Androgenic steroids induce pathologic scarring in a preclinical porcine model via dysfunctional extracellular matrix deposition.

Hypertrophic scarring is a major source of morbidity. Sex hormones are not classically considered modulators of scarring. However, based on increased frequency of hypertrophic scarring in patients on testosterone, we hypothesized that androgenic steroids induce abnormal scarring and developed a preclinical porcine model to explore these effects. Mini-swine underwent castration, received no testosterone (noT) or biweekly testosterone therapy (+T), and underwent excisional wounding. To create a delayed wound healing model, a subset of wounds were re-excised at 2 weeks. Scars from postoperative day 42 (POD42) and delayed wounds (POD28) were harvested 6 weeks after initial wounding for analysis via histology, bulk RNA-seq, and mechanical testing. Histologic analysis of scars from +T animals showed increased mean fibrosis area (16 mm2noT, 28 mm2+T; p = .007) and thickness (0.246 mm2noT, 0.406 mm2+T; p < .001) compared to noT. XX+T and XY+T scars had greater tensile burst strength (p = .024 and p = .013, respectively) compared to noT swine. Color deconvolution analysis revealed greater deposition of type I and type III collagen as well as increased collagen type I:III ratio in +T scars. Dermatopathologist histology scoring showed that +T exposure was associated with worse overall scarring (p < .05). Gene ontology analysis found that testosterone exposure was associated with upregulation of cellular metabolism and immune response gene sets, while testosterone upregulated pathways related to keratinization and laminin formation on pathway analysis. In conclusion, we developed a preclinical porcine model to study the effects of the sex hormone testosterone on scarring. Testosterone induces increased scar tissue deposition and appears to increase physical strength of scars via supraphysiologic deposition of collagen and other ECM factors. The increased burst strength seen in both XX and XY animals suggests that hormone administration has a strong influence on scar mechanical properties independent of chromosomal sex. Anti-androgen topical therapies may be a promising future area of research.

Receipt of Gender-Affirming Surgeries Among Transgender and Gender Diverse Veterans.

BACKGROUND: Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package. OBJECTIVE: To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest ("top") and genital ("bottom") surgeries. DESIGN: Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023. PARTICIPANTS: A total of 6653 Veterans (54% response rate) completed the survey. MAIN MEASURES: Self-reported "top" and "bottom" GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region. KEY RESULTS: Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18-39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master's degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery. CONCLUSIONS: GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.

Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know.

OBJECTIVE: To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). METHODS: A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. RESULTS: The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. CONCLUSION: Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.

Variant genital gender-affirming surgery: a systematic review.

OBJECTIVE: To review the available literature on variant genital gender-affirming surgery (GGAS), including the reasons for performing it, the surgeries themselves and their outcomes. METHODS: A systematic review on the performance of variant GGAS was conducted (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD42022306684) researching PubMed, Embase, Web of Science and Cochrane databases from inception up to 31 December 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and risk of bias was assessed for each study using the five-criteria quality assessment checklist. RESULTS: In total 23 case series were included, of which 17 on masculinising and six on feminising surgeries. Patients mainly choose these surgical procedures out of personal desire to avoid risk of complication or because they do not have dysphoria about certain parts of their genitalia. Complications in masculinising surgeries primarily arose from the extended urethra, which could be mitigated through primary perineal urethrostomy. Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved. In feminising surgeries, risk of visceral damage and requirement for lifelong self-dilation could be avoided when vulvoplasty was performed without vaginal canal creation. All studies had a high risk of bias. CONCLUSION: This review highlights the importance of variant GGAS and acknowledges the preferences of transgender and gender-diverse individuals. Patients should be informed about the risks and benefits of each step in these procedures.

Is size in the eye of the beholder? Visual estimation of penis size among transgender and cisgender people and implications for genital gender-affirming surgery and sexual medicine.

BACKGROUND: Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited. AIM: To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth. METHODS: There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model. OUTCOMES: We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW). RESULTS: TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models. CLINICAL IMPLICATIONS: When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety. STRENGTHS AND LIMITATIONS: To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions. CONCLUSION: Men and women (cisgender and transgender) tend to significantly overestimate penis length and width.

Requests for vulvoplasty as gender-affirming surgery: a cross-sectional study in Denmark.

