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AUTHOR REPLY TO COMMENTARY ON "INCIDENCE AND LONG-TERM OUTCOMES OF GENDER-AFFIRMING PHALLOPLASTY: ANALYSIS OF A LARGE STATEWIDE POPULATION-BASED DATASET" [Letter]

Zhang, Tenny R; Harel, Daphna; Rivera, Adrian; Shahnawaz, Samia; Qian, Yingzhi; Berry, Carolyn; Zhao, Lee C; Radix, Asa; Bluebond-Langner, Rachel; Mmonu, Nnenaya A
PMID: 38336134
ISSN: 1527-9995
CID: 5632062

Impact of Medicaid Expansion on Genital Gender-Affirming Surgery in New York State

Zhang, Tenny R.; Zhao, Lee C.; Qian, Yingzhi; Radix, Asa; Bluebond-Langner, Rachel; Harel, Daphna; Mmonu, Nnenaya A.
SCOPUS:85181839491
ISSN: 2352-0779
CID: 5630032

Impact of Medicaid Expansion on Genital Gender-Affirming Surgery in New York State

Zhang, Tenny R; Zhao, Lee C; Qian, Yingzhi; Radix, Asa; Bluebond-Langner, Rachel; Harel, Daphna; Mmonu, Nnenaya A
PMID: 37914410
ISSN: 2352-0787
CID: 5612752

Gender Surgery in Adolescents and Young Adults: A Review of Ethical and Surgical Considerations

Robinson, Isabel S; Carswell, Jeremi M; Boskey, Elizabeth; Agarwal, Cori A; Brassard, Pierre; Bélanger, Maud; Zhao, Lee C; Bluebond-Langner, Rachel
BACKGROUND:The incidence of transgender adolescents seeking gender affirming surgery (GAS) in increasing. Surgical care of the adolescent transgender patient is associated with several unique technical, legal, and ethical factors. The authors present a review of the current literature on gender affirming surgery for individuals under the age of legal majority and propose directions for future research. METHODS:A scoping review of recent literature was performed to assess evidence on gender affirming surgery in individuals under the age of legal majority. Papers were included that examined either ethical or technical factors unique to pediatric GAS. Study characteristics and conclusions were analyzed in conjunction with expert opinion. RESULTS:Twelve papers were identified meeting inclusion criteria. Ten of these papers discussed ethical challenges in adolescent GAS, seven papers discussed legal challenges, and five papers discussed technical challenges. Ethical discussions focused on the principles of beneficence, nonmaleficence, and autonomy. Legal discussions centered on informed consent and insurance coverage. Technical discussions focused on the impact of puberty blockade on natal tissue. CONCLUSIONS:Surgical care of the adolescent transgender patient involves important ethical, legal, and technical considerations that must be addressed by the clinical team. As the population of individuals seeking GAS after puberty blockade increases, future research is needed describing functional and psychosocial outcomes in these individuals.
PMID: 36827481
ISSN: 1529-4242
CID: 5434082

Operative Management of Complications Following Intestinal Vaginoplasty: A Case Series and Systematic Review

Robinson, Isabel S; Cripps, Courtney N; Bluebond-Langner, Rachel; Zhao, Lee C
OBJECTIVE:To 1) describe the authors' experience with surgical management of complications following intestinal vaginoplasty and 2) review the literature on incidence of complications following gender affirming intestinal vaginoplasty. METHODS:Retrospective chart review identified patients presenting with complications following prior intestinal vaginoplasty requiring operative management. Charts were analyzed for medical history, preoperative exam and imaging, intraoperative technique, and long-term outcomes. Systematic literature review was performed to identify primary research on complications following gender affirming intestinal vaginoplasty. RESULTS:Four patients presented to the senior authors' clinic requiring operative intervention for complications following intestinal vaginoplasty, all of whom underwent surgical revision. Complications included vaginal stenosis (2 patients, 50%), vaginal false passage (1 patient, 25%) and diversion colitis (1 patient, 25%). Postoperatively all patients were able to dilate successfully to a depth of at least 15cm. Systematic review identified 10 studies meeting inclusion criteria. There were 215 complications reported across 654 vaginoplasties (33% overall complication rate). Average return to OR rate was 18%. The most common complications were stenosis (11%), mucorrhea (7%), vaginal prolapse (6%), and malodor (5%). Six intestinal vaginoplasty segments developed vascular compromise leading to flap loss. There were 2 reported mortalities. CONCLUSIONS:Intestinal vaginoplasty is associated with a range of complications including vaginal stenosis, mucorrhea, and vaginal prolapse. Intra-abdominal complications, including diversion colitis, anastomotic bowel leak, and intra-abdominal abscess can occur many years after surgery, be life-threatening and require prompt diagnosis and management.
PMID: 37479146
ISSN: 1527-9995
CID: 5536232

Should BMI Help Determine Gender-Affirming Surgery Candidacy?

