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There is an increased demand for gender affirmation surgery. Chest contouring, or "top" surgery, is especially important in the female-to-male (FtM) transgender population. This Continuing Medical Education (CME) article critically appraises the available literature on top surgery to allow plastic surgeons to understand current practices and determine the best surgical technique using a decision algorithm and the patient's preoperative anatomy and characteristics. Because a single best surgical approach does not exist due to significant variance in preoperative patient anatomy, and in order to provide a useful framework for decision making, surgical approaches described are categorized as: approach 1-remote incision procedures without skin excision; approach 2-procedures with periareolar skin excision; and approach 3-mastectomy procedures with skin excision other than periareolar skin excision. Decision algorithms that help determine the most suitable surgical technique for individual patients are reviewed. Data on complication rates and patient satisfaction will improve informed consent discussions and create realistic patient expectations.

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/m 2 (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.

Background: Although the benefits of gender-affirming surgery may be apparent to patients and providers, there remains a paucity of studies assessing the impact of these procedures. As an initial step, preoperative patient-reported outcomes using validated measures of depression, anxiety, and body image were used and compared to cisgender normative data. Methods: Patients presenting for gender-affirming mastectomy were approached and surveyed using validated instruments measuring anxiety, depression, and body image. In addition, clinical data were collected from the medical record. Results were compared to published instrument norms in the general cisgender population. Results: One hundred three patients completed the preoperative assessment; 70.3 percent and 66.3 percent of the cohort screened positive for mild to severe depression and anxiety, respectively. Only 25 percent and 29.8 percent of the cohort, respectively, had a previous diagnosis of depression and anxiety. The rates of depression and anxiety were significantly higher than those in cisgender normative data [mean Patient Health Questionnaire score, 2.7 (p < 0.0001); mean Generalized Anxiety Disorder Scale 7 score, 2.66 (p < 0.0001)]. Body Image Quality of Life Index and BREAST-Q scores were also significantly lower than those in cisgender normative data. Conclusions: Patients seeking gender-affirming mastectomy have a significant mental health burden that appears to be underdiagnosed. They further have significant challenges with body image compared with cisgender normative data. These findings signify dramatic mental health disparities in the preoperative transgender population and the need for ongoing prospective research of gender-affirming surgery.

Objective: To determine the impact of gender-affirming mastectomy on depression, anxiety, and body image. Background: There are many cross-sectional and ad-hoc studies demonstrating the benefits of gender-affirming surgery. There are few prospective investigations of patient-reported outcomes in gender-affirming surgery using validated instruments. Methods: In this prospective study, patients presenting to the University of Michigan for gender-affirming Mastectomy were surveyed preoperatively and 6-months postoperatively. Primary outcomes were patient-reported measurements of anxiety measured by General Anxiety Disorder-7, depression measured by Patient Health Questionnaire-9, body image measured by BODY-Q and Body Image Quality of Life Index, psychosocial and sexual functioning measured by BREAST-Q, and satisfaction with decision measured by BREAST-Q. Linear regression analysis was used to control for presence of complication and existing history of mental health conditions. Results: A total of 70 patients completed the study. The average age of participants was 26.7. The mean Patient Health Questionnaire-9 score pre-operatively was 7.8 and postoperatively was 5.4 (P=0.001). The mean preoperative and postoperative General Anxiety Disorder-7 scores were 7.6 and 4.6, respectively (P < 0.001). There were significant improvements in both psychosocial (35 to 79.2, P < 0.001) and sexual (33.9 to 67.2, P < 0.001) functioning related to chest appearance as measured by the BREAST-Q and global psychosocial functioning (-15.6 to +32, P < 0.001) as measured by the Body Image Quality of Life Index. Satisfaction with chest contour (14.3 to 93.8, P < 0.001) and nipple appearance (29.3 to 85.9, P < 0.001) measured by the BODY-Q significantly improved. Patients had a mean satisfaction with outcome score of 93.1. Conclusions: Patients undergoing gender-affirming mastectomy in this single-center prospective study reported significant improvements in anxiety, depression, body image, psychosocial, and sexual functioning after this procedure. Patients were extremely satisfied with the decision to undergo this operation.

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Background: Penile inversion vaginoplasty (PIV) is a common procedure for transfeminine patients, with the goal of creating a functional vaginal canal and clitoris and a natural-appearing vulva. Creation of the neovagina requires opening of the prerectal space, most commonly from a perineal approach, and the reported rates of rectal perforation during this dissection range from 3% to 5%. Methods: Adult patients who underwent PIV at the authors’ institution were identified retrospectively. Demographics, operative information, and postoperative clinical outcomes were extracted from the electronic medical record. Results: Ten of 146 patients (6.8%) experienced a rectal injury. All patients underwent an immediate repair (two-layer repair in eight patients, and three-layer repair in two), with two patients subsequently requiring temporary fecal diversion and two requiring muscle flaps (1.4% each). Literature review identified 18 relevant publications, with scarce in-depth analysis of management of initial rectal injuries. Conclusion: The authors’ algorithmic approach to rectal injury during PIV is designed to facilitate decision-making based on preoperative preparation, consistent intraoperative monitoring, feasibility of primary repair of the rectum, and a multidisciplinary approach to longitudinal postoperative care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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