Atlas of Operative Techniques in Gender Affirmation Surgery

As transgender and gender non-binary individuals are a growing demographic, the number of patients seeking gender confirmation surgery is increasing. Atlas of Operative Techniques in Gender Affirmation Surgery is a highly illustrated and practical guide to the different types of gender affirmation surgery. Top and bottom surgeries are illustrated include facial feminization, mastectomy, techniques in phalloplasty, metoidioplasty, different approaches to vaginoplasty, management of complications of gender affirming surgery, and more.This comprehensive textbook is a must-have guide for individuals interested in gender affirmation surgery to master the complex operative procedures that this field demands and to refine their techniques.

• Guides the user step-by-step through both feminizing and masculinizing procedures
• Features high-resolution illustrations of techniques to enhance visual understanding
• Includes recent surgical updates that include comparative advantages and disadvantages of each surgery

• Language: English
• Publisher: Academic Press
• Release date: Apr 18, 2023
• ISBN: 9780323985574

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Chapter 1: Developing a transgender health center of excellence: The Mount Sinai model

Anish Kumar; Joshua D. Safer    Icahn School of Medicine at Mount Sinai, Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, United States

Abstract

Dedicated centers of excellence have emerged as a mechanism to provide comprehensive, high-quality care within specific clinical areas or to certain populations. Transgender and gender diverse (TGD) populations patients often have unique health needs and may find it difficult to receive appropriate care given the lack of training regarding transgender healthcare among providers and availability of culturally sensitive care. Centers for excellence can fill this gap by leveraging expertise across multi-disciplinary teams to provide comprehensive care to TGD patients. In this chapter, we explore the structure and function of a transgender center of excellence, using the Mount Sinai Center for Transgender Medicine and Surgery as model.

Keywords

Transgender; Gender diverse; Center of excellence

Introduction

According to estimates, 1.4 million people in the United States identify as transgender and gender diverse (TGD) [1]. These patients may have unique health needs compared to their cisgender counterparts, which may be related to several etiologies [2]. Minority stress connected to discrimination is associated with an elevated incidence of mental health morbidity, substance use, and sexually transmitted infection [3]. Other health needs often include expertise in the gender-affirming medical and surgical interventions typically used to better align the body with the gender identity of TGD people.

Accessing high-quality, culturally sensitive health care can be difficult for TGD people, given the lack of training in transgender healthcare at both the medical school and residency levels [4,5]. Further, many TGD people may not feel comfortable seeking gender-affirming healthcare, based on negative previous experiences with clinicians. Additionally, TGD patients are more likely to face economic instability with corresponding lack of access to comprehensive insurance [6].

The unique health needs of TGD people, along with the relative difficulty in accessing quality gender-affirming healthcare, may be addressed in part with transgender health centers of excellence [6,7]. Centers of excellence are designed to be specialized department service lines within larger healthcare institutions that focus on providing high quality care in a certain clinical area or to a specific population. Such centers are generally designed with a multidisciplinary perspective in order to leverage high levels of expertise across different subject areas to deliver optimal care.

The Mount Sinai Center for Transgender Medicine and Surgery (CTMS) in New York, NY, was established in 2016. The mission of CTMS includes both (1) the consolidation of care for TGD patients within the greater Mount Sinai Hospital System in one specific program and (2) the modeling of structure for a center of excellence for TGD health. In line with these goals, CTMS provides a unified point of contact for all patients seeking TGD-related care [8]. Given the wide range of clinical expertise required for TGD healthcare, navigating a large, complex health system can be challenging. The multidisciplinary nature of CTMS allows patients to access pediatric/adolescent, adult medical, behavioral, and gender-affirming surgical care through one contact point, instead of seeking care that is siloed across different teams, without a unifying center of operations.

CTMS brings together resources from medicine, pediatrics, surgery, social work, chaplaincy/spiritual care, and behavioral health to guide patients through care. Fig. 1 provides a high-level overview of how patients begin and navigate these services at CTMS. The interdisciplinary model begins from the onset of care, when a patient approaches CTMS for services and their needs are evaluated by a team of navigators who help direct them into one of three major clinical workflows: (1) gender-affirming medical care, (2) gender-affirming surgical procedures, and (3) gender-affirming pediatric services.

