Nationwide Resident Access to Elective Rotations: A Survey Study.

OBJECTIVE: This study seeks to assess the status of elective rotations offered in plastic and reconstructive surgery residency programs throughout the country while also qualifying resident and alumni experiences and identifying barriers to offering electives. DESIGN: Two prospective surveys were created for (1) program leadership and (2) residents, fellows, and alumni's who have graduated in the last 5 years. SETTING: This is a multi-institutional survey study. PARTICIPANTS: Of 81 plastic and reconstructive surgery programs, 45 programs, and 102 residents, fellows and/or recent graduates responded to survey 2. RESULTS: Fifty-six percent of respondents stated that their institution offered electives, 62% of which permitted residents to participate in regional, national, and international rotations primarily in the fifth and sixth years of training. Types of elective rotations completed included aesthetic, craniofacial, sex, hand, and microsurgery. Fifty-three percent responding programs denied barriers to offering elective rotations. When programs noted barriers, the most common were cost to resident/department (28%), institutional Graduate Medical Education policy (22%), and lack of service coverage at the home institution (22%). There was no difference between departments versus divisions offering electives (56.3% vs 57.1%, P = 0.95). Programs that did not offer electives spent an average of 14.6 months on general surgery compared with 9.4 months for programs that did offer electives ( P = 0.06). For programs that did not currently offer elective rotations, 71% indicated a desire to do so. CONCLUSION: The primary goal of plastic surgery training programs is to produce plastic surgeons of the highest caliber with regard to safety and competence. Although several regulatory bodies ensure that programs adhere to a similar standard, not all programs have opportunities for residents to experience the breadth of our multifaceted specialty. Elective rotations constitute an excellent supplement to a well-rounded training where gaps may exist.

Partial Flap Loss in Gender Affirming Phalloplasty.

BACKGROUND: Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. METHODS: This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. RESULTS: Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. CONCLUSION: PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

Gender-Affirming Health Insurance Reform in the United States.

INTRODUCTION: In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change. METHODS: Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision. RESULTS: Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation. CONCLUSIONS: After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.

Masculinizing Genital Surgery: An Imaging Primer for the Radiologist.

OBJECTIVE. Masculinizing genital surgeries for transgender individuals are currently performed at only a select few centers; however, radiologists in any geographic region may be confronted with imaging studies of transgender patients. The imaging findings of internal and external genital anatomy of a transgender patient may differ substantially from the imaging findings of a cisgender patient. This article provides the surgical and anatomic basis to allow appropriate interpretation of preoperative and postoperative imaging findings. We also expand on the most common complications and associated imaging findings. CONCLUSION. As these procedures become more commonplace, radiologists will have a growing role in the care of transgender patients and will be faced with new anatomic variants and differential diagnoses. Familiarity with these anatomic variations and postoperative complications is crucial for the radiologist to provide an accurate and useful report.

Gender Surgery Beyond Chest and Genitals: Current Insurance Landscape.

BACKGROUND: Plastic surgery plays an essential role in the treatment of gender dysphoria. International standards of care currently consider genital and chest surgeries to be medically necessary. Ancillary procedures such as facial surgery, chondrolaryngoplasty, hair restoration/removal, and body contouring are considered cosmetic surgeries except in individual circumstances. OBJECTIVE: The authors sought to assess the frequency of coverage provision for ancillary transition-related surgeries through a cross-sectional analysis of US insurance policies. METHODS: The authors selected insurance companies based on state enrollment data and market share. Policies were identified through web-based search and telephone interviews. A list of eligible procedures was compiled and grouped into 5 categories: body masculinization, body feminization, facial procedures, hair restoration/removal, and chondrolaryngoplasty. Medical necessity criteria from publicly accessible policies were then abstracted. RESULTS: Sixty-one insurance companies held an established policy. One-third of these policies offered favorable coverage for at least 1 ancillary procedure. Chondrolaryngoplasty was the most covered category (26%, n = 16), whereas body masculinization was the least covered (8%, n = 5). Almost two-thirds of the companies with favorable policies listed coverage criteria. We identified 4 recurring requirements: age, hormone therapy, continuous living in a congruent gender role, and referral from a mental health professional. CONCLUSIONS: There is a low prevalence of US insurance coverage for ancillary gender surgeries and wide variability in coverage criteria. Reevaluation of ancillary transition-related procedures from cosmetic to medically necessary based on clinical judgement or establishment of defined coverage criteria may augment coverage and better address the needs of transgender patients.

The Role of Facial Gender Confirmation Surgery in the Treatment of Gender Dysphoria.