BACKGROUND: Vulvoplasty, described as a promising procedure for transgender and gender diverse (TGD) persons who were assigned male at birth and who, for example, do not need a vagina or who have contraindications to vaginoplasty, is a procedure that in accordance with current guidelines is not offered as genital gender-affirming surgery in Denmark. AIM: In this study we sought to quantify the need for offering vulvoplasty in Denmark. MATERIALS AND METHODS: An online questionnaire was developed. The target group included TGD persons who were assigned male at birth and a minimum of 18 years old. Prior to data collection, the questionnaire was tested with stakeholders from the target group and was subsequently distributed exclusively in closed groups and online fora for TGD persons. Data collection took place from September 1 to October 31, 2022. OUTCOMES: Primary outcomes were type of bottom surgery respondents preferred, when vulvoplasty was chosen, the reason(s) for choosing it. RESULTS: A total of 152 responses were included for data analysis, and 134 records were complete responses. Out of 134 respondents, 35 (26.1%) preferred vulvoplasty. The reasons for preferring vulvoplasty were the belief that there is less risk with the procedure (71%), followed by not wanting to dilate (54%), no need for a vagina (48%), and no need for vaginal penetration (40%). Health issues or other reasons were infrequent (5%). Out of 122 respondents who had not had prior bottom surgery, 106 (86.9%) wanted it in the future. CLINICAL IMPLICATIONS: Some TGD individuals in Denmark could benefit from vulvoplasty and would choose it if offered. STRENGTHS AND LIMITATIONS: Strengths of this study were that the questionnaire was thoroughly tested prior to application and that the survey could only be accessed via closed fora and groups for TDG persons. Limitations were that the sample size was small, and that the response rate could not be estimated. CONCLUSION: The results of this study imply that there is an unmet need for vulvoplasty, and bottom surgery in general, in Denmark.

Double longitudinal myotomy in gender-affirming colovaginoplasty: an innovative surgical technique to prevent and treat neovaginal spasms.

BACKGROUND: Gender-affirming colovaginoplasty (GACv) presents excellent postoperative results. However, neovaginal spasms, reported as painful cramps, can affect the sexual life of patients. AIM: The study sought to describe an innovative surgical technique and evaluate its impact on the prevention and treatment of neovaginal spasms. METHODS: This was a single-center prospective observational study with 2 series of patients: (1) patients who underwent GACv with double myotomy (DM) for spasm prevention (series A), in which longitudinal myotomies were performed across the defunctionalized colon, transecting the taenias, and resecting 2 strips of the intestinal muscle layer of approximately 1- to 2-mm wide and tall, leaving intact colonic tissue between strips; and (2) patients who reported neovaginal spasms in whom intravaginal-DM was performed as treatment surgery (series B), in which the posterior wall of the neovagina was dissected from the rectum and transected by longitudinal myotomies, resecting 2 strips of endoluminal mucosa and submucosal muscle of approximately 1- to 2-mm wide and tall, and the colonic mucosa was subsequently closed. OUTCOMES: Patient-reported outcomes and neovaginal examination were performed following standardized protocols. RESULTS: In series A, 177 patients underwent GACv with the DM technique and were prospectively followed for a median time of 18 months (interquartile range, 13-60 months). No patients reported neovaginal spasms. In series B, 18 patients who reported neovaginal spasms after GACv were treated with intravaginal DM. After a median time of 35 months (interquartile range, 26-45 months), 83% (n = 15 of 18) reported remission of symptoms. CLINICAL IMPLICATIONS: Double longitudinal myotomy performed on the derived portion of the colon in colovaginoplasty is an easy-to-perform and safe technique that may prevent and treat postoperative neovaginal spasms. STRENGTHS AND LIMITATIONS: Our results presented certain limitations, mainly associated with a low prevalence of neovaginal spasms, which, being of personal perception, can be underdiagnosed. To the same extent, the fact that it is a monocentric experience limits the possibility of extrapolating it to other centers. Moreover, a more trained surgical team may be the cause of fewer postoperative complications. On the other hand, the fact of being a reference center for gender-affirming surgery, having our procedures protocolized, and the prospective nature of the study allowed us to obtain a certain homogeneity and granularity of the results. CONCLUSION: DM is a safe procedure and appears to be highly effective for the prevention and treatment of neovaginal spasms after GACv. Routine use of this technique does not increase the operating time or postoperative complications. Multicenter, prospective studies are required to validate our results.

Patient-reported outcomes after one-stage neourethral reconstruction in transmen with phalloplasty-associated strictures and fistulas.