Castle, Elijah; Kimberly, Laura; Blasdel, Gaines; Parker, Augustus; Bluebond-Langner, Rachel; Zhao, Lee C
Use of body mass index (BMI) as a health care metric is controversial, especially in candidacy assessments for gender-affirming surgery. When considering experiences of fat trans individuals, it is important to advocate for equitable divisions of responsibility for and recognition of systemic fat phobia. This commentary on a case suggests strategies for increasing equitable access to safe surgery for all body types. If surgeons use BMI thresholds, simultaneous effort must be made to advocate for data collection so that surgical candidacy criteria are evidence-based and equitably applied.
PMID: 37432002
ISSN: 2376-6980
CID: 5537012

Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes

Robinson, Isabel; Chao, Brian W; Blasdel, Gaines; Levine, Jamie P; Bluebond-Langner, Rachel; Zhao, Lee C
OBJECTIVE:1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS:Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS:Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION/CONCLUSIONS:ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.
PMID: 37054922
ISSN: 1527-9995
CID: 5502792

Use of Tranexamic Acid in Gender-Affirming Mastectomy Reduces Rates of Postoperative Hematoma and Seroma

Rifkin, William J; Parker, Augustus; Bluebond-Langner, Rachel
BACKGROUND:The established safety and efficacy of tranexamic acid (TXA) in minimizing perioperative blood loss has led to increased interest within plastic surgery. Prior studies demonstrate decreased edema, ecchymosis, and reduced rates of postoperative collections with administration of TXA, however its use has not been reported in gender-affirming mastectomy. This represents the first study to evaluate the impact of TXA on postoperative outcomes in patients undergoing gender-affirming mastectomy. METHODS:A single-center cohort study was performed analyzing all consecutive patients undergoing top surgery with the senior author between February 2017 and October 2022. Beginning in June 2021, all patients received 1000 mg intravenous TXA prior to incision and 1000 mg at the conclusion of the procedure. Patients were stratified according to intraoperative administration of TXA, with demographics, surgical characteristics, and postoperative outcomes compared between groups. RESULTS:A total of 851 patients underwent gender-affirming mastectomy. Of these, 646 cases were performed without TXA, while 205 patients received intravenous TXA intraoperatively as above. Patients who received TXA had significantly lower rates of seroma (20.5% vs. 33.0%; p<0.001), and hematoma (0.5% vs. 5.7%; p=0.002). There was no difference in rates of surgical site infection (p=0.74), and use of TXA was not associated with increased rates of venous thromboembolism (p=0.42). CONCLUSIONS:Intraoperative administration of TXA in patients undergoing top surgery may safely reduce the risk of postoperative seroma and hematoma without increased risk of thromboembolic events. Additional data collection and prospective studies are warranted to corroborate these findings.
PMID: 37399532
ISSN: 1529-4242
CID: 5539072

How Should Surgeons Approach Gender-Affirming Surgery Revisions When Patients Were Not, Perhaps, Well Informed in Prior Counseling?

Zhao, Lee C; Blasdel, Gaines; Parker, Augustus; Bluebond-Langner, Rachel
Surgeons often encounter patients with realistic goals yet who desire unrealistic means of achieving them. This tension is compounded when surgeons consult with patients eager to revise a prior gender-affirming procedure completed by another surgeon. Two key factors of ethical and clinical relevance are that (1) a consulting surgeon's job is complicated when a population-specific evidence base is lacking and (2) a patient's marginalization is exacerbated by their having suffered the downstream effects of compromised initial access to comprehensive, realistic surgical care. This case commentary about revision of gender-affirming phalloplasty canvasses the pitfalls of a limited evidence base and focuses on strategies surgeons can use to help guide consultation. In particular, informed consent discussion may need to reframe a patient's expectations about clinical accountability for irreversible interventions.
PMID: 37285292
ISSN: 2376-6980
CID: 5541282

CASE AND COMMENTARY: PEER-REVIEWED ARTICLE How Should Surgeons Approach Gender-Affirming Surgery Revisions When Patients Were Not, Perhaps, Well Informed in Prior Counseling?

Zhao, Lee C.; Blasdel, Gaines; Parker, Augustus; Bluebond-Langner, Rachel
Surgeons often encounter patients with realistic goals yet who desire unrealistic means of achieving them. This tension is compounded when surgeons consult with patients eager to revise a prior gender-affirming procedure completed by another surgeon. Two key factors of ethical and clinical relevance are that (1) a consulting surgeon"™s job is complicated when a population-specific evidence base is lacking and (2) a patient"™s marginalization is exacerbated by their having suffered the downstream effects of compromised initial access to comprehensive, realistic surgical care. This case commentary about revision of gender-affirming phalloplasty canvasses the pitfalls of a limited evidence base and focuses on strategies surgeons can use to help guide consultation. In particular, informed consent discussion may need to reframe a patient"™s expectations about clinical accountability for irreversible interventions.
SCOPUS:85181887339
ISSN: 2376-6980
CID: 5630702