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Makkonen M, Myllykangas HM, Kaarela O, Nuutinen H. Masculinizing chest-wall surgeries in transgender patients, a retrospective single-center study. ANN CHIR PLAST ESTH 2024; 69:131-135. [PMID: 37852821 DOI: 10.1016/j.anplas.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/17/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Masculinizing chest-wall contouring surgery is an important surgical intervention for most transmasculine patients; a vast improvement in quality of life for this group of patients has been documented as a result of receiving surgery. The aim of this study was to evaluate the results of such surgeries performed at our university hospital between 2008 and 2020, as well as the current quality of life of the patients. METHODS All 16 patients operated between 2008 and 2020 were sent a questionnaire consisting of both BREAST-Q and BODY-Q modules, considered fitting for our study purposes, as well as the BECK Depression Index and a short two-question form with space for feedback. Patients were divided into groups called double incision (DI) and periareolar (PA) depending on the surgical technique used. RESULTS We found an overall complication percentage of 31.3%, with the DI group scoring 33.3% and PA 28.6%, while secondary aesthetic corrections were necessary for 50% of all patients. The questionnaires yielded 6 responses (37.5%). Participants rated on a scale of 1 to 10 their willingness to undergo the operation again if given the choice; the DI group averaged 10/10, and the PA group 9/10, despite the statistically significant complication and correction rates. CONCLUSIONS Masculinizing chest-wall contouring surgery has significant complication risks. In our study, frequency of complications did not appear to depend on the surgical technique used. Additionally, the complication rates found in our low volume centre seem to be comparable with those reported from bigger units.
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Affiliation(s)
- M Makkonen
- Department of Surgery, University of Eastern Finland, Kuopio, Finland.
| | - H M Myllykangas
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
| | - O Kaarela
- Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
| | - H Nuutinen
- Department of Surgery, University of Eastern Finland, Kuopio, Finland; Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland
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Chartier R, Herlin C, Sinna R. [Thoracic reassignment surgeries]. ANN CHIR PLAST ESTH 2023; 68:436-445. [PMID: 37596145 DOI: 10.1016/j.anplas.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/23/2023] [Indexed: 08/20/2023]
Abstract
Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.
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Affiliation(s)
- R Chartier
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Nord, CHU Amiens Picardie, 80054 Amiens cedex 1, France
| | - C Herlin
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Lapeyronie, CHRU de Montpellier, 34295 Montpellier, France
| | - R Sinna
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Nord, CHU Amiens Picardie, 80054 Amiens cedex 1, France.
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Cohn J. The Detransition Rate Is Unknown. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:1937-1952. [PMID: 37308601 PMCID: PMC10322769 DOI: 10.1007/s10508-023-02623-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 06/14/2023]
Affiliation(s)
- J Cohn
- Society for Evidence-Based Gender Medicine, Twin Falls, ID, 83301-5235, USA.
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Sundhagen HP, Opheim AB, Wæhre A, Oliver NK, Tønseth KA. Chest Wall Contouring in Transgender Men: A 20-Year Experience from a National Center. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4952. [PMID: 37124388 PMCID: PMC10146532 DOI: 10.1097/gox.0000000000004952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 02/22/2023] [Indexed: 05/02/2023]
Abstract
Several western countries have experienced a drastic increase of referrals to specialist gender services of transgender and gender-diverse people. Chest wall contouring is an important element in treatment of gender dysphoria. National data concerning this group have yet to be investigated. The aim of this study was to examine and evaluate the techniques and surgical outcome of chest wall contouring from the last 20 years from a single center in Norway. Methods This study is a retrospective review of all female-to-male patients who underwent chest wall contouring surgery at Oslo University Hospital between 2000 and 2020. Statistical analysis with comparison of techniques and evaluation of development over time was examined. Results In total, 333 patients underwent bilateral chest wall contouring, 209 (62.8%) with inframammary incision with free nipple graft (IM), and 124 (37.2%) with periareolar technique (PA). In 20 years, the average age decreased from 31 (19-68) to 24.9 years (17-61). Average body mass index was significantly lower in the PA-group than in the IM-group. Complication rate was 20.7%, with postoperative bleeding being the most frequent (9.6%). Revision surgery was required in 24.9% of the cases; periareolar technique required significantly more procedures. Conclusions The number of patients referred and operated on has increased drastically over a 20-year period. When comparing the techniques, the outcome concerning complications and revisions is at an acceptable level. Postoperative bleeding and revision surgery occur more often with the periareolar technique. There remains a knowledge gap concerning quality of life and satisfaction after surgery within this patient group.
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Affiliation(s)
- Henriette Pisani Sundhagen
- From the Department of Plastic and Reconstructive surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Ane Bøyum Opheim
- From the Department of Plastic and Reconstructive surgery, Oslo University Hospital, Oslo, Norway
| | - Anne Wæhre
- Department of Child and Adolescent Psychiatry, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Nina Kristine Oliver
- From the Department of Plastic and Reconstructive surgery, Oslo University Hospital, Oslo, Norway
| | - Kim Alexander Tønseth
- From the Department of Plastic and Reconstructive surgery, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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5
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Kearns S, O'Shea D, Neff K. Transgender and non-binary demographics, referrals, and comorbidities among young Irish adults (2014-2020). Ir J Med Sci 2022:10.1007/s11845-022-03163-y. [PMID: 36121602 DOI: 10.1007/s11845-022-03163-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Over the last 6 years, there has been a change in the demographics of people presenting to gender services in Ireland. This is in line with international trends describing a higher number of transgender men (Female-Male, FTM, AFAB) presenting to gender services as compared to transgender women (Male-Female, MTF, AMAB), and lower ages at referral. Given the changes in demographics, it would be anticipated that clinical needs may have changed. This study describes the demographics of a young Irish sample (participants aged 18-30 years old) and explores the referral pathways and clinical needs of this cohort. METHODS The study was performed as a retrospective chart review of 167 charts at The National Gender Service in Ireland over a five-month period. RESULTS Transgender men represented 62.3% of the sample, transgender women 35.3%, and transmasculine/non-binary individuals represented 2.4%. Over two-thirds of participants were on gender affirming hormone therapy or GnRH antagonists and 16.1% had undergone surgical interventions. The median time from referral received to being seen at the clinic was 450 days (481 mean). Mental health comorbidities remain high with 49.1% of youth experiencing depression, a further 15.6% low mood and 26.3% anxiety. CONCLUSION This is the first study to show increasing referrals of people who were assigned female at birth (AFAB) over assigned male at birth (AMAB) individuals in Ireland, and to document the clinical needs of this cohort. By understanding the changing demographics and clinical needs, we can better plan for care and service improvements.
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Affiliation(s)
- Seán Kearns
- School of Medicine, University College Dublin, Dublin, Ireland. .,National Gender Service, St Columcille's Hospital, Loughlinstown, Co., Dublin, Ireland.
| | - Donal O'Shea
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Karl Neff
- School of Medicine, University College Dublin, Dublin, Ireland
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Vazquez IM, Labanca T, Arno AI. Functional, Aesthetic and Sensory Postoperative Complications of Female Genital Gender Affirmation Surgery: a Prospective Study. J Plast Reconstr Aesthet Surg 2022; 75:4312-4320. [DOI: 10.1016/j.bjps.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 06/10/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
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Mehra G, Boskey ER, Peters CJ, Njubigbo C, Charlton BM, Ganor O. Assessing Fertility Intentions in Patients Presenting for Gender-Affirming Surgery. LGBT Health 2022; 9:325-332. [PMID: 35749209 DOI: 10.1089/lgbt.2021.0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose: For some transgender and gender-diverse (TGD) individuals, gender-affirming surgery may represent the last opportunity to engage in gamete banking (GB) and other forms of fertility preservation (FP). Previous research has assessed fertility intentions among TGD people initiating hormone therapy. The objective of this study was to describe the fertility intentions of patients seeking gender-affirming surgery. Methods: A retrospective chart review was conducted for 233 patients seeking chest or genital surgery between 2017 and 2019. Data abstracted included interest in having children (biological or non-biological) and GB, and barriers to FP. Associations between fertility intentions, sex assigned at birth, and surgical procedure sought were assessed. Results: Of the 233 records reviewed, 162 (70%) documented information about fertility intentions for patients without a history of sterilizing surgery. At initial consultation, 94% were receiving hormone therapy. Among the 60 patients seeking genital surgery, 30% expressed interest in GB and 38% were not interested in biological children. Among the 102 patients seeking chest surgery, 11% expressed interest in GB and 47% were not interested in biological children. Patients assigned male at birth were more likely to have already completed GB (p < 0.001). Among the patients interested in FP, 41% reported barriers to access. Conclusion: Many TGD people in our study expressed no interest in biological parenthood; however, 30% of patients seeking genital surgery expressed interest in GB. This suggests that some who defer FP when starting hormones may wish to pursue it later in life. Ongoing assessment of fertility intentions and reducing barriers to FP are integral to caring for TGD people.
