Gender Affirming Surgery
Number: 0615
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses gender affirming surgery.
Note: Some plans may cover gender affirming procedures in addition to the following policy. Please check the specific benefit plan documents.
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Medical Necessity
Aetna considers gender affirming surgery medically necessary when criteria for each of the following procedures is met:
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Requirements for Breast Removal
- Signed letter from a qualified mental health professional (see Appendix) assessing the transgender/gender diverse individual’s readiness for physical treatment; and
- Documentation of marked and sustained gender dysphoria (see Appendix); and
- Other possible causes of apparent gender incongruence have been excluded; and
- Mental and physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed; and
- Capacity to consent for the specific physical treatment; and
- For members less than 18 years of age, completion of one year of testosterone treatment, unless hormone therapy is not desired or medically contraindicated; and
- Risk factors associated with breast cancer have been assessed.
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Requirements for Breast Augmentation (Implants/Lipofilling)
- Signed letter from a qualified mental health professional (see Appendix) assessing the transgender/gender diverse individual’s readiness for physical treatments; and
- Documentation of marked and sustained gender dysphoria (see Appendix); and
- Other possible causes of apparent gender incongruence have been excluded; and
- Mental and physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed; and
- Capacity to consent for the specific physical treatment; and
- Completion of six months of feminizing hormone therapy (12 months for adolescents less than 18 years of age) prior to breast augmentation surgery, unless hormone therapy is not desired or medically contraindicated); and
- Risk factors associated with breast cancer have been assessed.
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Requirements for Gonadectomy (Hysterectomy and Oophorectomy or Orchiectomy)
- Signed letter from a qualified mental health professional (see Appendix) assessing the transgender/gender diverse individual’s readiness for physical treatments; and
- Documentation of marked and sustained gender dysphoria (see Appendix); and
- Other possible causes of apparent gender incongruence have been excluded; and
- Mental and physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed; and
- Capacity to consent for the specific physical treatment; and
- Six months of continuous hormone therapy as appropriate to the member's gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated.
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Requirements for Genital Reconstructive Surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, placement of a testicular prosthesis and erectile prosthesis, penectomy, vaginoplasty, labiaplasty, clitoroplasty and electrolysis or laser hair removal sessions for skin graft preparation for genital surgery)
- Signed letter from a qualified mental health professional (see Appendix) assessing the transgender/gender diverse individual’s readiness for physical treatments; and
- Documentation of marked and sustained gender dysphoria (see Appendix); and
- Other possible causes of apparent gender incongruence have been excluded; and
- Mental and physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed; and
- Capacity to consent for the specific physical treatment; and
- Six months of continuous hormone therapy as appropriate to the member’s gender goals (12 months for adolescents less than 18 years of age), unless hormone therapy is not desired or medically contraindicated.
Note on gender specific services for the transgender community: Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:
- Breast cancer screening may be medically necessary for transmasculine persons who have not undergone chest masculinization surgery;
- Prostate cancer screening may be medically necessary for transfeminine persons who have retained their prostate.
Aetna considers reversal of gender affirming surgery (performing surgical procedures to return anatomy to that of the sex assigned at birth) medically necessary for persons who regret their gender-related surgical intervention, where applicable requirements for gender affirming surgery listed above are met.
Aetna considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria (see CPB 0501 - Gonadotropin-Releasing Hormone Analogs and Antagonists).
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Not Medically Necessary
Aetna considers more than one breast augmentation not medically necessary. This does not include the medically necessary replacement of breast implants (see CPB 0142 - Breast Implant Removal).
