Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Evaluation of the antiseptic activity of 5% alcoholic povidone-iodine solution using four different modes of application: a randomized open-label study.

BACKGROUND: Before some invasive procedures, such as injections, surgical incision or intravascular catheter insertions, alcoholic antiseptics (e.g., alcoholic povidone-iodine (PVP-I)) are widely used to prevent infection. AIM: This randomized, open-label study investigated the impact of mode of application (which includes both application technique and volume) on the antiseptic activity of 5% alcoholic PVP-I solution. METHODS: Alcoholic PVP-I was administered to the backs of healthy adults using four modes of application: (A) concentric circle method, 3 mL; (B) concentric circle method, 10 mL; (C) back-and-forth friction method, 3 mL; (D) back-and-forth friction method, 10 mL. PRIMARY ENDPOINT: antiseptic activity of alcoholic PVP-I, assessed via change from baseline in log10/cm2 colony-forming units (cfu) count for total aerobic and facultative anaerobic bacteria. Safety was monitored. FINDINGS: A total of 113 healthy participants were screened; 32 were randomized. Alcoholic PVP-I showed significant antiseptic activity with all modes of application (P<0.001 for each), providing an overall mean decrease from baseline in cfu count of >3 log10/cm2 (P<0.001). Significantly greater efficacy was seen with back-and-forth friction (modes C and D) versus concentric circles (modes A and B): covariate adjusted change in log10/cm2 cfu count 0.22; 90% confidence intervals: 0.07, 0.37 (P=0.017). No safety issues were observed. CONCLUSIONS: Alcoholic PVP-I demonstrated high antiseptic activity for all modes of application. Greater efficacy was achieved with back-and-forth friction versus concentric circles, showing that application technique may influence antiseptic activity; these findings suggest that when comparing the efficacy of antiseptic substances (e.g., alcoholic PVP-I and alcoholic chlorhexidine), comparable application techniques should be used.

Routine histopathological examination after female-to-male gender-confirming mastectomy.

BACKGROUND: The number of transmen seeking gender-confirming surgery has risen steadily throughout the last decade. Pathologists are increasingly confronted with transmale mastectomy specimens. It is not clear whether routine histopathological examination is useful. This study explored the possible benefit of routine investigation through detailed description of lesions encountered in mastectomy specimens after female-to-male gender-confirming surgery. METHODS: Breast tissue from a cohort of transmen was reviewed. The presence of benign and malignant breast lesions was recorded. The number of terminal duct-lobule units (TDLUs) per ten low-power fields (LPFs) was quantified. Information on hormone therapy and morphometry was retrieved for selected patients. RESULTS: The cohort included 344 subjects with a mean age of 25·8 (range 16-61) years at the time of surgery; the age at surgery decreased significantly over time. Older individuals presented with a significantly higher number of breast lesions. The number of TDLUs per LPF was lower in heavier breasts, but did not correlate with age. Breast lesions, either benign or malignant, were present in 166 individuals (48·3 per cent). Invasive breast cancer was found in two (0·6 per cent); one tumour was an unexpected finding. The number of breast lesions encountered on histopathological examination increased significantly when more tissue blocks were taken. CONCLUSION: The discovery of an unexpected breast cancer in a 31-year-old transman emphasizes the importance of thorough routine histopathological examination of mastectomy specimens. The number of tissue blocks taken should be based on age and breast weight.

Pilomatricoma in children: common but often misdiagnosed.

A pilomatricoma, also known as pilomatrixoma or calcifying epithelioma of Malherbe, is a benign skin tumor arising from the hair follicle matrix. This tumor is common in children and young adults, especially in the head and neck region. However, pilomatricomas are frequently misdiagnosed or not recognized. The history is typical of a slowly enlarging mass, irregularly contoured, it is fixed to the skin but slides freely over the, underlying tissues, often with a discolouration which varies from red to purple-bluish. Ultrasound examination, MRI-scan and fine-needle aspiration can be helpful if the diagnosis is uncertain. Spontaneous regression has never been observed and malignant degeneration is very rare. Surgical excision with clear margins is the treatment of choice, otherwise recurrence may occur due to incomplete resection.