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Affiliation(s)
| | - Elizabeth R Boskey
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston Massachusetts, USA
| | - Carson J Peters
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Chinelo Njubigbo
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Brittany M Charlton
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Division of Adolescent Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Oren Ganor
- Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston Massachusetts, USA
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Agochukwu-Mmonu N, Radix A, Zhao L, Makarov D, Bluebond-Langner R, Fendrick AM, Castle E, Berry C. Patient reported outcomes in genital gender-affirming surgery: the time is now. J Patient Rep Outcomes 2022; 6:39. [PMID: 35467181 PMCID: PMC9038968 DOI: 10.1186/s41687-022-00446-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 04/02/2022] [Indexed: 11/16/2022] Open
Abstract
Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.
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Affiliation(s)
- Nnenaya Agochukwu-Mmonu
- Department of Urology, NYU School of Medicine, New York University, 221 East 41st Street, New York, NY, 10017, USA.
- Department of Population Health, NYU School of Medicine, New York, NY, USA.
| | - Asa Radix
- Department of Medicine, NYU School of Medicine, New York, NY, USA
- Callen-Lorde Community Health Center, New York, NY, USA
| | - Lee Zhao
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Danil Makarov
- Department of Urology, NYU School of Medicine, New York University, 221 East 41st Street, New York, NY, 10017, USA
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | | | - A Mark Fendrick
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Public Policy, University of Michigan, Ann Arbor, MI, USA
| | - Elijah Castle
- Department of Urology, NYU School of Medicine, New York University, 221 East 41st Street, New York, NY, 10017, USA
- Department of Population Health, NYU School of Medicine, New York, NY, USA
| | - Carolyn Berry
- Department of Population Health, NYU School of Medicine, New York, NY, USA
- Department of Medicine, NYU School of Medicine, New York, NY, USA
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Kearns S, Houghton C, O'Shea D, Neff K. Study protocol: navigating access to gender care in Ireland-a mixed-method study on the experiences of transgender and non-binary youth. BMJ Open 2022; 12:e052030. [PMID: 35292489 PMCID: PMC8928252 DOI: 10.1136/bmjopen-2021-052030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION There has been a global increase in demand for gender-specific healthcare services and a recognition that healthcare access is complex and convoluted, even in countries with well-developed healthcare services. Despite evidence in Ireland supporting the improvement in physical and mental health following access to gender care, little is known about the local healthcare navigation challenges. Internationally, research focuses primarily on the experience of service users and omits the perspective of other potential key stakeholders. Youth experiences are a particularly seldom-heard group. METHODS AND ANALYSIS This study will use a sequential exploratory mixed-methods design with a participatory social justice approach. The qualitative phase will explore factors that help and hinder access to gender care for young people in Ireland. This will be explored from multiple stakeholders' perspectives, namely, young people, caregivers and specialist healthcare providers. Framework analysis will be used to identify priorities for action and the qualitative findings used to build a survey tool for the quantitative phase. The quantitative phase will then measure the burden of the identified factors on healthcare navigation across different age categories and gender identities (transmasculine vs transfeminine vs non-binary). ETHICS AND DISSEMINATION This study has been approved by St Vincent's Hospital Research Ethics Committee (RS21-019), University College Dublin Ethics Committee (LS-21-14Kearns-OShea) and the Transgender Equality Network Ireland's Internal Ethics Committee (TIECSK). We aim to disseminate the findings through international conferences, peer-review journals and by utilisation of expert panel members and strategic partners.
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Affiliation(s)
- Seán Kearns
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Catherine Houghton
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland
| | - Donal O'Shea
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Karl Neff
- School of Medicine, University College Dublin, Dublin, Ireland
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Jann JT, Cunningham NJ, Assaf RD, Krysiak RC, Herman D. Evolving Primary Care Utilization of Transgender and Gender-Nonconforming People at a Community Sexual Health Clinic. Transgend Health 2021; 7:340-347. [PMID: 36033210 PMCID: PMC9398480 DOI: 10.1089/trgh.2021.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose Prior research has found that transgender people are less likely to have access to health care and health insurance than their cisgender peers and are more likely to delay seeking care due to systemic discrimination and stigma. To this end, this study seeks to measure transgender and gender-nonconforming (TGNC) clients' primary care utilization and compare them to their cisgender peers. Methods Demographic data and self-reported primary care utilization from 14,372 clients attending a community health center in Los Angeles, CA, from 2018 to 2020 were examined. Descriptive statistics and multivariable regression analyses were used to examine correlates of gender identity on primary care utilization metrics-Hepatitis A, Hepatitis B, and Human Papillomavirus (HPV) vaccinations and recent primary care visits. Results Of TGNC clients, 38.0% reported being vaccinated for Hepatitis A compared to 49.2% of cisgender clients (p<0.01) and 42.6% reported being vaccinated for Hepatitis B compared to 51.6% of cisgender clients (p<0.01). TGNC clients had higher odds of engaging with the HPV vaccination series than their cisgender peers (adjusted odds ratio [aOR]=1.28, 95% confidence interval [CI] 1.03-1.59). TGNC clients had higher odds of seeing their primary care provider within the preceding 2 years (aOR=1.72, 95% CI 1.01-2.93) compared to non-TGNC clients. Conclusions This study's results found that TGNC clients were more likely to access certain primary care services more often than their cisgender counterparts. Our results support the efficacy of such interventions, such as a health care setting designed to support the health of gender minority people, and see similar, if not greater, primary care engagement in transgender persons compared to their cisgender peers.
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Affiliation(s)
- Jamieson T. Jann
- Health Services, Los Angeles LGBT Center, Los Angeles, California, USA
| | | | - Ryan D. Assaf
- Health Services, Los Angeles LGBT Center, Los Angeles, California, USA
- Department of Epidemiology, University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, California, USA
| | - Robyn C. Krysiak
- Health Services, Los Angeles LGBT Center, Los Angeles, California, USA
| | - David Herman
- Health Services, Los Angeles LGBT Center, Los Angeles, California, USA
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11
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Vaginoplasty in Male to Female transgenders: single center experience and a narrative review. Int J Impot Res 2021; 33:726-732. [PMID: 34561673 DOI: 10.1038/s41443-021-00470-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 08/27/2021] [Accepted: 09/10/2021] [Indexed: 11/08/2022]
Abstract
Vaginoplasty in Male to Female (M to F) transgenders is a challenging procedure, often accompanied by numerous complications. Nowadays the most commonly used technique involves inverted penile and scrotal flaps. In this paper the data of 47 M to F patients who have undergone sex affirmation surgery at the Department of Urology of the University of Trieste, Italy since 2014, using our modified vaginoplasty technique with the "Y" shaped urethral flap, have been retrospectively reviewed. Moreover, a non structured review of the literature with regards to short and long-term complications of vaginoplasty has been provided. All patients followed a standardized neo-vaginal dilation protocol. At follow up 2 patients were lost. At 12 months 88.9% of patients (40/45) were able to reach climax, 75.6% (34/45) were having neo-vaginal intercourses and median neo-vaginal depth was 11 cm (IQR 9-13.25): no statistically significant decrease in depth was found at follow up. Only one patient was dissatisfied with aesthetic appearance at 12 months. Our technique provided excellent cosmetic and functional results without severe complications (Clavien-Dindo ≥ 3). The review of the literature has highlighted the need to standardize a postoperative follow up protocol with particular regard to postoperative dilatation regimen. Further, larger randomized clinical trials are pending to draw definitive conclusions.
