Maximizing surgical outcomes with gender affirming hormone therapy in gender affirmation surgery.

Gender Affirmation Surgery (GAS) is a super specialized subset within the field of plastic and reconstructive surgery (PRS) that is ever evolving and of increasing interest to the PRS community. It is a multifaceted process which, in addition to surgical therapy, involves mental health therapy and hormonal therapy. One rapidly emerging interest within GAS is the role that gender affirming hormone therapy (GAHT) plays in enhancing surgical outcomes. GAHT has been used adjunctively with GAS as a comprehensive therapy to ameliorate gender dysphoria. This literature review will examine the positive effects of GAHT on the surgical outcomes on GAS, as well as other important considerations prior to surgery. As such, the primary objective of this literature review is to evaluate and assess the current evidence concerning the efficacy and safety of GAHT, as it relates to Gender Affirmation Surgery procedures.

Use of allograft fat for aesthetic and functional restoration of soft tissue contour deformities.

The authors report a case series of five patients with Leneva grafted into the nose, hand, genitalia and below-the-knee stump. Leneva is an allograft adipose matrix derived from aseptically processed human adipose tissue with retained matrix proteins, growth factors, cytokines and collagens. It is manufactured hydrated and is available in pre-loaded syringes. Five patients (3F, 2 M) with a mean age of 50.7 (range 31-77 years) injected with a mean volume of 4.2 cc (range 3-6 cc) of Leneva in various anatomic locations with an average follow up time of 4.25 months (range 0.5-12 months) experienced no allergic reactions, infection, fat necrosis or oil cysts. All patients were pleased with the restoration of fullness to the injected site. The authors believe that Leneva is a promising multi-use filler for restoring soft tissue defects following resection of tumours, to rejuvenate age-related atrophy, aesthetically enhance the genitals and provide padding for transtibial prostheses.

Vaginal and reproductive organ preservation in trans men undergoing gender-affirming phalloplasty: technical considerations.

Gender affirmation surgeries are performed to decrease the patient's dysphoria and improve quality of life. Preservation of the vaginal canal with reproductive organs is uncommon though becoming increasingly discussed in trans men. This series examines surgical complexities of vaginal and/or reproductive organ preservation in patients undergoing phalloplasty, highlighting considerations for safety and well-being. Two patients who underwent phalloplasty met inclusion and exclusion criteria for the study and were treated in accordance with World Professional Association for Transgender Health standards. We retrospectively reviewed patients' medical records and extracted demographic data. Phallus and clitoral sensation, ability for penetrative intercourse and treatment of gender incongruence were assessed postoperatively. At an average of 22 months postoperatively, both flaps survived with tactile sensation two-thirds down the shaft, and the clitoris of both maintained erogenous sensation from stimulation. Gender incongruence was described to be reduced, and both patients were able to receive penetrative vaginal intercourse.

Surgical creation of microphallus for cis-gender female desire for intersex condition.

As the desire for an intersex phenotypic condition increases, surgeons need to become aware of the surgical possibilities there are realistic expectations and a sound mind. A 43-year-old married cis-gender female, on testosterone desired conversion of her enlarged clitoris into a micropenis or metoidioplasty without scrotoplasty or urethral lengthening to increase the size and accentuate her orgasmic response. Following clearance by mental health, a diamond perineoplasty and metoidioplasty using her labia minora was performed. At 1 year her Arizona Sexual Experience Scale increased and she was happy with the operation. Creation of a micropenis, in a cis-gender patient for an intersex state and heightened orgasmic response is surgically feasible.

The impact of negative-pressure wound therapy with instillation on wounds requiring operative debridement: Pilot randomised, controlled trial.

Presence of bacteria in wounds can delay healing. Addition of a regularly instilled topical solution over the wound during negative-pressure wound therapy (NPWT) may reduce bioburden levels compared with standard NPWT alone. We performed a prospective, randomised, multi-centre, post-market trial to compare effects of NPWT with instillation and dwell of polyhexamethylene biguanide solution vs NPWT without instillation therapy in wounds requiring operative debridement. Results showed a significantly greater mean decrease in total bacterial counts from time of initial surgical debridement to first dressing change in NPWT plus instillation (n = 69) subjects compared with standard NPWT (n = 63) subjects (-0.18 vs 0.6 log10 CFU/g, respectively). There was no significant difference between the groups in the primary endpoint of required inpatient operating room debridements after initial debridement. Time to readiness for wound closure/coverage, proportion of wounds closed, and incidence of wound complications were similar. NPWT subjects had 3.1 times the risk of re-hospitalisation compared with NPWT plus instillation subjects. This study provides a basis for exploring research options to understand the impact of NPWT with instillation on wound healing.

