Skip to main content

Advertisement

SpringerLink
Log in

Preoperative and Postoperative Considerations in Gender-Affirming Surgery

  • Male Sexual Dysfunction and Disorders (AW Pastuszak and NK Gupta, Section Editors)
  • Published:
Current Sexual Health Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The review is aimed at determining critical factors in the preoperative and postoperative care of transgender patients undergoing gender-affirming surgery. General and procedure-specific considerations are summarized to improve the longitudinal perioperative care of transgender patients.

Recent Findings

Surgical providers should follow World Professional Association for Transgender Health (WPATH) guidelines regarding eligibility for surgery. Important elements in preoperative evaluation include mental health screening, fertility discussion, and adjustment of hormone replacement therapy. Postoperative considerations include proper cancer screening, mental health support, appropriate outcomes assessment, and awareness of potential procedure specific complications.

Summary

Proper perioperative care for transgender patients undergoing gender-affirming surgery involves a multidisciplinary approach to healthcare to create a comprehensive treatment environment at an institutional level.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major Importance

  1. Black DW, Grant JE. Gender dysphoria. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, D.C.: American Psychiatric Association; 2014.

    Google Scholar 

  2. Flores AR, Herman JL, Gates GJ, Brown T. How many adults identify as transgender in the United States. 2016. https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf. Accessed May 25, 2018.

  3. Collin L, Reisner SL, Tangpricha V, Goodman M. Prevalence of transgender depends on the “case” definition: a systematic review. J Sex Med. 2016;13(4):613–26. https://doi.org/10.1016/j.jsxm.2016.02.001.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. Eur Psychiatry. 2015;30(6):807–15. https://doi.org/10.1016/j.eurpsy.2015.04.005.

    Article  PubMed  CAS  Google Scholar 

  5. • Papadopulos NA, Zavlin D, Lelle JD, Herschbach P, Henrich G, Kovacs L, et al. Male-to-female sex reassignment surgery using the combined technique leads to increased quality of life in a prospective study. Plast Reconstr Surg. 2017;140(2):286–94. https://doi.org/10.1097/PRS.0000000000003529. This study analyzed quality of life outcomes in patients that underwent vaginoplasty and demonstrated significant improvement in multiple domains.

    Article  PubMed  CAS  Google Scholar 

  6. Weigert R, Frison E, Sessiecq Q, Al Mutairi K, Casoli V. Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plast Reconstr Surg. 2013;132(6):1421–9. https://doi.org/10.1097/01.prs.0000434415.70711.49.

    Article  PubMed  CAS  Google Scholar 

  7. Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC, 2nd et al. Temporal trends in gender-affirming surgery among transgender patients in the United States. JAMA Surg. 2018. https://doi.org/10.1001/jamasurg.2017.6231.

  8. •• The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender nonconforming people. 7th Version. 2011. https://www.wpath.org/media/cms/Documents/Web Transfer/SOC/Standards of Care V7–2011 WPATH.pdf. Accessed April 10, 2018. The World Professional Association for Transgender Health Standards of Care outlines the critical guidliens in the medical and surgical care of transgender patients.

  9. Berli JU, Knudson G, Fraser L, Tangpricha V, Ettner R, Ettner FM, et al. What surgeons need to know about gender confirmation surgery when providing care for transgender individuals: a review. JAMA Surg. 2017;152(4):394–400. https://doi.org/10.1001/jamasurg.2016.5549.

    Article  PubMed  Google Scholar 

  10. Center of Excellence for Transgender Health. How to accurately capture data on trans clients. 2007. http://www.transhealth.ucsf.edu/trans?page=lib-trans-count. Accessed April 12, 2018.

  11. Deutsch MB, Green J, Keatley J, Mayer G, Hastings J, Hall AM, et al. Electronic medical records and the transgender patient: recommendations from the World Professional Association for Transgender Health EMR Working Group. J Am Med Inform Assoc. 2013;20(4):700–3. https://doi.org/10.1136/amiajnl-2012-001472.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Green J, McGowan S, Levi J, Wallbank R, Whittle S. Recommendations from the WPATH consensus process for revision of the DSM diagnosis of gender identity disorders: implications for human rights. Int. J. Transgenderism. 2011;13(1):1–4.

    Article  Google Scholar 

  13. Callahan EJ, Sitkin N, Ton H, Eidson-Ton WS, Weckstein J, Latimore D. Introducing sexual orientation and gender identity into the electronic health record: one academic health center’s experience. Acad Med. 2015;90(2):154–60. https://doi.org/10.1097/ACM.0000000000000467.

    Article  PubMed  Google Scholar 

  14. Morrison SD, Chong HJ, Dy GW, Grant DW, Wilson SC, Brower JP, et al. Educational exposure to transgender patient care in plastic surgery training. Plast Reconstr Surg. 2016;138(4):944–53. https://doi.org/10.1097/PRS.0000000000002559.