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12
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Kearns S, Kroll T, O‘Shea D, Neff K. Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography. PLoS One 2021; 16:e0257194. [PMID: 34506559 PMCID: PMC8432766 DOI: 10.1371/journal.pone.0257194] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 08/25/2021] [Indexed: 11/19/2022] Open
Abstract
Objective Transgender and non-binary individuals frequently engage with healthcare services to obtain gender-affirming care. Little data exist on the experiences of young people accessing gender care. This systematic review and meta-ethnography aimed to identify and synthesise data on youths’ experiences accessing gender-affirming healthcare. Method A systematic review and meta-ethnography focusing on qualitative research on the experiences of transgender and non-binary youth accessing gender care was completed between April-December 2020. The following databases were used: PsychINFO, MEDLINE, EMBASE, and CINAHL. The protocol was registered on PROSPERO, international prospective register of Systematic Reviews (CRD42020139908). Results Ten studies were included in the final review. The sample included participants with diverse gender identities and included the perspective of parents/caregivers. Five dimensions (third-order constructs) were identified and contextualized into the following themes: 1.) Disclosure of gender identity. 2.) The pursuit of care. 3.) The cost of care. 4.) Complex family/caregiver dynamics. 5.) Patient-provider relationships. Each dimension details a complicated set of factors that can impact healthcare navigation and are explained through a new conceptual model titled “The Rainbow Brick Road”. Conclusion This synthesis expands understanding into the experience of transgender and non-binary youth accessing gender-affirming healthcare. Ryvicker’s behavioural-ecological model of healthcare navigation is discussed in relation to the findings and compared to the authors’ conceptual model. This detailed analysis reveals unique insights on healthcare navigation challenges and the traits, resources, and infrastructure needed to overcome these. Importantly, this paper reveals the critical need for more research with non-binary youth and research which includes the population in the design.
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Affiliation(s)
- Seán Kearns
- School of Medicine, University College Dublin, Dublin, Ireland
- National Gender Service, St Columcille’s Hospital, Dublin, Ireland
- * E-mail: ,
| | - Thilo Kroll
- Centre for Interdisciplinary Research, Education and Innovation in Health Systems, School of Nursing, Midwifery and Health Systems, University College Dublin, Dublin, Ireland
| | - Donal O‘Shea
- School of Medicine, University College Dublin, Dublin, Ireland
- National Gender Service, St Columcille’s Hospital, Dublin, Ireland
- Department of Endocrinology and Diabetes Mellitus, St Vincent’s University Hospital, Dublin, Ireland
| | - Karl Neff
- School of Medicine, University College Dublin, Dublin, Ireland
- National Gender Service, St Columcille’s Hospital, Dublin, Ireland
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Kim JK, Na W, Cho JH, Ahn EJ, Kim E, Song IG, Han EC, Lee DW, Park BK, Park YG, Kim BG. Refinement of recto-sigmoid colon vaginoplasty using a three-dimensional laparoscopic technique. Medicine (Baltimore) 2021; 100:e27042. [PMID: 34477135 PMCID: PMC8416006 DOI: 10.1097/md.0000000000027042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 08/11/2021] [Indexed: 01/18/2023] Open
Abstract
To investigate the feasibility, safety, and outcomes of three-dimensional (3D) laparoscopic vaginoplasty with a rectosigmoid colon flap for vaginal reconstruction.Following appropriate preoperative patient counseling, 17 consecutive patients underwent vaginoplasty using a 3D laparoscopic system. Perioperative and postoperative outcomes were retrospectively evaluated.Between September 2016 and February 2020, 17 patients underwent 3D laparoscopic vaginoplasty with a rectosigmoid colon flap. Of them, 15 (88%) were transgender female patients, and 2 (12%) were cisgender female patients with congenital deformities. Among the 15 transgender patients, 12 (80%) underwent de novo surgeries and 3 (20%) underwent re-do surgeries. The mean age at the time of operation was 33.0 years, and the mean total operation time was 529 ± 128 minutes. The initial intraoperative mean vaginal depth was 15.2 ± 1.3 cm, and the 30-day readmission rate was 5.9% (1/17 cases). The mean follow-up duration was 24.8 months.Perioperative and postoperative outcomes suggest that 3D laparoscopic rectosigmoid colon vaginoplasty is a potentially acceptable, effective, and safe method for vaginal reconstruction.
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Affiliation(s)
- Jeong-ki Kim
- Department of Surgery, National Medical Center, Seoul, Republic of Korea
- Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Woong Na
- Department of Urology, National Medical Center, Seoul, Republic of Korea
| | - Jeong Hyun Cho
- Department of Urology, National Medical Center, Seoul, Republic of Korea
| | - Eun Jung Ahn
- Department of Surgery, National Medical Center, Seoul, Republic of Korea
| | - Eunyoung Kim
- Department of Surgery, National Medical Center, Seoul, Republic of Korea
| | - In-Gyu Song
- Department of Surgery, National Medical Center, Seoul, Republic of Korea
| | - Eon Chul Han
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Republic of Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Republic of Korea
| | - Byung Kwan Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Yong-Gum Park
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Beom Gyu Kim
- Department of Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
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Martin SA, Patel V, Morrison SD, Kahn D, Satterwhite T, Nazerali R. Assessing Gender-Affirming Chest Surgery Outcomes: Does Gender Identity Alter Gaze? Aesthetic Plast Surg 2021; 45:1860-1868. [PMID: 34114074 DOI: 10.1007/s00266-021-02378-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 05/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Outcomes of gender-affirming chest surgery can be variable. Placement of nipple-areolar complexes and orientation of scars can drastically affect the aesthetic outcomes of these procedures, as may observer gender identity. Here, we compared attention and perception of outcomes following gender-affirming chest surgery between laypersons, based on gender identity. METHODS Transgender and cisgender participants were enrolled and shown images of surgery naïve chests and postoperative masculinized and feminized chests, blinded to the gender identity of the photographed subject. Gaze data were captured using the Tobii X2 60 eye-tracking device. Participants scored the perceived gender and aesthetic appearance of each image. RESULTS Eighteen cisgender and 14 transgender participants were enrolled. When viewing male chests, transgender participants spent significantly longer fixated on the nipples (naïve: 802 vs. 395 ms; p = 0.02, masculinized: 940 vs. 692 ms, p = 0.002). For masculinized chests, cisgender participants spent significantly longer fixated on the inframammary scar (483 vs. 391 ms; p = 0.04). On images of feminized chests, transgender participants spent longer viewing the nipples when compared to cisgender participants (1017 vs. 847 ms; p = 0.04). Cisgender viewers spent longer fixating on the postoperative scar on feminized chests (113 vs. 59 ms; p = 0.02) and also viewed feminized chests as significantly more masculine and masculinized chests as more feminine, when compared to transgender participants (p < 0.05). CONCLUSIONS This is the first study to use eye-tracking to assess how laypersons assess chests for gender determination. The findings suggest that observer gender identity has an effect on areas of focus and gender perception of chests that underwent gender-affirmation surgery. 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 .
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Affiliation(s)
- Shanique A Martin
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Viren Patel
- Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shane D Morrison
- Section of Plastic Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA.
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - David Kahn
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA
| | | | - Rahim Nazerali
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford Hospital and Clinics, Palo Alto, CA, USA
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Female-to-Male Transgender Chest Contouring: A Systematic Review of Outcomes and Knowledge Gaps. Ann Plast Surg 2020; 83:589-593. [PMID: 31082837 DOI: 10.1097/sap.0000000000001896] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The number of gender affirmation surgeries performed in the United States is increasing. Frequently, chest contouring is the first surgery for female-to-male transgender patients; it fosters assimilation into the new gender role with a desired sense of masculinity. Creating an aesthetic male chest requires adjustment of breast tissue volume, proper nipple-areolar complex placement, and abolishment of the inframammary fold. Although much has been published on various techniques and outcomes, there is no consensus on how to approach transmale top surgery. We have reviewed the most up-to-date literature and in so doing have uncovered significant knowledge gaps. METHODS An electronic literature review was performed. PubMed search keywords included combinations of "female-to-male," "transgender surgery," "chest contour," and "nipple-areolar complex." Articles were included if the patients were transgender female to male. RESULTS Our literature search yielded 67 unique articles, 22 of which met our inclusion criteria. A total of 2447 unique patients were analyzed. The articles discussed aspects of chest surgery in female-to-male transsexuals including mastectomy and nipple aesthetics. Relevant data trends were extracted and subsequently investigated. DISCUSSION Female-to-male transgender patients often undergo chest contouring as their initial gender affirmation surgery. As the surgical treatment of gender dysphoria continues to grow, it is imperative for plastic surgeons to understand the surgical options and associated outcomes for transmasculine top surgery. Future research is needed to improve patient selection, surgical decision making, and patient-reported outcomes for different chest contouring techniques. In addition, there is a significant knowledge gap for the ideal nipple-areolar complex shape, size, and location.
