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Journal Club: 10 journal articles on gender-affirming surgery every plastic surgery resident should read

As more gender-diverse individuals seek gender-affirming treatment, it's become essential that providers understand the specific needs of their transgender and gender non-conforming patients. The following articles recognize such needs, make informed recommendations and describe techniques to address the physical, emotional and social needs of this growing patient population.

1. Standards of Care for the Health of Transgender, Transsexual, and Gender-Nonconforming People, Version 7

Coleman E, Bockting W, Botzer M, et al. Int J Transgenderism 2012(13):165-232

These guidelines from the World Professional Association for Transgender Health (WPATH) were created in 2012 and address the unique healthcare needs of gender-diverse patients, based on current literature and expert recommendations. This summarizes, and includes references for, the current influential literature at the time of its publication. It provides recommendations in regard to social needs, mental health, hormone therapies, preoperative decision-making, postoperative care and long-term health maintenance. This document also discusses the recommendations for treatment prior to gender-affirming surgery. The updated Version 8 is scheduled to be released in 2020.

2. Facial Gender Confirmation Surgery – Review of the Literature and Recommendations for Version 8 of the WPATH Standards of Care

Berli JU, Capitan L, Simon D, Bluebond-Langner R, Plemons E, Morrison SD. Int J Transgenderism 2017;18(3):264-270

This comparative literature review summarizes recent publications on facial gender confirmation surgery (FGCS). Articles published since WPATH Standards of Care, Version 7, demonstrate minimal complications and significantly higher satisfaction rates in people who have facial gender dysphoria and underwent FGCS relative to those who did not. It provides statistical results, outlines systematic approaches to full FGCS and describes the changes in standardized outcome measures. The authors advocate for these as medical necessities for gender affirmation in the upcoming WPATH Standards of Care, Version 8.

3. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts

Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. JAMA Pediatrics 2018;172(5):431-436

This cohort study of minors and young adults evaluates chest satisfaction pre- and postoperatively in transmasculine youth ages 13-25. The study's original Chest Dysphoria Scale considers physical wellbeing, avoidance of certain activities, emotional distress and future planning due to chest appearance. In the sample of 136 patients, the mean age of both the pre- and post-op groups was 17, with 25 percent of the post-op group under age 15. There were very low rates of regret in post-surgical patients. Nonsurgical participants had a stronger desire for reconstruction proportional to the length of time of hormone therapy. Limits include cross-sectional design and the unvalidated Chest Dysphoria Scale. This study concludes that individuals should be considered for surgery regardless of their age and potentially in conjunction with puberty blockers.

4. Nonsurgical Management of Facial Masculinization and Feminization

Ascha M, Swanson MA, Massie JP, et al. Aesthetic Surgery Journal 2019;39(5):NP123-NP137

This literature review summarizes articles on nonoperative facial gender confirmation, as well as techniques currently used in cisgender patients. Fillers and neurotoxins provide temporary and less-invasive, yet powerful, options for facial feminization or masculinization. The authors identify and address the classic characteristics of each gender and provide nonsurgical techniques for facial modification. They additionally discuss the differences in treatment for transwomen, primarily that genetically male skin tends to require additional volume of fillers and neurotoxin. They conclude that cisgender techniques can be employed and modified for facial gender confirmation.

5. Chest-Wall Contouring Surgery in Female-to- Male Transsexuals: A New Algorithm

Monstrey, S., Selvaggi, G., Ceulemans, P., et al. Plast Reconstr Surg 2008;121(3):849-859

This retrospective review of a total of 184 mastectomies (92 patients) compares the outcomes of five subcutaneous mastectomy techniques used at one hospital. The indications, procedural steps, strengths and limitations for the semicircular, transareolar, concentric circular, extended concentric circular and free nipple-graft techniques are described. Hematoma was most common in the transareolar and semicircular techniques, while complications requiring reoperation were most commonly seen in the extended concentric circular technique. The authors recommend increased consideration of skin laxity, along with breast size, ptosis and nipple-areolar complex size, when determining the approach for subcutaneous mastectomy, and they present an algorithm for preoperative decision-making.

