Perioperative Patient-Initiated Communication in Gender-Affirming Mastectomy.

Background: Gender-affirming mastectomy (GAM) improves the psychosocial functioning and quality of life of transgender and non-binary (TGNB) individuals. However, the perioperative period is often marked by emotional stress, concerns about surgical outcomes, and physical discomfort. While inpatient procedures provide multiple opportunities to engage with and educate patients, outpatient surgeries, such as GAM, pose a unique challenge as patients are followed for <24 h postoperatively. Given the heightened emotional and psychological distress related to gender dysphoria TGNB individuals often experience, addressing these gaps can significantly improve outcomes. This study aims to characterize patient and surgical characteristics associated with patient-initiated communication (PIC) frequency in this population. Methods: A single-center retrospective review of TGNB patients undergoing GAM from February 2018 to November 2022 was conducted. Demographics, surgical characteristics, and frequency of and reasons for perioperative PIC (30 days before and after surgery) were recorded. The primary outcome was the incidence of perioperative PIC. The secondary outcomes included (1) the rationale for PIC and (2) patient and surgical characteristics associated with PIC. Results: A total of 352 patients were included. Of these, 285 (74.6%) initiated communication in the perioperative period, totaling 659 PICs. The median age was 25.0 (interquartile range [IQR]: 9.0) years. The median body mass index (BMI) was 28.5 (IQR: 8.5) kg/m2. The mean number of PICs was 0.7 ± 1.3 preoperatively and 1.3 ± 1.7 postoperatively (p < 0.001). The most frequent preoperative PIC subjects were administrative issues (AI; n = 66, 30.7%), preoperative requirements (n = 43, 20.0%), and cost and insurance (n = 33, 15.0%). The most frequent postoperative PIC subjects were wound care (n = 77, 17.3%), AI (n = 70, 15.0%), activity restrictions (n = 60, 13.5%), drainage (n = 56, 12.6%), and swelling (n = 37, 8.3%). Collectively, older patients (ß = 0.234, p = 0.001), those with a history of major depressive disorder or generalized anxiety disorder (2.4 ± 3.0 vs. 1.7 ± 1.9; p = 0.019), and those without postoperative drains (n = 16/17, 94.1% vs. n = 236/334, 70.7%; p = 0.025) engaged in higher levels of PIC. There were no significant associations between other patient characteristics, perioperative details, or complications and PIC frequency. Conclusions: Perioperative PIC is prevalent among the majority of GAM patients at our institution, with age, psychiatric diagnosis, and postoperative drain use identified as significant predictors. To mitigate PIC frequency, it is crucial to ensure adequate support staffing and provide comprehensive postoperative instructions, particularly concerning activity restrictions and drainage management. These interventions may reduce PICs in high-volume centers. Further research should investigate targeted interventions to further support TGNB patients during the perioperative period.

Body Contouring as Gender-Affirming Surgery in Transgender Patients: A Systematic Review of the Current Literature.

Background: There is an increasing demand for body contouring and gender-affirming surgeries, and so is the need to compare outcomes between techniques. Gender dysphoria is a discrepancy between gender identity and the sex assigned at birth. One way to address this is to perform procedures to enable patients to look according to their desired gender identity. Gaps in knowledge regarding the best approaches and which surgical techniques yield the most patient satisfaction remain. This article summarizes up-to-date studies, including upper and lower body contouring procedures. Methods: A systematic review was performed using terms related to body contouring in gender-affirming surgery for transgender patients. All articles included surgical and patient-reported outcomes following either chest or lower body contouring procedures. Results: 15 studies, including trans male chest wall contouring, trans female breast augmentation, and lower body contouring, with 1811 patients, fulfilled the inclusion criteria. The double incision (DI) techniques consistently resected more tissue and had better BODY Q scores than non-overweight patients. Bleeding was increased in periareolar, semicircular, and obese patients with DI techniques. Nipple depigmentation and sensation loss were more common with double-incision-free nipple graft techniques (DIFNG). Lower body contouring patients had average implant sizes bigger than 200 mL and reported 2 gluteal implant displacements, 1 exposure, and one rupture. Eight percent of patients who underwent large-volume fat grafting reported dissatisfaction due to fat reabsorption. Conclusions: The debate between the double incision and periareolar techniques continues. Variations of the DIFNG technique continue to be the most common approach; however, nipple depigmentation and loss of sensation are also more common with it. Regarding increased bleeding with periareolar techniques, there is still no evidence that hormonal therapy may be playing a role in it. For lower-body trans female contouring, implants could help with the longevity of contouring results in patients needing large-volume fat grafting. There is an increasing evaluation of gender-affirming body contouring patient-reported outcomes; however, there is still a need for a validated way to report satisfaction scores in lower body contouring. Validated surveys could help identify surgical candidates based on satisfaction patterns, specifically for transgender and non-binary patients.