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Köhler A, Strauß B, Briken P, Riechardt S, Fisch M, Nieder TO. [Feminizing Genital Gender-affirmative Surgery in Centralized and Decentralized Health Care Settings - The Hamburg TransCare study]. Psychother Psychosom Med Psychol 2020; 71:132-140. [PMID: 33063307 DOI: 10.1055/a-1243-0715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Gender Dysphoria (GD, formerly known as transsexualism) describes distress and impairment in an individual caused by the incongruence between the experienced gender and the sex assigned at birth (Gender Incongruence: GI). Transgender health care focusses on gender-affirmative treatments (e. g., hormone therapy) and associated needs (e. g., psychotherapy). Moreover, genital surgery is considered an effective treatment to reduce GI/GD and improve mental health and quality of life. Interdisciplinary cooperation between the associated medical facilities is regarded as evidence-based health care. OBJECTIVES To date, THC is delivered in zwei different health care settings: interdisciplinary and centralized from one medical institution vs. decentralized, spread over several medical institutions. In Germany, individuals with GI/GD access health care mostly in decentralized structures. The consequences of feminizing genital surgery carried out in centralized and decentralized health care structures in terms of quality and effectiveness have not been investigated so far. The goal of the TransCare study is to prospectively examine individuals with GI/GD seeking feminizing genital surgery regarding demographics and clinical characteristics as well as to analyze the influence of centralized and decentralized health care settings on the psychosocial and clinical outcome. MATERIALS AND METHODS To recruit a valid and comprehensive sample, participants were questioned prospectively. RESULTS The results of the study should help gain new insights into the influence of centralized and decentralized health care settings carrying out feminizing genital surgery on psychosocial and clinical outcomes for the patients. CONCLUSION Based on the TransCare study, we suggest that health care should be improved according to individual patient needs.
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Affiliation(s)
- Andreas Köhler
- Institut für Sexualforschung, Sexualmedizin und Forensische Psychiatrie, Universitätsklinikum Hamburg-Eppendorf
| | - Bernhard Strauß
- Institut für Psychosoziale Medizin und Psychotherapie, Universitätsklinikum Jena
| | - Peer Briken
- Institut für Sexualforschung, Sexualmedizin und Forensische Psychiatrie, Universitätsklinikum Hamburg-Eppendorf
| | - Silke Riechardt
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf
| | - Timo O Nieder
- Institut für Sexualforschung, Sexualmedizin und Forensische Psychiatrie, Universitätsklinikum Hamburg-Eppendorf
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Schlosshauer T, Kiehlmann M, Riener MO, Rothenberger J, Sader R, Rieger UM. Effect of low-thermal dissection device versus conventional electrocautery in mastectomy for female-to-male transgender patients. Int Wound J 2020; 17:1239-1245. [PMID: 32368860 DOI: 10.1111/iwj.13382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/06/2020] [Accepted: 04/13/2020] [Indexed: 11/28/2022] Open
Abstract
Subcutaneous mastectomy, the first step in sexual reassignment surgery of female-to-male transsexuals, is associated with high rates of complication and revision surgery. Also, conventional electrosurgery and the associated thermal tissue damage may compromise outcome. This retrospective randomised clinical study evaluated the effect of low-thermal plasma dissection device (PEAK PlasmaBlade, Medtronic, Minneapolis, Minnesota) in comparison with conventional electrosurgery. A total of 17 female-to-male transsexuals undergoing mastectomy were randomised to PEAK PlasmaBlade on one breast side and to monopolar electrosurgery on the other side of the same patient. Wounds of 17 patients were examined histologically for acute thermal injury. Significantly less total volume of drain output (58.8 ± 37.4 mL vs 98.5 ± 76.4 mL; P = .012) was found on the PEAK PlasmaBlade side compared with the electrosurgery side. Duration of drain was significantly shorter on the PEAK PlasmaBlade side (2.5 ± 0.7 days vs 3.2 ± 0.6 days; P = .010). Furthermore, the PEAK PlasmaBlade side showed fewer thermal damages (41.2% vs 82.4%; P = .039) and thermal injury depth from PEAK PlasmaBlade side was less (3170 vs 4060 μm). PEAK PlasmaBlade appears to be superior to monopolar electrosurgery for mastectomy in female-to-male transsexuals, because it demonstrated less thermal tissue damage, less total volume of drain output, and shorter duration of drain, resulting in faster wound healing.
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Affiliation(s)
- Torsten Schlosshauer
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany.,Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Ev. Hospital, Giessen, Germany
| | - Marcus Kiehlmann
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Marc-Oliver Riener
- OptiPath, Institute of Pathology, Frankfurt, Germany.,Institute of Pathology, University Hospital Erlangen, Nuremberg, Germany
| | - Jens Rothenberger
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
| | - Robert Sader
- Department for Oral, Cranio-Maxillofacial and Facial Plastic Surgery, Medical Center of the Goethe University Frankfurt, Frankfurt, Germany
| | - Ulrich M Rieger
- Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Frankfurt, Germany
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T'Sjoen G, Arcelus J, De Vries ALC, Fisher AD, Nieder TO, Özer M, Motmans J. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020; 17:570-584. [PMID: 32111534 DOI: 10.1016/j.jsxm.2020.01.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 01/07/2020] [Accepted: 01/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice. AIM We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction. METHODS The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available. OUTCOMES The foci of the study are assessment and hormonal aspects of trans health care. RESULTS As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment. CLINICAL IMPLICATIONS This is an up-to-date ESSM position statement. STRENGTHS & LIMITATIONS These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited. CONCLUSION This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020;17:570-584.
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Affiliation(s)
- Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University and Ghent University Hospital, Gent, Belgium.
| | - Jon Arcelus
- Institute of Mental Health, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Annelou L C De Vries
- Department of Child and Adolescent Psychiatry, Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Alessandra D Fisher
- Andrology, Women's Endocrinology, Gender Incongruence Unit, Careggi University Hospital, Florence, Italy
| | - Timo O Nieder
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Interdisciplinary Transgender Health Care Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Joz Motmans
- Transgender Infopunt, Ghent University Hospital, Ghent, Belgium
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Francis C, Grober E, Potter E, Blodgett N, Krakowsky Y. A Simple Guide for Simple Orchiectomy in Transition-Related Surgeries. Sex Med Rev 2020; 8:492-496. [PMID: 31959532 DOI: 10.1016/j.sxmr.2019.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/23/2019] [Accepted: 11/24/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND To date, there is no literature on orchiectomy as a stand-alone procedure in the transgender surgical context. AIM To propose a simple guide to aid health-care professionals caring for transgender and gender nonconforming individuals seeking bilateral simple orchiectomy. METHODS We use expert opinion to provide a novel guide for simple orchiectomy in the transition-related context for health-care professionals caring for transgender and gender nonconforming individuals. A review of relevant literature was also performed focusing on simple orchiectomy and vaginoplasty surgeries for transgender and gender nonconforming individuals. MAIN OUTCOME MEASURE We describe the indications, surgical approach, preoperative and postoperative assessment, and the risks and benefits of bilateral simple orchiectomy in the context of gender surgery. RESULTS This article is the first, to our knowledge, to describe a structured guide to bilateral simple orchiectomy in the context of gender surgery for health-care professionals caring for transgender and gender nonconforming individuals. CLINICAL IMPLICATIONS Bilateral scrotal orchiectomy is a simple surgical procedure that has a defined role in the surgical management of many transgender individuals. STRENGTHS AND LIMITATIONS This article provides an approach to simple orchiectomy in the context of gender surgery for health-care professionals. Only guidelines written in English were included. The quality of the included guidelines was not evaluated, but this was beyond the scope of this review. CONCLUSION We present a novel guide for health-care professionals caring for transgender and gender nonconforming individuals seeking bilateral simple orchiectomy in the context of gender surgery. Francis C, Grober E, Potter E, et al. A Simple Guide for Simple Orchiectomy in Transition-Related Surgeries. Sex Med Rev 2020;8:492-496.
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Affiliation(s)
| | - Ethan Grober
- Division of Urology, Transition Related Surgery Program, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Emery Potter
- Transition Related Surgery Program, Women's College Hospital, Toronto, ON, Canada
| | - Nolan Blodgett
- Transition Related Surgery Program, Women's College Hospital, Toronto, ON, Canada
| | - Yonah Krakowsky
- Division of Urology, Transition Related Surgery Program, Women's College Hospital, University of Toronto, Toronto, ON, Canada.
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Mastectomy in female-to-male transgender patients: A single-center 24-year retrospective analysis. Arch Plast Surg 2019; 46:433-440. [PMID: 31550748 PMCID: PMC6759454 DOI: 10.5999/aps.2018.01214] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 07/31/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Mastectomy in male transgender patients is an important (and often the first) step toward physical manhood. At our department, mastectomies in transgender patients have been performed for several decades. METHODS Recorded data were collected and analyzed for all male transgender patients undergoing mastectomy over a period of 24 years at our department. RESULTS In total, 268 gender-reassigning mastectomies were performed. Several different mastectomy techniques (areolar incision, n=172; sub-mammary incision, n=96) were used according to patients' habitus and breast features. Corresponding to algorithms presented in the current literature, certain breast qualities were matched with a particular mastectomy technique. Overall, small breasts with marginal ptosis and good skin elasticity allowed small areolar incisions as a method of access for glandular removal. In contrast, large breasts and those with heavy ptosis or poor skin elasticity often required larger incisions for breast amputation. The secondary correction rate (38%) was high for gender reassignment mastectomy, as is also reflected by data in the current literature. Secondary correction frequently involved revision of chest wall recontouring, suggesting inadequate removal of the mammary tissue, as well as scar revision, which may reflect intense traction during wound healing (36%). Secondary corrections were performed more often after using small areolar incision techniques (48%) than after using large sub-mammary incisions (21%). CONCLUSIONS Choosing the suitable mastectomy technique for each patient requires careful individual evaluation of breast features such as size, degree of ptosis, and skin elasticity in order to maximize patient satisfaction and minimize secondary revisions.