Aetna considers nerve grafting for gender affirming breast surgery not medically necessary.Aetna considers the following procedures that may be performed as a component of a gender transition as not medically necessary and cosmetic (not an all-inclusive list) (see also CPB 0031 - Cosmetic Surgery):
- Hair removal (e.g., electrolysis, laser hair removal) (Exception: A limited number of electrolysis or laser hair removal sessions are considered medically necessary for skin graft preparation for genital surgery)
- Tracheal shave (reduction thyroid chondroplasty)
- Facial Gender Affirming Procedures, including:
- Brow (reduction, augmentation, lift)
- Hair line advancement and/or hair transplant
- Facelift/mid-face lift (following alteration of the underlying skeletal structures) (platysmaplasty)
- Blepharoplasty (lipofilling)
- Rhinoplasty (+/- fillers)
- Cheek (implant, lipofilling)
- Lip (upper lip shortening, lip augmentation)
- Lower jaw (reduction of mandibular angle, augmentation)
- Chin reshaping (osteoplastic, alloplastic (implant-based))
- Chondrolaryngoplasty (also known as Adam's apple reduction, thyroid cartilage reduction, or tracheal shave)
- Vocal cord surgery
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Body contouring gender affirming surgery, including (not an all-inclusive list):
- Liposuction/lipofilling/implants (pectoral, hip, gluteal, calf).
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Experimental, Investigational, or Unproven
Aetna considers the use of facial recognition neural networks experimental, investigational, or unproven for facial feminization surgery because the effectiveness of this approach has not been established.
Related Policies
Background
The International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) are the diagnostic classifications and criteria manuals used in the United States. Notwithstanding, the World Professional Association of Transgender Health Standard of Care 8th edition (WPATH SOC8) states: “While Gender Dysphoria (GD) is still considered a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) of the American Psychiatric Association. Gender incongruence is no longer seen as pathological or a mental disorder in the world health community. Gender Incongruence is recognized as a condition in the International Classification of Diseases and Related Health Problems, 11th Version of the World Health Organization (ICD-11). Because of historical and current stigma, TGD people can experience distress or dysphoria that may be addressed with various gender-affirming treatment options. While nomenclature is subject to change and new terminology and classifications may be adopted by various health organizations or administrative bodies, the medical necessity of treatment and care is clearly recognized for the many people who experience dissonance between their sex assigned at birth and their gender identity.”
Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.
Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).
The criterion noted above for some types of genital surgeries is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2022).
It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 6 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.
In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.
Nakatsuka (2012) noted that the third versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively. On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which gender-affirming hormones may be given. A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters. After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with gender-affirming hormone or puberty-delaying hormone to prevent developing undesired sex characters. These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school.
Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints. Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment. Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high. For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs. Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations. For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty. Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known. All patients considering treatment need counseling and medical monitoring.
Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health. These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving gender-affirming hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York. Through 2009, a total 192 MTF and 50 FTM transgender persons were seen. These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability. Mental health and psychiatric problems were inversely correlated with age at presentation. The prevalence of gender affirming surgery was low (31 % for MTF). The number of persons seeking treatment has increased substantially in recent years. Gender-affirming hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages. The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency. The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers. They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.
Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism. Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.
Note on Breast Reduction/Mastectomy and Nipple Reconstruction
The CPT codes for mastectomy (CPT codes 19303) are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male (transmasculine) gender affirmation surgery. CPT 2020 states that “Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either for treatment or prevention of breast cancer.” CPT 2020 also states that "Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved.
Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast. Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed. A full-thickness skin graft is taken from the right groin to reconstruct the areola. The right groin donor site is closed primarily in layers.”
