, including vaginoplasty and phalloplasty. Demographics, including race, age, insurance payer, discharge status, and median income for patients were collected. Hospital-level and inpatient safety characteristics were also collected, including bed size, teaching status, for-profit status, region, length of stay, pre-existing comorbidities, and inpatient medical complications. Results were stratified by race and evaluated for significant differences using univariate analysis. Statistical significance was set at p<0.05.

Results A total of 1260 patients were included in the present study. The cohort identifying as White represented 67.5%, while 9.1% were Hispanic or Latino, 5.6% were Black or African American, and 3.1% were Asian or Pacific Islander. After stratification of variables by race, significantly fewer Black patients had a routine discharge (64.3%, p<0.001), and significantly more Hispanic/Latino patients left against medical advice (4.3%, p=0.047). Mean length of stay was significantly longer among Black patients (5.21 days, p=0.033). Mean total charges were highest among Black patients ($199,651, CI $90,216-$309,085, p<0.001). Finally, Black patients experienced significantly more inpatient medical complications (14.3%, p<0.001).

Conclusions While the healthcare population is becoming more diverse, healthcare disparities still exist among non-White individuals receiving gender-affirming genital surgery. These non-White individuals experience significantly more challenges when attempting to receive care, which is further complicated by the United States' policy landscape. Future studies will analyze more historical and recent data to assess trends at this intersection.

Background: It is increasingly recognized that success in surgical care should be defined by both the achievement of technical goals and the patient experience. As past studies have shown conflicting results on the association between the quality of surgical care and patient satisfaction (1), it remains crucial to utilize validated patient reported outcome measures (PROMs) to better define surgical success. In particular, gender-affirming care is a key clinical area that can benefit from PROMs. No validated measure exists exclusively for patients undergoing gender-affirming procedures such as chest masculinization surgery (2). Therefore, the purpose of our study was to understand the association between PROMs and complications on chest wall masculinization surgery.

Methods: A single-center retrospective chart review was performed on patients who received periareolar or double-incision gender affirming top surgery (GATS) between January 2015 to August 2019. Patients completed eleven categories of the BODY-Q and three categories of the SCAR-Q measures postoperatively. These PROMs were used to assess the association of complications and patient-reported outcomes in GATS. The complications cohort consisted of individuals with hematoma, seroma, dehiscence, infection, and NAC hypopigmentation requiring revisions. All patients with reported complications were compared to patients without, with univariate analysis through chi-squared and t-tests, and a multivariate analysis of variables significantly related to complications on univariate analysis. A p-value < 0.05 was considered statistically significant.

Results: A total of 151 patients who underwent GATS were included, and 19 (13%) were noted to have a complication. Patients in the complications group had a significantly higher age (31.58, SD 13.26 vs. 27.24, SD 7.97, p=0.02) with no other differences in demographics and preoperative variables. There were no significant differences between the two groups in the BODY-Q and SCAR-Q responses. There was no significant difference in the adjusted odds of low satisfaction between patients who developed a complication and those who did not (OR = 1.02, 95% CI [0.98, 1.08]).

Conclusions: In our cohort of patients undergoing gender affirming chest masculinization surgery, we found that there was no correlation between the development of a complication and long-term patient reported outcomes measured by two validated PROMs. PROMs should be a primary focus on the success of a plastic surgery procedure, and its continued validation and standardization through hospital systems is critical. Given that complications did not impact long-term satisfaction, this study offers an added reassurance that providers may use to inform their patients.

References 1. Tsai TC, Orav EJ, Jha AK. Patient satisfaction and quality of surgical care in US hospitals. Ann Surg. 2015;261(1):2-8. 2. Kamran R, Jackman L, Chan C, Suk Y, Jacklin C, Deck E, et al. Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review. JAMA Netw Open. 2023;6(4):e236425.

Purpose:   For transfeminine and gender-diverse patients, orchiectomy serves as a critical intervention for alleviating gender dysphoria by aligning the physical appearance with gender identity (1). Following orchiectomy, adjustments in medications and monitoring of hormones are necessary due to the removal of endogenous testosterone. However, guidelines for perioperative medication management in this context are limited. Therefore, this study aims to conduct a descriptive analysis of pre- and post-surgical hormone levels to better understand trends in medication dosing and hormonal monitoring perioperatively.

Methods:   A retrospective chart review was conducted at a single tertiary hospital, focusing on transfeminine patients aged 18 years or older who underwent gender-affirming orchiectomy between January 2018 and December 2024. Data collection included demographic information, surgical details, pre-surgical hormone therapy, associated lab values, post-surgical hormone therapy, and associated lab values. Patients were included if they had at least one pre- and post-surgical value recorded for both medications and labs. Follow-up was conducted up to one year postoperatively.