INTRODUCTION: Urethral strictures and fistulas arising after gender-affirming surgery in transmen require meticulous management strategies. This study evaluates the safety and efficacy of urethral reconstruction and patient satisfaction post-surgery. METHODS: A retrospective analysis examined peri- and postoperative data from transmen undergoing urethral reconstruction for urethral fistula and/or strictures at the distal urethral anastomosis between December 2017 and April 2023. Follow-up involved clinical examinations, uroflowmetry, and voiding cystourethrography. Patient satisfaction and quality of life were assessed using USS PROM and ICIQ-S questionnaires. RESULTS: Among 25 patients, 88% (n = 23) had urethral fistulas, and 48% (n = 12) had urethral strictures. 41% of fistula patients also had strictures, while 75% of stricture patients had concurrent fistulas. Previous surgeries for fistula or stricture repair were noted in 26% of cases. Techniques for stricture included modified flap (50%), buccal oral mucosal grafting (33%), and primary anastomosis (17%). Post-operative urethrogram revealed urethral strictures in 15% (n = 3) and urinary extravasation in an equal number. Postoperative uroflow parameters showed improvement (Qmax 18 ml/s, Qave 7.9 ml, time 37 s, volume 332 ml). Perioperative complications were low (n = 6, 24%), all grade one (Clavien-Dindo). Follow-up revealed that 33% required another surgical intervention. The mean six-item LUTS score was 6.7 (SD 3.9). Mean ICIQ-S overall satisfaction score was 8.6 (SD 1.6) and outcome score was 20 (SD 2.8). DISCUSSION: Our study found a significant recurrence rate of urethral strictures and fistulas post-surgery. Despite this, patient satisfaction remains high and complications are generally low-grade, highlighting the importance of expert surgical intervention.

Association Between Body Mass Index and Clinical Outcomes of Gender-Affirming Masculinizing Chest Reconstruction.

INTRODUCTION: Body mass index (BMI) is often used in surgical settings to determine patients' risk of complications. In the context of gender-affirming care, BMI requirements for surgery can limit access to necessary care for larger-bodied people. There is a critical need to understand the association between BMI and postoperative outcomes for this population. METHODS: A retrospective chart review was conducted using the first 250 consecutive gender-affirming masculinizing chest reconstructions performed between 2017 and 2021 at a large academic medical institution. The relationships between BMI, preoperative factors, and common postsurgical outcomes were assessed. RESULTS: Average BMI at surgery was 27.5 ± 6.7 kg/m2. Increases in BMI were associated with longer drain stays, larger volume of tissue resected, higher likelihood of nipple grafts, and lower likelihood of periareolar surgery (all P < 0.0001). Simple logistic regression revealed that BMI increases were significantly related to the likelihood of experiencing dog ears in the intermediate term (P = 0.002). Multivariate logistic regression adjusted for common covariates (age, ethnicity, smoking status, asthma, autoimmune disorders, cardiovascular conditions, and mental health disorders) did not reveal any significant relationships between BMI and the likelihood of experiencing complications at any study point. CONCLUSIONS: Masculinizing chest reconstruction is safe and satisfactory for young adult patients across the range of BMI, with significant differences in outcomes found only for esthetic complications (i.e., dog ears). Surgeons should inform patients with higher BMIs about what outcomes to expect but higher BMI should not preclude surgery access.

Barriers to Completing Preoperative Hair Removal for Penile Inversion Vaginoplasty.

Penile inversion vaginoplasty (PIV) is a gender-affirming surgical procedure where the skin of the penis and scrotum is reconstructed into the neovaginal lining. To prevent hair-bearing skin from becoming incorporated into the neovaginal canal, transgender patients are encouraged to undergo hair removal of their external genitalia. The goal of this preoperative hair removal is to minimize the risk of potential hair-related complications after vaginoplasty. To better support patients seeking preoperative hair removal and identify current treatment barriers, we surveyed patients about their progress and satisfaction with hair removal. A cross-sectional survey was constructed to assess patient experiences with hair removal in advance of PIV. Sixty-seven patients met the inclusion criteria, of which 46 participated (68.7%). Both laser hair removal (LHR) and electrolysis were used. Although all patients had completed some preoperative hair removal at the time of survey (average of 14 sessions), the cohort completed only two-thirds of their total expected hair clearance. Multiple peri-procedural pain management therapies were employed, but overall satisfaction with pain management was low (57.4 ± 5.0 out of 100). LHR was associated with significantly lower procedural pain compared to electrolysis (p < .001). The average global satisfaction with the hair removal process was 57.9 ± 5.7 and incidents of mistreatment were associated with a statistically significant reduction in overall satisfaction (p = .02). Most patients felt that hair removal was important prior to surgery. Overall, LHR and electrolysis were both utilized as effective preoperative hair removal modalities; however, LHR has better pain tolerability than electrolysis.