The AMA vignette for CPT code 19318 (reduction mammaplasty) clarifies that this CPT code includes the work that is necessary to reposition and reshape the nipple to create an aesthetically pleasing result, as is necessary in female to male breast reduction. "The physician reduces the size of the breast, removing wedges of skin and breast tissue from a female patient. The physician makes a circular skin incision above the nipple, in the position to which the nipple will be elevated. Another skin incision is made around the circumference of the nipple. Two incisions are made from the circular cut above the nipple to the fold beneath the breast, one on either side of the nipple, creating a keyhole shaped skin and breast incision. Wedges of skin and breast tissue are removed until the desired size is achieved. Bleeding vessels may be ligated or cauterized. The physician elevates the nipple and its pedicle of subcutaneous tissue to its new position and sutures the nipple pedicle with layered closure. The remaining incision is repaired with layered closure" (EncoderPro, 2019). CPT code 19350 does not describe the work that that is being done, because that code describes the actual construction of a new nipple. Code 19350 is a CCI “incidental to” edit to code 19318, and, accordingly, the services of code 19350 are included in code 19318. Similarly, graft codes, such as code 15200 (full thickness skin graft) and 15877 (liposuction), are CCI “incidental to” edits to code 19318, and, accordingly, the services of graft codes, such as 15200, and liposuction codes, such as 15877, are included in code 19318.
Vulvoplasty Versus Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women
Jiang and colleagues (2018) noted that 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. These investigators described the factors influencing patient choice or surgeon recommendation of vulvoplasty (creation of the external appearance of female genitalia without creation of a neovaginal canal) and evaluated the patient's satisfaction with this choice. 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. These investigators reported 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. A total of 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 (BMI) than those seeking vaginoplasty. The majority (63 %) of the patients seeking vulvoplasty chose this surgery despite no contraindications 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. The authors concluded that this was 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 was the first reported series of patients undergoing vulvoplasty only.
Drawbacks of this study included its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how vulvoplasty was offered. 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.
Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment Surgery
Seyed-Forootan and colleagues (2018) stated that plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells. These researchers compared the results of amnion grafts with amnion seeded with autograft fibroblasts. Over 8 years, these investigators compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction; 16 patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding. The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years. Patients were followed-up from 30 months to 8 years (mean of 36 ± 4) after surgery. The depth of the vaginas for group A was 14 to 16 and 13 to 16 cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B. These researchers only had 2 cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina; 75 % of patients had sexual experience and of those, 93.7 % in group A and 87.5% in group B expressed satisfaction. The authors concluded that the creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7 % of patients had satisfaction with sexual intercourse. They stated that amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a 2-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded. Level of Evidence = IV. These preliminary findings need to be validated by well-designed studies.
Pitch-Raising Surgery in Transfeminine Persons
Van Damme and colleagues (2017) reviewed the evidence of the effectiveness of pitch-raising surgery performed in male-to-female transsexuals. These investigators carried out a search for studies in PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and the references in retrieved manuscripts, using as keywords "transsexual" or "transgender" combined with terms related to voice surgery. They included 8 studies using cricothyroid approximation, 6 studies using anterior glottal web formation, and 6 studies using other surgery types or a combination of surgical techniques, leading to 20 studies in total. Objectively, a substantial rise in post-operative fundamental frequency was identified. Perceptually, mainly laryngeal web formation appeared risky for decreasing voice quality. The majority of patients appeared satisfied with the outcome. However, none of the studies used a control group and randomization process. The authors concluded that future research needs to investigate long-term effects of pitch-raising surgery using a stronger study design.
Azul and associates (2017) evaluated the currently available discursive and empirical data relating to those aspects of trans-masculine people's vocal situations that are not primarily gender-related, and identified restrictions to voice function that have been observed in this population, and made suggestions for future voice research and clinical practice. These researchers conducted a comprehensive review of the voice literature. Publications were identified by searching 6 electronic databases and bibliographies of relevant articles. A total of 22 publications met inclusion criteria. Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in trans-masculine people. The quality of the evidence was appraised. The extent and quality of studies investigating trans-masculine people's voice function was found to be limited. There was mixed evidence to suggest that trans-masculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality. The authors concluded that more research into the different factors and practices affecting trans-masculine people's voice function that took account of a range of parameters of voice function and considered participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.