The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series.

INTRODUCTION: Some transgender men express the wish to undergo genital gender-affirming surgery. Metoidioplasty and phalloplasty are procedures that are performed to construct a neophallus. Genital gender-affirming surgery contributes to physical well-being, but dissatisfaction with the surgical results may occur. Disadvantages of metoidioplasty are the relatively small neophallus, the inability to have penetrative sex, and often difficulty with voiding while standing. Therefore, some transgender men opt to undergo a secondary phalloplasty after metoidioplasty. Literature on secondary phalloplasty is scarce. AIM: Explore the reasons for secondary phalloplasty, describe the surgical techniques, and report on the clinical outcomes. METHODS: Transgender men who underwent secondary phalloplasty after metoidioplasty were retrospectively identified in 8 gender surgery clinics (Amsterdam, Belgrade, Bordeaux, Austin, Ghent, Helsinki, Miami, and Montreal). Preoperative consultation, patient motivation for secondary phalloplasty, surgical technique, perioperative characteristics, complications, and clinical outcomes were recorded. MAIN OUTCOME MEASURE: The main outcome measures were surgical techniques, patient motivation, and outcomes of secondary phalloplasty after metoidioplasty in transgender men. RESULTS: Eighty-three patients were identified. The median follow-up was 7.5 years (range 0.8-39). Indicated reasons to undergo secondary phalloplasty were to have a larger phallus (n = 32; 38.6%), to be able to have penetrative sexual intercourse (n = 25; 30.1%), have had metoidioplasty performed as a first step toward phalloplasty (n = 17; 20.5%), and to void while standing (n = 15; 18.1%). Each center had preferential techniques for phalloplasty. A wide variety of surgical techniques were used to perform secondary phalloplasty. Intraoperative complications (revision of microvascular anastomosis) occurred in 3 patients (5.5%) undergoing free flap phalloplasty. Total flap failure occurred in 1 patient (1.2%). Urethral fistulas occurred in 23 patients (30.3%) and strictures in 27 patients (35.6%). CLINICAL IMPLICATIONS: A secondary phalloplasty is a suitable option for patients who previously underwent metoidioplasty. STRENGTHS & LIMITATIONS: This is the first study to report on secondary phalloplasty in collaboration with 8 specialized gender clinics. The main limitation was the retrospective design. CONCLUSION: In high-volume centers specialized in gender affirming surgery, a secondary phalloplasty in transgender men can be performed after metoidioplasty with complication rates similar to primary phalloplasty. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med 2019;16:1849-1859.

Combined General and Epidural Anesthesia is Associated With Decreased Opioid Consumption and Enhanced Pain Control After Penile Inversion Vaginoplasty in Transwomen.

BACKGROUND: Penile skin inversion vaginoplasty is a gender-affirming surgical procedure for transwomen with limited surgical analgesic protocol. This study compares the postoperative pain and opioid use in patients managed for surgery with general anesthesia (GA) with patients who were given combined epidural and general anesthesia (E/GA) with continuing postoperative epidural analgesia. METHODS: All patients who underwent penile inversion vaginoplasty between May of 2016 and May of 2018 under the care of single surgeon were identified retrospectively, 18 patients of which met the inclusion criteria. A retrospective chart review was conducted. Outcome measures were postoperative pain using visual analog scale, type and dosage of postoperatively administered intravenous or oral opioids (converted to morphine milligram equivalents, duration of inpatient admission, and time to ambulation. RESULTS: Patients who received combined E/GA reported significantly less pain and used less opioids during the first 4 postoperative days in comparison with patients who received GA alone. The reduction in mean pain associated with the use of an epidural was found to be statistically significant (P < 0.0005) as was the difference in opioid used in the 2 groups (P < 0.005) over the first 4 days postoperatively. Differences in day 5 pain suggest that postoperative pain is significantly lower even after the epidural has been removed (P < 0.005). There was no significant difference in length of hospital stay and time to ambulation (P > 0.05). CONCLUSIONS: Combined E/GA was associated with decreased inpatient opioid consumption after surgery and provided superior pain control than administration of GA alone. Based on these findings, combined E/GA should be strongly considered for patients undergoing penile inversion vaginoplasty.

