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.

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 .

Conscientious Objection to Gender-Affirming Surgery: A Cross-Sectional Analysis of Plastic Surgery and Urology Residency Programs.

OBJECTIVE: Medical conscientious objection is a federally protected right of physicians to refuse participation in medically indicated services or research activities that are incompatible with their ethical, moral, or religious beliefs. Individual provider objections to gender-affirming surgery have been documented, however the prevalence of such objections is unknown. Our study aimed to characterize physician objections to gender-affirming surgery in plastic surgery and urology residencies and to assess related institutional policies. DESIGN, SETTING, PARTICIPANTS: A cross-sectional electronic survey was administered to program leadership of 239 accredited US plastic surgery and urology residencies from February to October 2023. Trainee exposure to gender-affirming surgery, programmatic experience with objections, and presence and content of institutional objection policies were collected. Bivariate analyses were performed to determine associations with objectors. RESULTS: One-hundred and twenty-four plastic surgery (n = 59) and urology (n = 65) residencies completed the survey, representing a 52% response rate. Most programs included didactic training (n = 107, 86%) and direct clinical exposure (n = 98, 79%) to gender-affirming surgery. Few (n = 24, 19%) endorsed existent objection policies. Sixteen programs (13%) experienced objections to gender-affirming surgery by trainees (n = 15), faculty (n = 6), and staff (n = 1). Neither geographic region, exposure to gender-affirming surgery, nor presence of objection policies significantly contributed to programmatic objections. Programs with formal objection policies reported increased confidence in addressing future objection events (p = 0.017). CONCLUSIONS: Objection to gender-affirming surgery is a rare, but plausible occurrence amongst plastic surgery and urology trainees. Residency programs should consider anticipatory policies to protect patients and, when feasible, provide reasonable accommodations for objecting trainees.

Genital gender-affirming surgery trends in Germany: Total population data with 19,600 cases from 2006 to 2022.

PURPOSE: To delineate the current trends regarding gender-affirming surgeries (GAS) in Germany. METHODS: Analysis of German hospital quality reports from 2006 to 2022 was conducted using the reimbursement.info tool. The German procedure classification (OPS) codes 5-646.0 for masculinizing- and 5-646.1 for feminizing surgery were assessed to identify GAS. Linear regression models were utilized for the analysis and depiction of current trends. RESULTS: A total of 19,632 gender-affirming procedures were performed during the study period with an exponential increase over the years. Masculinizing surgeries increased from 246 in 2006 to 1291 cases in 2022 (increase by 424%; p < 0.001). The highest annual increase of 37.2% in numbers was from 2018 to 2019 (from 1235 to 1694 cases). Feminizing surgeries increased from 180 cases in 2006 to 799 procedures in 2022 (increase by 343%; p < 0.001). The cases increased most between 2015 and 2016 from 277 to 502 cases (81.2%). The number of hospitals offering these surgeries expanded from 24 in 2006 to 29 in 2022 (21% increase; p < 0.001). CONCLUSION: This study demonstrates an exponential growth in numbers feminizing and masculinizing of GAS performed each year in Germany. Furthermore, a discernible trend emerges with a propensity for concentration of procedures within selected high-caseload centers across Germany.

"Prostatectomy after gender-affirming vaginoplasty for a transgender woman with prostate cancer".

We present the case of a 75 year old transgender woman 18 months post gender-affirming vaginoplasty found to have unfavorable, intermediate risk prostate cancer. She elected a robotic radical prostatectomy with bilateral pelvic lymph node dissection. Postoperatively, the patient resumed neovaginal dilation without difficulty, and had improvements on International Prostate Symptom Score when compared to post-vaginoplasty, pre-prostatectomy. Incontinence measured by Revised Urinary Incontinence Scale remained mild. Robotic prostatectomy can, under appropriate circumstances, allow preservation of the neovaginal vault, but requires considerable experience and multidisciplinary intraoperative collaboration.

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.

Determinants of Public Opinion Toward Gender-Affirming Surgery in the United States.

