Faculty Bibliography

Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.

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.

Background/UNASSIGNED:Transmasculine individuals may not have undergone gender-affirming mastectomy and retain natal breast tissue. Our center offers simultaneous oncologic mastectomy with gender-affirming reconstruction to patients who are diagnosed with breast cancer. This study is the first reported series of concurrent gender-affirming and oncologic mastectomies. Methods/UNASSIGNED:A retrospective chart review of all patients undergoing gender-affirming mastectomy at a single institution from February 2017 to October 2021 was performed. Patients were included who had breast cancer diagnoses or pathologic lesions preoperatively. Demographic factors, comorbidities, surgical details, and oncologic history were collected. Both plastic surgery and breast surgery were present for the gender-affirming oncologic mastectomies. Results/UNASSIGNED:Five patients were identified who presented for gender-affirming mastectomy in the context of breast pathologies. Average patient age was 50.2 ± 14.8 years, and no patients used testosterone at any time. Two (40%) patients had a prior breast surgery that included a breast reduction in one patient and breast conserving lumpectomies in another. Sentinel lymph node biopsies were performed in all patients. Only one patient had a positive sentinel lymph node and was subsequently referred for postoperative radiation and chemotherapy. No oncologic recurrence has been detected with 20.6 and 10.0 months of mean and median follow-up. Conclusions/UNASSIGNED:When performed in a multidisciplinary and collaborative setting with breast surgeons and plastic surgeons, oncologic mastectomy can be performed safely while concurrently offering patients an aesthetic gender-affirming reconstructive outcome.

BACKGROUND:Sexually transmitted infections (STIs) following penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations has not previously been described, despite known risk factors in the population. Following T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines. METHODS:A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups. RESULTS:128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups January to May 2020. Seven respondents (5.5%) self-reported one or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (p = 0.002). STIs were correlated with reporting sex with cisgender men (p = 0.001), transgender men (p = 0.009), and transgender women (p = 0.012). Of healthcare access variables, only receiving healthcare at a Community Health Center was correlated with STI history (p = 0.003). CONCLUSION/CONCLUSIONS:This exploratory survey indicates STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of post-reconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of healthcare provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm following gender affirming penile reconstruction.

OBJECTIVE:To describe the authors' experience diagnosing and managing intra-abdominal complications following robotic peritoneal flap vaginoplasty. The peritoneal flap vaginoplasty is a technique used to achieve consistent vaginal depth regardless of available natal tissue. Intra-abdominal complications following robotic peritoneal flap creation are rare but prompt diagnosis and management is critical to preventing patient harm. Given the infancy of the technique there is limited data on associated complications and their management. METHODS:Retrospective chart review identified patients undergoing robotically assisted peritoneal flap vaginoplasty by the senior authors between 2017 and 2020 who subsequently developed intra-abdominal complications requiring readmission and/or return to the operating room. Patient charts were analyzed for preoperative demographics, medical comorbidities, intraoperative details, postoperative complication presentation, diagnosis, management, and long-term outcomes. RESULTS:Out of 274 patients undergoing peritoneal flap vaginoplasty during the study period, six patients were identified who developed intra-abdominal complications (2.2%). One patient developed a postoperative hematoma requiring return to the operating room for diagnostic laparoscopy and hematoma evacuation. Two patients developed intraabdominal abscesses requiring diagnostic laparoscopy and abscess drainage. One patient developed recurrent episodes of small bowel obstructions that resolved with bowel rest. Two patients developed incarcerated internal hernias requiring diagnostic laparoscopy and internal hernia reduction. In one case, the hernia occurred at the peritoneal flap closure site, and in the other case the hernia occurred at the peritoneal flap donor site. CONCLUSIONS:Intra-abdominal complications following robot assisted peritoneal flap vaginoplasty are rare.  In addition to hematoma and abscess, small bowel incarceration and internal hernias are potential complications of peritoneal flap vaginoplasty that require prompt attention.

SUMMARY/CONCLUSIONS:As the field of plastic surgery continues to advance, so too do the number and complexity of ethical challenges faced by plastic surgeons. There is a paucity of literature, however, focusing on ethics in plastic surgery. Therefore, the authors offer a timely special topic series discussing ethical issues relevant to the field of plastic surgery. The goals of this series are four-fold: (1) to increase awareness of both frequently and less commonly encountered ethical issues in plastic surgery, (2) to foster discussion and debate of relevant and significant ethical issues, (3) to facilitate clinical ethics education and scholarship in plastic surgery, and (4) to apply an understanding and analysis of ethical issues in a way that optimizes clinical decision-making and delivery of patient care. In this introductory article, the authors discuss the current state of medical ethics scholarship in plastic surgery and introduce the first of several topics that will be detailed in the series. Ultimately, the hope is that increased awareness of the ethical challenges faced by surgeons and patients will improve the practice of plastic surgery.

BACKGROUND:The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM/OBJECTIVE:We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS:Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES/RESULTS:Sexual orientation, gender, and age were independent predictors of interest in interventions. RESULTS:There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS/CONCLUSIONS:A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS/UNASSIGNED:This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION/CONCLUSIONS:Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2021;XX:XXX-XXX.