Facial Feminization Surgery
Raffaini and colleagues (2016) stated that gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth. The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender affirmation surgery, which is, in part, an irreversible change of sexual identity. Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation. Facial feminization surgery can include forehead re-modeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures. These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling. A total of 33 patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures. Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs. Most facial feminization surgery procedures could be safely completed in 6 months, barring complications. All patients showed excellent cosmetic results and were satisfied with their procedures. Both frontal and profile views achieved a loss of masculine features. The authors concluded that patient satisfaction following facial feminization surgery was high; they stated that the reduction of gender dysphoria had psychological and social benefits and significantly affected patient outcome. The level of evidence of this study was IV.
Morrison and associates (2018) noted that facial feminization surgery encompasses a broad range of cranio-maxillofacial surgical procedures designed to change masculine facial features into feminine features. The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone desiring feminization of the face. Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately 1 in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed. These researchers appraised the current facial feminization surgery literature. They carried out a comprehensive literature search of the Medline, PubMed, and Embase databases was conducted for studies published through October 2014 with multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. A total of 15 articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports. Articles covered a variety of facial feminization procedures. A total of 1,121 patients underwent facial feminization surgery, with 7 complications reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. The authors concluded that facial feminization surgery appeared to be safe and satisfactory for patients. These researchers stated that further studies are needed to better compare different techniques to more robustly establish best practices; prospective studies and patient-reported outcomes are needed to establish quality-of-life (QOL) outcomes for patients.
In a systematic review, Gorbea et al (2021) provided a portrait of gender affirmation surgery (GAS) insurance coverage across the U.S., with attention to procedures of the head and neck. State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the U.S. were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined. Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17 %); 13 states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy; 92 % of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100 % of the commercial policies reviewed; 93 % discussed coverage of FGAS, but 51 % considered these procedures cosmetic. Thyroid chondroplasty (20 %) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13 % of the medical policies reviewed. The authors concluded that while certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers. Level of Evidence = V.
Hohman and Teixeira (2022) stated that with respect to gender affirmation procedures for the face, the majority of interventions will occur in patients transitioning from male to female, i.e., transgender women. While there are slightly more transgender women than transgender men in the population (33 % transgender women, 29 % transgender men, 35 % non-binary, 3 % cross-dressers, according to the USTS), the reason that more females require surgery than males is that testosterone therapy typically produces enough changes in secondary sex characteristics of the face (growth of facial hair, thickening of the skin, increase in frontal bossing, lowering of the voice, etc.) that surgery is not necessary . In some cases, placement of implants or fat transfer can increase volume in the lower 1/3 of the face and contribute to masculinization. Still, the primary area of focus for facial feminization is generally the upper 1/3. Feminization of the upper 1/3 of the face often requires several techniques to be applied in combination: The advancement of the hairline, hair transplantation, brow-lifting, and reduction of frontal bossing or "frontal cranioplasty". While the advancement of a scalp flap, hair transplant, and pretrichial brow-lifting are commonly employed cosmetic surgery interventions, frontal cranioplasty bears special consideration. Several methods of reducing the brow's prominence are often described as type 1, 2, and 3 frontal cranioplasties. Type 1 cranioplasty reduces the supra-orbital ridge's protrusion, usually using a drill, including decreasing the thickness of the anterior table of the frontal sinus. This technique is the simplest, but it is only effective in patients with either a very thick anterior frontal sinus table or an absent pneumatized frontal sinus. Type 2 cranioplasty involves augmentation of the forehead's convexity using bone cement or methyl methacrylate in addition to a reduction of the supra-orbital ridge with a drill. Type 3 cranioplasty is advocated by many prominent facial feminization surgeons and consists of removal of the anterior table of the frontal sinus, thinning of the bone flap, and replacement of that bone onto the frontal sinus but in a more recessed position, in addition to a reduction of the remainder of the supra-orbital ridge. An alternative to removal and recession of the frontal sinus's anterior table is to thin the bone with a drill and then fracture it in a controlled fashion to produce the desired contour, which is also performed routinely by some authors.