Fig. 1

Fig. 1 Overview of three major clinical workflows for patients starting care at Mount Sinai CTMS.

After review of the model and operations in 2018, CTMS aimed to foster a more comprehensive, interdisciplinary care (IDC) approach to inpatient treatment of TGD patients, specifically those undergoing surgical procedures. This new framework was developed by adapting a model used in existing transplant and bariatric programs that had previously demonstrated successful approaches to providing IDC [8].

Overview of services

Pediatric and adolescent health services

Mount Sinai CTMS provides TGD-related care to pediatric and adolescent patients and their families. Minors and their guardians begin care with CTMS by completing an intake with a mental health provider who conducts an evaluation to determine the best course of action for their care. The provider ultimately provides the family with advice, connects them with ongoing mental health or family support, or refers them to the medical teams for puberty blocker or hormone therapy.

Established patients who have been under longitudinal care at CTMS can have surgeries if they are old enough and meet all requirements for the operation. Typically, these patients are shifted to adult care teams, with the narrow exception of transmasculine patients who might get masculinizing chest surgeries as young as age 16 and remain with their pediatric/adolescent health provider.

Adult medical services

Mount Sinai CTMS provides comprehensive care with both services specifically related to TGD health as well as standard clinical care. CTMS maintains a network of primary care providers across the Mount Sinai Health System network. Since the primary care clinicians at CTMS have experience working with TGD patients, they can provide expertly informed care. Further, providing services connected to a dedicated TGD health center may allay the concerns of patients who are reluctant to seek out health services for fear of discrimination or misinformed understanding of their healthcare needs.

Endocrinology

CTMS’s trained endocrinologists work with medical teams at CTMS to develop plans for gender-affirming hormone therapy (GAHT). GAHT is a medical intervention that is often used to help align a patient’s appearance with their gender identity. Feminizing hormone therapy aims to change the shape of a patient’s face and body as well as alter hair growth patterns. Masculinizing hormone therapy similarly alters body and face shape as well as hair growth in addition to stopping menstruation and deepening the pitch of the patient’s voice. Endocrinologists at CTMS are available for other endocrinology-related care (thyroid health, bone health, diabetes, etc.) and have expertise in managing such conditions in concordance with gender-affirming hormone replacement therapy.

Gynecology

Gynecology services are available at CTMS, with focus on providing care for transgender men as well as pre- and postoperative care for various genital modification procedures. Clinicians in this service are also well trained in a range of minimally invasive gynecological procedures, as well as vaginectomies and other gender-affirming surgeries.

Surgical services

Gender-affirming surgical procedures can be categorized into transfeminine and transmasculine operations. For both categories, there are a wide range of surgical procedures that modify primary and secondary sex characteristics. It is important to remember that the experience of each TGD person is different so that care must be individualized. Patients seek varying levels of customization when considering surgical-based operations: some opt for genital based procedures over those that modify secondary sex characteristics and vice versa, while others may seek both. Some procedures, like phalloplasties, are commonly performed in conjunction with other procedures. The exact parameters of care are discussed in detail with the patient and surgery team during initial consultations and goal planning. Fig. 2 provides a detailed overview of the flow through the surgical process at CTMS.

Fig. 2

Fig. 2 Interdisciplinary approaches to care for TGD patients receiving gender-affirming surgical procedures at Mount Sinai CTMS.

Transfeminine surgeries

Table 1 lists commonly performed transfeminine surgical procedures. These procedures can be split into three broad categories: breast augmentation, facial feminization, and genital reconstruction. Breast augmentation involves the addition of implants (often fat or tissue from other parts of the body) to the chest to make it more typically feminine appearing. Facial feminization procedures include an array of different procedures that contour or shape different parts of the head and neck, depending on the patient’s goals and desires, as well as the recommendations of their surgeon. Transfeminine genital reconstruction procedures involve orchiectomy and/or surgical construction of a vagina, clitoris, and labia.