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Agana MG, Greydanus DE, Indyk JA, Calles JL, Kushner J, Leibowitz S, Chelvakumar G, Cabral MD. Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century. Dis Mon 2019; 65:303-356. [DOI: 10.1016/j.disamonth.2019.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Cristofari S, Revol M. [Postoperative complications after genital gender confirming surgery in transgender women]. ANN CHIR PLAST ESTH 2019; 64:667-673. [PMID: 31451328 DOI: 10.1016/j.anplas.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/02/2019] [Indexed: 11/16/2022]
Abstract
Genital gender affirmation surgery in transgender women is usually performed by single-stage penile inversion vaginoplasty, with creation of vagina, perineal urethral meatus, majora and minora labia, and clitoris. Postoperative functional or aesthetic complications are common, affecting every reconstructed part of the neovulva. Patients should be preoperatively informed of those possible complications. Postoperative close follow-up must be conducted, beginning with therapeutic learning of the self-dilation regimen, detecting and treating any complication, and ending up when complete healing is obtained among satisfied patient.
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Affiliation(s)
- S Cristofari
- Department of plastic, reconstructive and aesthetic surgery, Tenon hospital, 4, rue de la Chine, 75020 Paris, France; Sorbonne university, 75006 Paris, France.
| | - M Revol
- Department of plastic, reconstructive and aesthetic surgery, Tenon hospital, 4, rue de la Chine, 75020 Paris, France; Diderot university, 75007 Paris, France
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Sigma-lead Male-to-Female Gender Affirmation Surgery: Blending Cosmesis with Functionality. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2169. [PMID: 31321174 PMCID: PMC6554166 DOI: 10.1097/gox.0000000000002169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 01/08/2019] [Indexed: 11/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Current male-to-female (MtF) sex-reassignment-surgery techniques have not been fully successful to achieve the ideal objectives. The ordeal of multiple procedures, associated complications, and suboptimal results leads to high rate of dissatisfaction. We have tried to overcome functional inadequacy and address the esthetic issues for outer genitalia and vagina with our innovative “true shape sigma-lead SRS: Kaushik’s technique,” which has now become the technique of choice for MtF genital SRS for our patients. Methods: Between April 2007 and April 2017, authors performed 386 sigma-lead SRS in MtF transsexuals. Results were analyzed based on complications, resurgeries, and esthetic/functional outcomes. Corrective SRS using rectosigmoid constituted 145 cases and is not a part of this study. Results: Maximum follow-up was 7 years (average 34 months). Seventy-eight (20.2%) patients had complications, majority being minor (97.4%). Forty-four (11.4%) required resurgeries, 10 (2.6%) were corrective for introital stricture and mucosal prolapse, whereas 34 (8.8%) opted for optional minor esthetic enhancement. The overall satisfaction rate for cosmetic and functional outcomes was 4.7 out of 5. In addition to review of the literature, innovations in the technique have been explained. Conclusions: Kaushik’s sigma-lead MtF SRS technique is a step short to become the gold standard of genital SRS because it has proven to be safe and reliable. It allows faster healing, minimal dilation, and nearly natural cosmetic results in the form of clitoris/clitoral hood, labia minora, labia majora along with self-lubricating, fully deep, and sensate neovagina with orgasmic capabilities. This is perhaps the largest reported series of rectosigmoid use in transsexuals carried out for primary vaginoplasty.
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Cristofari S, Bertrand B, Leuzzi S, Rem K, Rausky J, Revol M, Atlan M, Stivala A. Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study. ANN CHIR PLAST ESTH 2019; 64:24-32. [DOI: 10.1016/j.anplas.2018.08.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 08/19/2018] [Indexed: 11/29/2022]
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Zurada A, Salandy S, Roberts W, Gielecki J, Schober J, Loukas M. The evolution of transgender surgery. Clin Anat 2018; 31:878-886. [DOI: 10.1002/ca.23206] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Anna Zurada
- Department of Radiology, Collegium Medicum, School of Medicine; University of Warmia and Mazury; Olsztyn Poland
- Department of Anatomy; University of Warmia and Mazury; Olsztyn Poland
| | - Sonja Salandy
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Wallisa Roberts
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Jerzy Gielecki
- Department of Radiology, Collegium Medicum, School of Medicine; University of Warmia and Mazury; Olsztyn Poland
- Department of Anatomy; University of Warmia and Mazury; Olsztyn Poland
| | - Justine Schober
- Department of Pediatric Urology; UPMC Hamot; Erie Pennsylvania
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
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Abstract
The landscape of gender dysphoria has changed dramatically in recent years secondary to increased societal acceptance, legislative changes, and medical providers' increased awareness of the associated psychosocial burden associated with the diagnosis. National and global advocacy efforts, in conjunction with expanded third-party insurance coverage, have resulted in new health care opportunities for patients suffering from gender dysphoria. Delivering quality, streamlined health care to these patients requires a complex multidisciplinary approach, involving multiple medical and mental health disciplines, including plastic surgeons. To accommodate the expanding demand for gender-affirmation surgery, academic medical centers specializing in these procedures are gradually emerging. Advancing surgical techniques in the setting of rising patient demand encourage plastic surgeons to increasingly provide high-quality health care to this diverse patient population in an effort to optimize psychosocial functioning and minimize the burden of gender dysphoria. Although the current literature is replete with the evolving surgical and technical approaches to gender-affirming surgery, there remain critical gaps in the plastic surgery literature describing the delivery of comprehensive care to these patients. To address these gaps, the authors establish a framework that plastic surgeons can use to guide their management of patients with gender dysphoria to optimize surgical and psychosocial outcomes. First, the authors describe a timeline of events that have shaped present-day transgender medicine and characterize the current role of the plastic surgeon in the management of gender dysphoria. Subsequently, the authors discuss psychosocial and ethical considerations surrounding gender dysphoria. Finally, the authors discuss the future scope of transgender medicine.
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Abstract
PURPOSE Female-to-male transgender individuals frequently seek out chest wall masculinization as part of their gender transition and to aid with treating gender dysphoria. Critical evaluation of techniques, complications, and outcomes is important particularly as the surgery becomes more commonly performed. METHODS A retrospective review was performed of all patients undergoing female-to-male chest wall reconstruction by the senior author from 2008 to 2015. Charts were reviewed to evaluate patient demographics, intraoperative details, and postoperative outcomes. Complications were stratified into major and minor complications based on the need to return to the operating room. Inframammary fold techniques and periareolar techniques cohorts were compared for major complications, minor complications, and need for revision surgeries. RESULTS Over 8 years, 130 patients were identified. One hundred ten patients underwent inframammary fold techniques, and 20 patients underwent periareolar incisions. Early postoperative complications occurred in 25% of patients. Hematoma was the most common complications, occurring in 14% of patients. Major complications occurred in 8% of patients. Minor complications occurred in 16% of patients, with respiratory problems found to be a significant risk factor. On long-term follow up, 9% of patients had a revision procedure performed. Patients with prior breast surgery were more likely to require revisions (P = 0.009). Of patients requiring revision, 38% had a periareolar incision, compared with only 13% of patients who did not (P = 0.03). For unplanned revisions, there was no difference in periareolar and inframammary techniques. CONCLUSIONS Our patient cohort demonstrates that female-to-male patients who undergo chest wall contouring through a transverse inframammary fold incision with either composite or standard free nipple grafting have decreased rates of revision surgery and trend toward having lower complication rates as compared with periareolar and limited scar techniques. To best manage expectations, patients undergoing a periareolar or other limited incision technique are counseled regarding an increased risk of hematoma and an increased likelihood of revisions.