Forehead Feminization Cranioplasty
Eggerstedt and colleagues (2020) stated that forehead feminization cranioplasty (FFC) is an important component of gender-affirming surgery and has become increasingly popular in recent years. However, there is little objective evidence for the procedure's safety and clinical impact via patient-reported outcome measures (PROMs). In a systematic review, these researchers determined what complications are observed following FFC, the relative frequency of complications by surgical technique, and what impact the procedure has on patient's QOL. They carried out database searches in PubMed/Medline, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO. The search terms included variations of forehead setback/FFC. Both controlled vocabularies (i.e., MeSH and CINAHL's Suggested Subject Terms) and keywords in the title or abstract fields were searched. Two independent reviewers screened the titles and abstracts of all articles; and 2 independent surgeon reviewers examined the full text of all included articles, and relevant data points were extracted. Main outcomes and measures included complications and complication rate observed following FFC. Additional outcome measures were the approach used, concurrent procedures carried out, and the use and findings of a PROM. A total of 10 articles describing FFC were included, entailing 673 patients. The overall pooled complication rate was 1.3 %; PROMs were used in 50 % of studies, with no standardization among studies. The authors concluded that complications following FFC were rare and infrequently required reoperation. Moreover, these researchers stated that further studies into standardized and validated PROMs in facial feminization patients are needed. Level of Evidence = III.
Hand Feminization and Masculinization
Lee and colleagues (2021) noted that anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria. Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands. These researchers examined the anatomical features that define feminine and masculine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand; and adapted established aesthetic hand techniques for gender affirming care. They carried out a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of feminine or masculine hands, hand treatments related to gender affirmation, and articles related to techniques for hand feminization and masculinization in the non-transgender population. From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search. There is currently no medical literature specifically examining the surgical or non-surgical options for hand gender affirmation. The available techniques for gender affirming procedures discussed in this paper were appropriated from those more commonly used for hand rejuvenation. The authors concluded that there is very little evidence addressing the options for transgender individuals seeking gender affirming procedures of the hand. These researchers stated that although established procedures used for hand rejuvenation may be employed in gender affirming care, further study is needed to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs. Level of Evidence = III.
Peritoneal Pull-Through Technique Vaginoplasty in Neovagina Construction in Gender-Affirming Surgery
Tay and Lo (2022) reviewed the application, effectiveness and outcomes of a novel surgical technique, peritoneal pull-through technique vaginoplasty, in gender-affirming surgery. Specific outcome parameters included healing time, depth of cavity achieved,) alleviation of dysphoria, and morbidity of the surgery. These researchers carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PROSPERO registration obtained before commencement. A search was performed in OVID Medline, Embase, Willey Online Library and PubMed. Specialty-related journals, grey literature and reference lists of relevant articles were manually searched. From 476 potentially relevant articles, 12 articles were analyzed; and the publications were all level 4 or level 5 evidence. Healing times were poorly reported or often not mentioned. A total of 8 authors reported neovagina cavity depth of at least 13 cm and good patient satisfaction. Alleviation of dysphoria was not discussed by any of the publications and only 6reported complications. Average follow-up ranged from 6 weeks to 14.8 months. The authors concluded that the use of peritoneal pull-through vaginoplasty in gender-affirming surgery is promising and novel; however, there is a paucity of data. These investigators stated that further research and longer-term data are needed to examine the safety and effectiveness of this technique including stabilization of vaginal depth, later morbidity and complications. Patients seeking this surgery overseas should be informed of the potential difficulties they may face.