The effect of ultrasound-assisted liposuction and conventional liposuction on the perforator vessels in the lower abdominal wall.

Scientific reports of clinical in vivo research into the effects and side-effects of ultrasonic-assisted liposuction (UAL) are scarce. Advocates of UAL claim that the damage to vascular and nervous structures is limited and even less than with conventional and/or tumescent liposuction (CL). The effect of tumescent infiltration alone and combined with either CL or UAL was assessed by performing injection studies of the panniculus adiposus of the lower abdominal wall of 20 fresh cadavers and five abdominoplasty specimens. Besides the control and infiltration groups (n=5 in each), there was an additional group of ten cadaver flaps and five abdominoplasty flaps that underwent infiltration followed by UAL in the right half of the flap and infiltration followed by CL in the left half of the flap. Radiographs of these flaps were shown to a blinded panel of ten plastic surgeons, who were asked to evaluate and compare the damage on the basis of the number and magnitude of contrast-medium extravasations in the flap. Vascular damage to the perforating vessels was seen even after infiltration alone, although it was very limited. A variable amount of damage (ranging from little to extensive) was observed in the CL and UAL groups. Statistical analysis of the judgments of the observers could not show that either technique was less damaging than the other. UAL is, therefore, probably more beneficial to the surgeon than to the patient. The financial investment in the device is justified for surgeons with large liposuction practices, mainly, and probably solely, because of the reduced physical strain for the surgeon.

Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps.

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.

The use of pedicled perforator flaps for reconstruction of lumbosacral defects.

Large lumbosacral defects remain a difficult challenge in reconstructive surgery, especially in the nonparaplegic patient. Traditional options for closure include local rotation or transposition flaps and musculocutaneous flaps. These flaps, however, are not an optimal option in previously irradiated or operated areas, or in cases of large defects. Application of the perforator principle to the traditional musculocutaneous flap creates perforator flaps, which are an additional tool in the treatment of these defects in the nonparaplegic patient. A large amount of healthy, well-vascularized tissue can be transferred on one perforator without sacrificing important underlying muscles. The arc of rotation is also larger than in traditional flaps. The authors present an anatomic overview of three types of pedicled perforator flaps: the superior gluteal artery perforator flap, the lumbar artery perforator flap, and the intercostal artery perforator flap. They also report 4 patients in whom a pedicled perforator flap was used to reconstruct a large lumbosacral defect.

Sensory nerve repair in perforator flaps for autologous breast reconstruction: sensational or senseless?

The spontaneous return of sensation in autologously reconstructed breasts, especially in the Transverse Rectus Abdominis Myocutaneous (TRAM) flap, generated the belief that sensory reinnervation by nerve repair of the flap would be superfluous. This study compares the sensation of the following non-reconstructed and reconstructed breasts: (1) non-operated breasts; (2) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap with sensory nerve repair; (3) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap without nerve repair; and (4) flaps of patients reconstructed with the free TRAM flap without nerve repair. Statistically significant lower pressure thresholds were found for DIEP flaps with nerve repair through Semmes-Weinstein testing. More segments of the DIEP flaps with nerve repair reacted to cold, warm and vibratory stimuli compared to flaps without nerve repair. Delayed but satisfactory sensory evoked potential responses were obtained for all reconstructed breasts, but in 46% of TRAM flaps no response could be registered compared with 23% and 0% for DIEP flaps without and with nerve repair, respectively. Questionnaires confirmed the objective data and showed return of erogenous sensation in 30% of the patients with DIEP flaps with nerve repair. Our data reconfirm the possibility of spontaneous return of sensation in pedicled and/or free lower abdominal flaps without nerve repair. Nerve repair in free DIEP flaps nevertheless does restore sensation earlier postoperatively, increases the quality and quantity of sensation in the flap and has a higher chance of providing erogenous sensation. The benefits obtained outweigh the disadvantages of the increased operating time.

The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores.

