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One goal of an ideal phallic reconstruction is achieving tactile and erogenous sensation. Traditionally, the most common flap used in phalloplasty has been the radial forearm flap, where the medial and lateral antebrachial cutaneous nerves are coapted to meet this goal. The purpose of this article is to draw attention to the lesser-known posterior antebrachial cutaneous nerve (PABC) as an alternative or additional nerve for coaptation that innervates a majority of the shaft, where sensation is most desired. The presence, anatomical location, and territory of innervation of the antebrachial cutaneous nerves were assessed in a series of 12 consecutive in vivo radial forearm phalloplasties. A literature review was conducted to establish which nerves have traditionally been used for sensory reinnervation of the phallus. The PABC was the first nerve encountered on the radial border of the flap lying on the fascia in the interval between the brachioradialis and extensor carpi radials longus. The posterior and lateral antebrachial cutaneous nerves innervated the phallic shaft, whereas the anterior branch of the medial antebrachial cutaneous nerve innervated the phallic urethra. There were no articles in our review that used PABC for nerve coaptation in radial forearm phalloplasty. The skin innervated by the PABC represents a significant portion of the phallic shaft when using the standard template for radial forearm phalloplasty. Despite this, its use is not described in the literature. The authors introduce the PABC as an alternative or additional nerve for coaptation in radial forearm phalloplasty.

In the radial forearm phalloplasty multiple nerves are harvested to provide phallic sensation, resulting in iatrogenic nerve injuries. Despite this, nerve morbidity following this procedure has been minimally assessed. The purpose of this study was to assess donor site nerve morbidity following radial forearm phalloplasty.Patients who underwent gender-affirming phalloplasty at our institution between 2016-2020 using the radial forearm were included. Pain characteristics were assessed with a modified Mackinnon Pain questionnaire consisting of 33 items, including visual analog scales (VAS) for reporting of pain and impact on aspects of quality of life (QoL), as well as 20 descriptive pain adjectives and a 21-item questionnaire to capture overall pain experience.A total of 37 patients were included. 31 had minimal-mild pain (VAS scores 0-3), and 6 patients had moderate-severe pain (VAS scores 4-10). The mild pain group reported a mean 2.74 (0-7) pain descriptors and reported minimal impact on QoL metrics. The moderate-severe pain group reported mean 6.33 (2-15) pain descriptors and reported significant impacts on QoL metrics. Significant differences were observed with decreased QoL (p = 0.018), increased sadness (p = 0.009), increased frustration (p = 0.030), increased anger (p = 0.0496), and decreased hopefulness (p = 0.0496) in the moderate-severe pain group along with interference of pain with sleep (p = 0.002).In a cross-sectional analysis of 37 patients who underwent gender-affirming radial forearm phalloplasty, the majority (31) experienced a minimal degree of donor site nerve pain. Six patients suffered from more significant nerve pain that was associated with a decreased QoL. Treatment and prevention of this nerve pain represent important areas for future exploration.

Objective This study seeks to assess the status of elective rotations offered in plastic and reconstructive surgery residency programs throughout the country while also qualifying resident and alumni experiences and identifying barriers to offering electives. Design Two prospective surveys were created for (1) program leadership and (2) residents, fellows, and alumni's who have graduated in the last 5 years. Setting This is a multi-institutional survey study. Participants Of 81 plastic and reconstructive surgery programs, 45 programs, and 102 residents, fellows and/or recent graduates responded to survey 2. Results Fifty-six percent of respondents stated that their institution offered electives, 62% of which permitted residents to participate in regional, national, and international rotations primarily in the fifth and sixth years of training. Types of elective rotations completed included aesthetic, craniofacial, sex, hand, and microsurgery. Fifty-three percent responding programs denied barriers to offering elective rotations. When programs noted barriers, the most common were cost to resident/department (28%), institutional Graduate Medical Education policy (22%), and lack of service coverage at the home institution (22%). There was no difference between departments versus divisions offering electives (56.3% vs 57.1%, P = 0.95). Programs that did not offer electives spent an average of 14.6 months on general surgery compared with 9.4 months for programs that did offer electives (P = 0.06). For programs that did not currently offer elective rotations, 71% indicated a desire to do so. Conclusion The primary goal of plastic surgery training programs is to produce plastic surgeons of the highest caliber with regard to safety and competence. Although several regulatory bodies ensure that programs adhere to a similar standard, not all programs have opportunities for residents to experience the breadth of our multifaceted specialty. Elective rotations constitute an excellent supplement to a well-rounded training where gaps may exist.

