Faculty Bibliography

UNLABELLED:Penile inversion vaginoplasty is the most common gender-affirming genital surgery performed around the world. Although individual centers have published their experiences, expert consensus is generally lacking. METHODS/UNASSIGNED:Semistructured interviews were performed with 17 experienced gender surgeons representing a diverse mix of specialties, experience, and countries regarding their patient selection, preoperative management, vaginoplasty techniques, complication management, and postoperative protocols. RESULTS/UNASSIGNED:There is significant consistency in practices across some aspects of vaginoplasty. However, key areas of clinical heterogeneity are also present and include use of extragenital tissue for vaginal canal/apex creation, creation of the clitoral hood and inner labia minora, elevation of the neoclitoral neurovascular bundle, and perioperative hormone management. Pathway length of stay is highly variable (1-9 days). Lastly, some surgeons are moving toward continuation or partial reduction of estrogen in the perioperative period instead of cessation. CONCLUSIONS/UNASSIGNED:With a broad study of surgeon practices, and encompassing most of the high-volume vaginoplasty centers in Europe and North America, we found key areas of practice variation that represent areas of priority for future research to address. Further multi-institutional and prospective studies that incorporate patient-reported outcomes are necessary to further our understanding of these procedures.

BACKGROUND:Insufficient genital tissue has been reported as a barrier to achieving depth in gender-affirming vaginoplasty. The authors sought to characterize vaginal depth and revision outcomes in patients with genital hypoplasia undergoing robotic peritoneal flap vaginoplasty. METHODS:Retrospective case-control analysis of patients undergoing robotic peritoneal vaginoplasty between September of 2017 and August of 2020 was used. All 43 patients identified as having genital hypoplasia (genital length <7 cm) were included with 49 random controls from the remaining patients with greater than 7 cm genital length. Baseline clinical characteristics and perioperative variables were recorded to identify potential confounders. Outcomes measured included vaginal size reported at last visit and undergoing revision surgery for depth or for vulvar appearance. RESULTS:Patients were well matched other than median body mass index at the time of surgery, which was greater in the hypoplasia cohort by 3.6 kg/m 2 ( P < 0.0001). Patients had a median of 1-year of follow-up, with a minimum follow-up of 90 days. No significant differences in outcomes were observed, with a median vaginal depth of 14.5 cm (interquartile range, 13.3 to 14.5 cm), and a median width of dilator used of 3.8 cm (interquartile range, 3.8 to 3.8 cm). No depth revisions were observed, and an 11% ( n = 10) rate of external revision occurred. CONCLUSIONS:Patients with genital hypoplasia had equivalent dilation outcomes in a case-control analysis with consistent follow-up past 90 days. The robotic peritoneal flap vaginoplasty technique provides vaginal depth of 14 cm or greater regardless of genital tissue before surgery. Further investigation with patient-reported outcome measures is warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.

OBJECTIVE:To address instances when there is insufficient remnant tissue to perform revision following canal-deepening gender affirming vaginoplasty revisions as indicated by insufficient depth. Options for lining of the vaginal canal include skin grafts, peritoneal flaps, or intestinal segment. Our center uses robotically harvested peritoneal flaps in vaginal canal revisions. When the peritoneal flap is insufficient for full canal coverage, we use AlloDerm, an acellular dermal matrix, for additional coverage. METHODS:Retrospective analysis of 9 patients who underwent revision RPV with AlloDerm was performed. Tubularized AlloDerm grafts were used to connect remnant vaginal lining to the peritoneal flaps. Revision indications, surgical and patient outcomes, and patient-reported post-op dilation were recorded. RESULTS:Nine patients underwent revision RPV using AlloDerm for canal deepening. Median follow-up was 368 days (Range 186-550). Following revision, median depth and width at last follow-up were 12.1 cm and 3.5 cm, and median increase in depth and width were 9.7 cm and 0.9 cm, respectively. There were no intraoperative complications. Two patients had focal areas of excess AlloDerm that were treated with in-office excision without compromise of the caliber or depth of the otherwise healed, epithelialized canal. CONCLUSION/CONCLUSIONS:AlloDerm is an off-the-shelf option that does not require a secondary donor site. The use of AlloDerm for a pilot cohort of patients lacking sufficient autologous tissue for revision RPV alone was demonstrated to be safe and effective at a median 1-year follow-up.