Urethral Complications and Outcomes in Transgender Men
Hu et al (2022) noted that urologic problems, such as urethral fistulas and strictures, are among the most frequent complications following phalloplasty. Although many studies have reported successful phalloplasty and urethral reconstruction with reliable outcomes in transgender men; so far, no method has become standardized. These researchers examined the reports on urological complications and outcomes in transgender men with respect to various types of urethral reconstruction. They carried out a comprehensive literature search of PubMed, Scopus, and Google Scholar databases for studies related to phalloplasty in transsexuals. Data on various phallic urethral techniques, urethral complications, and outcomes were collected and analyzed using the random-effects model. A total of 21 studies (1,566 patients) were included: 8 studies (1,061 patients) on "tube-in-tube", 9 studies (273 patients) on "prelaminated flap, and 6 studies (221 patients) on "second flap". Compared with the tube-in-tube technique, the pre-laminated flap was associated with a significantly higher urethral stricture/stenosis rate; however, there was no difference between the pre-laminated flap and the 2nd flap techniques. For all phalloplasty patients, the pooled rate of urethral fistula or stenosis was 48.9 %, the rate of the ability to void while standing was 91.5 %, occurrence rate of tactile or erogenous sensation was 88 %, the prosthesis complication rate was 27.9 %, and patient-reported satisfactory outcome rate was 90.5 %. The authors concluded that urethral reconstruction with a pre-laminated flap was associated with a significantly higher urethral stricture rate and increased need of revision surgery compared with that observed using a skin flap. Overall, most patients were able to void while standing and were satisfied with the outcomes.
Facial Gender Affirming Procedures
Oles et al (2022) stated that rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. Although some procedures have been carried out for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research. These investigators carried out the 1st systematic review of all available GAS publications across all procedures to evaluate both outcomes reported in the literature as well as the methods used for outcome assessment. This review was conducted following PRISMA guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data were pooled to examine currently reported complication, satisfaction, and other outcome rates. Overall, 15,186 references were identified, 4,162 papers advanced to abstract review, and 1,826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. Although 59.1 % of non-genitoplasty papers addressed PCOs in some form, only 4.3 % used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers. The authors concluded that this review represented the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offered a foundation for discussions regarding current methodologic limitations and what dimensions must be included in assessing surgical success. These investigators have assembled a comprehensive list of outcome instruments; this offered an ideal starting basis for emerging discussions between patients and providers regarding deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the 2 primary barriers to high-quality research where improvement efforts should be focused.
Siringo et al (2022) noted that facial feminization surgery is composed of a variety of cranio-maxillofacial surgical procedures that are increasingly sought after by male-to-female transgender patients and by those seeking feminization of the face. Facial feminization surgery can play a prominent role in alleviating gender dysphoria. In consideration of an observed increase in gender-affirming procedures carried out in recent years, a broad knowledge base in the techniques, outcomes, and challenges of facial feminization surgery should be established by surgeons offering these procedures. In a systematic review, these investigators examined the available evidence and informed future advancements in gender-affirming surgical practice. Furthermore, they detailed a representative case to illustrate the senior author's approach to full facial feminization. These researchers carried out a comprehensive literature search of the PubMed, Embase, and Cochrane databases for studies published through June 2020 using following the search terms: "Face" OR "facial" OR "craniofacial" AND "Feminization" OR "Feminization Surgery" OR "Gender Reassignment" OR "Gender Affirming Surgery" OR "Gender Confirmation Surgery". Data on procedures, outcomes, patient age, follow-up time, complications, and patient satisfaction were collected. The data were categorized by facial thirds and then further stratified by facial feature. The search yielded 388 articles; 30 fit the inclusion criteria, and of these, 23 were included in the review. These investigators extracted primary data pertaining to 3,554 patients with an age range of 18 to 73 years who underwent 8,506 total procedures. Most of the procedures addressed the upper facial third (hairline, forehead, and brow), comprising 49.1 % of total procedures performed. Further categorization by facial feature revealed that the most commonly addressed feature was the forehead (34.6 % of procedures), followed by the nose (12.8 %) and the chin (12.2 %). In studies that used quantitative measures to gauge patient-reported outcomes, satisfaction was high. The authors concluded that facial feminization surgery appeared to be safe, whether it was conducted in a single stage or as a staged procedure. Patients reported high satisfaction and better gender congruency following facial feminization procedures. Moreover, these researchers stated that further investigation is needed to establish best surgical practice and gauge patient satisfaction beyond the length of average follow-up and determine the frequency with which adjunctive procedures are sought out.