Background Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. Methods This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. Results Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. Conclusion PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

SUMMARY The creation of a sensate, aesthetic, and functional phallus for transmasculine individuals has high reported complication rates. Neourethra reconstruction is the most challenging aspect of this surgery, with widely varying techniques and staging between providers. In an operation of this complexity, surgeons should not be expected to offer all the options, but rather the specific variation that works in their given setting. For some, it is single-stage phalloplasty with full-length urethroplasty. For others, staged phalloplasty with separation of perineal masculinization from phallus reconstruction works better. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors' intent to establish the "best" or "only" way, but rather to compile different options with their respective pros and cons.

Background Phalloplasty often requires free tissue transfer. There is ample literature describing flap-related outcomes, but the microsurgical technique used, including choice of recipient vessels, has been an overlooked yet important topic. In this study, the authors review the outcomes of their experience with the deep inferior epigastric artery and locoregional veins and outline technical modifications that occurred during the study period. Methods A retrospective chart analysis of patients who underwent microsurgical phalloplasty between September of 2016 and July of 2019 was performed. Variables included flap design, donor site, and recipient vessels. The outcome measures were return to the operating room for flap compromise and partial or complete flap loss. Results Forty-two phalloplasties using the deep inferior epigastric artery were identified. There were six take-backs for flap compromise, and four patients required venous revision, one of whom lost his urethral flap on postoperative day 9. There was a decrease in take-back rate from 30 percent in the first 20 patients to 0 percent in the second 22 patients in the study period. A total of 11.9 percent of patients had partial flap loss. This decreased from 15 percent to 9 percent in the two groups. Conclusion After an initial learning curve, the combination of deep inferior epigastric artery, deep inferior epigastric vein, and great saphenous vein combined with specific technical modifications such as targeted coagulation of the vasa nervorum of the clitoral nerve has proven to be a reliable technique. Clinical question/level of evidence Therapeutic, IV.

Objectives There are multiple approaches to vaginectomy for the purpose of masculinizing gender-affirming genital surgery including mucosal fulguration and excision. The outcomes of the approaches are not well described. We aim to describe the surgical outcomes of gender-affirming vaginectomy and colpocleisis by complete mucosal excision. Methods We performed a case series study of 40 transmasculine patients who underwent gender-affirming vaginectomy and colpocleisis. Vaginectomy was performed by complete excision of the vaginal mucosa via a transperineal approach. We recorded perioperative outcomes and operative time. We performed a multivariate analysis to assess patient factors on operative outcomes. Results Forty vaginectomies were performed between September 2016 and April 2019, 27 (67.5%) in phalloplasty patients and 13 (32.5%) in metoidioplasty patients. Perioperative complications included 2 blood transfusions, 1 pelvic hematoma, and 1 Clostridium cifficile colitis. No urethral fistulae to the vaginal space, mucoceles, or visceral injures were seen with a median follow-up of 7.7 months. Operative time decreased significantly with later surgery year. Conclusions This is a large series studying the outcomes of gender-affirming vaginectomy by complete mucosal excision approach in the literature. Perioperative complications were low. Operative time decreased overtime such that after approximately 20 cases, the procedure fairly consistently takes 2 to 2.5 hours to perform.

OBJECTIVE. Masculinizing genital surgeries for transgender individuals are currently performed at only a select few centers; however, radiologists in any geographic region may be confronted with imaging studies of transgender patients. The imaging findings of internal and external genital anatomy of a transgender patient may differ substantially from the imaging findings of a cisgender patient. This article provides the surgical and anatomic basis to allow appropriate interpretation of preoperative and postoperative imaging findings. We also expand on the most common complications and associated imaging findings. CONCLUSION. As these procedures become more commonplace, radiologists will have a growing role in the care of transgender patients and will be faced with new anatomic variants and differential diagnoses. Familiarity with these anatomic variations and postoperative complications is crucial for the radiologist to provide an accurate and useful report.