The robotic-assisted free jejunal flap for neovaginal canal creation in gender-affirming vaginoplasties.

INTRODUCTION: One of the biggest challenges with gender-affirming vaginoplasty was the creation of a long-lasting, durable, patent, and self-lubricating neovaginal canal that allowed for spontaneous, pain-free sexual intercourse. The jejunum was a durable, physiologic, and intestinal option to create the neovaginal canal that minimizes the adverse effects of skin graft, peritoneal, and colonic vaginoplasties. Free jejunal vaginoplasties had been performed in cis females for congenital genitourinary anomalies like Mullerian agenesis or after gynecologic-oncologic surgery but had yet to be reported for gender-affirming vaginoplasties. The purpose of this report was to present a technique for a physiologic, intestinal, gender-affirming vaginoplasty without the disadvantages of colonic vaginoplasties. PATIENTS AND METHODS: This report presented six patients, all natal males who identified as female, undergoing robotic-assisted free jejunal flap gender-affirming vaginoplasty. Mean age was 35.8 years (range: 21-66). Mean body mass index was 33.2 kg/m2 (range: 28.0-41.0). The proximal aspect of the neovaginal canal was created intra-abdominally by elevating peritoneal flaps from the posterior bladder wall to be reflected downward into the external neovaginal canal. The jejunal flap was harvested. The greater saphenous vein was harvested to create an arteriovenous loop between the flap vessels and the recipient femoral artery in an end-to-side fashion and a branch of the femoral vein. The jejunal flap was passed intra-abdominally through the groin incision and then trans-peritoneally into the neovaginal canal. The jejunal segment was inset to the proximal peritoneal flaps and the distal inverted penoscrotal skin of the neovaginal introitus. RESULTS: Mean length of the harvest jejunal segment was 19.2 cm (range: 15-20). Mean time to ambulation, foley removal, and first vaginal dilation were 3.3 (range: 3-4), 4.0 (range: 3-5), and 4.5 days (range: 4-6), respectively. By a mean follow-up duration of 8.0 months (range: 1-14), mean vaginal depth and diameter were 7.0 and 1.3 cm (range: 1.0-1.5), respectively. Two (33.3%) patients experienced postoperative complications, including groin hematoma (n = 1, 16.7%) and reoperation for correction of dehiscence of the jejunal flap to the vaginal introitus (n = 1, 16.7%). CONCLUSION: Gender-affirming surgeons should consider a free vascularized segment of jejunum as an option to line the neovaginal canal in the correct patients.

Factors influencing intraoperative conversion from double- to single-incision mastectomy with free nipple grafts in 352 transgender and non-binary patients.

BACKGROUND: Double-incision mastectomy (DIM) with free nipple grafts (FNG) is a common technique employed in gender-affirming mastectomy (GAM), but is associated with a high scar burden. Intraoperatively, the surgeon may opt for a single-incision mastectomy (SIM) along the inframammary folds (IMF) to optimize aesthetic outcomes. This study sought to identify factors predictive of intraoperative conversion. METHODS: From February 2018 to November 2022, TGNB patients who underwent GAM at a single institution were retrospectively reviewed. Data regarding patient characteristics, perioperative details, postoperative complications, and aesthetic satisfaction were collected. RESULTS: A total of 352 patients were identified. Median age and body mass index (BMI) were 25.0 years (IQR: 9.0) and 28.5 kg/m2 (IQR: 8.5), respectively. Most patients received IMF incisions (n = 331, 94.0%); of whom, 66 (19.9%) underwent intraoperative conversion from DIM to SIM with FNG. Larger breast cup-size (p < 0.001) and a greater degree of ptosis (p = 0.002) preoperatively were significantly associated with intraoperative conversion to SIM. There was no significant association between intraoperative conversion and the ratio of intermammary distance to the width of the chest wall (p = 0.086). Overall complication rates were significantly higher among patients with diabetes mellitus (p = 0.015) and a greater degree of ptosis (p = 0.018). 77.8% (n = 274) of patients were satisfied with their aesthetic outcome. NPWT usage was associated with higher rates of aesthetic satisfaction (83.6% vs. 77.8%; p = 0.005). CONCLUSION: Patients with larger breast cup size and greater degree of ptosis should be counseled preoperatively that they may be at a higher risk of conversion to a singular incision.

