Patient education and surgical decision-making in genital gender-affirming surgery.

PURPOSE OF REVIEW: An update on the latest advances in surgical decision-making for genital gender-affirming surgery (GGAS), with an emphasis on patient education from three perspectives: surgeon-team perspectives, patient perspectives, and educational resources available to the public on social media. RECENT FINDINGS: Transgender, nonbinary, and other culturally specific gender identities (TGNB) patients overwhelmingly desire an active role in the decision-making process. New developments in patient-engagement strategies help mitigate the harm of historical gatekeeping practices by centering the needs and experiences of TGNB patients to create a prioritized research agenda for GGAS effectiveness. Patient educational resources play an integral role in navigating the complexity of GGAS-surgical options, informing patients of the technical and logistical knowledge required for GGAS surgical decision-making. Peer support experiences are a critical facilitator for patient surgical decision-making, both for informed decision-making and for psychosocial support. SUMMARY: Several developments have been made in examining shared-decision making, educational resources from the perspectives of both the surgical team and patients, and the role of social media in GGAS. Surgeons must continue to initiate robust conversations of patient goals, GGAS surgical options, the possible risk and benefit profiles of each option, and aftercare requirements, all while prioritizing patient-engagement strategies.

Exploring Decisional Conflict Experienced by Individuals Considering Metoidioplasty and Phalloplasty Gender-affirming Surgery.

Background: Metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) is increasingly performed and requires patients to make complex decisions that may lead to decisional uncertainty. This study aimed to evaluate decisional conflict in individuals considering MaPGAS. Methods: We administered a cross-sectional survey to adult participants assigned female sex at birth and considering MaPGAS, recruited via social media platforms and community health centers. We collected data on demographics, medical and surgical history, MaPGAS type considered, and the Decisional Conflict Scale (DCS). DCS scores range from 0 to 100 (>37.5 indicates greater decisional conflict). Demographic characteristics and DCS scores were compared between subgroups, using descriptive and chi-square statistics. Participants commented on MaPGAS uncertainty, and their comments were evaluated and thematically analyzed. Results: Responses from 264 participants were analyzed: mean age 29 years; 64% (n = 168) trans men, 80% (n = 210) White, 78% (n = 206) nonrural, 45% (n = 120) privately insured, 56% (n = 148) had 4 or more years of college, 23% (n = 84) considering metoidioplasty, 24% (n = 87) considering phalloplasty, and 26% (n = 93) considering metoidioplasty and phalloplasty. DCS total scores were significantly higher (39.8; P < 0.001) among those considering both MaPGAS options, as were mean ratings on the Uncertainty subscale [64.1 (SD 25.5; P < 0.001)]. Concerns surrounding complications were the top factor contributing to uncertainty and decisional conflict. Conclusions: In a cross-sectional national sample of individuals seeking MaPGAS, decisional uncertainty was the highest for those considering both MaPGAS options compared with metoidioplasty or phalloplasty alone. This suggests this cohort would benefit from focused decision support.

Pilot Test of A Gender-conscious Sexual Health Intake Questionnaire: Increasing Inclusivity and Mitigating Bias in Sexual History Taking.

Background: Sexual health is critical to overall health, yet sexual history taking is challenging. LGBTQ+ patients face additional barriers due to cis/heteronormativity from the medical system. We aimed to develop and pilot test a novel sexual history questionnaire called the Sexual Health Intake (SHI) form for patients of diverse genders and sexualities. Methods: The SHI comprises four pictogram-based questions about sexual contact at the mouth, anus, vaginal canal, and penis. We enrolled 100 sexually active, English-speaking adults from a gender-affirming surgery clinic and urology clinic from November 2022 to April 2023. All surveys were completed in the office. Patients also answered five feedback questions and 15 questions from the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction (PROMIS-SexFS) survey as a validated comparator. Results: One hundred patients aged 19-86 years representing an array of racial/ethnic groups, gender identities, and sexuality completed the study. Forms of sexual contact varied widely and included all possible combinations asked by the SHI. Feedback questions were answered favorably in domains of clinical utility, inclusiveness of identity and anatomy, and comprehensiveness of forms of sexual behavior. The SHI captured more positive responses than PROMIS-SexFS in corresponding questions about specific types of sexual activity. The SHI also asks about forms of sexual contact that are not addressed by PROMIS-SexFS, such as penis-to-clitoris. Conclusions: SHI is an inclusive, patient-directed tool to aid sexual history taking without cisnormative or heteronormative biases. The form was well received by a diverse group of participants and can be considered for use in the clinical setting.

A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today.