Background Plastic surgery plays an essential role in the treatment of gender dysphoria. International standards of care currently consider genital and chest surgeries to be medically necessary. Ancillary procedures such as facial surgery, chondrolaryngoplasty, hair restoration/removal, and body contouring are considered cosmetic surgeries except in individual circumstances. Objective The authors sought to assess the frequency of coverage provision for ancillary transition-related surgeries through a cross-sectional analysis of US insurance policies. Methods The authors selected insurance companies based on state enrollment data and market share. Policies were identified through web-based search and telephone interviews. A list of eligible procedures was compiled and grouped into 5 categories: body masculinization, body feminization, facial procedures, hair restoration/removal, and chondrolaryngoplasty. Medical necessity criteria from publicly accessible policies were then abstracted. Results Sixty-one insurance companies held an established policy. One-third of these policies offered favorable coverage for at least 1 ancillary procedure. Chondrolaryngoplasty was the most covered category (26%, n = 16), whereas body masculinization was the least covered (8%, n = 5). Almost two-thirds of the companies with favorable policies listed coverage criteria. We identified 4 recurring requirements: age, hormone therapy, continuous living in a congruent gender role, and referral from a mental health professional. Conclusions There is a low prevalence of US insurance coverage for ancillary gender surgeries and wide variability in coverage criteria. Reevaluation of ancillary transition-related procedures from cosmetic to medically necessary based on clinical judgement or establishment of defined coverage criteria may augment coverage and better address the needs of transgender patients.

Background Expansion of insurance coverage for gender confirmation surgery (GCS) has led to a large demand for GCS in the US. We sought to determine the financial impact of providing comprehensive GCS services at an academic medical center. Methods This was a cross-sectional study of patients older than 18 years who presented for GCS between January 1, 2015 and July 31, 2018 at a single academic medical center. The use of GCS services and associated work relative value units is reported. Departmental and hospital-level operating (profit) margins are reported relative to other hospital services, as well as the payer mix. Results A total of 818 patients underwent 970 GCS procedures between January 2015 and July 2018. Mean (SD) age was 35.32 (12.84) years. Four hundred and ninety-three (60.3%) patients underwent a masculinizing procedure, and 325 (39.7%) had a feminizing procedure. The most commonly performed procedure was chest masculinization (n = 403). The GCS case volume grew to generate 23.8% (plastic surgery) and 17.8% (urology) of total annual departmental work relative value units, and was associated with positive operating margins after recouping new faculty hiring costs. There were positive operating margins for GCS procedures for the hospital system that compare favorably with other common procedures and admissions. Medicare and Medicaid remained the most common payer throughout the study period, but dropped from 70% in 2015 to 48% in 2018. Conclusions We found that providing GCS at our academic medical center is profitable for both the surgical department and the hospital system. This suggests such a program can be a favorable addition to academic medical centers in the US.

OBJECTIVE:To describe the incidence of pelvic floor dysfunction in transgender women undergoing gender-affirming vaginoplasty and outcomes in a program providing pelvic floor physical therapy (PT).METHODS:We conducted a retrospective, single-institution study on vaginoplasty patients between May 1

INTRODUCTION AND OBJECTIVE:Penile amputation is a traumatic injury that can be an intimidating problem for surgeons. Successful replantation requires multi-disciplinary care, including a urologist ...

Summary:. Shaft-only phalloplasty (SOP) has been described as an alternative option for phalloplasty. Although traditional phalloplasty represents the most complete form of genital gender-affirming surgery, this variation also carries the greatest surgical risk. Patients may opt for a lower risk SOP for reasons including gender identity, gender expression, sexual function, desire for future childbearing, or minimal gender dysphoria associated with sedentary urination. Further, some patients may, due to associated co-morbidities, not be a candidate for neourethral reconstruction. Forgoing urethral reconstruction also means forgoing the presence of a distal urethral meatus and thereby compromising on one of the basic tenets of phalloplasty surgery—the aesthetic appearance. In an SOP, the flap is usually a simple tube with a purse-string suture placed at the distal end. Another concern can be the insufficient bulk of the phallus due to the absence of the volume added by the inner tube. The purpose of this article is to review our technical modifications that allow for creation of a phallic meatus as well as increasing phallic girth when needed. The most frequently described technique to create a neo-urethra is the tube-within-tube concept. We expanded on this and apply it as a short segment for distal meatal creation in an SOP. Improved aesthetics are achieved by creating the appearance of a phallic meatus and when desired, utilizing a lateral de-epithelialized strip to increase phallic bulk and girth. We hope these technical refinements can assist the surgeon in better meeting the goal of creating an aesthetically pleasing phallus.