Cross-Cultural Adaptation and Face Validation of the Chilean Version of the Operated Male to Female Sexual Function Index.

INTRODUCTION AND HYPOTHESIS: Transgender and gender-diverse people often experience discrimination or even outright exclusion when undergoing medical attention. It has been shown that gender-affirming treatments improve quality of life in transgender patients, and genital-affirming surgery (GAS) is increasingly spreading worldwide. Sexual function after male-to-female GAS has long been evaluated by using tools designed for assigned female at birth (AFAB), resulting in suboptimal assessments. Currently, the operated Male to Female Sexual Function Index (oMtFSFI) is the only validated questionnaire to assess the sexual function of operated transgender women. The current study was aimed at performing cross-cultural adaptation and to test the face validity of the Chilean version of the oMtFSFI. METHODS: We carried out an observational descriptive study. The questionnaire was translated into Spanish, adapted, and face validated in five phases with eight participants. The study was approved by the Universidad del Desarrollo Scientific Ethics Committee. RESULTS: According to participants, the questionnaire was shown to both pertinently and exhaustively evaluate the sexual function of post-feminizing genitoplasty transgender women. The questionnaire was well understood by the participants, except for a difficulty in understanding certain terms. Some participants criticized the perspective of the instrument in terms of the assumption of having a partner or having penetrative intercourse via the neovagina. The amendments to the Italian version of the questionnaire were discussed until an agreement on adaptation considering the patient´s perspective was reached. The present preliminary data support the face validity of the Chilean version of the oMtFSFI in the assessment of sexual function in operated transgender women. CONCLUSIONS: This adapted questionnaire could be a valuable tool for clinicians and researchers.

Flaps and Grafts in Robotic Reconstructive Surgery.

PURPOSE OF REVIEW: The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques. RECENT FINDINGS: Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site. Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.

Perioperative risk predictors for gender affirming surgery in the NSQIP database.

INTRODUCTION: Gender affirming surgeries (GAS), such as phalloplasty (PLPs) and vaginoplasty (VGPs), are important aspects of medical care for transgender patients. Here, we aim to better characterize patient demographics and surgical outcomes for PLPs and VGPs using the National Surgical Quality Improvement Program (NSQIP). We hypothesized that frailty indices would be predictive of perioperative PLP and VGP risk and outcomes for PLPs and VGPs. MATERIALS AND METHODS: Primary GAS, specifically PLPs and VGPs performed from 2006-2020 were identified in NSQIP. Baseline frailty was based on NSQIP's modified frailty index (mFI) and preoperative morbidity probability (morbprob) variable. RESULTS: Fifty-eight PLPs and 468 VGPs were identified. The overall 30-day complication rate for PLP was 26%, with 17% of total patients experiencing minor complications and 16% experiencing major complications. The overall, minor, and major complication rates for VGP were 14%, 7%, and 9% respectively. Readmissions and reoperations occurred in 7% PLP and 5% VGP patients. No deaths occurred in either group within 30 days. The mFI scores were not predictive of 30-day complications or LOS. NSQIP morbprob was predictive of 30-day complications for both PLP (OR 4.0, 95% CI 1.08-19.59, p = 0.038) and VGP (OR 2.39, 95% CI 1.46-3.97, p = 0.0005). NSQIP's morbprob was also predictive of extended LOS for PLP patients (6.3 ± 1.3 days, p = 0.03). CONCLUSIONS: This study describes patient characteristics and complication rates of PLPs and VGPs. The NSQIP preoperative morbprob is an effective predictor of surgical complications and is better than the mFI.

Peri-surgical imaging of intersex and gender diverse youths.

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Overview of gender-affirming surgery.

This publication will discuss the diversity of procedures that are common to those with intersex traits,/differences of sex development (I/DSD), and transgender and gender diverse (TGD) patients. It will address how these procedures are performed, and common after care and long-term considerations which are relevant to the pediatric radiologist. Some surgeries offered to these patient populations have shared surgical approaches and radiographic considerations. With the growth of TGD procedures as a field, more pediatric subspecialties are performing these procedures, and the approaches are informing the surgical care of the growing number of I/DSD individuals who are seeking surgery in adolescence and young adulthood. Surgeries discussed will include procedures to masculinize or feminize breast/chest tissue, facial bony contours, as well as internal and external genital structures. Patients are diverse and this includes their embodiment goals. As such, not all TGD and I/DSD patients will desire to undergo these procedures. It is important for radiologists to have a foundational understanding of this heterogenous set of procedures so they can provide optimal care for these patient populations.