We describe the use of a large skin-subcutaneous tissue flap based on one perforator of the superior gluteal artery (SGA) to reconstruct large midline posterior defects in one stage. The integrity of the gluteus muscles is preserved and we feel this is particularly important in non-paralysed patients. Donor sites were always closed primarily. Use of the superior gluteal artery perforator (SGAP) flap preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We recommend this flap in an area where reconstructive possibilities are limited, as it preserves other reconstructive flap options, both on the ipsilateral and contralateral sides.

A simple mathematical formula for custom-made croissant tissue expanders.

The popularity of croissant-type tissue expanders has increased steadily during the past 5 years. Croissant-shaped expansion offers the advantage of creating a tailored skin flap that is advanced easily into an elliptical skin defect without the formation of dog-ears or without the need for backcuts in the expanded flap. Because the majority of lesions can be considered elliptical in shape, surgical removal is performed easily with an adapted croissant expander. We present a simple mathematical formula for calculating the exact dimensions of the required croissant expander. A good clinical result was obtained using this formula to design large custom-made croissant tissue expanders in a patient with a giant nevus.

The antecubital fasciocutaneous island flap for elbow coverage.

Soft-tissue defects in the area of the periolecranon may be a source of concern to the reconstructive surgeon who aims for durable protection with a minimum of drawbacks. Lamberty and Cormack described the antecubital fasciocutaneous flap both as a local transposition and as a free flap. The island version of this flap enables a single-stage transfer of thin, pliable, sensitive skin into the region of the periolecranon without further scarring around the defect. In general, most of the donor site can be closed primarily together with a small, full-sheet, split-thickness skin graft on the remaining skin defect on the volar surface of the distal forearm. An additional advantage of this flap is the rather straightforward dissection with minimal repercussion on the forearm contour. An anatomic overview as well as 4 patients are described to illustrate the appealing features of this fasciocutaneous flap.

Doppler flowmetry in the planning of perforator flaps.

Perforator flaps have become the first choice in free flap reconstruction of contour defects or skin and fat replacement in our department. The Deep Inferior Epigastric Perforator (DIEP), the Superior Gluteal Artery Perforator (S-GAP) and the Thoracodorsal Artery Perforator (TAP) flaps are now routinely used. By evaluating the vascular anatomy of these flaps preoperatively, we intend to improve our surgical strategy so that these operative procedures can proceed in a faster and safer way. In this study, the results of the colour Duplex scanning in 50 consecutive DIEP flap patients are reviewed and evaluated for their sensitivity and positive predictive value. Also the preoperative information from unidirectional Doppler flowmetry in 30 S-GAP flaps and 11 TAP flaps is evaluated for its reliability. Due to the variable vascular anatomy of the lower abdominal wall and the dorso-lateral thoracic wall we now prefer using the colour Duplex scanning for planning the DIEP and TAP flaps. The more constant course of the branches of the superior gluteal artery allows us to use the easier and cheaper unidirectional Doppler flowmetry for planning the S-GAP flap.

The fate of the oblique abdominal muscles after free TRAM flap surgery.

During recent years, clinical research on the donor site morbidity after free or pedicled transverse rectus abdominis myocutaneous (TRAM) flap surgery has been focusing on the reduced flexion capacity of the abdominal wall. However, the rectus abdominis muscles have close interactions with their synergists and antagonists and collaborate with their neighbouring muscles. The purpose of this study was to examine the consequences of partially resecting the rectus abdominis muscle on the different muscle groups of the abdominal wall. Twenty free TRAM flap patients, 12-61 months (mean 32.1 months) after surgery, were clinically examined, evaluated for curl-up performance and underwent isokinetic dynamometry for flexion, extension and rotation. The patients were compared with 20 non-operated controls. Nineteen patients answered a questionnaire. Abdominal wall abnormalities occurred in 10 patients: umbilical asymmetry (n = 3), abdominal wall asymmetry (n = 4), lower abdominal bulging (n = 2) and hernia (n = 1). Curl-up performance was less in the TRAM flap patients (P = 0.001, Mann-Whitney). Isokinetic flexion, extension and rotation were also less in the TRAM flap patients (Fisher's exact test). This study indicates that what has been believed to be 'limited' surgical damage to the abdominal wall leads to an important reduction in flexion strength but to an even more important reduction of rotation strength due to bilateral displacement and damage of the insertion of the oblique muscles. Partial compensation by synergists is variable and unpredictable on an individual basis. These functional disorders can potentially lead to important changes in activities of daily life.