    Article  PubMed  CAS  Google Scholar 

  15. Smith JR, Morrison SD, Gottlieb LJ. Are surgical residents prepared for fellowship training in gender-confirming surgery? J Sex Med. 2017;14(8):1066–7. https://doi.org/10.1016/j.jsxm.2017.05.017.

    Article  PubMed  Google Scholar 

  16. Schechter LS, Cohen M. Gender confirmation surgery: a new frontier in plastic surgery education. Plast Reconstr Surg. 2016;138(4):784e–5e. https://doi.org/10.1097/PRS.0000000000002594.

    Article  PubMed  CAS  Google Scholar 

  17. Davey A, Bouman WP, Arcelus J, Meyer C. Social support and psychological well-being in gender dysphoria: a comparison of patients with matched controls. J Sex Med. 2014;11(12):2976–85. https://doi.org/10.1111/jsm.12681.

    Article  PubMed  Google Scholar 

  18. Factor RJ, Rothblum ED. A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence. J LGBT Health Res. 2007;3(3):11–30.

    Article  PubMed  Google Scholar 

  19. Green J. Transsexual surgery may be covered by Medicare. LGBT Health. 2014;1(4):256–8. https://doi.org/10.1089/lgbt.2014.0076.

    Article  PubMed  Google Scholar 

  20. Baker KE. The future of transgender coverage. N Engl J Med. 2017;376(19):1801–4. https://doi.org/10.1056/NEJMp1702427.

    Article  PubMed  Google Scholar 

  21. • Padula WV, Heru S, Campbell JD. Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: a cost-effectiveness analysis. J Gen Intern Med. 2016;31(4):394–401. https://doi.org/10.1007/s11606-015-3529-6. This study analyzed the implications of health insurance coverage for transgender patients and demonstrated that coverage is affordable and cost-effective.

    Article  PubMed  Google Scholar 

  22. •• Weissler JM, Chang BL, Carney MJ, Rengifo D, Messa CA, Sarwer DB, et al. Gender-affirming surgery in persons with gender dysphoria. Plast Reconstr Surg. 2018;141(3):388e–96e. https://doi.org/10.1097/PRS.0000000000004123. This study outlines the current state of gender-affirming surgery and summarizes the relevant guidelines and recommendations for the perioperative care of transgender patients.

    Article  PubMed  CAS  Google Scholar 

  23. Lee CN, Ubel PA, Deal AM, Blizard LB, Sepucha KR, Ollila DW, et al. How informed is the decision about breast reconstruction after mastectomy?: a prospective, cross-sectional study. Ann Surg. 2016;264(6):1103–9. https://doi.org/10.1097/SLA.0000000000001561.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Lee CN, Deal AM, Huh R, Ubel PA, Liu YJ, Blizard L, et al. Quality of patient decisions about breast reconstruction after mastectomy. JAMA Surg. 2017;152(8):741–8. https://doi.org/10.1001/jamasurg.2017.0977.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Egekeze N, Dubin J, Williams K, Bernhardt M. The age of OrthoInfo: a randomized controlled trial evaluating patient comprehension of informed consent. J Bone Joint Surg Am. 2016;98(19):e81. https://doi.org/10.2106/JBJS.15.01291.

    Article  PubMed  Google Scholar 

  26. Serpico V, Liepert AE, Boucher K, Fouts DL, Anderson L, Pell J, et al. The effect of Previsit education in breast cancer patients: a study of a shared-decision-making tool. Am Surg. 2016;82(3):259–65.

    PubMed  Google Scholar 

  27. Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005;35(1):89–99.

    Article  PubMed  Google Scholar 

  28. Selvaggi G, Giordano S. The role of mental health professionals in gender reassignment surgeries: unjust discrimination or responsible care? Aesthet Plast Surg. 2014;38(6):1177–83. https://doi.org/10.1007/s00266-014-0409-0.

    Article  Google Scholar 

  29. Dhejne C, Lichtenstein P, Boman M, Johansson AL, Langstrom N, Landen M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One. 2011;6(2):e16885. https://doi.org/10.1371/journal.pone.0016885.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  30. Dhejne C, Van Vlerken R, Heylens G, Arcelus J. Mental health and gender dysphoria: a review of the literature. Int Rev Psychiatry. 2016;28(1):44–57. https://doi.org/10.3109/09540261.2015.1115753.

    Article  PubMed  Google Scholar 

  31. De Roo C, Tilleman K, T’Sjoen G, De Sutter P. Fertility options in transgender people. Int Rev Psychiatry. 2016;28(1):112–9. https://doi.org/10.3109/09540261.2015.1084275.