SUMMARY Genital masculinizing gender-affirming surgery is a growing field. Because of a spectrum of gender identity, gender expression, sexual expression, patient desires, and patient tolerance for complications, options for surgery vary accordingly. Shaft-only phalloplasty avoids urethral lengthening, but may still be accompanied by hysterectomy, vaginectomy, scrotoplasty, clitoroplasty (burying of the clitoris), glansplasty, and placement of erectile devices and testicular implants. Patients who desire retention of vaginal canal patency are candidates for vaginal preservation vulvoscrotoplasty; however, there is a paucity of literature describing the procedure and its outcomes. In this article, the authors review the technique used by the senior author at Oregon Health and Science University and report surgical outcomes for four patients. Future studies regarding patient-recorded outcome measures, aesthetics, sexual function, urologic function, patient satisfaction, and conversion to other options will help surgeons better understand patients pursuing gender-affirming surgery through shaft-only phalloplasty.

In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change.Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision.Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation.After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.

Forehead and brow lift are the main procedures for rejuvenation of the upper third of the face. Standard brow position has been one of the most important criteria of facial aesthetic and has changed over centuries. Given the substantial role of social media to define fashion and beauty nowadays, the frequency of these changes has significantly increased and lead to development of new trends. Although forehead/brow lift are among the earliest cosmetic surgeries that have been described, they have significantly evolved to provide less invasive/more effective method as well as addressing new trends. This chapter reviews new trends in forehead and brow lift.

Gender dysphoria, or the distress caused by the incongruence between a person's assigned and experienced gender, can lead to significant psychosocial sequelae and increased risk of suicide (>40% of this population) and assault (>60% of this population). With an estimated 25 million transgender individuals worldwide and increased access to care for the transgender population, trauma surgeons are more likely to care for patients who completed or are in the process of medical gender transition. As transgender health is rarely taught in medical education, knowledge of the unique health care needs and possible alterations in anatomy is critical to appropriately and optimally treat transgender trauma victims. Considerations of cross-gender hormones and alterations of the craniofacial, laryngeal, chest, and genital systems are offered in this review. Further research on the optimal treatment mechanisms for transgender patients is needed.

Background Gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation. Aim Our objective is to describe the factors influencing patient choice or surgeon recommendation of vulvoplasty and to assess the patient’s satisfaction with this choice. Methods Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. Outcomes We report demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery. Results In total, 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty. 30 Patients either completed or are scheduled for vulvoplasty. Vulvoplasty patients were older and had higher body mass index than those seeking vaginoplasty. The majority (63%) of the patients seeking vulvoplasty chose this surgery despite no contra-indications to vaginoplasty. The remaining patients had risk factors leading the surgeon to recommend vulvoplasty. Of those who completed surgery, 93% were satisfied with the surgery and their decision for vulvoplasty. Clinical Translation Vulvoplasty creates the external appearance of female genitalia without creation of a neovaginal canal; it is associated with high satisfaction and low decision regret. Conclusions This is the first study of factors impacting a patient’s choice of or a surgeon’s recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also is the first reported series of patients undergoing vulvoplasty only. Limitations of this study include its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how we offer vulvoplasty. Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

Facial gender confirmation surgery (FGCS), also popularly known and referred to in the scientific literature as facial feminization surgery (FFS), was previously treated as a collection of aesthetic procedures complementing other aspects of gender-confirming surgery. Recent literature on quality-of-life outcomes following FGCS has supported the substantial impact these procedures have on overall well-being and reduction of psychosocial sequelae in patients. The World Professional Association for Transgender Health Standards of Care, Version 7 (WPATH SOC 7), did not deem FGCS a medical necessity. Based on these new studies, increasing evidence points to the need to include FGCS among medically necessary gender-confirming surgeries, though more-prospective studies are needed. Updates to the WPATH SOC 8 are proposed based on available quality of life studies.