The University of Michigan has played an important role in advancing gender-affirming surgery programs in the United States. The University of Michigan was home to a little-known gender identity clinic shortly after the opening of the first such clinic at Johns Hopkins. Since 1995, the University of Michigan Comprehensive Services Program (UMCGSP) has been continually offering surgical services to transgender and gender diverse patients. Here, we present the history of both programs, drawn from program documents and oral history, and explore their implications for the future sustainability of gender-affirming surgery programs. The original gender identity clinic opened in 1968, and operated in a multidisciplinary fashion, similar to other clinics at the time. Eventually, the clinic was closed due to disinvestment and lack of sufficient providers to maintain the program, problems which are being increasingly recognized as barriers for similar programs. The modern program, UMCGSP is perhaps the longest continually running gender-affirming surgical program at an academic center. In spite of challenges, key investments in education, statewide community engagement, and the development of a comprehensive care model have helped UMCGSP avoid the pitfalls of the earlier clinic and remain relevant throughout its nearly 30-year history. In the face of rising challenges to gender-affirming care in the United States, much can be learned from the sustainability of the UMCGSP. Institutions seeking to maintain gender-affirming surgery programs should ensure the availability of comprehensive care and promote the education of the health care workforce.

Urinary Reconstruction in Genital Gender-Affirming Surgery: Checking Our Surgical Complication Blind Spots.

BACKGROUND: Urologic complications in genital gender-affirming surgery are imperfectly measured, with existing evidence limited by "blind spots" that will not be resolved through implementation of patient-reported outcomes alone. Some blind spots are expected in a surgical field with rapidly expanding techniques, and they may be exacerbated by factors related to transgender health. METHODS: The authors provide a narrative review of systematic reviews published in the past decade to describe the current options for genital gender-affirming surgery and surgeon-reported complications, as well as contrasting peer-reviewed sources with data not reported by the primary surgeon. In combination with expert opinion, these findings help estimate complication rates. RESULTS: Eight systematic reviews describe complications in patients undergoing vaginoplasty, including 5% to 16.3% mean incidence of meatal stenosis and 7% to 14.3% mean incidence of vaginal stenosis. Compared with surgeon-reported cohorts, patients undergoing vaginoplasty or vulvoplasty in other reports had higher rates of voiding dysfunction (47% to 66% versus 5.6% to 33%), incontinence (23% to 33% versus 4% to 19.3%), or misdirected urinary stream (33% to 55% versus 9.5% to 33%). Outcomes in six reviews of phalloplasty and metoidioplasty included urinary fistula (14% to 25%), urethral stricture or meatal stenosis (8% to 12.2%), and ability to stand to void (73% to 99%). Higher rates of fistula (39.5% to 56.4%) and stricture (31.8% to 65.5%) were observed in alternate cohorts, along with previously unreported complications such as vaginal remnant requiring reoperation. CONCLUSIONS: The literature does not completely describe urologic complications of genital gender-affirming surgery. In addition to standardized, robustly validated patient-reported outcome measures, future research on surgeon-reported complications would benefit from using the IDEAL (idea, development, exploration, assessment, and long-term study) framework for surgical innovation.

How Do Prescribing Clinicians Obtain Consent to Initiate Gender-Affirming Hormones?

Purpose: Multiple consent models exist for initiating gender-affirming hormone therapy (GAHT). Our study aim was to examine the variety of approaches utilized by clinicians. Methods: Online and in-person recruitment of clinicians involved in gender-affirming care was undertaken from June 2019 through March 2020. Participants completed an online survey. Results: Of the 175 respondents, 148 prescribed GAHT. Sixty-one (41.2%) prescribed to adults only, 11 (7.4%) to minors only, and 76 (51.4%) prescribed to adults and minors. Of those who prescribed to adults, more than half (n=74, 54.4%) utilized a written consent model, one-fourth only verbal consent (n=33, 24.3%), and one-fifth required an additional mental health assessment (MHA) (n=29, 21.3%). Of those prescribing to minors, most required either written consent (n=39, 44.8%) or an additional MHA (n=35, 40.2%). Only 11 (12.6%) utilized only verbal consent for minors. Rationales provided for requiring an additional MHA in adults included protection from litigation, lack of competence in assessing psychosocial readiness for GAHT, and believing that this is the best way to ensure the patient has processed the information. Practicing in multidisciplinary clinics was associated with not requiring an MHA for adult GAHT. Conclusion: Clinicians across fields are utilizing different models to provide the same treatment, with varying rationales for the same model. As a result, patients receive nonstandard access to care despite similar clinical presentations. Our study highlights an important area for further improvement in GAHT care.

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy.

Importance: There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments. Objective: To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy. Design, Setting, and Participants: For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020. Exposure: Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy. Main Outcomes and Measures: Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders. Results: A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses. Conclusions and Relevance: In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

Preoperative stricture length measurement does not predict postoperative outcomes in robotic ureteral reconstructive surgery.