Purpose: National polling data indicate that Americans support the right of transgender persons to undergo gender-affirming surgery (GAS). It remains unknown whether public perceptions of GAS differ depending on patient subpopulations, anatomical site, or insurance coverage and whether the public widely believes that transgender people will regret GAS. Methods: We built a Qualtrics™ survey derived from an online validated 2017 Ipsos survey and distributed it to American adults through Amazon Mechanical Turk. Associations of demographic characteristics with perception of GAS were determined using multinomial logistic regression. Results: Respondents (n=312) were predominantly non-Hispanic White (69.2%), held a bachelor's degree (64.7%), and reported an annual income of $25,000 to $74,999 (64.4%). Approximately half of respondents identified as socially liberal (50.3%); 34.0% as socially conservative; and 15.7% as neither. Respondents supported a right to GAS independent of anatomy and insurance. Support for transgender children (62%) was less than for adult transgender men (84%) and women (83%). Despite supporting a right to GAS, respondents agreed that transgender adults (67%) and children (74%) would regret GAS. Education was the strongest predictor of support for GAS rights. Socially conservative respondents were significantly more likely than nonideological or liberal respondents to believe that transgender people would regret GAS. Conclusion: This large online sample of American adults with diverse ideologies demonstrated support for GAS independent of anatomical site and insurance. Support of GAS for transgender children is robust, although lower than support for adults. Despite broad support, most laypersons believe that transgender people would regret GAS.

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.

Validation of the Brazilian Portuguese language version of the facial feminization surgery outcomes evaluation the Brazilian Portuguese language version of the FFSOE.

OBJECTIVE: To translate and validate the Facial Feminization Surgery Outcomes Evaluation in Brazilian Portuguese. METHODS: A standard back-translation method was applied to obtain the final Brazilian Portuguese language version. In total, 21 Brazilian native Portuguese speakers transgender women with surgical intent and 21 Brazilian native Portuguese speakers transgender women without surgical intent were included in the study. The FFSOE was administered to both groups and all patients underwent a test-retest two weeks later. RESULTS: The FFSOE showed a high internal consistency with Cronbach's alpha greater than 0.8. The test-retest reliability was high with repeated measures being highly correlated in all items, except for item 3, where the difference was significant (p =  0.027). CONCLUSION: The FFSOE showed reliability, internal consistency and reproducibility in the evaluations. It is easy to understand and quick to apply, making it a simple tool for pre- and post-operative assessment in facial feminization surgeries. THE OXFORD 2011 LEVELS OF EVIDENCE: Level 4.

Endocrine, gender dysphoria, and sexual function benefits of gender-affirming bilateral orchiectomy: patient outcomes and surgical technique.

Background: Gender-affirming bilateral orchiectomy (GABO) may be completed as either a standalone procedure (sGABO) or at the same time as gender-affirming vaginoplasty (vGABO). GABO is postulated to decrease gender-affirming hormone therapy (GAHT) dosages and reduce gender dysphoria, but these phenomena are not empirically described in the medical literature. Aim: The primary aim of this study was to describe changes in GAHT dosages after sGABO and vGABO. A secondary aim was to assess sGABO patients' preoperative decision-making priorities and postoperative satisfaction. Methods: A retrospective chart review identified 204 patients who completed GABO as either a standalone procedure (64% of patients) or at the same time as vaginoplasty (36%). Patient demographic data, surgical outcomes, and pre- and postoperative GAHT dosage data were recorded. Patients completed an opinion questionnaire to assessed decision-making priorities, as well as postoperative satisfaction and changes in quality-of-life measures. Outcomes: Primary outcomes included pre- and postoperative dosages of estradiol, progesterone, and spironolactone. Secondary outcomes included sGABO patient priorities, satisfaction with sGABO, changes in quality-of-life measures between sGABO and vGABO patients, and sGABO recommendations to future patients. Results: The sGABO and vGABO patients experienced a statistically significant dosage reduction in all three GAHT assessed: estradiol, progesterone, and spironolactone (P < .05). All patients discontinued spironolactone postoperatively. Zero complications related to GABO were recorded for patients in either group. The patient questionnaire revealed that sGABO patients prioritize decreasing endogenous testosterone and reducing their GAHT as most important in their decision to undergo sGABO prior to vaginoplasty. A majority of sGABO patients reported improvement in all nine quality-of-life indices. None of the sGABO patients would recommend against sGABO to a friend who is waiting for vaginoplasty. Clinical Implications: For patients who are interested in vaginoplasty, sGABO may serve as a more immediate, low-risk, intermediary step that comes with the benefits of GABO, including significant GAHT medication reduction and gender dysphoria relief. Strengths and Limitations: This study offers a comprehensive evaluation of the impact of GABO on patients, combining empirical data with subjective patient feedback. Limitations include the retrospective design and the use of unvalidated survey questions. Conclusion: Prevaginoplasty GABO is a viable option to more immediately alleviate gender dysphoria and reduce GAHT medications for patients who are interested in gender-affirming vaginoplasty.

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 .

[Advanced Surgical Techniques in Forehead Feminization and Hairline Redefinition]. / Techniques chirurgicales avancées dans la féminisation du front et la redéfinition de la ligne des cheveux chez les patientes transgenres.