The authors present their grading scale and the outcomes of the largest cohort of top surgery published to date. Application of this grading system can help determine which patients will benefit from a subcutaneous mastectomy with free nipple graft versus a circumareolar technique, with the primary endpoint being need for aesthetic revisions.The authors reviewed their database of transgender males who underwent bilateral mastectomy between 2006 and 2015. Data collected included age, body mass index, American Society of Anesthesiologists class, smoking, diabetes, testosterone use, months of social transition, technique used, postoperative complications, and need for revision. Two techniques were used, circumareolar incision and free nipple graft technique.Between 2006 and 2015, 1686 consecutive mastectomies were performed on 843 patients. Of those, 548 patients were excluded because of inadequate follow-up. Of the 295 included, 109 were treated using a circumareolar incision and 186 were treated using a free nipple graft technique. There was no statistically significant difference in complications between the two groups; however, there was a statistically significant difference in the rate of aesthetic revisions in the grade 2B circumareolar incision group (34 percent versus 8.8 percent).The authors' outcomes are comparable to the literature, and demonstrate that these procedures can safely be performed in an outpatient setting. The authors' grading scale classifies patients and helps the surgeon select a surgical technique. The authors show a statistical difference in rates of aesthetic revisions in Fischer grade 2B patients when a circumareolar incision is selected over a free nipple graft technique.Therapeutic, III.

The treatment of gender dysphoria related to genitourinary anatomy can be effectively treated with phalloplasty. A phalloplasty may include some or all of the following: penile shaft, glans, shaft urethra, perineal urethra, scrotoplasty, vaginectomy, testicular implants, and erectile devices. The literature does not currently support a gold standard for how best to stage these procedures. This article reviews current techniques for phalloplasty staging and proposes that a staged urethral reconstruction is a reliable technique that allows for potential complications to be managed individually, while minimizing the severity of complications and their impact on the outcome of the final reconstruction.

The population of transgender patients seeking gender confirmation surgery for gender dysphoria is increasing in the United States. Facial gender confirmation surgery (FGCS) is one of the treatment modalities patients require and is often a combination of soft tissue and cranio-maxilla-facial procedures. Despite evidence of the efficacy of FGCS, there remains some extant controversies to address, such as reimbursement for these procedures, categorization of aesthetic versus functional surgery, and evaluation of outcomes. This review provides a discussion of these topics, as well as the historical and psychosocial issues specific to transgender patients that surgeons should know when providing FGCS. We provide practice pearls for providing affirming transgender healthcare, illustrative patient clinical vignettes, and a discussion of the Standards of Care of the World Professional Association for Transgender Health to help guide surgeons who are interested in providing FGCS to transgender patients.

Phalloplasty is an exceptionally complicated reconstructive procedure that attempts to create a structure that is penis-like. As patient goals vary widely, it is helpful to think about phalloplasty as a modular set of procedures that can be combined, mixed and matched to meet the needs of each individual patient while also taking into account their anatomy. Each module—but particularly the shaft and penile urethra—can be performed using a variety of techniques. To date, there is no consensus among surgeons regarding the optimum staging of the reconstructive steps. Our primary goal is to outline the most frequently performed and reported options in phallic reconstruction and outline the various considerations that go into choosing a given sequence of procedures for the specific patient. The secondary goal of this article is to describe the complications common to each of those modules and how they interact when combined.

Endocrinologists are at the front line for providing gender-affirming care for transgender patients by managing hormone regiments before and after surgery. This article provides the endocrinologist with an overview of the surgical options for transgender and nonbinary patients considering gender confirmation surgery, including feminizing and masculinizing facial, chest, and genital reconstruction. Discussions of the impact of hormones on surgery, and vice versa, as well as information on surgical decision making are provided to help inform patient education via the endocrinologist.

Most surgeons who are not routinely treating gender dysphoric patients are more likely to see an isolated rhinoplasty consultation rather than a request for full facial gender confirmation surgery (FGCS). Different from other aspects of FGCS, the surgical basis of rhinoplasty is almost the same as for the cisgender population. Despite technical overlap, the care for patients seeking rhinoplasty for the indication of gender dysphoria vastly differs from that for the cisgender population. This review includes comments on gender norms and outline considerations for the preoperative work-up and operative execution as well as a comprehensive literature review.

INTRODUCTION AND OBJECTIVES:For transgender women undergoing gender-affirming vaginoplasty, the creation of the vaginal canal causes disruption of the pelvic floor; furthermore, patients must perfo...