Table 1

Transmasculine surgeries

Table 2 lists commonly performed transfeminine surgical procedures. Like transfeminine surgeries, these procedures can be split into three broad categories: chest reconstruction, reproductive organ removal, and genital reconstruction surgeries. Chest reconstruction surgeries involve the removal of breast and fat tissue as well as optional repositioning of the nipple to render a typically masculine appearing chest. Reproductive organ removal procedures include oophorectomies and hysterectomies, the removal of the ovaries and uterus, respectively. Transmasculine genital reconstruction includes two major options for procedures to reconstruct a penis. In a metoidioplasty procedure, surgeons construct a small phallus from clitoral tissue, as opposed to creating a phallus from skin grafted from other areas of the body in a phalloplasty. Both reconstructive surgeries can be conducted in conjunction with related procedures including vaginectomy, urethral lengthening, scrotoplasty, and/or penile prosthesis placement.

Table 2

a A procedure that is often conducted in conjunction with genital reconstruction surgeries.

Peri-operative services

A robust preoperative assessment and care plan is essential to providing high quality care that minimizes risk of complications and negative outcomes. As part of this process, CTMS medical teams complete an assessment of patients before scheduled surgeries and address specific risks as well as plan postoperative care. Further, behavioral health specialists and spiritual care specialists engage with patients to conduct assessments regarding readiness for procedures and ensure that they have adequate access to resources they may need postoperatively. Concurrently, social work teams assess the paraclinical needs of the patient and ensure that there is an appropriate plan for resource access, transportation, and secondary care after the operation [8]. Such readiness evaluations that consider psychosocial criteria are rarely prioritized regarding gender-affirming surgeries, but have shown a high potential in predicting surgical outcomes [9].

For both transmasculine and transfeminine procedures, there are an array of operations that are ambulatory along with others that require inpatient stays ranging from 1 to 7 days. For the latter, patients recover in the hospital under the supervision of medicine and surgical teams who can manage postoperative complications. Daily interdisciplinary clinical rounds are conducted during a patient’s postoperative stay [8]. Rounds are led by the same medical teams that conducted the patients’ preoperative health and risk assessment. The goal of these rounds is to facilitate communication among members of all teams involved in direct and indirect clinical care, including social work, nursing, behavioral health, nutrition, surgery, and spiritual care teams.

Robust postoperative care includes a detailed plan for discharge and transition of care to secondary support services. To ensure that quality care would continue outside of the hospital, CTMS selected a skilled care facility (SNF) and visiting nurse service as a primary location for continued care following discharge. Staff members at these services were given comprehensive training in postoperative management of patients following various gender-affirming surgical procedures to facilitate rehabilitation and minimize complications. Additionally, caregivers are provided with specific instructions and relevant resources for supporting patients during recovery periods until they can return to function.

Following the immediate recovery period, long-term care becomes important, especially in terms of reducing risk for complications and managing any that arise. Primary care and medical teams at CTMS provide longitudinal care following surgical procedures and ensure that there is routine monitoring and screening of surgically modified anatomy. This is especially important in terms of prophylaxis, monitoring and treatment of sexually transmitted infections as well as screening for certain types of cancer (breast, cervical, prostate, etc.).

Behavioral health services

Mount Sinai CTMS includes a behavioral health team staffed by psychiatrists, clinical psychologists and social workers who provide a range of services related to mental health. These clinicians have expertise in mood disorders, schizophrenia, eating disorders, posttraumatic stress disorder, and substance use disorders as well as experience managing the unique mental health needs of TGD patients.

By integrating behavioral health support within CTMS, patients have ready access to mental healthcare at any point in their healthcare relationship with the institution. Behavioral health specialists can perform presurgical evaluations as well as intake assessments for pediatric and adolescent patients for select services enumerated by practice guidelines, including the WPATH Standards of Care. The team also periodically facilitates support groups for patients who may benefit from engaging with other patients in moderated discussion and peer support. Clinicians also serve as a triage point to connect patients and caregivers with longitudinal behavioral health support both within the Mount Sinai health system and elsewhere.

Ancillary support

A comprehensive, interdisciplinary approach to TGD care should include a robust ancillary support service. The socio-political context has a significant impact on the burden of health disparities faced by TGD people, a situation that is exacerbated by consistent patterns of marginalization and reduced access to social resources [5,10]. Consequently, addressing the social determinants of health of TGD patients is inextricable to direct clinical care. For these reasons, Mount Sinai CTMS tightly integrates social workers into the clinical care workflows. Team members sort through insurance protocols and provide patients with an overview of services and serve as navigators through their care at CTMS.