Background: Patient-reported outcomes regarding sexual health are lacking or have not been validated for transgender patients following vaginoplasty. The aim of this study is to further characterize the difference in sexual health, genital self-image, and the relationship between them for patients who were pre- and postvaginoplasty. Methods: A community advisory board informed an anonymous online survey utilizing patient-reported outcomes. Pre- and postvaginoplasty respondents were recruited online. Survey measures included the Female Genital Self-Image Scale (FGSIS) and the Patient-Reported Outcomes Measurement Information System sexual health measures. Welch approximation t tests were performed for FGSIS and Patient-Reported Outcomes Measurement Information System questions, using Bonferroni correction. Results: A total of 690 respondents prevaginoplasty (n = 525; 76%) and postvaginoplasty (n = 165; 24%) participated. The postoperative cohort, compared with the preoperative cohort, reported higher scores for orgasm (P = 0.0003), satisfaction (P = 0.001), and pleasure (P = 0.002). FGSIS total score was higher among postoperative respondents (79.4% ± 17.1%) than preoperative respondents (50.6% ± 15.1%) (P < 0.0001). Using Spearman rho, no significant correlation between FGSIS total score and any Patient-Reported Outcomes Measurement Information System subsectional measures was observed for the postoperative cohort, but a correlation (P <0.001) was observed for the preoperative cohort. Conclusions: Individuals who are contemplating vaginoplasty have worse sexual health and genital self-image than those who underwent vaginoplasty, yet genital self-image does not correlate directly with sexual health. Sexual health is multimodal for each person.

BACKGROUND:Gender-affirming mastectomy, or "top surgery," has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone prior to top surgery. This represents the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone. METHODS:Retrospective review identified patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, prior to May 2019, all patients were required to discontinue testosterone prior to surgery, while all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographics and postoperative outcomes compared between groups. RESULTS:490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients, while 104 patients never received testosterone therapy. Demographics were similar between groups, and there was no difference in rates of hematoma (2.9% vs. 2.8% vs 2.9% respectively, p=0.99), seroma (1.1% vs. 0% vs 1%, p=0.31), venous thromboembolism (0% vs. 0.5% vs 0%, p=0.99), or overall complications (6.9% vs. 4.3% vs 5.8%, p=0.54). CONCLUSIONS:Our results demonstrate no difference in postoperative complication rates between groups. While further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy.

BACKGROUND:Hematomas are reported to be the most common immediate complication in patients undergoing gender-affirming mastectomy, with rates substantially higher than those associated with other types of breast surgery. This study sought to examine the breadth of current literature and provide evidence-based explanations regarding the development of hematomas in chest masculinizing surgery and technical considerations for reducing their incidence. METHODS:A systematic review was conducted to identify all articles related to gender-affirming mastectomy published through September 2021. Literature search yielded 2,661 articles for screening, of which 20 met inclusion criteria. Themes from the selected articles were compiled to generate consensus statements qualified by associated level of evidence (LOE). RESULTS:The rate of hematoma following gender-affirming mastectomy is reported in the literature ranging from 0% to 31.2%. The use of more limited, nipple-sparing incisions is associated with a higher hematoma rate than mastectomy with free nipple grafting (Level III). There is no conclusive evidence indicating any relationship between the use of masculinizing hormones and the incidence of hematoma (Level IV). Factors such as body mass index (Level III) and breast size (Level III) were not found to influence hematoma risk, though nicotine use (Level IV) was significantly associated with the incidence of hematoma. CONCLUSIONS:Hematoma is a known complication following gender-affirming mastectomy. The use of limited incision approaches has the strongest association with an increased risk of hematoma. There is no evidence indicating an association between hormone use (i.e., testosterone) and hematoma incidence. Future studies are needed to better define factors, interventions, and protocols to reduce the rate of hematoma. LEVEL OF EVIDENCE/METHODS:III.

SUMMARY:The surgical treatment of gender incongruence with gender-affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women and those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to mistakes during patient care. Based on the lessons learned from these experiences, the authors provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.

BACKGROUND:Following gender-affirming penile inversion vaginoplasty or vulvoplasty, patients may seek vulvar revision procedures for a variety of common aesthetic and functional concerns. These indications for revision and accompanying techniques are not well-described in the literature. METHODS:Patients who underwent vulvar revision surgery at the authors' institution were identified, and patient demographics, surgical indications, operative details, and complications were described. Common complaints requiring external genital revision were sorted into four categories: clitoral, labial, introital, and urethral. RESULTS:Thirty-five patients with a history of vaginoplasty underwent vulvar revision between May of 2017 and December of 2019. The mean age at surgical correction was 38.9 years. Ten patients (28.6 percent) had undergone prior secondary procedures (range, 1 to 3). Mean follow-up after revision surgery was 10.7 ± 8.7 months (range, 0 to 30.6 months). The majority of patients underwent concurrent revisions in multiple "categories". Labial aesthetic concerns were most common (n = 27, 77.1 percent), followed by clitoral (n = 20, 57.1 percent), urologic (n = 17, 48.6 percent), and introital complaints (n = 12, 34.3 percent). Twelve patients (34.3 percent) had canal stenosis requiring concurrent robot-assisted canal revision with peritoneal flaps. Complications included labial abscess (n = 1) and deep vein thrombosis (n = 1). Three patients (8.6 percent) underwent subsequent external genital revisions. Management approaches and surgical techniques for each of these common revision categories are provided. CONCLUSION/CONCLUSIONS:As more individuals seek vaginoplasty and vulvoplasty, surgeons must be prepared to address a range of common aesthetic and functional complaints requiring vulvar revision. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.