Outcomes of masculinizing gender-affirming surgeries
Authors:   , Elfering Lian 
Published: April 2023

SUMMARY

INTRODUCTION
Gender-affirming medical interventions contribute substantially to improvement of
long-term comfort in transgender individuals. Currently, there are many developments
in society, and also the technical aspects of gender-affirming surgical techniques
develops. Still, there is a lack of solid knowledge on both the clinical and patientreported
outcomes of these treatments. Therefore, in this thesis we investigated
clinical and patient-reported outcomes after different types of surgical interventions
in transmasculine persons, an umbrella term that refers to people who were assigned
female at birth but identify with masculinity, with the ultimate aim to improve this care.

PART I CHEST SURGERY
In chapter 2, we compared the safety of the mastectomy as a stand-alone procedure
with that of the mastectomy performed in a combined procedure with total
laparoscopic hysterectomy and bilateral salpingo-oophorectomy. The effect of
the order of the procedures in the combined session on safety outcomes was also
assessed. We found that the combined procedure was associated with an increased risk of postoperative hematoma (11.3%) and reoperations (7.5% )of the chest. The order of procedures in the combined group did not have significant effect on the occurrence of postoperative hematoma of the chest (p = 0.856), and reoperation (p = 0.689).

In chapter 3, the surgical indications and outcomes of masculinizing mastectomies
were assessed. Clinical and self-reported outcomes after mastectomy were assessed and surgical decision-making with regard to the operation technique was evaluated. The results showed that
surgical decision-making in this cohort matched closely with the decision algorithm of
Monstrey et al. based on breast size, ptosis and skin elasticity. Despite being performed
in a group with favourable preoperative breast quality, concentric circular mastectomy
showed a higher rate of secondary corrections, and lower cosmetic satisfaction compared with the inframammary skin resection group. Based on these results, surgeons may want to choose more frequently to perform an inframammary skin resection in case of doubt. Besides, preoperative counselling for concentric circular mastectomy candidates should moderate the individual’s expectations.

The effectiveness of gender-affirming surgery is best evaluated based on patientreported
outcomes (PROs). To date, no valid patient-reported outcome measures
(PROMs) for the transgender population exists. In chapter 4 we used the BODY-Q,
a questionnaire newly designed to measure outcomes in weight loss and/or body
contouring surgery, to measure the health-related quality of life and satisfaction with
the chest in transmasculine person after undergoing subcutaneous mastectomy. The present findings
indicate that chest and nipple satisfaction differences in transmasculine person undergoing mastectomy can be detected using the BODY-Q chest module.

PART II GENITAL SURGERY
Gender-affirming surgery in transmasculine persons can include genital reconstruction
(‘genital surgery’). Reconstruction of the phallus (phalloplasty) is meant to create a
sensate and cosmetically acceptable phallus. In chapter 5 the safety and effectiveness of pre-expansion before phalloplasty was assessed. Thirty-three transmasculine persons were included and underwent phalloplasty, of whom 15 (51.5%) underwent flap pre-expansion. A chart review was
performed to obtain patient demographics and expander-related. We concluded that donor-site expansion before phalloplasty was associated with high rates of expander-related complications and expander failure. Primary closure of the donor site was achieved in less than a third of the cases. Primary closure may potentially lead to smaller scars and greater satisfaction; however we concluded that the potential advantages of pre-expansion do not outweigh the high risk of complications and lack of success.

The study described in chapter 6 addressed another important outcome of phalloplasty;
the sensitivity. This study evaluated experienced tactile and erotic sensation of the neophallus in transmasculine persons and investigated how this experienced sensation
was related to objective tactile sensitivity.