    Article  PubMed  Google Scholar 

  32. De Sutter P. Reproductive options for transpeople: recommendations for revision of the WPATH’s standards of care. Int. J. Transgenderism. 2009;11(3):183–5.

    Article  Google Scholar 

  33. T'Sjoen G, Van Caenegem E, Wierckx K. Transgenderism and reproduction. Curr Opin Endocrinol Diabetes Obes. 2013;20(6):575–9. https://doi.org/10.1097/01.med.0000436184.42554.b7.

    Article  PubMed  Google Scholar 

  34. Salim A, Metz E, Constant JS, Gurjala A, Yokoo K, Tong WMY. Does previous breast reduction affect the outcome of gender-affirming subcutaneous mastectomy? Ann Plast Surg. 2018;80(5S Suppl 5):S279–S84. https://doi.org/10.1097/SAP.0000000000001414.

    Article  PubMed  CAS  Google Scholar 

  35. Hage JJ, Bloem JJ. Chest wall contouring for female-to-male transsexuals: Amsterdam experience. Ann Plast Surg. 1995;34(1):59–66.

    Article  PubMed  CAS  Google Scholar 

  36. • Bluebond-Langner R, Berli JU, Sabino J, Chopra K, Singh D, Fischer B. Top surgery in transgender men: how far can you push the envelope? Plast Reconstr Surg. 2017;139(4):873e–82e. https://doi.org/10.1097/PRS.0000000000003225. This study describes current techniques in top surgery for transgender men and provides useful algorithms for preoperative planning and decision-making.

    Article  PubMed  CAS  Google Scholar 

  37. Silva-Santisteban A, Raymond HF, Salazar X, Villayzan J, Leon S, McFarland W, et al. Understanding the HIV/AIDS epidemic in transgender women of Lima, Peru: results from a sero-epidemiologic study using respondent driven sampling. AIDS Behav. 2012;16(4):872–81. https://doi.org/10.1007/s10461-011-0053-5.

    Article  PubMed  Google Scholar 

  38. Wilson E, Rapues J, Jin H, Raymond HF. The use and correlates of illicit silicone or “fillers” in a population-based sample of transwomen, San Francisco, 2013. J Sex Med. 2014;11(7):1717–24.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Bartsich S, Wu JK. Silicon emboli syndrome: a sequela of clandestine liquid silicone injections. A case report and review of the literature. J Plast Reconstr Aesthet Surg. 2010;63(1):e1–3. https://doi.org/10.1016/j.bjps.2009.04.004.

    Article  PubMed  Google Scholar 

  40. Hage JJ, Kanhai RC, Oen AL, van Diest PJ, Karim RB. The devastating outcome of massive subcutaneous injection of highly viscous fluids in male-to-female transsexuals. Plast Reconstr Surg. 2001;107(3):734–41.

    Article  PubMed  CAS  Google Scholar 

  41. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696–704. https://doi.org/10.1542/peds.2013-2958.

    Article  PubMed  Google Scholar 

  42. Bouman MB, van der Sluis WB, Buncamper ME, Ozer M, Mullender MG, Meijerink WJ. Primary total laparoscopic sigmoid vaginoplasty in transgender women with Penoscrotal hypoplasia: a prospective cohort study of surgical outcomes and follow-up of 42 patients. Plast Reconstr Surg. 2016;138(4):614e–23e. https://doi.org/10.1097/PRS.0000000000002549.

    Article  PubMed  CAS  Google Scholar 

  43. de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8(8):2276–83. https://doi.org/10.1111/j.1743-6109.2010.01943.x.

    Article  PubMed  Google Scholar 

  44. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–54. https://doi.org/10.1210/jc.2009-0345.

    Article  PubMed  CAS  Google Scholar 

  45. U.S. Food and Drug Administration. Silicone gel-filled breast implants. 2018. https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm063871.htm. Accessed April 25, 2018.

  46. Pusic AL, Lemaine V, Klassen AF, Scott AM, Cano SJ. Patient-reported outcome measures in plastic surgery: use and interpretation in evidence-based medicine. Plast Reconstr Surg. 2011;127(3):1361–7. https://doi.org/10.1097/PRS.0b013e3182063276.

    Article  PubMed  CAS  Google Scholar 

  47. •• Andreasson M, Georgas K, Elander A, Selvaggi G. Patient-reported outcome measures used in gender confirmation surgery: a systematic review. Plast Reconstr Surg. 2018;141(4):1026–39. https://doi.org/10.1097/PRS.0000000000004254. This study reviews the currently available patient-reported outcome measures in gender-affirming surgery and importantly finds a signficiant needs for validated questionnaires.