As part of the transition to an IDC approach to inpatient care for surgical patients in 2018, CTMS examined the surgical preoperative criteria evaluation schema typically used to assess whether patients are ready for gender-affirming operations. The CTMS team modified the eligibility criteria delineated in the SOC 7 to be more patient-centered to reduce barriers to eligibility for gender-affirming surgeries. As part of this modification, they also augmented the criteria to consider access to social resources, given its importance to long-term outcome of many surgeries. Table 3 lists the criteria that used by the social work team to evaluate readiness for surgery [9].

Table 3

In addition to guiding patients through their care process, the CTMS team also connects patients with community organizations and resources, including those offering legal support. Coordination with the Mount Sinai Medical-Legal Partnership allows patients to access free, on-site services that assist with any issues pertaining to discriminatory denial of healthcare or other social benefits as well as guidance with legal name, pronoun, or other gender marker changes.

Though precise measurements are difficult to estimate, it is known that TGD people experience disproportionate rates of interpersonal violence and trauma. While behavioral health services can be effective for coping with the effects of these experiences, such issues play a central role in the well-being and health of TGD patients. In partnership with the New York-based nonprofit organization Crime Victims Treatment Center (CVTC), Mount Sinai CTMS offers the Transgender Healing and Resilience Initiative for Survivors of Violence (THRIV) to offer dedicated support for TGD individuals ages 13 and older who have faced interpersonal violence or trauma. Services, which include individual and group therapy, are tailored to meet the needs of each patient, and include both psychological education to process past traumas as well as skills training to protect oneself from future threats of violence, abuse, and trafficking.

Education

An important component of supporting access to high quality care for transgender patients includes investing in the education and training of clinicians to help them foster the skills to carry such work forward. CTMS also holds regular, live surgery courses to promote education of transgender-specific surgeries and to share expertise and best practices with other surgeons. Faculty also coordinate a freely accessible, online course regarding transgender healthcare for primary care physicians.

CTMS is connected to the Mount Sinai Health System and the Icahn School of Medicine at Mount Sinai, making it a popular choice through which Mount Sinai trainees rotate and gain valuable experience regarding transgender healthcare and gender-affirming procedures as well as pursue formal fellowships in specific areas of care. Placements at CTMS are core, mandatory rotations for residents of the Mount Sinai Plastic Surgery Residency and for the Mount Sinai Endocrinology Fellowship Program. Rotations are also core components of the training programs for fellows in both the Mount Sinai LGBTQ Medicine and the Mount Sinai Urology residency programs.

CTMS developed a Transgender Psychiatry Fellowship Program for physicians who have completed an Adult General Psychiatry residency and are licensed to practice in New York state. Through this program, fellows hone their skills in managing the mental health and behavioral health of transgender patients in both outpatient and inpatient settings through comprehensive curriculum encompassing psychotherapy, psychopharmacology, and the support of patients as they navigate gender-affirming procedures. A gender-affirming surgical fellowship is also available to board eligible plastic surgeons, allowing trainees to learn how to perform various gender-affirming surgical procedures and refine their surgical care for gender diverse patients. In addition, a one year reconstructive and transgender fellowship accredited through the Society of Genitourinary Reconstructive Surgeons (GURS) has been developed for the training of board eligible urologists to learn feminizing and masculinizing genital reconstructive surgery including vaginoplasty, metoidioplasty, phalloplasty, and management of urological complications of transgender surgery.

Research

Traditionally, there has been a dearth of biomedical and clinical research focused on the healthcare and health outcomes of transgender patients and much of the existing literature is focused on elucidating disparities in disease burden. However, the ability to offer a wide range of gender-affirming clinical interventions, both hormone therapy and surgery, is possible only with important research in the field. CTMS continues to invest in similar research to both optimize existing care as well as develop novel therapies and interventions for transgender patients.

There is a wide range of research at CTMS, spanning clinical outcomes of various procedures, social analyses of access and gaps in care, as well as studies examining or advocating for changes in curricular development and professional training of clinicians regarding transgender health and patients. As quality analysis and patient satisfaction with procedures is such an important area of research, CTMS created a database which allows patients to consent to provide de-identified data from their services to be used in prospective research projects. Researchers within the center have utilized quality surveys of patients who underwent transfeminine surgeries to identify prospective areas of improvements, with the goal of disseminating these findings and supporting recommendations to clinicians for integration into their medical and surgical care.