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Quality of life improvement after chest wall masculinization in female-to-male transgender patients: A prospective study using the BREAST-Q and Body Uneasiness Test. J Plast Reconstr Aesthet Surg 2018; 71:651-657. [DOI: 10.1016/j.bjps.2018.01.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 11/12/2017] [Accepted: 01/21/2018] [Indexed: 11/21/2022]
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Zavlin D, Schaff J, Lellé JD, Jubbal KT, Herschbach P, Henrich G, Ehrenberger B, Kovacs L, Machens HG, Papadopulos NA. Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes. Aesthetic Plast Surg 2018; 42:178-187. [PMID: 29101439 DOI: 10.1007/s00266-017-1003-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 10/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Currently available patient-reported outcome measures are limited in the field of sex reassignment surgery (SRS). Standardized questionnaires deliver high evidence data on satisfaction of male-to-female (MTF) transgender patients but do not allow any modification in their clinical application. We therefore designed a prospective study using self-developed indication-specific questionnaires to evaluate the aesthetic, functional, and sexual outcomes of MTF patients undergoing SRS. METHODS Forty-nine adult MTF transgender patients who underwent two-stage SRS were eligible for study inclusion between September 2012 and January 2014. Forty patients (= N) ultimately filled out both parts of the questionnaire sets: 1 day before the first stage (T0) and 6 months after the second stage of SRS (T1). These questionnaires focused on demographic characteristics, the satisfaction with aesthetic and functional results, and sexuality. RESULTS Patients rated their surgical satisfaction of most items with mean scores above 7 on a 0-10-point scale. Many items evaluating everyday life activities improved significantly after SRS compared to T0 (p < 0.01). All but one patient (97.5%) reported no regrets about having undergone surgery, and the majority recommended it to other patients with gender dysphoria. Femininity and sexual activity increased significantly postoperatively (p < 0.01). Satisfaction with intercourse and orgasm was high: 6.70 and 8.21, respectively, on a 0-10 scale. CONCLUSION Satisfaction with the cosmetic outcome, as well as the functional and sexual outcomes, reveal positive effects of SRS using the combined technique on transgender patient lives. Nevertheless, standardized and validated SRS-specific questionnaires are lacking. 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 .
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Affiliation(s)
- Dmitry Zavlin
- Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675, Munich, Germany
- Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX, USA
| | - Jürgen Schaff
- Department of Plastic Surgery, University Teaching Hospital Rotkreuzklinikum München, Munich Technical University, Munich, Germany
| | - Jean-Daniel Lellé
- Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Kevin T Jubbal
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Peter Herschbach
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Rechts der Isar, Munich Technical University, Munich, Germany
| | - Gerhard Henrich
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Rechts der Isar, Munich Technical University, Munich, Germany
| | - Benjamin Ehrenberger
- Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Laszlo Kovacs
- Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Hans-Günther Machens
- Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Nikolaos A Papadopulos
- Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Ismaninger Strasse 22, 81675, Munich, Germany.
- Department of Plastic Surgery and Burns, Alexandroupoli University Hospital, Democritus University of Thrace, 68100, Alexandroupoli, Greece.
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Dennis M, Granger A, Ortiz A, Terrell M, Loukos M, Schober J. The anatomy of the musculocutaneous latissimus dorsi flap for neophalloplasty. Clin Anat 2017; 31:152-159. [PMID: 29178203 DOI: 10.1002/ca.23016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/22/2017] [Indexed: 12/22/2022]
Abstract
In transgender surgery, the ideal neophallus is one that: (a) is constructed using a reproducible procedure, (b) possesses tactile and erogenous sensation, (c) is large and rigid enough (naturally, or using a prosthesis) to permit penetrative intercourse, (d) leaves acceptable donor site morbidity, (e) results in esthetically satisfactory appearance, and (f) allows for voiding while standing. The musculocutaneous latissimus dorsi (MLD) flap has favorable results in the area of neophalloplasty. Among its advantages are acceptable donor site appearance, stiffness sufficient for intercourse, and esthetically satisfactory genital appearance. The anatomy of the MLD flap supports the creation of a neophallus for transsexual anatomy revision. Herein, we give an overview of the advantages and disadvantages of the procedure, and the anatomical details and surgical steps involved. Novel illustrations were created from standard surgical text descriptions to clarify this topic for surgical training and patient understanding and decision making. A review of the relevant literature regarding the anatomy, procedure development, and outcomes is presented. The MLD flap uses part of the latissimus dorsi muscle with branches of the thoracodorsal vessels and nerve to construct a neophallus. A thin strip of muscle around the pedicle is harvested, resulting in a slightly curvilinear scar. The blood supply is connected to the femoral artery and saphenous vein or the deep inferior epigastric artery and vein, while the nerve is connected to the ilioinguinal nerve or the obturator nerve. The MLD flap for neophalloplasty is a reliable graft with a well concealed scar and low donor site morbidity. Clin. Anat. 31:152-159, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- M Dennis
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - A Granger
- School of Medicine, St. George's University, West Indies, Grenada.,Department of Neurology, NYU Langone Hospital - Brooklyn, Brooklyn, New York
| | - A Ortiz
- School of Medicine, St. George's University, West Indies, Grenada
| | - M Terrell
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - M Loukos
- School of Medicine, St. George's University, West Indies, Grenada
| | - J Schober
- Pediatric Urology, University of Pittsburgh Medical Center - Hamot Hospital, Erie, Pennsylvania
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Agarwal CA, Wall VT, Mehta ST, Donato DP, Walzer NK. Creation of an Aesthetic Male Nipple Areolar Complex in Female-to-Male Transgender Chest Reconstruction. Aesthetic Plast Surg 2017; 41:1305-1310. [PMID: 28698936 DOI: 10.1007/s00266-017-0935-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 06/22/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Female-to-male chest wall reconstruction is becoming more common, but while there is a growing body of the literature describing technique and algorithms, little detail is written on methods for creating a male appearing nipple areolar complex (NAC) from a female NAC utilizing free nipple graft techniques. Incorrect positioning of the NAC on the chest wall and suboptimal shaping and sizing of the NAC are common pitfalls in male NAC creation. METHODS With this paper, we present techniques for nipple grafting to achieve improved male appearing NACs, as well as a simple, reproducible method for appropriate placement of the NAC relative to the borders of the pectoralis muscle. To validate our technique, we performed photographic analysis of 64 NACs in 32 volunteers with BMI of 25 or less. RESULTS The anatomic study determined the cis-male nipple to be positioned on average 2.5 cm medial to the lateral border of the pectoralis muscle and 2.4 cm above the inferior pectoralis insertion. This supports our surgical technique of positioning the NAC in relation to the pectoralis borders rather than previously advocated anatomic landmarks. We also present reliable techniques for creating a round or horizontally oval final NAC shape as well as a composite grafting technique for cases of large papillae. CONCLUSIONS Our anatomic study supports placement of the male NAC relative to lateral and inferior borders of the pectoralis muscle. Nipple grafting techniques presented allow for a simple and reproducible method of creating an aesthetic male NAC shape in female-to-male transgender chest reconstruction. 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 .
