Background Many providers require cessation of gender affirming hormone therapy (GAHT) for transgender patients prior to undergoing masculinizing chest surgery due to concern for increased adverse events in the presence of exogenous hormones. Evidence has suggested that continuation of GAHT for certain patients may be safe for gender affirming procedures. Objectives To compare adverse event rates in GAHT cessation versus GAHT continuation in patients undergoing masculinizing chest surgery. Methods This multicenter, retrospective study included patients at the Cleveland Clinic and MetroHealth System who underwent masculinizing chest surgery between 2016 and 2020. Results There were 236 patients who met inclusion criteria. Of these, 172 (72.9%) discontinued testosterone GAHT prior to surgery (T-GAHT cessation), and 64 (27.1%) patients continued testosterone GAHT prior to surgery (T-GAHT continuous). Mean (SD) age at surgery was 25 (8) years, and mean (SD) BMI was 29.5 (6.6). Average duration of testosterone therapy was 18 months (range 0-300). There was no significant difference in tobacco use (p=0.73), diabetes (p=0.54), thrombophilia (p=0.97), or history of thromboembolism (p=0.39). Most patients underwent double incision free nipple graft technique (77.9%). There was no significant difference in surgical time (p=0.12), intraoperative complications (p=0.54), or postoperative complications (p=0.34). The most common complication was postoperative bleeding/hematoma (7.2%). Other complications included seroma (2.1%), infection (1.3%), and nipple graft failure (0.4%). There were no thromboembolic complications. Conclusions There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively versus patients who undergo GAHT cessation for masculinizing chest surgery.

Background Deep inferior epigastric perforator (DIEP) flaps are commonly used for autologous breast reconstruction, but reported rates of venous thromboembolism (VTE) are up to 6.8%. This study aimed to determine incidence of VTE based on preoperative Caprini score following DIEP breast reconstruction. Methods This retrospective study included patients who underwent DIEP flaps for breast reconstruction between January 1, 2016 and December 31, 2020 at a tertiary-level, academic institution. Demographics, operative characteristics, and VTE events were recorded. Receiver operating characteristic (ROC) analysis was performed to determine area under curve (AUC) of Caprini score for VTE. Univariate and multivariate analyses assessed risk factors associated with VTE. Results This study included 524 patients (mean age 51.2±9.6 years). There were 123 (23.5%) patients with Caprini score of 0-4, 366 (69.8%) with scores 5-6, 27 (5.2%) with scores 7-8, and 8 (1.5%) patients with scores >8. Postoperative VTE occurred in 11 (2.1%) patients, at a median time of 9 days (range 1-30) after surgery. VTE incidence by Caprini score was 1.9% for scores 3-4, 0.8% for scores 5-6, 3.3% for scores 7-8, and 13% for scores >8. Caprini score achieved an AUC of 0.70. A Caprini score >8 was significantly predictive of VTE on multivariable analysis relative to scores 5-6 (OR 43.41, 95% CI 7.46-252.76, p<0.001). Conclusions In patients undergoing DIEP breast reconstruction, VTE incidence was highest (13%) in Caprini scores greater than 8 despite chemoprophylaxis. Future studies are needed to assess the role of extended chemoprophylaxis in patients with high Caprini scores.

Breast reconstruction after mastectomy has positive effects on self-esteem and quality of life. 1,2 Patients eligible for breast conservation surgery are undergoing mastectomy at increasing rates, concomitant with increases in demand for breast reconstruction. 3 The desire for prophylactic surgery on the contralateral side in patients with breast cancer as well as prophylactic resection in gene mutation carriers also contribute to increasing mastectomy rates. Moreover, Background: Deep inferior epigastric perforator (DIEP) flaps are the standard for autologous breast reconstruction. This study investigated risk factors for DIEP complications in a large, contemporary cohort to optimize surgical evaluation and planning. Methods: This retrospective study included patients who underwent DIEP breast reconstruction between 2016 and 2020 at an academic institution. Demographics, treatment, and outcomes were evaluated in univariable and multivariable regression models for postoperative complications. Results: In total, 802 DIEP flaps were performed in 524 patients (mean age, 51.2 ± 9.6 years; mean body mass index, 29.3 ± 4.5). Most patients (87%) had breast cancer; 15% were BRCA-positive. There were 282 (53%) delayed and 242 (46%) immediate reconstructions and 278 (53%) bilateral and 246 (47%) unilateral reconstructions. Overall complications occurred in 81 patients (15.5%), including venous congestion (3.4%), breast hematoma (3.6%), infection (3.6%), partial flap loss (3.2%), total flap loss (2.3%), and arterial thrombosis (1.3%). Longer operative time was significantly associated with bilateral immediate reconstructions and higher body mass index. Prolonged operative time (OR, 1.16; P = 0.001) and immediate reconstruction (OR, 1.92; P = 0.013) were significant predictors of overall complications. Partial flap loss was associated with bilateral immediate reconstructions, higher body mass index, current smoking status, and longer operative time. Conclusions: Prolonged operative time is a significant risk factor for overall complications and partial flap loss in DIEP breast reconstruction. For each additional hour of surgical time, the risk of developing overall complications increases by 16%. These findings suggest that reducing operative time through co-surgeon approaches, consistency in surgical teams, and counseling patients with more risk factors toward delayed reconstructions may mitigate complications.

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