Results:   Fifty-two adult patients were included in the analysis with an average age of 35 years old. 22 (42.3%) underwent standalone orchiectomy while 30 (57.7%) underwent orchiectomy with concurrent vaginoplasty. Prior to surgery, 43 (82.7%) patients were taking Spironolactone with a mean daily dose of 184.9 mg. All patients were prescribed Estradiol with varying routes, including 20 (38.5%) receiving it sublingually at a mean daily dose of 5.6 mg, 10 (19.2%) orally at a mean daily dose of 4.6 mg, 13 (25%) via injectable at a mean daily dose of 0.85 mg, and 9 (17.3%) transdermally (TD) at a mean daily dose of 0.05 mg. The mean pre-surgical hormone levels were 87 ng/dL for testosterone and 187.73 pg/mL for estradiol. At our institution, the target concentrations for transfeminine hormonal therapy are < 50 ng/dL for testosterone and between 100-200 pg/mL for estradiol. Postoperatively, testosterone consistently decreased to < 50 ng/dL, aligning with target concentrations, while estrogen levels remained mostly within the target range, except for a mean value of 222.44 pg/mL at 24-52 weeks postoperatively. Spironolactone use was discontinued by 83.8% of patients within 52 weeks. Notably, sublingual and injectable forms of Estradiol decreased in dosing, while oral and transdermal forms increased during the 24-52 weeks postoperative interval.

Conclusion:   This study offers insights into perioperative hormonal changes and medication management after gender-affirming orchiectomy. Observation of these trends may serve as a resource for clinicians, enabling them to anticipate changes more effectively. By enhancing understanding of physiological changes and necessary medication adjustments, providers can provide better support in the perioperative period for patients undergoing gender-affirming orchiectomy.

Funding: This study was partially funded by the University of Utah Department of Family Medicine Health Studies Fund.

References:   1. Hehemann MC, Walsh TJ. Orchiectomy as Bridge or Alternative to Vaginoplasty. Urol Clin North Am. 2019;46(4):505-510. doi:10.1016/j.ucl.2019.07.005

Purpose Transgender and gender-diverse (TGD) individuals face many barriers that impede their access to gender-affirming surgery (GAS).1 Prior research has highlighted difficulty in searching for GAS providers and locating information about GAS, with considerable webpage inconsistencies and omission of online information.2,3 As TGD people increasingly rely on the internet when searching for GAS content,4 we investigated the accessibility of online GAS information relative to three of the most common, non-GAS procedures.

Methods The sample included the 100 largest U.S. hospitals by inpatient beds. The three most common surgeries in adults, hip arthroplasty, knee arthroplasty, and cesarean sections were used as comparative search terms. GAS-terms were: gender affirmation surgery, gender-affirming surgery, gender confirmation surgery, gender-confirming surgery, gender reassignment surgery, top surgery, chest masculinization, facial feminization, metoidioplasty, phalloplasty, and vaginoplasty. Non-GAS terms were: Cesarean section, C-section, knee replacement, knee arthroplasty, hip replacement, and hip arthroplasty.

Beginning at the hospital's homepage, each linked webpage was clicked by a Python puppeteer. Each link on subsequent webpages was then followed until 2500 links had been accessed. At each hyperlinked page, TGD terms and comparative non-GAS terms were identified. Information on states' bans on insurance exclusions for TGD-related care was gathered from the Movement Advancement Project.5 We used T-tests, chi-squared tests, and Fisher's exact tests to assess associations between variables.

Results Out of the top 100 hospitals, 82 had websites that could be scraped for key terms. All 82 hospitals' websites had non-GAS terms while only 34 (41.5%) had GAS terms. When averaging the minimum number of followed links needed from each hospital to reach a given term, there was a significant increase in average minimum number of links for GAS terms compared to non-GAS terms (2.56 links vs. 1.74 links; p = 0.005).

Out of the 20 states that had hospitals with GAS terms on their website, 11 states had laws which proscribed against private insurance transgender discrimination. Hospitals in states with these protective laws were more likely to provide information about GAS, with 57.6% (n = 19/33 ) in these states displaying GAS content compared to 30.6% (n = 15/49) in states without such laws (p = 0.015). However, there was no statistically significant difference in the average minimum number of followed links needed to find GAS terms between states that had and did not have protective laws (2.4 clicks vs. 2.8 clicks; p = 0.43).

Conclusions The study reveals disparities in the availability of GAS and the ease of access to GAS information online. The association between transgender-protective laws and offering GAS online GAS content suggests that these laws may foster an environment where hospitals are encouraged to offer GAS or are more willing to disclose that their surgeons perform GAS. Future efforts are needed to increase GAS capacity building around the country, and hospitals should become more transparent about their GAS offerings.

References:

1. Puckett JA, Cleary P, Rossman K, Newcomb ME, Mustanski B. Barriers to Gender-Affirming Care for Transgender and Gender Nonconforming Individuals. Sex Res Social Policy. 2018;15(1):48-59. doi:10.1007/s13178-017-0295-8
2. Evans YN, Gridley SJ, Crouch J, et al. Understanding Online Resource Use by Transgender Youth and Caregivers: A Qualitative Study. Transgend Health. 2017;2(1):129-139. doi:10.1089/trgh.2017.0011
3. Cohen W, Maisner RS, Mansukhani PA, Keith J. Barriers To Finding A Gender Affirming Surgeon. Aesthetic Plast Surg. 2020;44(6):2300-2307. doi:10.1007/s00266-020-01883-z
4. El-Hadi H, Stone J, Temple-Oberle C, Harrop AR. Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care. Plast Surg (Oakv). 2018;26(4):263-268. doi:10.1177/2292550318767437
5. Movement Advancement Project. Healthcare laws and policies. Boulder, CO; 2024. Available from: https://www.lgbtmap.org/equality-maps/healthcarelawsand_policies [Last accessed: February 15, 2024].

Purpose: Financial burden and geographic barriers are significant impediments to obtaining gender-affirming care. The geographical distribution of gender-affirming surgical care has been previously studied but has yet to be assessed through a socioeconomic status lens. This study investigates the association between neighborhood deprivation and availability of gender-affirming surgical care in order to better understand healthcare disparities for transgender and gender non-conforming communities.

Methods: Gender-affirming surgeons were identified using the World Professional Association for Transgender Health (WPATH) and TransHealthCare provider directories. Providers in the TransHealthCare directory were further categorized by surgical procedure(s) performed. Physician practice addresses were cross-referenced with their associated University of Wisconsin Area Deprivation Index (ADI), with higher ADI scores corresponding to areas with greater deprivation. Both state ADI (sADI) and national ADI (nADI) scores were collected. Comparisons between provider ADI quintile groups, region, and procedural category offered were made using one-way nonparametric ANOVA with post-hoc testing.

Results: We identified 817 gender-affirming surgical care providers. Regional distribution of gender-affirming surgical providers showed 307 (37.6%) practiced in the West, 192 (23.5%) in the Northeast, 193 (23.6%) in the South, and 125 (15.3%) in the Midwest. ADI could not be calculated for 87 providers; these providers were excluded from ADI cross-referenced analysis. Analysis of sADI and nADI scores for providers in different regions found that providers in the West on average served significantly more affluent areas while providers in the Midwest served significantly less affluent areas. Of the 817 providers evaluated, 509 (62.3%) offered Top Surgery, 172 (21.1%) offered Bottom Surgery, 281 (34.3%) offered Facial Surgery, 97 (11.9%) offered Body Surgery, 94 (11.5%) offered Reproductive Surgery, and 14 (1.7%) offered Voice Surgery. Analysis of procedure types offered by providers also revealed significant differences in sADI and nADI quintile groups, with Facial Surgery and Body Surgery being offered in areas of higher socioeconomic status. Analysis of the number of procedural categories offered and nADI quintile showed that providers offering only one gender-affirming procedural category practiced in areas of greater socioeconomic deprivation than those offering two (p = 0.03) or four (p = 0.04) procedural categories.

Conclusion: Individuals seeking gender-affirming surgery in different U.S. regions face serious inequities in access to care. Significantly more providers were found to practice in the West and served more affluent communities. There were the fewest number of gender-affirming providers available in the Midwest. In addition, neighborhoods of higher socioeconomic status were found to have providers that offered a wider range of procedures which may lead to greater continuity of care and additional treatment options for patients living in more affluent areas. These findings highlight the barriers to care that transgender patients face in many parts of the country. Increased training opportunities in gender-affirming procedures to improve availability of providers in underserved areas may help to alleviate current healthcare disparities.

Background Social media has become an increasingly popular tool for patients preparing to undergo phalloplasty. Although posts on social media are readily available, the content is not verified or peer-reviewed. This study aimed to assess the quality and reliability of TikTok, YouTube, and Instagram posts related to phalloplasty.

Methods The term "phalloplasty" was searched on TikTok, YouTube, and Instagram on a single day in December 2023. The top 50 posts on each platform were analyzed. The quality of information was assessed with 2 validated tools, the Patient Education Materials Assessment Tool (PEMAT) and the 5-point modified DISCERN instrument, with mean scores obtained by two reviewers. Relevant user metrics, such as number of likes, comments, engagement rate, type of account, and content type, were also collected for each post.