The population of transgender patients seeking gender confirmation surgery for gender dysphoria is increasing in the United States. Facial gender confirmation surgery (FGCS) is one of the treatment modalities patients require and is often a combination of soft tissue and cranio-maxilla-facial procedures. Despite evidence of the efficacy of FGCS, there remains some extant controversies to address, such as reimbursement for these procedures, categorization of aesthetic versus functional surgery, and evaluation of outcomes. This review provides a discussion of these topics, as well as the historical and psychosocial issues specific to transgender patients that surgeons should know when providing FGCS. We provide practice pearls for providing affirming transgender healthcare, illustrative patient clinical vignettes, and a discussion of the Standards of Care of the World Professional Association for Transgender Health to help guide surgeons who are interested in providing FGCS to transgender patients.

What is "Nonbinary" and What Do I Need to Know? A Primer for Surgeons Providing Chest Surgery for Transgender Patients.

BACKGROUND: Most transgender research focuses on patients who identify within the gender binary of either trans-male or trans-female. This largely omits understanding of the "nonbinary" gender identity as it pertains to surgical care. OBJECTIVES: We sought to describe a single-institution experience of chest-affirming procedures performed in nonbinary patients, including patient characteristics, surgical techniques, practice pearls, and outcomes. METHODS: This was an observational study of nonbinary patients who underwent "chest-affirming surgery" from 2012 to 2017. Demographic and surgical data were collected. A postoperative questionnaire assessing quality of life and body image outcomes was administered. RESULTS: A total of 458 patients with gender dysphoria underwent chest surgery; 58 (13%) patients were nonbinary. All nonbinary patients indicated female sex was assigned at their birth (100%). The most commonly performed procedure was the double incision technique with nipple grafts (72%), followed by the double incision technique without nipple grafts (19%). On a Likert scale, patients reported improved quality of life (4.88, SD ± 0.34), comfort with exercise (4.07, SD ± 0.98), sex life (4.02, SD ± 0.92), and comfort with physical appearance with (4.97, SD ± 0.18) and without clothes (4.69, SD ± 0.47). CONCLUSIONS: Chest surgery for nonbinary patients comprises a considerable proportion of transgender surgery practice, and surgeons who provide affirming care should be familiar with the unique characteristics and treatment options for this population.

Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women.

BACKGROUND: Gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation. AIM: Our objective is to describe the factors influencing patient choice or surgeon recommendation of vulvoplasty and to assess the patient's satisfaction with this choice. METHODS: Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. OUTCOMES: We report demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery. RESULTS: In total, 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty. 30 Patients either completed or are scheduled for vulvoplasty. Vulvoplasty patients were older and had higher body mass index than those seeking vaginoplasty. The majority (63%) of the patients seeking vulvoplasty chose this surgery despite no contra-indications to vaginoplasty. The remaining patients had risk factors leading the surgeon to recommend vulvoplasty. Of those who completed surgery, 93% were satisfied with the surgery and their decision for vulvoplasty. CLINICAL TRANSLATION: Vulvoplasty creates the external appearance of female genitalia without creation of a neovaginal canal; it is associated with high satisfaction and low decision regret. CONCLUSIONS: This is the first study of factors impacting a patient's choice of or a surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also is the first reported series of patients undergoing vulvoplasty only. Limitations of this study include its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how we offer vulvoplasty. Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret. Jiang D, Witten J, Berli J, et al. Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women. J Sex Med 2018;15:902-906.

Surgical management of early and late ureteral complications after renal transplantation: techniques and outcomes.

BACKGROUND: In this study, we present our experience with ureteral complications requiring revision surgery after renal transplantation and compare our results to a matched control population. METHODS: We performed a retrospective analysis of our database between 1997 and 2012. We divided the cases into early (<60 d) and late repairs. Kaplan-Meier and Cox proportional hazards models were used to compare graft survival between the intervention cohort and controls generated from the Scientific Registry of Transplant Recipients data set. RESULTS: Of 2671 kidney transplantations, 51 patients were identified as to having undergone 53 ureteral revision procedures; 43.4% of cases were performed within 60 d of the transplant and were all associated with urinary leaks, and 49% demonstrated ureteral stenosis. Reflux allograft pyelonephritis and ureterolithiasis were each the indication for intervention in 3.8%; 15.1% of the lesions were located at the anastomotic site, 37.7% in the distal segment, 7.5% in the middle segment, 5.7% proximal ureter, and 15.1% had a long segmental stenosis. In 18.9%, the location was not specified. Techniques used included ureterocystostomy (30.2%), ureteroureterostomy (34%), ureteropyelostomy (30.1%), pyeloileostomy (1.9%), and ureteroileostomy (3.8%). No difference in overall graft survival (HR 1.24 95% CI 0.33-4.64, p = 0.7) was detected when compared to the matched control group. CONCLUSION: Using a variety of techniques designed to re-establish effective urinary flow, we have been able to salvage a high percentage of these allografts. When performed by an experienced team, a ureteric complication does not significantly impact graft survival or function as compared to a matched control group.