Surgical techniques and outcomes of thyroid chondroplasty in transfeminine individuals: A systematic review.

Thyroid chondroplasty (TC) in facial gender-affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to TC and associated outcomes and complications. A systematic review (SR) of articles pertaining to TC was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve articles representing 368 patients were included for analysis. Nine articles described open approaches, and three articles described endoscopic techniques. The rate of total complications was 4.3% (n = 12) in the open approach compared to 15% (n = 13) in the endoscopic approach. Positive esthetic results were reported in 92% of cases performed with the open approach and 90% with the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage, and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal. In addition, data of individuals who underwent "cervical tracheoplasty" for gender dysphoria from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed, and there was no incidence of wound or major complications among patients who underwent tracheoplasty alone. Although the advantage of the endoscopic approach is a scarless neck incision, the rate of complications is higher with the open approach. Endoscopic approaches are still not widely used, and continued investigations are warranted to improve familiarity with this approach and reduce postoperative complications.

The Effect of Obesity on Vaginoplasty Outcomes.

BACKGROUND: Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. METHODS: A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. RESULTS: A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). CONCLUSIONS: Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.

Association of High Body Mass Index With Postoperative Complications After Chest Masculinization Surgery.

PURPOSE: Body mass index (BMI) requirements for transgender and nonbinary patients undergoing chest masculinization surgery (CMS) are not standardized and based on small sample sizes. This is the largest and first national retrospective study to determine the association between BMI and postoperative complications. METHODS: The National Surgical Quality Improvement Program 2012-2020 was queried for CMS patients. The primary outcome was incidence of at least one complication within 30 days. Secondary outcomes were incidence of major and minor complications. Body mass index (in kilograms per square meter) was categorized as category 0 (<30), 1 (30-34.9), 2 (35-39.9), 3 (40-44.9), 4 (45-49.9), and 5 (≥50). Logistic regression was used to evaluate the association between BMI and outcomes. RESULTS: Of 2317 patients, median BMI was 27.4 kg/m 2 (interquartile range, 23.4-32.2 kg/m 2 ). Body mass index range was 15.6 to 64.9 kg/m 2 . While increasing BMI was significantly associated with greater odds of at least one complication, no patients experienced severe morbidity, regardless of BMI. Patients with BMI ≥50 kg/m 2 had an adjusted odds ratio [aOR, 95% confidence interval (CI)] of 3.63 (1.02-12.85) and 36.62 (2.96->100) greater odds of at least one complication and urinary tract infection compared with nonobese patients, respectively. Patients with BMI ≥35 kg/m 2 had an adjusted odds ratio (95% CI) of 5.06 (1.5-17.04) and 5.13 (1.89-13.95) greater odds of readmission and surgical site infection compared with nonobese patients, respectively. CONCLUSIONS: Chest masculinization surgery in higher BMI patients is associated with greater odds of unplanned readmission. Given the low risk for severe complications in higher BMI individuals, we recommend re-evaluation of BMI cutoffs for CMS patients.

Intra-operative evaluation of textured anatomic implant rotation: a prospective study.

BACKGROUND: Textured implants were developed with the goal of reducing rates of capsular contracture and preventing implant malposition (eg., malrotation). Recent evidence has questioned whether textured implants are as resistant to malrotation as previously reported. METHODS: Women presenting to a single healthcare system for removal of textured implants were prospectively enrolled in the study from September 2019 to July of 2022. Patients who underwent removal of an anatomic, textured implant in the operating room were included in the study, while those who did not undergo implant removal, or were found to have a smooth implant, or a round, textured implant were excluded. The degree of implant rotation upon removal of the implant was measured intra-operatively. Implant specific factors, as well as patient demographics, clinical factors, and operative characteristics were collected. RESULTS: A total of 51 patients (80 implants) were included in the study. 45% of implants were malrotated (rotated >30 degrees) and the median degree of rotation was 30. Having more than one previous revision of the breast pocket was predictive of implant rotation (42 degrees) on multivariate linear regression analysis. Patients who presented with a complaint of "aesthetic dissatisfaction" had 2.89 increased odds of having an implant rotated > 30 degrees. CONCLUSION: Our study found a high rate of malrotation of textured, shaped implants upon explantation.