Results Across social media platforms, the majority of top phalloplasty posts were created by patients who had phalloplasty (TikTok: 90%, YouTube: 78%, Instagram: 94%; p=0.0435) and focused on the patient experience (TikTok: 78%, YouTube: 64%, Instagram: 86%; p=0.0334). Healthcare professionals made up a small proportion of posts (TikTok: 8%, YouTube: 18%, Instagram: 4%; p=0.0556). Of that number, plastic surgeons made up 6% of posts. Phalloplasty posts on TikTok received the highest number of likes (p=0.00012), views (p=0.0002), comments (p=0.0014), and engagement rate (p=0.0094). YouTube posts had the highest DISCERN (TikTok: 1.9, Youtube: 3.2, Instagram: 2.1; p<0.00001), PEMAT understandable (TikTok: 84.4, Youtube: 91.2, Instagram: 77.3; p<0.00001), and PEMAT actionable (TikTok: 15.3, Youtube: 86.3, Instagram: 38.5; p<0.00001) scores. Posts created by healthcare professionals had the highest DISCERN scores compared to patients (Healthcare: 3.5, Patients: 2.2; p=0.00002), but had similar PEMAT understandable (Healthcare: 85.5, Patients: 84.2; p=0.719) and actionable (Healthcare: 62.2, Patients: 45; p=0.154) scores. Posts with higher engagement were associated with lower DISCERN scores (r=-0.292, p=0.00029).

Discussion This is the first study to evaluate reliability and quality of content related to phalloplasty across the three most popular social media platforms. Our results indicate the need to enhance the quality of medical information about phalloplasty on social media platforms with the goal of properly educating patients. It behooves plastic surgeons providing gender-affirming surgery, to create high-quality posts on TikTok and other social media platforms to help better educate transgender patients undergoing this procedure. Greater efforts to disseminate existing high-quality posts on social media should be made among the medical community providing gender-affirming care.

Introduction Gender-affirmation surgeries are a rapidly growing set of procedures in the field of plastic surgery. This study is novel in that a thorough analysis has not been performed quantifying, identifying, and recognizing the reasons and factors associated with regret in a largely US population.

Methods A PRISMA analysis incorporating Embase, PubMed, and Web of Science was conducted on April 2023. After compiling the articles, study characteristics were extracted. From the data set, weighted proportions were generated and analyzed.

Results A total of 24 articles were included in this study, with a population size of 3662 patients. A total of 3673 procedures were conducted in the US, 514 in European nations, 97 in Asian nations which included only Thailand, and 19 in South American nations which included only Brazil. A total of 1102 (30.1%) patients underwent transfeminine procedures, and 2560 (69.9%) patients underwent transmasculine procedures. 437 patients underwent a mammoplasty, 583 underwent a vaginoplasty, 333 patients underwent an orchiectomy, 30 patients underwent a vulvoplasty, and 73 patients underwent other procedures for transfeminine patients. For the transmasculine patients, 2361 underwent some form of masculinizing chest surgery, 65 underwent a phalloplasty, 8 underwent an oophorectomy, 486 underwent a hysterectomy, and 69 underwent other procedures. The pooled prevalence of regret was 1.94%. The prevalence of transfeminine regret was 4.0% whilst the prevalence of transmasculine regret was 0.8%. The overall rate of de-transitioning was 0.6%.

Conclusion Both transfeminine and transmasculine patients had significantly lower rates of regret in the US when compared with the rest of the world. The average age of transfeminine patients was older in the US when compared to the rest of the world, while the average age of transmasculine patients was younger. Additionally, both transfeminine and transmasculine patients had significantly lower rates of regret in the US when compared with the rest of the world. Our study agrees with the present literature that transmasculine patients exhibit significantly lower rates of regret than transfeminine patients. Since transmasculine procedures have been conducted more frequently than transfeminine ones, they have had more opportunities to improve and reduce complications resulting in safer procedures with a low rate of revision. Regret was differentiated into social, gender related, and medical regret with the latter being the most prevalent. Loss of nipple sensation, complaints of genital hair, inability to achieve orgasm, and post-operative pain were the most commonly reported associated concerns for medical regret. Most patients reporting social regret had difficulties due to unsupportive home and social environments. Due to its paradoxical nature, gender related regret may be the most difficult to predict or eliminate. However, physicians can help patients lower regret by exploring of the gender spectrum prior to surgery. To our knowledge this is the most recent review performed on the topic of regret amongst gender affirming surgery patients with an emphasis on a US cohort. This analysis can help shed light on better ways to enhance patient selection and surgical experience.