Midfacial volumetric and upper lip soft tissue changes after Le Fort I advancement of the cleft maxilla.

PURPOSE: To analyze, using 3-dimensional photogrammetric data, midfacial soft tissue and volumetric changes in the cleft maxilla after 1- or 2-piece Le Fort I (LF1) advancement. MATERIALS AND METHODS: This was a retrospective study of patients with cleft and maxillary hypoplasia who underwent LF1 advancement. The primary predictor variable was the type of advancement (1 piece vs 2 pieces). Outcome measurements were changes in soft tissue linear measurements (subnasale [Sn], labium superius [LS], and stomion [SO]) and midfacial volume after maxillary advancement. RESULTS: Eleven patients (7 male, 4 female) underwent LF1 advancements (4 underwent 2-piece advancement). The mean maxillary advancement was 6.2 ± 1.7 mm. Soft tissue changes at the Sn, LS, and SO were 5.2 ± 2.0, 5.8 ± 2.5, and 5.2 ± 1.8 mm, respectively. The average volume change was 12.2 ± 5.7 cm(3). The mean ratios of soft tissue change to the amount of maxillary advancement (millimeters per millimeter) at the Sn, LS, and SO were 0.89 ± 0.49, 0.97 ± 0.44, and 0.89 ± 0.34, respectively. Volume increased by 2.1 ± 1.3 cm(3)/mm. Patients undergoing 1-piece advancement had greater mean advancement and greater soft tissue changes at the LS and SO (P < .03). After controlling for the amount of advancement, 1-piece LF1 osteotomy showed significantly greater improvements at the LS and SO (P < .04). CONCLUSIONS: Midface advancement at the LF1 level in patients with cleft consistently expands upper lip soft tissue and midfacial volume. Greater changes at the LS and SO were seen with 1-piece than with 2-piece osteotomy.

The Role of Postoperative Antibiotics in Mandible Fractures: A Systematic Review of the Literature.

INTRODUCTION: Little debate exists regarding the use of preoperative and perioperative antibiotic prophylaxis in the setting of mandibular fracture management; however, employing postoperative prophylactic antibiotics remains an inexact science based on experience rather than evidence. In this systematic review, the authors evaluate scientific literature and report results of an international survey that provide information regarding current practices of the plastic surgery community. METHODS: Systematic literature review was performed using Medline, Embase, PubMed, and Cochrane databases to identify studies evaluating use of antibiotics in patients suffering from mandible fractures. Level 1, 2, and large retrospective studies were included. Case reports were excluded. Additionally, an E-survey was distributed to all ASPS members and data were collected over a 5-month period through SurveyMonkey. RESULTS: Four hundred twenty-seven articles published before December 2012 were identified. Seventy-one articles met inclusion criteria. Five articles remained when exclusion criteria were applied.ASPS member survey demonstrated 13% response rate (687 responses/5299 questionnaires). Of respondents, 75% placed patients (ORIF group) with open mandible fractures on prophylactic antibiotics for up to 3 days (44.1%), 1 week (54.8%), and more than 1 week (1.1%). Of respondents, 51% placed patients (ORIF group) with closed mandible fracture on prophylactic antibiotics for up to 3 days (50.5%), 1 week (48.6%), and more than 1 week (1%). CONCLUSION: Critical literature review demonstrates a trend towards no postoperative antibiotic coverage (>24 hours) in patients undergoing mandibular ORIF. There is further need for prospective, randomized control trials with a standardized regimen. Our survey elucidates the variability of plastic surgeons' clinical practices.

Immediate Single-Stage Cranioplasty Following Calvarial Resection for Benign and Malignant Skull Neoplasms Using Customized Craniofacial Implants.