Background A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. Methods This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. Conclusions In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Surgical education requires three things: dedication, mentorship, and exposure. This is true today as it was in 1878 when Dr. William Stewart Halsted travelled through Europe and returned to the United States (U.S.) to lay the ground stone for what would be the modern U.S. residency model. This article is intended to help understand the evolution and current state of the U.S. residency model and is written through the lens of the first author who has trained in both systems. We hope to outline some key differences that we deem particularly interesting. Concrete lessons we can learn from the U.S. system are to abolish favoritism, enroll residents in formal training programs with a set start and finish date, consider implementing midlevel practitioners and establishing a steeper hierarchy within the residency itself. The U.S. model, despite all its own inherent issues, has managed to balance the three ingredients of surgical education: dedication, mentorship, and exposure. Contrarily, in many European countries medical school is followed by years of uncertainty. With demographical and societal changes this deficiency has led to many potential young surgeons turning towards other specialties and industries.

BACKGROUND:Most transgender research focuses on patients who identify within the gender binary of either trans-male or trans-female. This largely omits understanding of the "nonbinary" gender identity as it pertains to surgical care. OBJECTIVES:We sought to describe a single-institution experience of chest-affirming procedures performed in nonbinary patients, including patient characteristics, surgical techniques, practice pearls, and outcomes. METHODS:This was an observational study of nonbinary patients who underwent "chest-affirming surgery" from 2012 to 2017. Demographic and surgical data were collected. A postoperative questionnaire assessing quality of life and body image outcomes was administered. RESULTS:A total of 458 patients with gender dysphoria underwent chest surgery; 58 (13%) patients were nonbinary. All nonbinary patients indicated female sex was assigned at their birth (100%). The most commonly performed procedure was the double incision technique with nipple grafts (72%), followed by the double incision technique without nipple grafts (19%). On a Likert scale, patients reported improved quality of life (4.88, SD ± 0.34), comfort with exercise (4.07, SD ± 0.98), sex life (4.02, SD ± 0.92), and comfort with physical appearance with (4.97, SD ± 0.18) and without clothes (4.69, SD ± 0.47). CONCLUSIONS:Chest surgery for nonbinary patients comprises a considerable proportion of transgender surgery practice, and surgeons who provide affirming care should be familiar with the unique characteristics and treatment options for this population. LEVEL OF EVIDENCE: 4

This article focuses on flap-related complications after creation of a neophallus for transgender individuals. It outlines the most frequently used flaps for this procedure and how flap-related complications can affect the overall outcome of the phalloplasty. With surgeons staging the procedure in different stages, it is important to understand the different strategies and the implication a flap-related complication can have on the end result and how it may be prevented.

To analyze, using 3-dimensional photogrammetric data, midfacial soft tissue and volumetric changes in the cleft maxilla after 1- or 2-piece Le Fort I (LF1) advancement.This was a retrospective study of patients with cleft and maxillary hypoplasia who underwent LF1 advancement. The primary predictor variable was the type of advancement (1 piece vs 2 pieces). Outcome measurements were changes in soft tissue linear measurements (subnasale [Sn], labium superius [LS], and stomion [SO]) and midfacial volume after maxillary advancement.Eleven patients (7 male, 4 female) underwent LF1 advancements (4 underwent 2-piece advancement). The mean maxillary advancement was 6.2 ± 1.7 mm. Soft tissue changes at the Sn, LS, and SO were 5.2 ± 2.0, 5.8 ± 2.5, and 5.2 ± 1.8 mm, respectively. The average volume change was 12.2 ± 5.7 cm(3). The mean ratios of soft tissue change to the amount of maxillary advancement (millimeters per millimeter) at the Sn, LS, and SO were 0.89 ± 0.49, 0.97 ± 0.44, and 0.89 ± 0.34, respectively. Volume increased by 2.1 ± 1.3 cm(3)/mm. Patients undergoing 1-piece advancement had greater mean advancement and greater soft tissue changes at the LS and SO (P.03). After controlling for the amount of advancement, 1-piece LF1 osteotomy showed significantly greater improvements at the LS and SO (P .04).Midface advancement at the LF1 level in patients with cleft consistently expands upper lip soft tissue and midfacial volume. Greater changes at the LS and SO were seen with 1-piece than with 2-piece osteotomy.