PURPOSE: We sought to determine whether preoperative stricture length measurement affected the choice of procedure performed, its correlation to intraoperative stricture length, and postoperative outcomes. METHODS: The Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database was queried for patients undergoing robotic ureteral reconstructive surgery from 2013 to 2021 who had surgical stricture length measurement. From this cohort, we identified patients with and without preoperative stricture length measurement via retrograde pyelogram or antegrade nephrostogram. Outcomes evaluated included intraoperative complications, 30-day complications greater than Clavien-Dindo grade II, hardware-free status, and need for additional procedures. RESULTS: Of 153 patients with surgical stricture length measurements, 102 (66.7%) had preoperative radiographic measurement. No repair type was more likely to have preoperative measurement. The Pearson correlation coefficient between surgical and radiographic stricture length measurements was + 0.79. The average surgical measurement was 0.71 cm (± 1.52) longer than radiographic assessment. Those with preoperative imaging waited on average 5.0 months longer for surgery, but this finding was not statistically significant (p = 0.18). There was no statistically significant difference in intraoperative complications, 30-day complication rates, hardware-free status at last follow-up, or need for additional procedures between patients with and without preoperative measurement. The only significant predictive factor was preoperative stricture length on 30-day postoperative complications. CONCLUSIONS: Despite relatively high prevalence of preoperative radiographic stricture length measurement, there are few measures where it offers clinically meaningful diagnostic information towards the definitive surgical management of ureteral stricture disease.

Should BMI Help Determine Gender-Affirming Surgery Candidacy?

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.

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

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.

Decision making in metoidioplasty and phalloplasty gender-affirming surgery: a mixed methods study.

BACKGROUND: Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information. AIM: (1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid. METHODS: This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework. OUTCOMES: Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables. RESULTS: We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing. CLINICAL IMPLICATIONS: The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty. STRENGTHS AND LIMITATIONS: This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway. CONCLUSIONS: This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution.

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

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: 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.

Genital Hypoplasia before Gender-Affirming Vaginoplasty: Does the Robotic Peritoneal Flap Method Create Equivalent Vaginal Canal Outcomes?

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.

Does Genital Self-image Correspond with Sexual Health before and after Vaginoplasty?

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.

Mending the Gap: AlloDerm as a Safe and Effective Option for Vaginal Canal Lining in Revision Robotic Assisted Gender Affirming Peritoneal Flap Vaginoplasty.

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: 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.

Perioperative Hormone Management in Gender-Affirming Mastectomy: Is Stopping Testosterone before Top Surgery Really Necessary?

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 before top surgery. This is the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone. METHODS: This retrospective review included patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, before May of 2019, all patients were required to discontinue testosterone before surgery; 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 demographic characteristics and postoperative outcomes compared among groups. RESULTS: A total of 490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients; 104 patients never received testosterone therapy. Demographic characteristics were similar among groups and there was no difference in rates of hematoma (2.9% versus 2.8% versus 2.9%, respectively; P = 0.99), seroma (1.1% versus 0% versus 1%, respectively; P = 0.31), venous thromboembolism (0% versus 0.5% versus 0%, respectively; P = 0.99), or overall complications (6.9% versus 4.3% versus 5.8%, respectively; P = 0.54). CONCLUSIONS: Our results demonstrate no difference in postoperative complication rates among groups. Whereas 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. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Gender-affirming Mastectomy: Comparison of Periareolar and Double Incision Patterns.

Background: Gender-affirming mastectomy has become one of the most frequently performed procedures for transgender and nonbinary patients. Although there are a variety of potential surgical approaches available, the impact of technique on outcomes remains unclear. Here we present our experience performing periareolar and double incision mastectomies, with a focus on comparing patient demographics, preoperative risk factors, and surgical outcomes and complication rates between techniques. Methods: Retrospective review identified patients undergoing gender-affirming mastectomy by the senior author between 2017 and 2020. Patients were stratified according to surgical technique, with demographics and postoperative outcomes compared between groups. Results: In total, 490 patients underwent gender-affirming mastectomy during the study period. An estimated 96 patients underwent periareolar mastectomy, whereas 390 underwent double incision mastectomy. Demographics were similar between groups, and there were no differences in rates of hematoma (3.1% versus 5.6%, respectively; P = 0.90), seroma (33.3% versus 36.4%; P = 0.52), or revision procedures (14.6% versus 15.8% P = 0.84) based on technique. Conclusions: Our results demonstrate no difference in the rates of postoperative complications or revision procedures based on surgical technique. These results also suggest that with an experienced surgeon and proper patient selection, both techniques of gender-affirming mastectomy can be performed safely and with comparable outcomes.

Recommendations for Communication in Gender-Affirming Surgical Care.

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.