The aesthetic items scale: A tool for the evaluation of aesthetic outcome after breast reconstruction

__Background:__ Valid tools to assess aesthetic outcomes after breast reconstructive surgery are scarce. Previously a professional aesthetic assessment scale was introduced, the Aesthetic Items Scale (AIS). We aim to determine if this method is a valid and reliable tool to assess aesthetic outcome after breast reconstructive surgery. __Methods:__ The study population was consenting women who underwent prophylactic mastectomy with subsequent implant-based breast reconstruction. The aesthetic outcome with regard to breast volume, shape, symmetry, scars, and nipple areola complex was rated on a 5-point scale using standardized photographs to give a summed total score. Photographs were evaluated by the patient, 5 plastic surgeons, and 3 mammography nurses. An overall rating of aesthetic outcome on a 1-10 scale was given separately. We determined the intraclass correlation coefficient and assessed interobserver agreement. To assess validity, we calculated the correlation between total score and overall rating of aesthetic outcome. __Results:__ Interobserver reliability was highest between plastic surgeons for the subitem and overall scores and ranged between 0.56 and 0.82. The summed score of the AIS correlates strongly with the overall rating in professionals but not in patients. __Conclusions:__ The AIS is a valid and reliable method for evaluating aesthetic outcome of breast reconstruction by plastic surgeons. The results indicate that patients judge aesthetic outcome differently, taking into account factors that are not represented in the AIS. Professionals can use this method to evaluate surgical results, but other measurements are needed to map satisfaction of the patient with her breasts

Ileal vaginoplasty as vaginal reconstruction in transgender women and patients with disorders of sex development: an international, multicentre, retrospective study on surgical characteristics and outcomes

OBJECTIVE: To describe the surgical outcomes of ileal vaginoplasty in transgender women and patients with disorders of sex development (DSD). PATIENTS AND METHODS: Transgender women and patients with DSD, who underwent ileal vaginoplasty at the VU University Medical Center Amsterdam, University Hospital Trieste, University Hospital Essen, and Belgrade University Hospital, were retrospectively identified. A chart review was performed, recording surgical technique, intraoperative characteristics, complications, and re-operations. RESULTS: We identified a total of 32 patients (27 transgender and five non-transgender), with a median (range) age of 35 (6-63) years. Ileal vaginoplasty was performed as the primary procedure in three and as a revision procedure in the remaining 29. The mean (sd) operative time was 288 (103) min. The procedure was performed laparoscopically (seven patients) or open (25). An ileal 'U-pouch' was created in five patients and a single lumen in 27. Intraoperative complications occurred in two patients (one iatrogenic bladder damage and one intraoperative blood loss necessitating transfusion). The median (range) hospitalisation was 12 (6-30) days. Successful neovaginal reconstruction was achieved in all. The mean (sd) achieved neovaginal depth was 13.2 (3.1) cm. The median (range) clinical follow-up was 35 (3-159) months. In one patient a recto-neovaginal fistula occurred, which lead to temporary ileostomy. Introital stenosis occurred in four patients (12.5%). CONCLUSION: Ileal vaginoplasty can be performed with few intra- and postoperative complications. It appears to have similar complication rates when compared to sigmoid vaginoplasty. It now seems to be used predominantly for revision procedures

Symptomatic Neovaginal Candidiasis in Transgender Women After Penile Inversion Vaginoplasty: A Clinical Case Series of Five Consecutive Patients

Background: Vaginoplasty is performed as gender-affirming surgery in transgender women. While multiple surgical techniques exist for this goal, penile inversion vaginoplasty is performed most frequently. Neovaginal symptoms may impede sexual functioning after surgery. Methods: A total of five consecutive patients with symptoms and positive swabs for neovaginal candida infection were described. Results: All patients presented with white-colored neovaginal discharge and some with neovaginal itching and/or malodor. All were topically treated with miconazole, which resulted in symptom clearance. Follow-up swabs were negative for candida. Conclusions: To our knowledge, this is the first report on (symptomatic) candidiasis of the penile-inverted neovagina

An external validation of a novel predictive algorithm for male nipple areolar positioning: an improvement to current practice through a multicenter endeavor

The correct positioning of nipple-areolar complexes (NAC) during gender-affirming mastectomies remains a particular challenge. Recently, a Dutch two-step algorithm was proposed predicting the most ideal NAC-position derived from a large cisgender male cohort. We aimed to externally validate this algorithm in a Belgian cohort. The Belgian validation cohort consisted of cisgender men. Based on patient-specific anthropometry, the algorithm predicts nipple-nipple distance (NN) and sternal-notch-to-nipple distance (SNN). Predictions were externally validated using the performance measures: R2-value, means squared error (MSE) and mean absolute percentage error (MAPE). Additionally, data were collected from a Belgian and Dutch cohort of transgender men having undergone mastectomy with free nipple grafts. The observed and predicted NN and SNN were compared and the inter-center variability was assessed. A total of 51 Belgian cisgender and 25 transgender men were included, as well as 150 Dutch cisgender and 96 transgender men. Respectively, the performance measures (R2-value, MSE and MAPE) for NN were 0.315, 2.35 (95%CI:0-6.9), 4.9% (95%CI:3.8-6.1) and 0.423, 1.51 (95%CI:0-4.02), 4.73%(95%CI:3.7-5.7) for SNN. When applying the algorithm to both transgender cohorts, the predicted SNN was larger in both Dutch (17.1measured(±1.7) vs. 18.7predicted(±1.4), p= <0.001) and Belgian (16.2measured(±1.8) vs. 18.4predicted(±1.5), p= <0.001) cohorts, whereas NN was too long in the Belgian (22.0measured(±2.6) vs. 21.2predicted(±1.6), p = 0.025) and too short in the Dutch cohort (19.8measured(±1.8) vs. 20.7predicted(±1.9), p = 0.001). Both models performed well in external validation. This indicates that this two-step algorithm provides a reproducible and accurate clinical tool in determining the most ideal patient-tailored NAC-position in transgender men seeking gender-affirming chest surgery