References

[1] Safer J.D., Tangpricha V. Care of transgender persons. N Engl J Med. 2019;381:2451–2460. doi:10.1056/NEJMcp1903650.

[2] Tollinche L.E., Walters C.B., Radix A., Long M., Galante L., Goldstein Z.G., Kapinos Y., Yeoh C. The perioperative care of the transgender patient. Anesth Anal. 2018;127:359–366. doi:10.1213/ANE.0000000000003371.

[3] Safer J.D. Research gaps in medical treatment of transgender/nonbinary people. J Clin Invest. 2021;131:142029. doi:10.1172/JCI142029.

[4] Korpaisarn S., Safer J.D. Gaps in transgender medical education among healthcare providers: a major barrier to care for transgender persons. Rev Endocr Metab Disord. 2018;19:271–275. doi:10.1007/s11154-018-9452-5.

[5] Safer J.D., Coleman E., Feldman J., Garofalo R., Hembree W., Radix A., Sevelius J. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23:168–171. doi:10.1097/MED.0000000000000227.

[6] Wolf-Gould C. From margins to mainstream: creating a rural-based center of excellence in transgender health for upstate, New York. In: S P Fernandez C., Corbie-Smith G., eds. Leading community based changes in the culture of health in the US—experiences in developing the team and impacting the community. IntechOpen; 2021:doi:10.5772/intechopen.98453.

[7] Klein P., Narasimhan S., Safer J.D. The Boston Medical Center experience: an achievable model for the delivery of transgender medical care at an academic medical center. Transgender Health. 2018;3:136–140. doi:10.1089/trgh.2017.0054.

[8] Shin S.J., Pang J.H., Tiersten L., Jorge N., Hirschmann J., Kutsy P., Ashley K., Stein L., Safer J.D., Barnett B. The Mount Sinai interdisciplinary approach to perioperative care improved the patient experience for transgender individuals. Transgender Health. 2021;doi:10.1089/trgh.2020.0134.

[9] Lichtenstein M., Stein L., Connolly E., Goldstein Z.G., Martinson T., Tiersten L., Shin S.J., Pang J.H., Safer J.D. The Mount Sinai patient-centered preoperative criteria meant to optimize outcomes are less of a barrier to care than WPATH SOC 7 criteria before transgender-specific surgery. Transgender Health. 2020;5:166–172. doi:10.1089/trgh.2019.0066.

[10] Hardacker C., Ducheny K., Houlberg M., eds. Transgender and gender nonconfirming health and aging. 1st ed. Berlin Heidelberg, New York, NY: Springer; 2018.

Chapter 2: Satisfaction and outcomes after genitourinary gender affirmation surgery

Krystal A. DePortoa; Melissa M. Pohb; Polina Reyblata; Amanda C. Chia    a Department of Urology, Kaiser Permanente Southern California, Los Angeles, CA, United States

b Department of Plastic Surgery, Kaiser Permanente Southern California, Los Angeles, CA, United States

Abstract

Gender-affirming surgery (GAS) encompasses a heterogeneous group of surgical procedures and techniques. Recognition of the lack of standardization is imperative when assessing surgical, functional, aesthetic, sexual, and psychosocial outcomes in addition to complications. Objective, physician-reported outcomes are limited to physical examinations, measurements of anatomical and physiological parameters, and calculations of complication rates. In order to develop best practice techniques, these objective measures need to be linked to patient-reported outcomes. Surgeons must appropriately identify patient goals regarding genital appearance, functionality, and desired sexual outcomes prior to formulating a surgical treatment plan through shared decision-making. Patients must thoroughly understand the available options and potential complications in order to best achieve their transition goals.

Keywords

Gender-affirming surgery; Outcomes

Introduction

Approximately 25 million people identify as transgender worldwide, including more than 1 million individuals in the United States [1–7]. Gender dysphoria often motivates transgender individuals to seek gender-affirming procedures. One option is genitourinary gender-affirming surgery (GAS), with the goals of better aligning one’s genitourinary anatomy with that of their gender identity and improving quality of life [5–11].