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Dreher PC, Edwards D, Hager S, Dennis M, Belkoff A, Mora J, Tarry S, Rumer KL. Complications of the neovagina in male-to-female transgender surgery: A systematic review and meta-analysis with discussion of management. Clin Anat 2017; 31:191-199. [PMID: 29057562 DOI: 10.1002/ca.23001] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 10/13/2017] [Accepted: 10/19/2017] [Indexed: 11/12/2022]
Abstract
Gender-affirmation surgery is often the final gender-confirming medical intervention sought by those patients suffering from gender dysphoria. In the male-to-female (MtF) transgendered patient, the creation of esthetic and functional external female genitalia with a functional vaginal channel is of the utmost importance. The aim of this review and meta-analysis is to evaluate the epidemiology, presentation, management, and outcomes of neovaginal complications in the MtF transgender reassignment surgery patients. PUBMED was searched in accordance with PRISMA guidelines for relevant articles (n = 125). Ineligible articles were excluded and articles meeting all inclusion criteria went on to review and analysis (n = 13). Ultimately, studies reported on 1,684 patients with an overall complication rate of 32.5% and a reoperation rate of 21.7% for non-esthetic reasons. The most common complication was stenosis of the neo-meatus (14.4%). Wound infection was associated with an increased risk of all tissue-healing complications. Use of sacrospinous ligament fixation (SSL) was associated with a significantly decreased risk of prolapse of the neovagina. Gender-affirmation surgery is important in the treatment of gender dysphoric patients, but there is a high complication rate in the reported literature. Variability in technique and complication reporting standards makes it difficult to assess the accurately the current state of MtF gender reassignment surgery. Further research and implementation of standards is necessary to improve patient outcomes. Clin. Anat. 31:191-199, 2018. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Paulette Cutruzzula Dreher
- Department of Urology, Hahnemann University Hospital/Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Daniel Edwards
- Department of Urology, Hahnemann University Hospital/Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Shaun Hager
- Department of Urology, Hahnemann University Hospital/Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Margeaux Dennis
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Andie Belkoff
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Jamie Mora
- Department of Surgery, Hahnemann University Hospital/Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Susan Tarry
- Department of Urology, Hahnemann University Hospital/Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Kathy L Rumer
- Department of Surgery, Hahnemann University Hospital/Drexel University College of Medicine, Philadelphia, Pennsylvania
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Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:3869-3903. [PMID: 28945902 DOI: 10.1210/jc.2017-01658] [Citation(s) in RCA: 1147] [Impact Index Per Article: 163.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/24/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. PARTICIPANTS The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. CONCLUSION Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
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Affiliation(s)
- Wylie C Hembree
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York 10032
| | | | - Louis Gooren
- VU University Medical Center, 1007 MB Amsterdam, Netherlands
| | | | - Walter J Meyer
- University of Texas Medical Branch, Galveston, Texas 77555
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota 55905
| | - Stephen M Rosenthal
- University of California San Francisco, Benioff Children's Hospital, San Francisco, California 94143
| | - Joshua D Safer
- Boston University School of Medicine, Boston, Massachusetts 02118
| | - Vin Tangpricha
- Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia 30322
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Combined vaginoplasty technique for male-to-female sex reassignment surgery: Operative approach and outcomes. J Plast Reconstr Aesthet Surg 2017. [DOI: 10.1016/j.bjps.2017.05.040] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Frey JD, Poudrier G, Thomson JE, Hazen A. A Historical Review of Gender-Affirming Medicine: Focus on Genital Reconstruction Surgery. J Sex Med 2017; 14:991-1002. [DOI: 10.1016/j.jsxm.2017.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/22/2017] [Accepted: 06/24/2017] [Indexed: 10/19/2022]
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Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of Single Stage Phalloplasty by Pedicled Anterolateral Thigh Flap versus Radial Forearm Free Flap in Gender Confirming Surgery. J Urol 2017; 199:206-214. [PMID: 28765066 DOI: 10.1016/j.juro.2017.07.084] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 11/19/2022]
Abstract
PURPOSE Phalloplasty is a critical step in female-to-male (transmale) gender confirming genital surgery. We examined outcomes between transmales who underwent phalloplasty with vaginectomy and full-length urethroplasty using the anterolateral thigh pedicled flap or the radial forearm free flap. MATERIALS AND METHODS We performed a single center, retrospective study of patients who underwent phalloplasty with vaginectomy and full-length urethroplasty using an anterolateral thigh pedicled flap or a radial forearm free flap from April 2013 to July 2016. All patients had at least 6 months of followup. Urethral and nonurethral complications were recorded. Complication rates were assessed using the OR of the anterolateral thigh pedicled flap and the radial forearm free flap groups. RESULTS Of the 213 patients 149 and 64 underwent radial forearm free flap and anterolateral thigh pedicled flap phalloplasty, respectively. Patients with a radial forearm free flap had a significantly higher body mass index than those with an anterolateral thigh pedicled flap. The overall urethral complication rate for radial forearm free flap and anterolateral thigh pedicled flap phalloplasty was 31.5% and 32.8%, and the rate of partial or total neophallus loss was 3.4% and 7.8%, respectively. Patients in the pedicled flap cohort experienced significantly greater odds of urethral fistula (OR 2.50, p = 0.024), nonurethral complications (OR 2.38, p = 0.027) and phallus wound dehiscence (OR 5.03, p = 0.026). CONCLUSIONS Anterolateral thigh pedicled flap phalloplasty was associated with overall greater odds of urethral and other complications at 6 months of followup. Our findings can help guide surgical decision making when selecting a flap for phalloplasty.
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Affiliation(s)
- Mona Ascha
- Division of Plastic Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Jonathan P Massie
- Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Curtis N Crane
- Division of Plastic Surgery, Department of Surgery, Brownstein and Crane Surgical Services, San Francisco, California
| | - Mang L Chen
- Division of Plastic Surgery, Department of Surgery, Brownstein and Crane Surgical Services, San Francisco, California.
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Bertrand B, Perchenet AS, Colson TR, Drai D, Casanova D. [Female-to-male transgender chest reconstruction: A retrospective study of patient satisfaction]. ANN CHIR PLAST ESTH 2017. [PMID: 28624268 DOI: 10.1016/j.anplas.2017.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mammaplasty in gender reassignment surgery is often poorly understood, due to a lack of information about this condition and its therapy. The aim of this work was to evaluate patient satisfaction following bilateral mastectomy for female-to-male gender reassignment. METHODS We contacted 22 patients who underwent mammaplasty for female-to-male gender reassignment between January 2012 and March 2013 in our university hospital. Patients were sent postal questionnaires. A modified Q-breast questionnaire adapted for gender reassignment surgery enabled us to objectively evaluate patient aesthetic and psychological satisfaction. An overall score superior to 320 was considered as very satisfied for the patient. RESULTS A total of 73% of the patients answered the questionnaire. The mean score was 332/378. This score corresponded to "very satisfied" on our questionnaire. The psychological score was 54.5/60. CONCLUSION This study showed that a real benefit was obtained in terms of patient quality of life and self-confidence. The high level of patient satisfaction confirmed that gender reassignment mastectomy is a useful and valid procedure, which enables these patients to reclaim their place in society. It can only be considered if it is within the framework of structures that ensure comprehensive and pluridisciplinary treatment for the patient.
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Affiliation(s)
- B Bertrand
- Service de chirurgie plastique, Aix-Marseille université, hôpital de la Conception, Assistance publique-Hôpitaux de Marseille, 147, boulevard Baille, 13005 Marseille, France.
| | - A-S Perchenet
- Service de chirurgie plastique, Aix-Marseille université, hôpital de la Conception, Assistance publique-Hôpitaux de Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - T R Colson
- Service de chirurgie plastique, Aix-Marseille université, hôpital de la Conception, Assistance publique-Hôpitaux de Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - D Drai
- Service de psychiatrie, hôpital de la Conception, Assistance publique-Hôpitaux de Marseille, 147, boulevard Baille, 13005 Marseille, France
| | - D Casanova
- Service de chirurgie plastique, Aix-Marseille université, hôpital de la Conception, Assistance publique-Hôpitaux de Marseille, 147, boulevard Baille, 13005 Marseille, France
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Jacobsson J, Andréasson M, Kölby L, Elander A, Selvaggi G. Patients’ Priorities Regarding Female-to-Male Gender Affirmation Surgery of the Genitalia—A Pilot Study of 47 Patients in Sweden. J Sex Med 2017; 14:857-864. [DOI: 10.1016/j.jsxm.2017.04.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 12/01/2022]
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Lo Russo G, Tanini S, Innocenti M. Masculine Chest-Wall Contouring in FtM Transgender: a Personal Approach. Aesthetic Plast Surg 2017; 41:369-374. [PMID: 28175969 DOI: 10.1007/s00266-017-0796-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 01/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chest-wall contouring surgery is one of the first steps in sexual reassignment in female-to-male (FtM) transsexuals that contributes to strengthening of the self-image and facilitates living in the new gender role. The main goal is to masculinize the chest by removing the female contour. Chest contour, scar placement, scar shape, scar length, nipple-areola position, nipple size and the areola size are the key points. METHODS Between July 2013 and June 2016, 25 FtM transgender patients underwent surgical procedures to create a masculine chest-wall contour. In our study, we just considered 16 patients who have undergone chest surgery with the double incision method. RESULTS The patients' survey revealed a high satisfaction rate with the aesthetic result. In our group, no complications occurred, and two patients have undergone supplementary surgery for axillary dog-ear revision and nipple reconstruction. CONCLUSION The authors propose a new technical approach and indications for FtM transgender patients' surgery. A longer scar that emphasizes the pectoralis muscle, a smaller nipple and a resized and refaced areola are the key points of our technique to give a masculine appearance to the chest. The scars are permanent, but most of them will fade and the patients are enthusiastic with their new "male" chest appearance. The high level of satisfaction, the great aesthetic result and the low rate of complications suggest to us the use of this technique in medium- and large-size breasts. 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 .