A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty

Objectives: To assess surgical outcomes of penile prosthesis implantation in transgender men who underwent phalloplasty. Patients and Methods: Transgender men who underwent penile prosthesis implantation after phalloplasty between January 1989 and September 2018 were retrospectively identified. A chart study was performed recording patient demographics, perioperative complications, and reoperations. Results: A total of 32 patients were identified: 22 underwent free radial forearm flap, 5 anterolateral thigh, 4 anterolateral thigh/free radial forearm flap, and 1 fibular flap phalloplasty. The median age at prosthesis implantation was 36 (range 21-59) years, the mean BMI 25.9 ± 4.0 kg/m2. At first implantation, 16 inflatable (AMS Dynaflex (n = 13), AMS Ambicor (n = 3)) and 16 malleable (Coloplast genesis (n = 14), AMS Spectra (n = 2)) prostheses were placed. Of these, 5 (16%) were removed/replaced because of infection, 2 (6%) because of leakage, 2 because of extrusion, 2 because of dislocation, 2 because of dysfunction, and 1 (3%) because of pain. The postoperative course was completely uneventful in 10 (31.3%) patients. Of all implanted prostheses, including revision procedures (n = 45), 21 (44%) were surgically replaced or removed. Conclusion: Prosthesis explantation, replacement, or revision surgery occurs frequently after penile prosthesis implantation. Patients need to be well-informed preoperatively on these complication rates

An external validation of a novel predictive algorithm for male nipple areolar positioning: an improvement to current practice through a multicenter endeavor

The correct positioning of nipple-areolar complexes (NAC) during gender-affirming mastectomies remains a particular challenge. Recently, a Dutch two-step algorithm was proposed predicting the most ideal NAC-position derived from a large cisgender male cohort. We aimed to externally validate this algorithm in a Belgian cohort. The Belgian validation cohort consisted of cisgender men. Based on patient-specific anthropometry, the algorithm predicts nipple-nipple distance (NN) and sternal-notch-to-nipple distance (SNN). Predictions were externally validated using the performance measures: R 2-value, means squared error (MSE) and mean absolute percentage error (MAPE). Additionally, data were collected from a Belgian and Dutch cohort of transgender men having undergone mastectomy with free nipple grafts. The observed and predicted NN and SNN were compared and the inter-center variability was assessed. A total of 51 Belgian cisgender and 25 transgender men were included, as well as 150 Dutch cisgender and 96 transgender men. Respectively, the performance measures (R 2-value, MSE and MAPE) for NN were 0.315, 2.35 (95%CI:0–6.9), 4.9% (95%CI:3.8–6.1) and 0.423, 1.51 (95%CI:0–4.02), 4.73%(95%CI:3.7–5.7) for SNN. When applying the algorithm to both transgender cohorts, the predicted SNN was larger in both Dutch (17.1measured(±1.7) vs. 18.7predicted(±1.4), p= <0.001) and Belgian (16.2measured(±1.8) vs. 18.4predicted(±1.5), p= <0.001) cohorts, whereas NN was too long in the Belgian (22.0measured(±2.6) vs. 21.2predicted(±1.6), p = 0.025) and too short in the Dutch cohort (19.8measured(±1.8) vs. 20.7predicted(±1.9), p = 0.001). Both models performed well in external validation. This indicates that this two-step algorithm provides a reproducible and accurate clinical tool in determining the most ideal patient-tailored NAC-position in transgender men seeking gender-affirming chest surgery

Development of a Decision Aid for Genital Gender-Affirming Surgery in Transmen

Background: As genital gender-affirming surgery (GAS) is a demanding and life-changing intervention, transmen should be able to make choices about the surgical treatment based on outcomes that are most important to them, while taking into consideration the concomitant risks involved. Aim: Develop a decision aid (DA) for genital surgery in transmen (DA-GST) that can assist both transmen and health care professionals (HCPs) in making a well-informed decision about the surgical treatment. Methods: A qualitative focus group study was performed. 5 Focus groups were organized with both HCPs and transmen. These were led by an independent professional moderator. Data collected during these focus groups were analyzed to provide content for the DA. Outcomes: To develop content for a DA-GST. Results: Data collected during the focus groups related to the treatment options, information deemed relevant by transmen, and the arguments for or against each treatment option. Collected items were divided into the following themes: outcome, quality of life, environment, sexuality, and beliefs. Clinical Implications: The tool will be useful in assisting both transmen and HCPs in the shared decision-making process regarding genital GAS by exploring which domains are most relevant for each specific individual. Strengths & Limitations: This DA was developed according to an iterative participatory design approach to fit the needs of both transmen and HCPs. Issues that transmen find important and relevant pertaining to genital GAS were translated into arguments that were incorporated in the DA-GST. The study is limited by the group that had participated. Not all arguments for or against specific surgical options may be covered by the DA-GST. Conclusion: An online DA was developed to support transmen with their decision-making process concerning all surgical options for removal of reproductive organs and genital GAS. Özer M, Pigot GL, Bouman M‐B, et al. Development of a Decision Aid for Genital Gender-Affirming Surgery in Transmen. J Sex Med 2018;XX:XXX–XXX