Facial Gender-Affirming Surgery (FGAS) has emerged as a transformative option for individuals who wish to align their external appearance with their asserted gender identity. This article delves into the surgical techniques employed in forehead feminization and hairline redefinition, highlighting the nuanced approaches used to modify specific facial characteristics to achieve the desired feminizing outcomes. Our extensive experience, encompassing over 2300 forehead feminization surgeries conducted over the past 16 years, provides a robust foundation for understanding the complexities and intricacies of these procedures. This knowledge is crucial for maxillofacial and plastic surgeons, as well as other healthcare professionals involved in comprehensive gender-affirming care, ensuring they are well-equipped to deliver optimal results for their patients.

French validation of the oMtFSFI Questionnaire for assessing the sexual function of Transgender women after vulvo-vaginoplasty.

INTRODUCTION: The Operated Male-to-Female Sexual Function Index (oMtFSFI) questionnaire is the first scoring system developed to assess sexual function after gender-affirming vulvo-vaginoplasty, and was initially developed and validated in Italian. The aim of this study was to provide linguistic validation of the questionnaire in French through several steps including use of the questionnaires across a series of patients who had undergone gender-affirming vulvo-vaginoplasty between 2020 and 2022 at two French academic centers. METHOD: The French version of the oMtFSFI questionnaire was obtained through a double translation (Italian to French) and a back-translation (French to Italian), validated by a scientific committee, and cognitively assessed by a panel of expert patients. The questionnaire was then distributed to transgender male to female patients who had undergone genital gender affirming surgery at two French academic centers. RESULTS: The oMtFSFI score consists of 18 questions exploring 7 domains (genital self-image, desire, arousal, lubrication, orgasm, satisfaction, sexual pain). Among the sixty-four patients who responded to the questionnaire, 16 patients (25%) reported abstaining from sexual activity involving vaginal penetration at the time of the study were excluded. The mean total score was 37, corresponding to mild to moderate sexual dysfunction and 60.4% of the patients reported normal overall sexual function. The level of sexual satisfaction was normal for 68.8% of the patients and the genital self-image was normal for 52.1%. Most of the patients (79.2%) reported at least mild dyspareunia and 10.4% had critical sexual dysfunction. Surgery improved gender dysphoria in 96.7% of patients. There was a strong correlation between the overall oMtFSFI score and the happiness Visual Analog Scale (VAS) (P<0.001) as well as with the quality of life VAS (P<0.001). CONCLUSION: The French version of the oMtFSFI questionnaire is the only scoring system specifically developed to assess sexual function after vulvo-vaginoplasty in transgender women linguistically validated in French. Its validation in French language makes it an interesting tool for research and clinical practice.

"Escaping the Gender Prison"-Transgender Men's Experience Before and After Hysterectomy: A Qualitative Study.

This study aimed to examine the experiences of female-to-male transgendered individuals (FtMs) who underwent gender-affirming hysterectomy (GAH) and to investigate patients' perceptions of GAH and their expectations and support needs from healthcare professionals before and after the surgery. The study used a phenomenological approach and a qualitative research method. Data were collected through in-depth interviews. The sample was selected using diversity sampling, which is one of the deliberate sampling methods. The study included 20 FtMs with a GAH in Turkey between February 2022 and 2023. As a result of the study, participants identified three main themes: experiences with body and gender identity, experiences with health professionals and systems, and mental and physical recovery from surgery. FtMs individuals reported less distress and more happiness after undergoing a hysterectomy. The participants expected health professionals and society to raise awareness, normalize the process, and improve legal procedures. They advocated for legal regulations that address reproductive deprivation and identity issues without surgery and the ability to freeze oocytes before hysterectomy. This study sheds light on the experiences of transgender FtMs before and after GAH. These findings can potentially improve gender-affirming healthcare, particularly in our country.

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.

Imaging the acute complications of gender-affirming surgeries: a primer for radiologists in the emergency setting.

Gender-affirming surgery (GAS) is increasingly being performed. GAS is tailored to the patient leading to a diverse spectrum of radiologic post-operative findings. Radiologists who are unfamiliar with expected anatomic alterations after GAS may misdiagnose important complications leading to adverse patient outcomes. This collaborative multi-institutional review aims to: Describe relevant embryology and native anatomy. Describe relevant Gender-Affirming Surgery (GAS) techniques and expected neo-anatomy with associated complications, including common terminology. Review expected imaging appearance of neo-anatomy/postoperative findings. Review multi-modality [ultrasound, plain film, retrograde urethrogram, computed tomography] emergent imaging findings. Understand unique patient evaluation and imaging protocol considerations in the GAS population. Discuss pearls and pitfalls of imaging in the acute post-GAS setting.