An Evaluative Study of a Nurse-Led Surgical Information Initiative for Gender Diverse Individuals Seeking Genital Surgery.

AIM: To evaluate the impact of nurse-led one-on-one psychoeducation sessions on gender diverse individuals seeking gender-affirming genital surgery. DESIGN: A quasi-experimental, pre- and post-test research design was employed to examine the impact of a nurse-led initiative on improving patients self-perceived knowledge and confidence pertaining to gender affirming genital surgery. The study followed the SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence) guidelines and the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines. METHODS: The curriculum for the initiative was crafted through literature reviews, expert panel engagements, multidisciplinary team input and was delivered by two specialist gender nurses. RESULTS: The results indicated a statistically significant increase in all participants' self-perceived knowledge and confidence scores. Furthermore, the study increased confidence in the ability to ask questions and plan for the logistical and financial aspects of surgery. CONCLUSION: Participants reported that the sessions were very useful, and for most, the information did not change their desire to seek surgery but did help them make more informed choices about the procedure, timing and preferred surgeon. IMPLICATIONS FOR PATIENT CARE: The study underscores the imperative role of support networks and recommends interventions to facilitate open communication within families. The study emphasises the importance of customising healthcare approaches to align with the preferences of patients. IMPACT: The study addressed the need for psychoeducation sessions for individuals considering gender-affirming genital surgery. The main findings revealed a significant increase in participants' self-perceived knowledge and confidence, following a nurse-led intervention. The research's impact extends to gender-diverse individuals seeking surgery globally. PATIENT OR PUBLIC CONTRIBUTION: Four individuals who had undergone gender-affirming surgeries contributed their perspectives to the study design, ensuring that the educational content addressed specific information needs and concerns.

Temporary Declines and Demand Resurgence: Gender-Affirming Surgery Volume and Complication Trends During and After the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic prompted surgical volume reductions due to lockdown measures. This study evaluates COVID-19's impact on gender-affirming surgery (GAS) volume and complications from the pandemic onset through the recovery period. METHODS: The 2019-2021 National Surgical Quality Improvement Program databases were queried for transgender or gender-diverse patients using ICD-10 codes. Five time periods were analyzed: Pre-pandemic, Immediate pre-pandemic and COVID-19 outbreak, Initial COVID-19 peak, Pre-COVID-19 vaccine, and Post-vaccine release. Complications included reoperation, urinary tract infections, and wound complications. Multivariate logistic regressions assessed factors associated with undergoing surgery during the initial COVID-19 peak and experiencing surgical complications. RESULTS: Out of 2,963,230 patients, 4637 underwent GAS between 2019 and 2021. Chest feminizing and masculinizing procedures comprised 60.1% of all GAS. During the initial COVID-19 peak, all GAS surgeries nearly halved, with breast augmentations dropping to 15.3% of pre-pandemic volumes. White patients constituted a significantly higher proportion of GAS patients during the initial COVID-19 peak than in 2019 (74.7% vs. 61.0%, p = 0.014). Post-vaccine, GAS levels surged, exceeding pre-pandemic volumes by 45.5% and initial peak levels by 188.5%. The overall complication rate was 4.9%, and was significantly associated with older age, increased operative time, feminizing and masculinizing genital surgeries, and hysterectomies. The initial COVID-19 peak showed no significant correlations with surgical complications. CONCLUSIONS: GAS volume temporarily decreased during the initial COVID-19 outbreak and has since rebounded and surpassed pre-pandemic levels, corresponding with past-decade trends. Complication risks remained consistent despite the pandemic, though the results highlight potentially significant race-based disparities in GAS access during COVID-19. IMPORTANT POINTS: During the COVID-19 pandemic, public health measures led to severe volume reductions in gender-affirming surgical (GAS) procedures. Since the initial COVID-19 peak, GAS volumes have fully recovered and surpassed pre-pandemic volumes. Surgical complication rates for various GAS procedures were within expected ranges, emphasizing the overall safety of these surgeries. The study's results highlight racial disparities in undergoing GAS during the COVID-19 pandemic, with White patients disproportionately represented among those who had surgery during the COVID-19 lockdown. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

Feminization of the Forehead: A Scoping Literature Review and Cohort Study of Transfeminine Patients.