Analysis of Epineurial Lidocaine Injection for Nerve Transfers in a Rat Sciatic Nerve Model.

PURPOSE: Nerve transfers for peripheral nerve injuries can result in variable outcomes. We investigated the neuroprotective effect of epineurial lidocaine injection in the donor nerve prior to transection, with the hypothesis that proximal axon loss would be decreased with consequent increased neuroregeneration and functional recovery. METHODS: A rat sciatic nerve model was used with 4 intervention groups: (1) lidocaine; (2) lidocaine/calcium gluconate (CG); (3) CG; or (4) saline (control). Behavioral testing and qualitative and quantitative histological evaluation was performed at 8 and 12 weeks. Histological assays included transmission electron microscopy, retrograde fluorogold labeling, and whole mount immunostaining. RESULTS: Functional assessments through the sciatic functional index and Basso, Beattie, and Bresnahan scale showed a statistically significant increase in recovery at 8 and 12 weeks with lidocaine treatment. Significantly higher axonal counts were obtained in the lidocaine-treated groups. Fragmentation and increased myelin damage was present in the CG and saline groups. Retrograde fluorogold labeling showed a statistically significant increase in the number of L4-6 dorsal root ganglion neurons in the lidocaine-treated groups. Whole mount immunostaining identified extension of the axonal growth cone past the nerve coaptation site in lidocaine-treated groups, but not in CG and saline groups. CONCLUSIONS: Our results suggest that epineurial lidocaine injection prior to donor nerve transection for nerve transfer has a neuroprotective effect, resulting in increased proximal axon counts and improved functional recovery. CLINICAL RELEVANCE: These findings may have direct clinical application because epineurial lidocaine can be used in surgery as a simple and inexpensive intervention for promoting improved clinical outcomes after nerve transfer.

Supersonic Transporter Deformity in Transgender Men following Phalloplasty.

Phalloplasty is often the final stage of gender-affirmation surgery for transgender men. Obtaining penile rigidity is important for sexual function, but may also bring complications, including supersonic transporter deformity, in which the glans becomes ventrally displaced and flaccid. Two cases of supersonic transporter deformity are presented here, one with a hydraulic penile implant and one with an autologous bone transplant. Attempt at surgical correction was performed in both. Careful attention must be paid to the unique anatomy of the neophallus and type of penile prosthesis to prevent or correct supersonic transporter deformity in transgender men. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Wound healing elective: an opportunity to improve medical education curriculum to better manage the increasing burden of chronic wounds.

Chronic wounds are highly prevalent and have become a public health crisis. Successful treatment of chronic wounds requires that healthcare providers study both the pathophysiology of wound healing and maintain knowledge of the most current wound care guidelines set forth by the Agency for Healthcare Research and Quality. Unfortunately, medical students currently receive limited wound care training. A focused and well-organized course integrating a diverse group of medical and surgical faculty, residents, and medical students in the clinical years has been created to address this growing medical issue. The goal of such curricular innovations is to help future physicians gain exposure to chronic wounds and develop crucial clinical skills so they enter residency prepared to offer basic treatments and prevent rapid deterioration of the many wounds they will encounter.

Evaluation of BMI as a Risk Factor for Complications following Gender-affirming Penile Inversion Vaginoplasty.