    Article  PubMed  CAS  Google Scholar 

  48. Weyers S, Villeirs G, Vanherreweghe E, Verstraelen H, Monstrey S, Van den Broecke R, et al. Mammography and breast sonography in transsexual women. Eur J Radiol. 2010;74(3):508–13. https://doi.org/10.1016/j.ejrad.2009.03.018.

    Article  PubMed  CAS  Google Scholar 

  49. Maglione KD, Margolies L, Jaffer S, Szabo J, Schmidt H, Weltz C, et al. Breast cancer in male-to-female transsexuals: use of breast imaging for detection. AJR Am J Roentgenol. 2014;203(6):W735–40. https://doi.org/10.2214/AJR.14.12723.

    Article  PubMed  Google Scholar 

  50. Bazzi AR, Whorms DS, King DS, Potter J. Adherence to mammography screening guidelines among transgender persons and sexual minority women. Am J Public Health. 2015;105(11):2356–8. https://doi.org/10.2105/AJPH.2015.302851.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Moss SM, Wale C, Smith R, Evans A, Cuckle H, Duffy SW. Effect of mammographic screening from age 40 years on breast cancer mortality in the UK Age trial at 17 years’ follow-up: a randomised controlled trial. Lancet Oncol. 2015;16(9):1123–32. https://doi.org/10.1016/S1470-2045(15)00128-X.

    Article  PubMed  Google Scholar 

  52. Gooren L, Morgentaler A. Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia. 2014;46(10):1156–60. https://doi.org/10.1111/and.12208.

    Article  PubMed  CAS  Google Scholar 

  53. Hoffman MA, DeWolf WC, Morgentaler A. Is low serum free testosterone a marker for high grade prostate cancer? J Urol. 2000;163(3):824–7.

    Article  PubMed  CAS  Google Scholar 

  54. National Cancer Institute. Prostate cancer screening (PDQ®)—health professional version. 2018. https://www.cancer.gov/types/prostate/hp/prostate-screening-pdq. Accessed April 12, 2018.

  55. Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist’s and urologist’s perspective. Acta Obstet Gynecol Scand. 2015;94(6):563–7. https://doi.org/10.1111/aogs.12618.

    Article  PubMed  Google Scholar 

  56. Weyers S, De Sutter P, Hoebeke S, Monstrey G, G TS, Verstraelen H, et al. Gynaecological aspects of the treatment and follow-up of transsexual men and women. Facts Views Vis Obgyn. 2010;2(1):35–54.

    PubMed  PubMed Central  CAS  Google Scholar 

  57. Gatos KC. A literature review of cervical cancer screening in transgender men. Nurs Womens Health. 2018;22(1):52–62. https://doi.org/10.1016/j.nwh.2017.12.008.

    Article  PubMed  Google Scholar 

  58. Potter J, Peitzmeier SM, Bernstein I, Reisner SL, Alizaga NM, Agenor M, et al. Cervical cancer screening for patients on the female-to-male spectrum: a narrative review and guide for clinicians. J Gen Intern Med. 2015;30(12):1857–64. https://doi.org/10.1007/s11606-015-3462-8.

    Article  PubMed  PubMed Central  Google Scholar 

  59. MacDonald T, Noel-Weiss J, West D, Walks M, Biener M, Kibbe A, et al. Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: a qualitative study. BMC Pregnancy Childbirth. 2016;16:106. https://doi.org/10.1186/s12884-016-0907-y.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Patzelt M, Zarubova L, Klener P, Barta J, Benkova K, Brandejsova A, et al. Anaplastic large-cell lymphoma associated with breast implants: a case report of a transgender female. Aesthet Plast Surg. 2018;42(2):451–5. https://doi.org/10.1007/s00266-017-1012-y.

    Article  Google Scholar 

  61. Clemens MW, Brody GS, Mahabir RC, Miranda RN. How to diagnose and treat breast implant-associated anaplastic large cell lymphoma. Plast Reconstr Surg. 2018;141(4):586e–99e. https://doi.org/10.1097/PRS.0000000000004262.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA

    Ara A. Salibian, Nathan Levitt, Lee C. Zhao & Rachel Bluebond-Langner

  2. Department of Urology, New York University Langone Health, 222 41st Street, 11th Floor, New York, NY, 10017, USA

    Lee C. Zhao

Authors
  1. Ara A. Salibian
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nathan Levitt
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lee C. Zhao
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rachel Bluebond-Langner
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lee C. Zhao.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Male Sexual Dysfunction and Disorders

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Salibian, A.A., Levitt, N., Zhao, L.C. et al. Preoperative and Postoperative Considerations in Gender-Affirming Surgery. Curr Sex Health Rep 10, 186–195 (2018). https://doi.org/10.1007/s11930-018-0159-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11930-018-0159-0

Keywords

Search

Navigation