GAS encompasses a heterogeneous group of surgical procedures and techniques. Recognition of the lack of standardization is imperative when assessing surgical, functional, aesthetic, sexual, and psychosocial outcomes in addition to complications [5,12]. Objective, physician-reported outcomes are limited to physical examinations, measurements of anatomical and physiological parameters, and calculations of complication rates [13]. In order to develop best practice techniques, these objective measures need to be linked to patient-reported outcomes. Unfortunately, there is a paucity of validated questionnaires for use in transgender individuals after undergoing GAS [11,13,14]. In this chapter, we will review the reported objective and subjective outcome measures for genitourinary GAS. For feminizing surgeries, this can include orchiectomy, penectomy, partial urethrectomy, zero- or shallow-depth vaginoplasty (also termed vulvoplasty), or full-depth vaginoplasty. Masculinizing surgery can include hysterectomy with or without oophorectomy, vaginectomy, metoidioplasty, phalloplasty, glansplasty, scrotoplasty, perineal reconstruction, testicular prosthesis insertion, and penile prosthesis insertion.

Feminizing surgery

Orchiectomy

Gender-affirming orchiectomy was historically the first step in the surgical transition process; however, it is now more commonly performed on individuals not interested in vaginoplasty or as a staged approach to transition [15,16]. The relative simplicity of the procedure, low complication rates, and increased awareness and acceptance by the surgical community all make orchiectomy more accessible to patients. In addition to the visual and physical relief that patients may experience after orchiectomy, it also has a direct physiological impact on reducing the need for antiandrogen therapy [15–17]. In their series of 43 patients who underwent orchiectomy, van der Sluis et al. reported a 9% complication rate at an average follow-up of 7.6 (0.4–77.6) months. In our experience, complication rates after simple bilateral orchiectomy seem lower than those reported in the literature. Overall, the procedure is well-tolerated and followed by an expeditious recovery [15].

Vulvoplasty/zero- or shallow-depth vaginoplasty

The decision to undergo creation of a neovagina is a critical branch point for individuals perusing feminizing GAS. Vulvoplasty, which is also referred to as zero-depth or shallow-depth vaginoplasty, is an excellent option for individuals who do not wish to have vaginal penetrative intercourse or commit to long-term neovaginal dilation [18–21]. Vulvoplasty typically involves penectomy, orchiectomy, clitoroplasty, creation of the labia majora and the labia minora, and a shortened urethra that allows for voiding in a seated position. In addition to personal preference, indications for vulvoplasty may include prior pelvic radiation, radical prostatectomy, rectal surgery, and physical limitations such as the lack of hand dexterity required for neovaginal dilation [20–24].

In a series of 17 patients who underwent this type of reconstruction, the overall postoperative complication rate was 35% [19]. Complications consisted of three cases of minor wound dehiscence that resolved with conservative measures, two cases of urethral meatal stenosis, one case of remnant corpus spongiosum that required additional resection, and one case of postoperative urinary tract infection (UTI) [19]. Regarding sexual outcomes, Jiang et al. surveyed 16 patients after vulvoplasty at a mean follow-up of 8.7 months. They found that 58% of sexually active patients were able to achieve orgasms [21]. The overall patient satisfaction with vulvoplasty is reported to be 93% in the literature [21].

Full-depth vaginoplasty

Feminizing genitoplasty was first reported in the medical literature in 1930 when Dr. Kurt Warnekros operated on Lili Elbe [25,26]. Full-depth vaginoplasty typically includes penectomy, orchiectomy, partial urethrectomy, clitoroplasty, vulvoplasty, and creation of a neovaginal canal [27,28]. The goal of feminizing genitoplasty is to create a perigenital complex that is cosmetically appealing and sensate, with a neovaginal canal capable of receptive penetration [5,27,28]. There are several surgical techniques that can be used to line the neovagina, including genital skin flaps and grafts, nongenital skin grafts, pedicled intestinal flaps, and peritoneal flaps [5,28–30]. The most common approach is penile inversion vaginoplasty, which involves the use of a penile skin flap in conjunction with scrotal skin graft to line the neovagina