Perioperative misgendering experiences in patients undergoing gender-affirming surgery: a call for a gender-inclusive healthcare environment.

Background: Transgender individuals have long experienced discrimination and exclusion from medicine. Misgendering occurs when an individual is referred to using a gender or address incongruent with their identity. We evaluated the incidence of misgendering throughout the perioperative experience for patients undergoing gender-affirming surgery (GAS). Methods: Patients diagnosed with gender dysphoria who previously received GAS by the senior author were contacted to complete an IRB-approved survey to evaluate instances of misgendering while in the hospital for GAS. Study results were summarized using descriptive statistics. Results: Of 471 patients contacted, 182 completed the survey (38.6%). The most cited gender identity was transfemale (28.0%). Most patients reported respect for their gender identity (60.4%) and name (76.8%) during their perioperative experience. Twenty-two percent cited triggering experiences, and 15.4% reported interactions with healthcare employees causing them to reach out to a support system. Misgendering most commonly included incorrect use of patients' preferred names and/or pronouns (n = 50, 86.2%), most commonly at surgical check-in (n = 10, 45.5%). Recommendations to improve feelings of gender congruence during patients' stay included updated names and gender identities in electronic medical records (80.8%), and names and pronouns listed on curtains and doors (52.3%) and name tags (51.5%). Conclusions: Until now, the exact incidence of misgendering among patients seeking GAS have not been well established. Despite high levels of satisfaction, a large proportion still reported serious instances of misgendering. Improvements must be made to the perioperative experience to reduce misgendering and provide support and comfort during the sensitive period surrounding patients' gender transition.Level of evidence: Not gradable. Supplementary Information: The online version contains supplementary material available at 10.1007/s00238-022-02040-2.

Selecting a chest masculinization plastic surgeon: a survey of transgender patients.

Background: Chest masculinization is a commonly performed gender-affirming procedure in transmasculine and non-binary patients and has increased in prevalence in recent years despite continued barriers to surgical care. With the expansion of insurance coverage and trained surgeons, patients at times have the opportunity to be selective in choosing their gender-affirming surgeon. This study aimed to investigate factors that transmasculine individuals consider important when selecting their chest masculinization plastic surgeon. Methods: All patients who underwent chest masculinization with a single surgeon between January 2018 and December 2021 were surveyed via an online questionnaire to rate 21 factors associated with surgeon selection. Multiple-choice questions and free text space were included to further clarify patient preferences. Results were analyzed to rate factors in order of importance. Results: One hundred three individuals completed the survey, generating a response rate of 49.5%. Average patient age at time of surgery was 27.0 years, and 2.0% of patients had prior gender affirmation surgery (GAS). The top five most important factors were surgeon specialization in GAS, insurance coverage, board certification, number of times surgeon has performed procedure, and availability of Before and After photographs. The five least important factors were age of surgeon, medical publications, availability of YouTube videos, location of training, and surgeon presence on social media. Conclusions: Transmasculine patients employ distinct criteria when selecting a chest masculinization gender-affirming plastic surgeon. An improved understanding of these factors informs providers of ways to enhance patient access to information and gender-affirming care.Level of evidence: Not gradable.

Postoperative Outcomes following a Multidisciplinary Approach to HIV-positive Breast Cancer Patients.

Improvements in human immunodeficiency virus (HIV) treatment resulted in drastic increases in the lifespan of HIV-positive individuals, resulting in higher rates of non-AIDS-defining cancers. We describe our postoperative outcomes in HIV+ breast cancer (BC) patients, highlighting our multidisciplinary experience with this high-risk population. Methods: A 7-year multi-institutional retrospective review of all HIV+ BC patients who underwent surgical intervention was performed. Patient demographics, therapeutic interventions, and treatment outcomes were collected. Results: Twenty-four patients were identified, including one male patient (4.2%). Most patients were African American (83.3%). Mean age was 52.1 + 9.7 years at the time of diagnosis in HIV+ BC patients. Surgical interventions included lumpectomy (n = 16, 66.7%), simple mastectomy (n = 3, 12.5%), and skin-sparing mastectomy (n = 5. 20.8%). All patients were on antiretroviral therapy, and 81.3% had undetectable viral loads at the time of operation. Seventeen patients (70.8%) underwent breast reconstruction, with three (17.7%) undergoing delayed reconstruction. Thirty-day postoperative complications occurred in three patients (17.6%), including flap necrosis (11.8%), infection (11.8%), dehiscence (5.9%), and return to OR (11.8%). Three patients (12.5%) experienced recurrence at a median of 18 months since operation. Mean follow-up was 51.4 + 33.3 months since BC diagnosis. Conclusions: While postoperative complication rates in HIV+ patients trended higher (17.6%) compared with the existing data on breast reconstruction patients overall (10.1%), HIV+ patients did not exhibit increased risk of BC recurrence (12.5%) compared with BC patients overall (12-27%). This highlights the importance of a combined multidisciplinary approach involving infectious disease, breast surgery, and plastic and reconstructive surgery to optimize surgical and oncologic outcomes in these high-risk patients.