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Affiliation(s)
- Giulia Lo Russo
- Department Plastic and Reconstructive Microsurgery, Careggi Universital Hospital, Florence, Italy.
| | - Sara Tanini
- Department Plastic and Reconstructive Microsurgery, Careggi Universital Hospital, Florence, Italy
| | - Marco Innocenti
- Department Plastic and Reconstructive Microsurgery, Careggi Universital Hospital, Florence, Italy
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Labanca T, Mañero I. Vulvar condylomatosis after sex reassignment surgery in a male-to-female transsexual: Complete response to imiquimod cream. Gynecol Oncol Rep 2017; 20:75-77. [PMID: 28349118 PMCID: PMC5358529 DOI: 10.1016/j.gore.2017.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 02/28/2017] [Accepted: 03/15/2017] [Indexed: 11/04/2022] Open
Abstract
Background The number of patients seeking sex reassignment surgery is increasing. Approximately 1:30,000 adult males and 1: 100,000 adult females seek this procedure. Neovaginal-related disorders after sex reassignment surgery are increasingly more common. Vulvar condylomatosis is the clinical manifestation of HPV 6- and 11 infection in biological women. The same HPV-subtypes are associated with anogenital warts and penile intraepithelial neoplasia in biological men. We aim to present a case of vulvar condylomatosis after sex reassignment surgery in a male-to-female transsexual and its complete response to 5% imiquimod cream. Case We describe a case of a 19-year-old female transexual who presented one year after male to female sex reassignment surgery by inverted penile skin vaginoplasty with condyloma accuminata of the vulva. The patient had a complete response to imiquimod 5% cream 12 weeks after initiation of treatment. Conclusion Gynecologists should be prepared to treat neovaginal-related disorders in male-to-female transsexuals. Gynecologists should be prepared to treat neovaginal-related disorders in male-to-female transsexuals. Vulvar condylomatosis may arise after sex reassignment surgery. Vulvar condylomatosis after vaginoplasty could be effectively treated with 5% imiquimod cream. A multidisciplinary team is mandatory for the correct assessment of the transsexual patient.
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Affiliation(s)
- Trinidad Labanca
- Department of Gynecology, Institute of Plastic Surgery Dr. Ivan Mañero, Barcelona, Spain
| | - Ivan Mañero
- Department of Plastic and Reconstructive Surgery, Institute of Plastic Surgery Dr. Ivan Mañero, Barcelona, Spain
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An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient. Plast Reconstr Surg 2017; 139:728-737. [DOI: 10.1097/prs.0000000000003062] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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World's First Baby Born Through Natural Insemination by Father With Total Phalloplasty Reconstruction. Ann Plast Surg 2017; 76 Suppl 3:S179-83. [PMID: 27070679 DOI: 10.1097/sap.0000000000000769] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Techniques for neophallus reconstruction have become increasingly refined, fulfilling more criteria for what is considered to be the ideal penis reconstruction. For both trauma and transgender populations, the radial forearm free flap remains the gold standard, although the pedicled or free anterolateral thigh flap is becoming a favored alternative. Despite the remarkably high rates of sexual activity reported by patients having benefited from these techniques, sexual function remains a significant challenge due to frequent complications including autologous and prosthetic stiffener failure, fistula formation, and inadequate erogenous sensation. Perhaps the ultimate criterion for neophallus reconstruction is one which not only avoids these complications by meeting the immediate goals of a competent neourethra, sensitivity, bulk, and aesthetic form but also successfully combines them into their true overarching function: procreation. In this article, we report the case of a pedicled anterolateral thigh flap neophallus reconstruction which allowed a patient to naturally conceive a child through penetrative intercourse without use of a stiffener, and led to pregnancy and subsequent birth of a baby son. We review the surgical techniques and factors that led to this patient's successful progeny.
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Smith FD. Perioperative Care of the Transgender Patient. AORN J 2016; 103:151-63. [PMID: 26849981 DOI: 10.1016/j.aorn.2015.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/05/2014] [Accepted: 12/08/2015] [Indexed: 11/18/2022]
Abstract
Transgender patients are individuals whose gender identity is not related to their biological sex. Assuming a new gender identity that does not conform to societal norms often results in discrimination and barriers to health care. The exact number of transgender patients is unknown; however, these patients are increasingly seen in health care. Transgender individuals may experience provider-generated discrimination in health care facilities, including refusal of service, disrespect, and abuse, which contribute to depression and low self-esteem. Transgender therapies include mental health counseling for depression and low self-esteem, hormone therapy, and sex reassignment surgery. Health care professionals require cultural competence, an understanding of the different forms of patient identification, and adaptive approaches to care for transgender patients. VA (Veterans Affairs) hospitals provide a model for the care for transgender patients and staff.
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A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the "Ideal" Neophallus an Achievable Goal? PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2016; 4:e1131. [PMID: 28293500 PMCID: PMC5222645 DOI: 10.1097/gox.0000000000001131] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/20/2016] [Indexed: 12/02/2022]
Abstract
Introduction: The complex anatomy and function of the native penis is difficult to surgically replicate. Metoidioplasty and radial forearm flap phalloplasty (RFFP) are the 2 most commonly utilized procedures for transgender neophallus construction. Methods: A MEDLINE search for metoidioplasty and RFFP in female-to-male genital reconstruction was performed. Primary outcome measures were subsequently compared. A systematic review was planned in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was utilized to evaluate the quality of evidence. Results: Using Population, Intervention, Comparison and Outcomes tool criteria, a total of 188 articles were identified; 7 articles related to metoidioplasty and 11 articles related to RFFP met inclusion criteria. The GRADE quality of evidence was low to very low for all included studies. In studies examining metoidioplasty, the average study size and length of follow-up were 54 patients and 4.6 years, respectively (1 study did not report [NR]). Eighty-eight percent underwent a single-stage reconstruction (0 NR), 87% reported an aesthetic neophallus (3 NR), and 100% reported erogenous sensation (2 NR). Fifty-one percent of patients reported successful intercourse (3 NR), and 89% of patients achieved standing micturition (3 NR). In studies examining RFFP, the average study size and follow-up were 60.4 patients and 6.23 years, respectively (6 NR). No patients underwent single-stage reconstructions (8 NR). Seventy percent of patients reported a satisfactorily aesthetic neophallus (4 NR), and 69% reported erogenous sensation (6 NR). Forty-three percent reported successful penetration of partner during intercourse (6 NR), and 89% achieved standing micturition (6 NR). Compared with RFFP, metoidioplasty was significantly more likely to be completed in a single stage (P < 0.0001), have an aesthetic result (P = 0.0002), maintain erogenous sensation (P < 0.0001), achieve standing micturition (P = 0.001), and have a lower overall complication rate (P = 0.02). Conclusions: Although the current literature suggests that metoidioplasty is more likely to yield an “ideal” neophallus compared with RFFP, any conclusion is severely limited by the low quality of available evidence.
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Loza O, Beltran O, Mangadu T. A qualitative exploratory study on gender identity and the health risks and barriers to care for transgender women living in a U.S.–Mexico border city. Int J Transgend 2016. [DOI: 10.1080/15532739.2016.1255868] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Oralia Loza
- Department of Public Health Sciences, University of Texas at El Paso, El Paso, Texas, USA
| | - Oscar Beltran
- Women's and Gender Studies, University of Texas at El Paso, El Paso, Texas, USA
| | - Thenral Mangadu
- Department of Public Health Sciences, University of Texas at El Paso, El Paso, Texas, USA
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Liang DG, Dusseldorp JR, van Schalkwyk C, Haertsch PA. Bowtie technique—a novel approach to correct the widened ventral labia majora after male-to-female gender reassignment surgery. EUROPEAN JOURNAL OF PLASTIC SURGERY 2016. [DOI: 10.1007/s00238-016-1191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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50
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Moradi B, Tebbe EA, Brewster ME, Budge SL, Lenzen A, Ege E, Schuch E, Arango S, Angelone N, Mender E, Hiner DL, Huscher K, Painter J, Flores MJ. A Content Analysis of Literature on Trans People and Issues. COUNSELING PSYCHOLOGIST 2016. [DOI: 10.1177/0011000015609044] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study provides a content analysis of more than a decade (2002–2012) of academic scholarship about trans people and issues. A total of 960 trans-focused publications were coded; there was a close balance of nonempirical (54%) and empirical (46%) publications. The analyses revealed that the literature on trans people and issues is growing, although many publications include trans people and issues nominally without substantive attention. The analyses also pointed to underutilized research designs and methodologies, the need for more clear assessment and more consistent reporting of demographic characteristics, and topics that warrant further attention. Specifically, literature on trans people and issues continues to be needed on the topics of focus thus far, such as psychological and identity-related distress. Scholarship is also needed to address important topics that have been understudied, including self-harm and suicide, positive functioning and mental health promoting factors, developmental issues across the life span, school and workplace experiences, and the training and competencies of health care providers to ensure affirmative and effective services for trans people.
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Affiliation(s)
| | | | | | | | | | - Engin Ege
- University of Florida, Gainesville, FL, USA
| | | | | | | | - Eli Mender
- University of Florida, Gainesville, FL, USA
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