Coon et al (2022) stated that increasing societal acceptance of transgender individuals has resulted in broader availability of gender surgery and rapid growth in transition-related operations. Facial gender surgery aims to modify patients' facial features to be more congruent with their physical expression of gender, reducing gender dysphoria and improving QOL. Growth in research and technique evolution has not kept pace with growth in clinical volume; thus, the 1st International Facial Gender Symposium was held at Johns Hopkins University in 2019, convening surgeons who perform facial gender surgery to share ideas and examine the state of clinical evidence. These investigators reviewed the literature on facial gender surgery, they developed a search strategy for 7 electronic databases (PubMed, PsycINFO, Embase, CINAHL, Web of Science, Cochrane, and Gender Studies) through May of 2019, following the PRISMA systematic review guidelines. Based on the English language literature and clinical experience, the authors suggested guidelines for screening, management, and appropriate surgical technique for patients undergoing facial gender surgery. They highlighted facial gender surgery as a medically necessary intervention and identify shortcomings in current guidelines. The authors concluded that facial gender surgery represents a complex array of cranio-facial and soft-tissue procedures that require application of advanced skills and decision-making. Facial gender operations are not cosmetic, are medically necessary, and require development of new CPT codes specific to facial gender surgery. It is imperative to create educational programs and methods to define sufficient training for facial gender surgery surgeons. These investigators stated that research priorities include better procedural outcomes data, more quality-of-life studies, and insight into variation in both patient and procedural subgroups.
Javier et al (2022) noted that many transgender women and men undergo GAS. Existing work showed that early surgery outcomes are generally positive, suggesting high surgical satisfaction and positive QOL outcomes. Less work, however, examines these outcomes in the longer-term. These investigators carried out a systematic literature review into the longer-term (i.e., 1 year or longer) surgical satisfaction and quality of outcomes following various forms of GAS in transgender populations. Specifically, they examined research on such outcomes at least 1-year post gender-affirming chest, genital, facial, vocal cord, and Adam's apple removal surgeries. Studies were identified via Google Scholar, PsycINFO, Scopus, and PubMed databases, as well as through Google Scholar search alerts. These researchers considered all studies published until October 2021; 2 reviewers extracted data from suitable studies using Covidence. Both reviewers also independently examined the identified studies' risk of bias and strength of evidence. A total of 79 low quality (e.g., small sample sizes, lack of control/comparison groups) studies suggested that most transgender patients were satisfied with surgical outcomes when assessed at least 1-year post-surgery. Low quality research also indicated that transgender women and men typically reported positive psychological and sexual well-being post-surgery, and similar well-being outcomes as those who have not had surgery. The authors concluded that to the best of their knowledge, this literature review was the first to critically summarize and evaluate all published studies on the longer-term QOL outcomes following chest, genital, facial, voice and Adam's apple removal surgeries for transgender women and men. These investigators stated that while the results suggested promising surgical satisfaction and QOL outcomes following surgery, many studies only drew on small samples, and most studies did not allow for causal conclusions. Furthermore, few studies have compared surgical outcomes between transgender women and men. These investigators offered concrete suggestions for future research.