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction.

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

Hyperbaric oxygen therapy and free radical production: an experimental study in doxorubicin (Adriamycin) extravasation injuries.

The role of hyperbaric oxygen (HBO) therapy in free radical-mediated tissue injury is not clear. HBO has been shown to enhance the antioxidative defense mechanisms in some animal studies, but HBO has also been reported to increase the production of oxygen free radicals. To investigate this controversy, we studied the effect of HBO in a doxorubicin (Adriamycin) extravasation model, because the cytotoxic activity of doxorubicin is partly related to its quinone structure, which leads to the formation of cytotoxic oxygen intermediates. Fifty-four Sprague-Dawley rats underwent injection of 0.3 ml doxorubicin solution (2 mg per milliliter) intradermally on both flanks as described by Rudolph and colleagues. Group I (N = 28) received HBO treatment (2 hours at 2 ATA) for 3 days prior to injection and 7 days postinjection. Group II (N = 26) received no HBO treatment. At 2, 3, and 5 weeks, the size of the ulcers and the surrounding area of alopecia in group I (+HBO) were significantly larger than in group II (-HBO): 112.2 mm2 vs. 42.8 mm2 (p < 0.01) and 1,132.2 mm2 vs. 364.8 mm2 (p < 0.005). Biochemical analysis of the biopsied skin ulcers, to measure the parameters of oxygen free radical production, indicated (similar) low levels of xanthine oxidase for both groups. However, significantly elevated levels of malonyldialdehyde (MDA), indirect evidence of free radical production, was observed in group I (+HBO) in comparison with group II (-HBO): 36.58 vs. 5.84 ng per minute per milligram protein (p < 0.001), which might indicate free radical-induced cellular injury. It is concluded that in this animal study the cytotoxicity of doxorubicin is potentiated by HBO therapy. The elevated levels of MDA suggest a direct additive cytotoxic effect by increased membrane lipid peroxidation. HBO therapy, therefore, might be deleterious in the early (preulcer) stage of doxorubicin extravasation.

A universal incision for tissue expander insertion.

A new type of V- or W-shaped intralesional incision for tissue expander insertion is presented. The experience with 50 of these incisions in 36 consecutive patients in the period 1990-93 without any complication has proved the safety of this approach and the advantages of V- or W-shaped incisions over tangential or radial incisions.

Scar-length reduction by ring-shaped expansion.

Conventional tissue expansion with rectangular or round expanders often results in considerable dog-ear formation and, after resection, in lengthening of the final scar. The resulting scar is, always much longer than the maximal diameter of the skin lesion. These disadvantages are partially avoided by the use of croissant-shaped expanders. Taking the idea of the croissant-shaped expander and thinking further in terms of differential expansion, a new expander has been designed. It consists of a ring-shaped expander that is placed under the normal skin around the lesion. When the appropriate expansion is reached, the skin lesion is excised and the defect is closed with a running subcuticular suture, pulling as much skin as possible centripetally. The resulting scar is shorter than the maximal diameter of the skin lesion. The new expander has been tested in two patients in regions that are reputed for poor scar quality (the back and the upper arm). The results are encouraging.

Intermittent occlusion of the ulnar artery.

Intermittent occlusion of the ulnar artery developed in a patient causing cramp in her right hand. Both flexion and extension of the wrist completely obstructed bloodflow in the ulnar artery, at a level just proximal to the wrist. At operation, a tight band of antebrachial fascia was found to be the cause of this intermittent arterial occlusion. Surgical release of this fascial band produced complete relief of her symptoms.