UNLABELLED: Craniectomy defects following resection of calvarial lesions are most often reconstructed using on-table manufacturing. With the advent of computer-aided design/manufacturing and customized craniofacial implants (CCIs), there seems to be more suited alternatives. In this study, the authors report their institutional experience and outcome using immediate, single-stage, CCI-based reconstruction for benign and malignant skull neoplasm defects. METHODS: A retrospective review of a prospectively maintained database of all implant cranioplasties performed between 2011 and 2014, by a single craniofacial surgeon at a tertiary academic medical institution was performed. Preoperative and postoperative computed tomography scans with 3D reconstruction were performed for the purpose of assessing adequate resection and reconstructive outcomes. Primary endpoints included length of surgery, predicted defect versus postoperative implant surface area, contour irregularities, and complications. RESULTS: Of the 108 patients with cranioplasty identified, 7 patients were found to undergo immediate CCI-based reconstruction for calvarial neoplasms; 4 patients (4/7, 57%) presented with malignant pathology. All defects were >5  cm2. As compared with their original size, all implants were modified intraoperatively between 0.2% and 40.8%, with a mean of 13.8%. With follow-up ranging between 1 and 16 months, there were no implant-related complications identified. The immediate and long-term aesthetic results, as well as patient satisfaction, were ideal. CONCLUSION: With this preliminary experience, the authors have successfully demonstrated that immediate customized implant reconstructive techniques, by way of intraoperative modification, are both safe and feasible for benign and malignant skull neoplasms. The authors believe that with wider acceptance of this multidisciplinary approach and increased surgeon familiarity, this technique will soon become the reconstructive standard of care.

Functional abdominal wall reconstruction using an innervated abdominal wall vascularized composite tissue allograft: a cadaveric study and review of the literature.

BACKGROUND: Large, composite abdominal wall defects represent complex problems requiring a multidisciplinary approach for reconstruction. Abdominal wall vascularized composite allotransplantation (AW-VCA) has been successfully performed in 21 patients, already receiving solid organ transplants, to provide immediate abdominal closure. The current study aims to establish a novel anatomic model for AW-VCA that retains motor and sensory function in an effort to preserve form and function while preventing complications. METHODS: Three fresh cadaver torsos were obtained. Dissection was started in the midaxillary line bilaterally through the skin and subcutaneous fascia until the external oblique was encountered. The thoracolumbar nerves were identified and measurements were obtained. A peritoneal dissection from the costal margin to pubic symphysis was performed and the vascular pedicle was identified for subsequent microsurgical anastomosis. RESULTS: The mean size of the abdominal wall graft harvested was 615 ± 120 cm(2). The mean time of abdominal wall procurement was ∼150 ± 12 minutes. The mean number of thoracolumbar nerves identified was 5 ± 1.4 on each side. The mean length of the skeletonized thoracolumbar nerves was 7.8 ± 1.7 cm. The cross-sectional diameter of all nerves as they entered the rectus abdominis was greater than 2 mm. CONCLUSIONS: Motor function and sensory recovery is expected in other forms of vascularized composite allotransplantation, such as the hand or face; however, this has never been tested in AW-VCA. This study demonstrates feasibility for the transplantation of large, composite abdominal wall constructs that potentially retains movement, strength, and sensation through neurotization of both sensory and motor nerves.

Abdominal- versus thigh-based reconstruction of perineal defects in patients with cancer.

BACKGROUND: An abdominoperineal resection is an invasive procedure that leaves the patient with vast pelvic dead space. Traditionally, the vertical rectus abdominus myocutaneous flap is used to reconstruct these defects. Oftentimes, this flap cannot be used because of multiple ostomy placements or previous abdominal surgery. The anterolateral thigh flap can be used; however, the efficacy of this flap has been questioned. OBJECTIVE: We report a single surgeon's experience with perineal reconstruction in patients with cancer with the use of either the vertical rectus abdominus myocutaneous flap or the anterolateral thigh flap to demonstrate acceptable outcomes with either repair modality. DESIGN: From 2010 to 2012, 19 consecutive patients with perineal defects secondary to cancer underwent flap reconstruction. A retrospective chart review of prospectively entered data was conducted to determine the frequency of short-term and long-term complications. SETTINGS: This study was conducted at an academic, tertiary-care cancer center. PATIENTS: Patients in the study were patients with cancer who were receiving perineal reconstruction. INTERVENTIONS: Interventions were surgical and included either abdomen- or thigh-based reconstruction. MAIN OUTCOME MEASURES: The main outcome measures included infection, flap failure, length of stay, and time to radiotherapy. RESULTS: Of the 19 patients included in our study, 10 underwent anterolateral thigh flaps and 9 underwent vertical rectus abdominus myocutaneous flaps for reconstruction. There were no significant differences in demographics between groups (p > 0.05). Surgical outcomes and complications demonstrated no significant differences in the rate of infection, hematoma, bleeding, or necrosis. The mean length of stay after reconstruction was 9.7 ± 3.4 days (± SD) in the anterolateral thigh flap group and 13.4 ± 7.7 days in the vertical rectus abdominus myocutaneous flap group (p > 0.05). LIMITATIONS: The limitations of this study include a relatively small sample size and retrospective evaluation. CONCLUSION: This study suggests that the anterolateral thigh flap is an acceptable alternative to the vertical rectus abdominus myocutaneous flap for perineal reconstruction (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A134).