BACKGROUND: Facial feminization may be performed to alleviate gender dysphoria among transfeminine patients. The upper third of the face has several characteristics, including hairline shape and position, brow position, and forehead protrusion, that may confer feminine identity. The purpose of this study is to conduct a scoping literature review of techniques performed for forehead feminization and to additionally study clinical outcomes within an institutional cohort. METHODS: A systematic literature review was conducted to review articles that discussed techniques and clinical outcomes associated with procedures performed for feminization of the upper third of the face. A retrospective review of patients undergoing such procedures by the senior author was then conducted. Variables collected included demographic factors, operative details, and postoperative outcomes such as complications, revisions, and re-operations. RESULTS: Initial review yielded sixty-seven articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of twenty-two studies for analysis. Priorities of forehead feminization entail frontal bossing reduction, frontonasal angle widening, orbital contouring, brow lifting, and hairline advancement. Eighty-five patients were included for analysis. The majority were of Caucasian race (56%) and had type 3 forehead classification (92%). The average planned setback of the anterior table was 4.12 mm. CONCLUSIONS: The core tenets of the feminization of the forehead lie in the overall creation of a harmonic curvature of the forehead with other facial features. Our multi-pronged analysis presents an updated review of these principles, which may help plastic surgeons in performing procedures to feminize the upper third of the face. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

The Type I+ Forehead in Facial Feminization Surgery.

BACKGROUND: Feminizing fronto-orbital reconstruction involves one of four possibilities with the Ousterhout Type III anterior table frontal sinus osteotomy and setback performed in most patients while the Type I reduction recontouring is reserved for patients without frontal sinuses or thick anterior tables. However, patients with frontal sinuses and either a moderately thick anterior table or a shallow frontal sinus in the sagittal plane represent an intermediate morphology. For such morphologies, we introduce the novel Type I+ fronto-orbital reconstruction technique, consisting of frontal bone recontouring supplemented with anterior table reconstruction and split cranial bone graft. METHODS: Transgender and gender non-conforming patients who underwent Type I+ or Type III feminizing fronto-orbital reconstruction (2019-2023) were included for retrospective review and comparison of techniques. RESULTS: In the 123 patients (mean age 32.2 ± 9.5 years) included, 6.5% underwent Type I+ and 94.5% underwent Type III feminizing fronto-orbital reconstruction. Morphologically, Type I+ patients displayed a shallower frontal sinus compared to Type III patients (median anterior to posterior table depth 4.1[interquartile range, IQR, 1.1-5.0] versus 9.8[IQR 7.5-12.0]mm, p<0.001). At the maximum prominence, Type I+ patients also demonstrated thicker anterior tables compared to Type III patients (median 6.6[IQR 5.0-8.8] versus 2.2[IQR 0.4-4.7]mm, p=0.001). Patients receiving Type I+ procedures underwent an anterior table reduction of 2.7±1.2mm versus 4.2 ± 1.2mm for Type III procedures in the sagittal plane (p=0.002). CONCLUSIONS: The current work introduces a novel solution to an intermediate frontal sinus phenotype for gender-affirming facial feminization surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of peritoneum in female genital gender-affirming surgery: A systematic review.

Genital gender-affirming surgery (GAS) plays a crucial role in alleviating psychological discomfort and assisting transgender patients in achieving their transition goals. One of the most common procedures for primary genital reconstruction in transwomen is penile inversion vaginoplasty. But it presents a risk of vaginal stenosis and limited depth, particularly in cases with inadequate penile and scrotal tissue. This limitation becomes more relevant as transgender individuals increasingly seek early hormone therapy and puberty blockade. We conducted a literature review focusing on studies published between 2000 and 2022 to explore the application of peritoneal vaginoplasty, a technique primarily used in cisgender women with congenital vaginal agenesis, to address these challenges in transwomen. Data were extracted from 13 selected articles reporting 313 patients who underwent peritoneal vaginoplasty. Peritoneal vaginoplasty was found to offer advantages in terms of neovaginal depth and width, with an average depth of 13.8cm and width of 3.5cm. Patient reporting satisfaction rates for sexual intercourse and dilatation achievement were high, with 96.2% and 94.4% respectively. The technique did not result in an increased rate of complications compared to traditional penile inversion vaginoplasty. This review suggests that peritoneal vaginoplasty could be consider first for transwomen genital GAS, especially in cases with limited penile tissue. The well-vascularized peritoneum provides tissue with regenerative capacities and reduces the risk of stenosis. Moreover, peritoneum remains unaffected by hormonal treatments and allows deep enough neovaginal canals. This method is safe and does not lead to increased complications compared to traditional techniques.