BACKGROUND: Gender affirmation surgery (GAS) has a positive impact on the health of transgender patients; however, some centers employ body mass index (BMI) as a strict selection criterion for surgical candidacy. Several single-center studies have found no clear correlation between BMI and complication rates. We conducted a retrospective multicenter study at 2 university-based centers to test the null hypothesis: obesity is not a significant determinant of the risk of acute surgical complications in patients undergoing penile inversion vaginoplasty (PIV). METHODS: This is a retrospective chart review of all adult patients at the University of Michigan and the University of Miami undergoing gender-affirming PIV with minimum follow-up time of 3 months between 1999 and 2017. A logistic regression model of analysis is used to examine the predictive factors for surgical complications and delayed revision urethroplasty in our patient sample. RESULTS: One hundred and one patients met inclusion criteria for this study. The mean BMI at the time of procedure was 26.9kg/m2 (range 17.8-48.2). Seventeen patients (16.8%) had major complications and 36 patients (35.6%) had minor complications. On logistic regression analysis, none of the recorded covariates were significant predictors of delayed revision urethroplasty or major, minor, or any complications. CONCLUSIONS: We found that obese patients can safely undergo GAS and that BMI alone should not preclude appropriately selected patients from undergoing GAS. We acknowledge that selection based on overall health and other medical comorbidities is certainly warranted for gender-affirming PIV and all other surgical procedures.

Abdominal Etching: Surgical Technique and Outcomes.

BACKGROUND: The ideal body is characterized by a muscular physique and defined anterior abdominal wall. Despite diet and exercise, many are unable to achieve this desired result. Liposuction with abdominal etching is used to achieve high-definition abdominal aesthetics. The etching technique is performed with liposuction in a superficial plane, to create indentures consistent with "six-pack abs," or definition of vertical abdominal lines. METHODS: The authors' abdominal etching preoperative markings, surgical technique, and postoperative care are discussed. The surgeons' experience with abdominal etching in 50 consecutive patients is reviewed, including rate of complications and patient satisfaction. RESULTS: The average patient age was 36.4 years. We had an almost equal number of men (n = 26) and women (n = 24), with an average body mass index of 26.7 kg/m. The average blood loss was 275 ml, the average tumescence was 6 liters, and the average lipoaspirate was 5 liters. There were no major complications such as fat embolus, deep venous thrombosis, or intraabdominal injury. The most common minor postoperative complications were contour irregularities (12 percent), seromas (10 percent), and hyperpigmentation (2 percent). The majority of patients were satisfied (98 percent). The average length of postoperative follow-up was 27 months. CONCLUSIONS: Abdominal etching is a safe and effective method of creating a defined anterior abdominal wall for patients who desire the muscular definition of vertical abdominal lines. Almost all of our patients reviewed were satisfied with this procedure, maintained long-term results, and had an acceptable rate of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema.

BACKGROUND: Treatment of advanced lymphedema requires not only restoration of physiological lymph drainage, but also excision of fibrotic tissue and excess skin. The aim of this study is to show how the combination of double vascularized lymph node transfers (VLNTs) and a modified radical reduction with preservation of perforators (RRPP) can accomplish both of these treatment goals. METHODS: Between 2010 and 2016, 16 patients (15 female and one male) with extremity lymphedema underwent a combined double gastroepiploic VLNTs and modified RRPP. Demographics, outcomes including circumference reduction rates, preoperative and postoperative lymphoscintigraphy, complications, and responses to the Lymphedema Quality of Life (LYMQOL) questionnaire were analyzed. RESULTS: All flaps survived. The mean follow-up period was 14.2 months (range, 12-19). The mean circumference reduction rate was 74.5% ± 6.9% for the upper limb and 68.0% ± 4.2% for the lower limb. There were no major complications. Minor complications, including numbness and hyperesthesia, were treated conservatively. LYMQOL showed a 2.7-fold quality-of-life improvement (P < 0.01). Postoperative lymphoscintigraphy showed improved lymphatic drainage in all cases. CONCLUSION: Combined double VLNTs and modified RRPP safely and effectively improves lymphatic drainage, reduces fibrotic tissue and excess skin, decreases episodes of infections, and improves patients' quality of life in the advanced stages of lymphedema.

Bucket-Handle Bipedicled Scalp Flaps for Coverage of Cranial Constructs in Cranioplasty.

Composite frontal scalp defects involving the frontal bone and full thickness scalp can pose a reconstructive challenge. Often, they necessitate the use of microsurgical free tissue transfer, which can be physiologically demanding in high-risk patients with multiple comorbidities, with exposure to prolonged general anesthesia time and increased surgical morbidity. The experience of a single surgeon was reviewed with reconstruction of composite frontal scalp wounds in 4 patients with structural framework and a bipedicled scalp advancement (ie, "bucket handle") flap, thus obviating the need for free tissue transfer. All 4 patients demonstrated complete wound healing by final follow-up, without need for further reoperations or ulcer recurrence. In face of composite frontal scalp defects in less than ideal candidates for lengthy microsurgical flap procedures, the bucket-handle flap can provide a simple and reliable reconstructive option.