6. Breast and Body Contouring for Transgender and Gender Non-Conforming Individuals

Morrison SD, Wilson, SC, Mosser SW. Clinics in Plastic Surgery 2018;45(3):333-342

This article reviews breast and body contouring procedures for transfemale patients in order to guide surgical planning, patient expectations and understanding of surgical limitations. It covers the basic anatomical differences between genders, highlighting the bony differences and soft tissues. Hormone therapies, antiandrogens and estrogen for transwomen, and testosterone for transmen, may alter soft-tissue distributions; however, some patients may desire further surgical gender affirmation. For breast augmentation, the authors briefly discuss ideal dimensions, then identify techniques addressing the obstacles of augmentation. These primarily include insufficient skin envelope and nipple-areolar complex positioning due to gender anatomy. While limited, feminization using body contouring with liposuction and fat grafting is summarized as a means of addressing the fat distribution between the sexes.

7. Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women

Buncamper ME, van der Sluis WB, van der Pas RS, et al. Plast Reconstr Surg 2016;138(5):999-1007

This article outlines the operative technique of penile inversion vaginoplasty and describes a retrospective review of the intraoperative and postoperative complications at one major center. The intraoperative and immediate post-op complications, including rectal or urethral injury and bleeding, are low, with the exception of small wound-healing issues or dehiscence reported at 24.6 percent. Compared to current literature, this study reports lower rates of introital and vaginal stenosis, attributing this to their dilation protocol and perineoscrotal flap. Less than 3 percent of patients required revision vaginoplasty. The authors conclude that, despite moderately high post-op complications, the majority of post-op issues are minor and few require reoperation.

8. Long-Term Outcomes of Rectosigmoid Neocolporrhaphy in Male-to-Female Gender Reassignment Surgery

Morrison SD, Satterwhite T, Grant DW, Kirby J, Laub DR Sr., VanMaasdam J. Plast Reconstr Surg 2015;136(2):386-394

This retrospective review of 83 patients over a 22-year period is one of the largest studies of pedicled rectosigmoid neocolporrhaphy. It includes a brief summary of the primary surgeon's technique, then focuses on the short- and long-term outcomes. While complications rates were 58 percent, they were primarily minor and improved with medical therapy or minor surgery. The most common complication was stricture, followed by protrusion of the corpus spongiosum and short-term muccorhea. In this sample, only 40 percent of responders required vaginal dilation beyond six months. The discussion directly compares the advantages and complications of rectosigmoid neocolporrhaphy and penile inversion vaginoplasty, and it concludes by advocating for rectosigmoid neocolporrhaphy as an effective and safe method for vaginal reconstruction.

9. Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique?

Monstrey S, Hoebeke P, Selvaggi G, et al. Plast Reconstr Surg 2009;124(2):510-518

This article briefly describes the history of penile reconstruction and the four major goals of transmasculine patients: sensation, intercourse, upright voiding and an aesthetically appropriate penis and scrotum. Currently, the radial forearm flap is considered the standard technique, and this article reviews the ability of the current technique to accomplish the above goals. The technique reviewed describes a combined approach with elevation of the radial forearm flap and simultaneous vaginectomy and urethral reconstruction. A second stage was used to address erections for intercourse. The major disadvantages were high rates of fistulae, urologic complications and donor-site scarring. In conclusion, the radial forearm flap is deemed an appropriate, but not ideal, method of penile reconstruction – and the authors highly recommend the multidisciplinary approach with urologic assistance intraoperatively.

10. Scrotal Reconstruction in Female-to-Male Transsexuals: A Novel Scrotoplasty

Selvaggi G, Hoebeke P, Ceulemans P, et al. Plast Reconstr Surg 2009;123(6):1710-1718

This technique article summarizes the obstacles and limitations of scrotal reconstruction. In this sample of 240 patients, all scrotal reconstruction was done using the labia majora at the time of penile reconstruction. Detailed descriptions and images are included to outline the procedural steps of the V-Y plasty and rotation of the labia majora to create a more realistic scrotum. The results yielded sensation, shape and position that was satisfying to patients. In conclusion, authors advocate for the reproducibility, safety and efficacy of this technique and recommend it as standard for scrotal reconstruction.

Dr. Leonhard is PGY-2, and Dr. Morrison is PGY-6, at the Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle.