Introduction
Gender affirmation surgery continues to grow in popularity and demand as over 1.4 million people in the United States currently identify as transgender. This represents a unique at risk medical population with barriers to healthcare and higher incidence of anxiety and depression. Gender dysphoria is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a person whose gender at birth is incongruent with gender identity. We as plastic surgeons play an essential role in the comprehensive approach to patients diagnosed with gender dysphoria as gender affirmation surgery is often the last step in the treatment process. This article aims to provide an overview regarding preoperative assessment and surgical options available for these patients.
Preoperative Assessment
Preoperative assessment of patients with gender dysphoria requires an interdisciplinary team and an individualized approach regarding expectations and personal goals for gender affirmation surgery. The World Professional Association for Transgender Health (WPATH) has developed recommendations and treatment guidelines for transgender patients. All patients that present for surgery must have the capacity to make fully informed consent. The age of consent for all gender affirmation surgeries is 18 years and older in the U.S. However, a patient underage that desires Female-to-Male (FtM) mastectomy can undergo surgery if they have a consenting guardian, have lived in the congruent gender identity for at least one year and completed one year of continuous testosterone therapy. All patients that present for surgery must have a referral from a mental health professional that documents persistent gender dysphoria with one referral required for chest reconstruction and two separate referrals required for patients seeking genital reconstruction. Patients seeking surgery should have well controlled comorbidities as well as be up to date consenting guardian, have lived in the congruent gender identity for at least one year and completed one year of continuous testosterone therapy. All patients that present for surgery must have a referral from a mental
health professional that documents persistent gender dysphoria with one referral required for chest reconstruction and two separate referrals required for patients seeking genital reconstruction. Patients seeking surgery should have well controlled comorbidities as well as be up to date with any recommended gender related health and routine cancer screening.
Hormone therapy is not required for chest gender affirmation surgery. However, for patients undergoing Male-to-Female chest reconstruction, twelve months of hormone therapy is recommended to allow for breast tissue growth and better aesthetic outcomes. Hormone therapy is required for twelve continuous months prior to any genital reconstruction surgery. In addition, patients must have lived twelve months continuously in the gender role congruent with their respective identity.
| WPATH Requirements | Chest/Breast | Genital | Facial or other Gender affirmation surgery |
|---|---|---|---|
| Documented Referral of Gender Dysphoria from Mental Health Provider | 1 referral | 2 referrals | Not required |
| Capacity of informed Consent | Required | Required | Required |
| Age of Consent | >18* | >18 only | >18 or guardian consent |
| Hormone therapy | Not Required | Required 12 Continuous Months | Not Required |
| Living in Congruence with Gender Identity | Not Required | Required 12 Continuous Months | Not Required |
*Age of majority in a given country is what WPATH uses for under age 18. This is reflected by the standard around the country and it is recommended that the patient stop developing before undergoing transitioning surgery.
Male-to-Female Surgery
Male-to-Female (MtF) patients represent the largest proportion of the transgender population with implant based breast augmentation being the most common MtF chest surgery. Although hormone therapy is not required for surgery, estrogen hormone therapy is recommended prior to surgery to allow for breast tissue growth and improved cosmetic surgical results. Fat grafting can also be utilized as an alternative. Breast augmentation in the MtF population is similar to the approach in the cis patients. The male chest is slightly wider than the female chest and could result in widened cleavage or laterally displaced nipple areolar complex (NAC). The preference of perioareolar, axillary, or inframammary approach and prepectoral verus subpectoral placement of the implants are surgeon and patient dependent. The complications of breast augmentation are similar to the general population and include capsular contracture, hematoma, and prosthesis rupture. Post gender affirmation patients should undergo breast mammography screening every 2 years starting at the age of 50 or after 5-10 years of feminizing hormone.
The goals of male-to-female genital reconstruction are sexual sensation, a functional vagina, and acceptable cosmesis. Penile inversion vaginoplasty is the gold standard for genital reconstruction in the MtF population. Inversion vaginoplasty includes performing scrotal excision, high end ligation orchiectomy, dissection of the penis, creation of a neovagina in the pre-rectal space, and creating of a neoclitoris utilizing the glans penis and a neourethra anastomosis. Urologic dysfunction is the most common long term complication of inversion vaginoplasty and occurs in 10-40% of patients These patients may experience meatal stenosis or splayed urinary stream. It is recommended that these patients continue the same prostate screening as cisgender men.
Female-to-Male Surgery
Subcutaneous mastectomy is performed in FtM patients that desire a male chest contour. The goals of surgery include a male chest contour, acceptable positioning of NAC, and minimal scars. This population is often more difficult than the male gynecomastia population because of larger breast size and excess skin. Breast size and skin elasticity are the most important factors when planning surgical incisions. For patients with small breasts or Grade I ptosis, liposuction alone can be performed only or a semicircular or transareolar incision approach can be utilized. For medium sized breasts or grade II ptosis, a concentric circular or extended concentric incision yields the best results. For large or grade III ptosis breasts, a free nipple graft is the best available surgical option for patients. Nipple necrosis and hematoma are the most common surgical complications. Post chest reconstruction surgery female-to-male patients should continue cisgender women screening guidelines for breast cancer if no mastectomy or only a breast reduction is performed.
The goals of FtM genital reconstruction are to create an ideal neophallus that is aesthetically pleasing, has intact tactile and erogenous sensation, provides standing urination, and imparts minimal donor site morbidity.
There are three surgical techniques in FtM genital reconstruction: metoidioplasty, pedicled phalloplasty with an anterolateral thigh (ALT) flap, and phalloplasty with a radial forearm free flap (RFFF). For all these reconstructive options urologic dysfunction including urethral strictures and fistulae are the most common complications. Metoidioplasty involves the creation of a neophallus from a hypertrophied clitoris. The clitoris is dissected with detachment of clitoral ligament and division of urethral plate with urethroplasty to increase neophallus length. The advantage of this approach is the principle of like-with-like reconstruction utilizing the glans and allowing for erectile rigidity without a prosthesis. The drawback of metoidoplasty is a shorter neophallus
(5-7cm). The pedicled ALT flap can be used for a “tube-within-a-tube” flap design for neourethral formation. This flap provides a reliable vascular supply with a discrete donor site. Difficulties of this option for genital reconstruction include a thick subcutaneous layer that limits tube formation and need for a prosthesis for erectile rigidity. Finally, the RFFF creates an aesthetic neophallus with adequate length for standing urination. Neurorrhaphy between donor antebrachial cutaneous nerves to the dorsal clitoral and/or ilioinguinal nerves provides tactile and erogenous sensation. Disadvantages with use of this flap include donor site morbidity. Most patients will undergo TAHBSO prior to phalloplasty, but will need to continue to follow screening for cervical cancer after genital reconstruction.
| FtM Genital Reconstruction | Length | Standing Urination | Sensation | Donor Morbidity |
|---|---|---|---|---|
| Metoidoplasty | Poor | Difficult | Great | Minimal |
| Pedicled ALT Phalloplasty | Good | Yes | Poor | Minimal | RFFF Phalloplasty | Excellent | Excellent | Great | Significant |
Conclusion
Gender affirmation continues to be an evolving field within plastic surgery. Studies have demonstrated that patients who undergo gender affirmation surgery have significant benefits of mental and psychosocial health with an extremely low rate of regret (2%). Thus, a comprehensive, multi-disciplinary preoperative assessment is vital for treatment of these patients. Each patient presents with different individual goals that can be addressed with many potential options for treatment.
References
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