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.

Maximizing Patient Satisfaction in Facial Feminizing Rhinoplasty.

Background: Although facial feminizing rhinoplasty can reduce gender dysphoria, there is limited evidence on approaches to maximize transgender patient satisfaction. In a retrospective cohort of transfeminine patients who underwent feminizing rhinoplasty, we compare pre- and postoperative nasal metrics and postoperative satisfaction. Methods: Records were retrospectively reviewed to identify transfeminine patients who had feminizing rhinoplasty and cisgender females who had aesthetic rhinoplasty at least 8 weeks post-rhinoplasty. Transgender patients were contacted to rate their aesthetic and functional rhinoplasty satisfaction. Patients with 75% or greater of the total survey score were "very satisfied," those between 50% and 75% were "satisfied," and those below 50% were "less satisfied." The Vectra 3D imaging software was utilized to measure each patient's pre- and post-rhinoplasty dorsal lengths; tip projection ratios; and nasolabial, nasofrontal, and nasofacial angles. Relative percent changes for each patient between pre- and post-rhinoplasty measurements were compared between transgender and cisgender females using descriptive statistics. Results: Twenty-five transgender patients met the inclusion criteria; 19 answered the survey with 12 very satisfied, 7 satisfied, and 0 less satisfied patients. The median age of surveyed patients was 35, and 42.1% identified as Hispanic. Between very satisfied and satisfied patients, median relative percent changes in dorsal length (-1.2% vs 5.7%, P = .043), tip projection ratio (2.4% vs 8.1%, P = .038), and nasolabial angle (-2.5% vs 9.7%, P = .026) significantly differed; median relative changes in nasofrontal angles (4.2% vs -0.6%, P = .071) and nasofacial angles (-0.7% vs -3.6%, P = .703) were insignificantly different. Satisfied transgender patients and cisgender patients (n = 5) had significant differences in median relative changes in dorsal length (5.7% vs 0.7%, P = .047), tip projection ratio (8.1% vs -3.5%, P = .033), and nasolabial angles (9.7% vs -5.4%, P = .042). Very satisfied transgender and cisgender females had no significant differences in relative metric changes. Conclusions: Very satisfied transgender patients had decreases in dorsal length, smaller increases in tip projection ratio, and decreases in the nasolabial angle compared with satisfied patients. These data can help focus feminizing rhinoplasty approaches to maximize satisfaction. Further, very satisfied transgender patients had similar changes as cisgender females, reaffirming the utility of applying cisgender female rhinoplasty considerations to feminizing rhinoplasty.

Medicaid coverage for gender-affirming surgery: A state-by-state review.

OBJECTIVE: To systematically review Medicaid policies state-by-state for gender-affirming surgery coverage. DATA SOURCES AND STUDY SETTING: Primary data were collected for each US state utilizing the LexisNexis legal database, state legislature publications, and Medicaid manuals. STUDY DESIGN: A cross-sectional study evaluating Medicaid coverage for numerous gender-affirming surgeries. DATA COLLECTION/EXTRACTION METHODS: We previously reported on state health policies that protect gender-affirming care under Medicaid coverage. Building upon our prior work, we systematically assessed the 27 states with protective policies to determine coverage for each type of gender-affirming surgery. We analyzed Medicaid coverage for gender-affirming surgeries in four domains: chest, genital, craniofacial and neck reconstruction, and miscellaneous procedures. Medicaid coverage for each type of surgery was categorized as explicitly covered, explicitly noncovered, or not described. PRINCIPAL FINDINGS: Among the 27 states with protective Medicaid policies, 17 states (63.0%) provided explicit coverage for at least one gender-affirming chest procedure and at least one gender-affirming genital procedure, while only eight states (29.6%) provided explicit coverage for at least one craniofacial and neck procedure (p = 0.04). Coverage for specific surgical procedures within these three anatomical domains varied. The most common explicitly covered procedures were breast reduction/mastectomy and hysterectomy (n = 17, 63.0%). The most common explicitly noncovered surgery was reversal surgery (n = 12, 44.4%). Several states did not describe the specific surgical procedures covered; thus, final coverage rates are indeterminate. CONCLUSIONS: In 2022, 52.9% of states had health policies that protected gender-affirming care under Medicaid; however, coverage for various gender-affirming surgical procedures remains both variable and occasionally unspecified. When specified, craniofacial and neck reconstruction is the least covered anatomical area compared with chest and genital reconstruction.