Applications of three-dimensional surgical planning in facial feminization surgery: A systematic review.

BACKGROUND: Despite some reports that have shown an increase in safety, efficiency, and accuracy during feminizing craniofacial procedures utilizing three-dimensional (3D) technology, there are no reports summarizing the available evidence on this matter for facial feminization surgery (FFS). Here, we aimed to systematically review the application of 3D technology on FFS. METHODS: We conducted a comprehensive search across PubMed, SCOPUS, Ovid MEDLINE®, Web of Science, and ScienceDirect looking for studies reporting the use of 3D surgical planning in the setting of FFS following the PRISMA guidelines. We extracted data on photographic assessment, imaging, surgical application, and surgical technique and outcomes. RESULTS: This review included 10 studies comprising 1473 transgender female patients and 50 cadaveric cranial specimens. Four studies employed virtual surgical planning (VSP) and the concomitant use of prefabricated cutting guides. One study reported the implementation of 3D VSP using a female skull as a reference. One study used computer-aided design cutting guides and custom plates for FFS. Standardized incorporation of 3D printed models allowed for preoperative planning in three studies. Three studies reported VSP using 3D reconstruction of CT images, but without the use of 3D printing. Three studies used 3D photography with specialized camera technology to enrich clinical documentation and provide a comprehensive facial analysis of soft tissue. Accuracy ranged from 85.7% to 97%. Morbidity ranged from 0% to 12.5%. CONCLUSION: Based on this data, we believe 3D VSP has promising outcomes in terms of accuracy and low morbidity, encouraging its implementation in FFS. However, further prospective double-arm cohort studies are required.

Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes.

Background: Facial feminization is a critical step in a transfeminine patient's surgical transition. However, the existing literature on the various types of feminization surgeries suffers from inadequate reporting on perioperative aspects of care, such as preoperative evaluation and postoperative outcomes. The aim of this study is to evaluate facial feminization surgery (FFS), preoperative planning, and patient reported outcomes after various types of procedures. Methods: An electronic database search of Ovid MEDLINE was completed according to PRISMA guidelines for articles pertaining to FFS. Study characteristics, operative information, and patient demographics were collected. Data concerning preoperative imaging, virtual simulation, postoperative complications, and patient-reported outcome measures (PROMs) were collected and analyzed for patterns. Results: A total of 22 papers representing 1302 patients were included for analysis. The most commonly discussed operations included upper face procedures, particularly of the forehead (17 studies, 77%). When discussed, preoperative planning for FFS included standard photography in 19 (86%) studies, advanced imaging, such as cephalometry or computed tomography, in 12 (55%) studies, and virtual simulation of surgical outcomes in four (18%) studies. Patient-centered outcomes, such as postoperative satisfaction, were described in 17 (77%) studies. Standardized PROMs were heterogenous across included studies with only 11 (50%) including at least one PROM. Conclusions: FFS is common, safe, and highly satisfying for transfeminine patients seeking surgical intervention for identity actualization. Future research concerning transgender care must evaluate advanced surgical planning and 3D simulation combined with more standardized assessment of PROMs to ensure high-quality analysis of patient satisfaction.

Utility of Negative Pressure Wound Therapy: Raising the Bar in Chest Masculinization Surgery.