Reconstruction of periorbital soft tissue defects.

Because of the complex anatomy and fine mechanics of the periorbital soft tissues, the reconstruction of this region can be particularly daunting. Through a structured assessment of the defect, based on subunit analysis and thorough understanding of the surgical layers, we believe to allow the reconstructive surgeon to develop an algorithmic approach to these complex problems. The sequela of a suboptimal reconstruction do not only result in an inferior aesthetic result, but also have the potential for long-term functional problems such as epiphora, dry eye, ptosis, eyelid retraction, and thus requiring secondary surgery. There is no better time to aim for a perfect reconstruction than at the time of the initial surgery. In this chapter, we hope to encourage the reader to strengthen and recapitulate these analytical skills and present the most commonly used and studied techniques to help achieve a reproducible functional and aesthetically appealing result.

Flattening the Curve and Cutting Corners-Pearls and Pitfalls Facial Gender Affirming Surgery.

Study Design: This is an experiential article based on the past 6 years experience of providing facial gender confirmation surgery (fGAS) at an academic medical center. Objective: While trainees are getting increasing exposure to aspects of facial gender affirming surgery (fGAS), the gap between trained providers and patients who can access care is currently still widening. A handful of fellowships across the country have emerged that include fGAS in their curriculum, but it will take another decade before the principles of affirming care and surgeries are systematically taught. Fortunately, the surgical principles and techniques required to perform fGAS are part of the skill set of any specialty surgeon trained in adult craniofacial trauma and esthetic facial surgery/rhinoplasty. It is the aim of this article to provide directly applicable knowledge with the goal to assist surgeons who consider offering fGAS in flattening the learning curve and hopefully contribute to increasing the quality of care provided for the transgender and gender diverse population. We hope to provide the reader with a very tangible article with the aims to 1) provide a simple systematic framework for an affirming consultation and preoperative assessment and 2) provide translatable surgical pearls and pitfalls for forehead feminization and gonial angle resection. The frontal sinus set back and gonial angle resection in our opinion are the most unique aspect to fGAS as rhinoplasty, genioplasty and other associated procedures (e.g., fat grafting) follow well established principles. We hope that the value of this article lies in the translatability of the presented principle to any practice setting without the need for VSP, special surgical instruments or technology beyond basic craniofacial tools. Methods: This is an experiential article based on the senior authors 6 year experience offering fGAS in an academic setting. The article is structured to outline both pearls and pittfalls and is supplemented by photographs and a surgical video. Results: A total of 19 pearls and pitfalls are outlined in the article. Conclusions: Facial gender affirming surgery mostly follows established craniofacial and esthetic surgery principles. Forehead feminization and gonial angle feminization are the 2 components that diverge most from established surgical techniques and this article hopefully provides guidance to shorten the learning curve of surgeons.

Developing Gender-Affirming Surgery Curricula for Plastic Surgery Residency and Fellowship via Delphi Consensus.

BACKGROUND: Gender-affirming surgery (GAS) is a rapidly growing field within plastic surgery, and residents and fellows must receive appropriate training. However, there are no standardized surgical training curricula. The objective of this study was to identify core curricula within the field of GAS. METHODS: Four GAS surgeons from different academic institutions identified initial curricular statements within six categories: (1) comprehensive GAS care, (2) gender-affirming facial surgery, (3) masculinizing chest surgery, (4) feminizing breast augmentation, (5) masculinizing genital GAS, and (6) feminizing genital GAS. Expert panelists consisting of plastic surgery residency program directors and GAS surgeons were recruited for three rounds of the Delphi-consensus process. The panelists decided whether each curriculum statement was appropriate for residency, fellowship, or neither. A statement was included in the final curriculum when Cronbach α value was greater than or equal to 0.8, meaning that 80% or more of the panel agreed on inclusion. RESULTS: A total of 34 panelists (14 plastic surgery residency program directors and 20 GAS surgeons representing 28 US institutions) participated. The response rate was 85% for the first round, 94% for the second, and 100% for the third. Out of 124 initial curriculum statements, 84 reached consensus for the final GAS curricula, 51 for residency, and 31 for fellowship. CONCLUSIONS: A national consensus on core GAS curriculum for plastic surgery residency and GAS fellowship was achieved by a modified Delphi method. Implementation of this curriculum will ensure that trainees in plastic surgery are adequately prepared in the field of GAS.