Gender Reassignment: Feminization and Masculinization of the Neck.

Facial stigmata associated with one's assigned gender can be very distressing for the gender dysphoric patient. The lower face and neck contain several structures that play a significant role in their ability to "pass" as their desired gender. Clinical recognition and modification of these structures will allow the patient to have facial and neck features that are consistent with their desired gender. This article reviews the techniques of mandibular angle contouring, genioplasty, chondrolaryngoplasty, facelift, and neck lift as they pertain to the feminization and masculinization of the face and neck of the patient with gender dysphoria.

Primary Sigmoid Vaginoplasty in Transwomen: Technique and Outcomes.

BACKGROUND: Many techniques have been described for reconstruction of the vaginal canal for oncologic, traumatic, and congenital indications. An increasing role exists for these procedures within the transgender community. Most often, inverted phallus skin is used to create the neovagina in transwomen. However, not all patients have sufficient tissue to achieve satisfactory depth and those that do must endure cumbersome postoperative dilation routines to prevent contracture. In selected patients, the sigmoid colon can be used to harvest ample tissue while avoiding the limitations of penile inversion techniques. METHODS: Records were retrospectively reviewed for all transwomen undergoing primary sigmoid vaginoplasty with the University of Miami Gender Reassignment service between 2014 and 2017. RESULTS: Average neovaginal depth was 13.9 +/- 2.0 centimeters in 12 patients. 67% were without complications, and all maintained tissue conducive to sexual activity. No incidences of bowel injury, anastomotic leak, sigmoid necrosis, prolapse, diversion neovaginitis, dyspareunia, or excessive secretions had occurred at last follow-up. CONCLUSIONS: Sigmoid vaginoplasty is a reliable technique for achieving a satisfactory vaginal depth that is sexually functional. Using a collaborative approach, it is now our standard of care to offer this surgery to transwomen with phallus length less than 11.4 centimeters.

Guidelines for the Standardization of Genital Photography.

Plastic surgery relies on photography for both clinical practice and research. The Photographic Standards in Plastic Surgery laid the foundation for standardized photography in plastic surgery. Despite these advancements, the current literature lacks guidelines for genital photography, thus resulting in a discordance of documentation. The authors propose photographic standards for the male and female genitalia to establish homogeneity in which information can be accurately exchanged. All medical photographs include a sky-blue background, proper lighting, removal of distractors, consistent camera framing, and standard camera angles. We propose the following guidelines to standardize genital photography. In the anterior upright position, feet are shoulder-width apart, and arms are placed posteriorly. The frame is bounded superiorly by the xiphoid-umbilicus midpoint and inferiorly by the patella. For circumferential documentation, frontal 180 degree capture via 45 degree intervals is often sufficient. Images in standard lithotomy position should be captured at both parallel and 45 degrees above the horizontal. Images of the phallus should include both the flaccid and erect states. Despite the increasing incidence of genital procedures, there lacks a standardized methodology in which to document the genitalia, resulting in a substantial heterogeneity in the current literature. Our standardized techniques for genital photography set forth to establish a uniform language that promotes more effective communication with both the patient as well as with colleagues. The proposed photography guidelines provide optimal visualization and standard documentation of the genitalia, allowing for accurate education, meaningful collaborations, and advancement in genital surgery.

Sexual Preferences and Partnerships of Transgender Persons Mid- or Post-Transition.

The process of gender transition has varying effects on various aspects of sexuality. The purpose of this study was to investigate the effects of transitioning on transgender persons' sexual preferences and partnerships. Data were collected through an anonymous online survey. Questions focused on timing of gender transition in relation to change in sexual preference. Transgender individuals have a variety of sexual partners, predominantly cisgender, and may change sexual preference when they transition. Transitioning can be associated with having no primary sexual partner, despite past sexual partnerships. Length of time between identifying as transgender and starting the transition might be associated with changing sexual partner preference, particularly in transgender women. The emerging trends of sexual partnerships and changing sexual preferences related to the transition in this study warrant further investigation. These data provide more understanding of the relationship between transitioning and sexual preferences and partnerships.