Early Penile and Donor Site Sensory Outcomes After Innervated Radial Forearm Free Flap Phalloplasty: A Pilot Prospective Study.

BACKGROUND: Radial forearm free flap phalloplasty (RFFF) is a set of complex reconstructive procedures aimed at creating an aesthetic and functional penis in transgender patients. Sensory recovery in the neophallus and donor site is crucial for optimizing outcomes, but the few prior studies that exist assess neophallus sensation at limited locations and time points. The purpose of this study was to prospectively quantify sensory outcomes in the neophallus and donor site following RFFF phalloplasty. METHODS: Sensation testing occurred prospectively over February 2019-January 2021 on Stage 1 RFFF phalloplasty patients using the Pressure Specified Sensory Device (PSSD). On the neophallus, one-point discrimination (1PS) pressure threshold and lengthwise sensory recovery were measured at six circumferential locations proximally to distally. On the donor site, 1PS was measured at three locations on the donor hand. RESULTS: Nineteen patients were included (average age 34.0 years old, range 18-53 years). Among patients that received neophallus testing (n = 13), eight had at least two follow-up appointments. Six of these patients had sensation as of their most recent measurement (75.0%), with an average of 73 days to regain sensation. There was a significantly greater proportion of patients with sensation at the right ventral (80.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.024) and right lateral (100.0% after 3 months vs. 11.1%-60.0% before 3 months, p = 0.004) aspects of the neophallus over time. Pressure required to elicit sensation decreased by 18.0% from 1 week-1 month postoperatively to 3-7.7 months postoperatively in the right ventral neophallus (96.2 g/mm2 ± 11.3 g/mm2 to 56.6 ± 39.9 g/mm2, p = 0.037). Among patients that received donor site testing (n = 11), mixed effects regression analysis with random intercepts demonstrated significant changes in the thumb (3.4 g/mm2 ± 1.4 g/mm2, p < 0.05) and webspace (13.5 g/mm2 ± 4.9 g/mm2, p < 0.01) that returned to baseline at 3 months postoperatively (1.7 g/mm2 ± 1.0 g/mm2, p > 0.05, and 2.3 g/mm2 ± 4.0 g/mm2, p > 0.05, respectively). CONCLUSION: This pilot study demonstrates that quantitative sensory testing can be used to monitor post-phalloplasty sensory changes. Recovery was significantly associated with contralateral (i.e, right side in a left forearm RFF) aspects of the neophallus, suggesting a possible pattern of circumferential sensory innervation via RFFF sensory nerves. Future studies with a larger sample size and longer follow-ups are necessary to fully characterize sensory recovery in phalloplasty patients.

Sociodemographics of Patient Populations Undergoing Gender-Affirming Surgery: A Systematic Review of All Cohort Studies.

Importance: Sociodemographic and health characteristics of patients undergoing gender-affirming surgery (GAS) are currently unknown. Understanding these patient characteristics is vital to optimizing patient-centered care for transgender patients. Objective: To determine sociodemographic characteristics for the transgender population undergoing GAS. Collected sociodemographic information included the following: age, race/ethnicity, body metrics, hormone replacement therapy administration and duration, substance use, psychiatric comorbidities, and medical comorbidities. Evidence Review: A search of seven electronic databases (PubMed, PsycINFO, Embase, CINAHL, Web of Science, Cochrane, and Gender Studies) was used to find all articles on GAS from inception through May 2019. The 15,190 articles were then subjected to two levels of screening, and articles unrelated to gender-affirming care, unavailable in English, n<5, and with no outcomes reporting were excluded. Textbook chapters and letters were also excluded. Findings: A total of 406 studies were fully extracted, with 307 studies reporting age (n=22,727 patients), 19 reporting race/ethnicity (n=1184), 74 reporting body metrics (body mass index [BMI] n=6852, height n=416, and weight n=475), 58 reporting hormone therapies (n=5104), 56 reporting substance use (n=1146), 44 reporting psychiatric comorbidities (n=574), and 47 reporting medical comorbidities (n=573). From the 406 studies, 80 were done in the United States. Regarding U.S. studies, 59 studies reported age (n=5365), 10 reported race/ethnicity (n=709), 22 reported body metrics (BMI n=2519), 18 reported hormone therapies (n=3285), 15 reported substance use (n=478), 44 reported psychiatric comorbidities (n=394), and 47 reported medical comorbidities (n=293). Age was the most reported characteristic, reported in 75.62% of studies (73.75% of U.S. studies). Race/ethnicity was the least commonly reported data, reported in 4.68% of studies (12.50% of U.S. studies). Conclusions and Relevance: The type of sociodemographic information reported by GAS studies is inconsistently reported. To improve patient-centered care for transgender patients, further work is needed to create a standardization of collected sociodemographic information.

Building an Academic Transgender Medicine Center of Excellence: The 5-Year Johns Hopkins Experience.

Gender-affirming care for transgender and gender diverse (TGD) individuals is a multidisciplinary endeavor that requires organized efforts of many specialized practitioners. TGD individuals experience many health care barriers, including the scarcity of multidisciplinary teams formed to coordinate and deliver complex care in an efficient and affirming way. The Johns Hopkins Center for Transgender Health was founded in 2017 with the mission of decreasing health disparities and improving the health of the TGD community. The authors present their experience building the center around a service line model in which patients have 1 point of contact, they are tracked throughout the care process, and the multidepartmental practitioners involved in their care are aligned. This model allowed for a patient-centered experience in which all involved disciplines were seamlessly integrated and the patient could navigate easily among them. With the structure and mission in place, the next challenge was to develop an infrastructure for culturally competent care. Through competency training and adjustment of systems-based logistics, measures were put in place to prevent traumatic experiences, such as misgendering, use of culturally inappropriate vocabulary, and use of incorrect names. Partnerships among colleagues in the fields of plastic surgery, urology, gynecology, otolaryngology, anesthesia, psychiatry/mental health, internal medicine, endocrinology, fertility, nursing, social work, speech therapy, and pediatrics/adolescent care were necessary to provide the appropriate breadth of services to care for TGD patients. Since its inception, the center has seen steady and continual growth, with more than 2,800 patients in its first 5 years. By sharing their experience in creating and developing a center of excellence, the authors hope to provide a blueprint for others to expand health care quality and access for TGD individuals.