BACKGROUND: Prophylactic use of negative pressure wound therapy (NPWT) has been shown to decrease the incidence of postoperative complications. This study aimed to evaluate the utility of NPWT in chest masculinization with free nipple graft (FNG). METHODS: All consecutive male patients undergoing chest masculinization with FNG by a single provider at a single center were reviewed. Postoperative treatment with either NPWT or standard wound care (SWC) defined this study's cohorts. Patient characteristics and postoperative complications were compared between patients receiving NPWT versus SWC. RESULTS: One hundred thirty-one patients with 262 closed breast incisions (NPWT=72, SWC=190) met inclusion criteria. Overall complications were higher in the SWC cohort (n=80/190, 42%) compared to the NPWT cohort (n = 13/72, 18%, p < 0.001). The NPWT group had significantly lower rates of partial nipple graft loss (9/72, 12.5% versus 47/190, 24.7%, p = 0.031), seroma formation (1/72, 1.4% versus 15/190, 7.9%, p = 0.037), and nipple hypopigmentation (6/72, 8.3% versus 36/190, 18.9%, p = 0.024) when compared to the SWC cohort. Time to drain removal was significantly faster in the NPWT group (NPWT 7 days versus SWC 9 days, p ≤ 0.001). CONCLUSIONS: Patients receiving NPWT over their closed incisions following chest masculinization with FNG were found to have significantly lower rates of partial nipple graft necrosis, seroma formation, and time to drain removal compared to those receiving SWC. Future prospective, randomized studies to further elucidate the role of NPWT in top surgery are warranted.

Building a gender-affirming surgery service: The fundamentals.

BACKGROUND: As the healthcare needs of transgender patients become increasingly recognized and supported, gender-affirming surgery services are in increasing demand. However, establishing a gender-affirming surgery service is unlike many other surgical specialties and requires unique expertise and administrative support. The aim of this article is to outline the considerations for starting a gender-affirming surgery service and identify pearls for success. METHODS: In this article, we describe the critical components of building and maintaining a successful gender-affirming surgery service. We intersperse findings from our own experiences developing a gender-affirming surgery service. RESULTS: A successful gender-affirming surgery service starts by developing a clear vision of the patient population within your hospital system's area, as well as the design of your center. Establishing a center relies on early engagement of hospital administration and its continued support. A multidisciplinary team with intensive interpersonal and operative training offers the best patient experience and surgical outcomes. By following these steps, our service has been able to provide gender-affirming surgery to more than 200 patients since its inception. Future goals entail partnerships with other institutions and continued outcomes evaluation to ensure sustained success of all gender-affirming surgery services. CONCLUSION: Although there are unique challenges and considerations for establishing a gender-affirming surgery service, careful planning and stakeholder engagement allow providers to deliver high-quality care. We hope that our experience can serve as a model for future much needed gender-affirming surgery services.

Minimizing opioid consumption by eliminating patient-controlled analgesia after penile inversion vaginoplasty with enhanced recovery after surgery (ERAS) protocol.

BACKGROUND: Genital-based gender affirmation surgery is a physically demanding procedure requiring extensive postoperative pain management. However, perioperative opioid use for these procedures is relatively understudied. OBJECTIVES: This study analyzes whether intravenous patient-controlled analgesia (PCA) enhances pain control after penile inversion vaginoplasty (PIV) in the setting of enhanced recovery after surgery (ERAS) protocols, and whether non-PCA (NCA)-based regimens could reduce postoperative opioid use. METHODS: All patients undergoing PIV with ERAS protocols by a single provider from December 2018 to November 2020 were retrospectively reviewed. Patient demographics, comorbid conditions, pain scores, length of stay (LOS), and opioid usage during their hospitalization were collected. Postoperative opioid use and pain scores were compared between PCA and NCA patient cohorts. RESULTS: A total of 61 patients were included. 30 patients received intravenous PCA postoperatively, and 31 patients used NCA-based narcotic pain control. All patients underwent ERAS protocol perioperatively. Average patient age was 34.5 years (SD 11.9) in the PCA cohort and 37.6 years (SD 11.9) in the NCA cohort (p = 0.242). Average total postoperative opioid use during hospital stay was reduced by 53.7% in the NCA cohort, with an average use of 501.6 morphine milligram equivalents (MME) (SD 410.3) among PCA patients and an average use of 232.0 MME (SD 216.5) among NCA patients (p = 0.003). Daily average pain scores for postoperative days 1 to 6 did not differ between the PCA and NCA patient groups (p > 0.05). Average hospital LOS was shorter among NCA patients, 6.2 days (SD 1.0) versus 7.3 days (SD 1.4), respectively, (p < 0.001). DISCUSSION: In combination with an ERAS non-narcotic pain control protocol, it may be possible to reduce opioid use by more than 50% and shorten length of postoperative hospital stay among patients by implementing NCA pain management protocols. CONCLUSION: Minimizing postoperative opioid consumption after PIV will benefit patients and their sustained well-being.