La Padula et al (2023) noted that facial feminization surgery (FFS) is often the first procedure requested by patients wishing to undergo GAS. These researchers examined the applicability and effectiveness of deep plane facelifts in FFS. They carried out a prospective study that included patients who requested a deep plane facelift as a stand-alone procedure to achieve a more feminine facial appearance as the only procedure of FFS. Subjects underwent deep plane facelifts to achieve a more feminine oval face shape and increased tissue projection of the zygomatic-malar region. To examine the effectiveness of the procedure and patient satisfaction, the Face-Q scales, Face and Neck lift Objective Photo-Numerical Assessment Scale, the Satisfaction With Life Scale, and the Subjective Happiness Scale were applied pre-operatively and 1 year after surgery. A total of 36 patients were included in the study. A statistically significant difference (p < 0.005) was observed between pre- and post-operative scores. The re-positioning of the malar fat pads increased the malar volume, providing a more oval overall shape of the face, which is typically feminine. No major complications were observed. The authors concluded that despite their encouraging results, new studies with a larger sample of patients are needed to support the benefits of the deep plane facelift as part of FFS to elevate this technique from an ancillary to a routine procedure for patients undergoing GAS.
Hoffman et al (2024) stated that facial masculinization surgery (FMS) is increasingly popular among cisgender and transgender men. The benefits of FMS are focused on facial identity and have been proven to decrease gender dysphoria in this population. Previous research showed increasing interest in GAS and facial feminization surgery; however, the prevalence of FMS has not been explored. It is difficult to find these data based on surgical records alone because institutions do not have standardized methods of reporting and lack publications in the field. These investigators analyzed public interest in FMS by using worldwide Google Trends to quantify these trends. They carried out a worldwide Google Trends search from January 1, 2008, to December 31, 2022, using terms focused on FMS. Then, search terms were analyzed for non-facial masculinization procedures and were aggregated. Lastly, a PubMed search was carried out for the terms "transgender" and "facial masculinization" from January 1, 2008, to December 31 , 2022, to compare publication rates. The data showed an increasing interest in FMS via Google search trends since the year 2008. A similar trend was demonstrated for non-FMS gender-affirming terms. PubMed analysis showed "transgender" medicine publishing rates were approximately 39.65 times greater than "facial masculinization" publishing rates, although "facial masculinization" medicine did produce a positive trend over the study period of approximately 4 publications per year. The medical literature on transgender surgeries rapidly outpaces publications specifically focusing on FMS. The authors concluded that this study showed increasing interest in GAS over time, especially FMS. These increasing trends should encourage greater scientific exploration of FMS and research to properly quantify and assess surgical outcomes in this special population. These investigators stated that additional educational interventions for both the general public and medical providers, to increase awareness of unique challenges that impact this community and highlight changes in healthcare coverage over time, should be created to keep pace with increasing patient demand and address the physical, systemic, and psychosocial issues faced by individuals who identify as transgender.
An UpToDate review on “Gender-affirming surgery: Male to female” (Ferrando, 2024) states that “Nongenital/nonbreast surgeries include a range of feminizing surgeries. While facial feminization and thyroid cartilage reduction are discussed here, other feminizing procedures include body contouring (e.g., liposuction) and body implants (e.g., buttock implants). WPATH has published recommended criteria that need to be met by patients considering and clinicians performing these types of surgeries. Patients should be fully counseled and informed of the risks and benefits prior to proceeding with surgery”.
Furthermore, an UpToDate review on “Gender-affirming surgery: Female to male” (Ferrando et al, 2024) does not mention facial gender affirming surgery.
Nerve Surgery / Neurotization at Gender-Affirming Breast Surgery
Rochlin et al (2020) noted that female-to-male mastectomy often renders the chest skin and nipple-areolar complex (NAC) insensate. These researchers proposed a new technique of preserving the intercostal nerves (ICN) and using them to re-innervate the NAC following mastectomy. They carried out a prospective analysis of transmasculine patients who underwent female-to-male mastectomy. The technique entailed dissecting out the lateral ICN to length and performing a neurorrhaphy to nerve stumps at the base of the NAC. Sensory outcomes, as assessed with Semmes-Weinstein monofilaments, were compared to a cohort of patients who underwent mastectomy without neurotization. A total of 10 patients with a mean age of 17.5 years (range of 16 to 19 years) underwent mastectomy. The final follow-up was a mean of 15.4 ± 4.3 months for the treated group and 40.7 ± 12.9 months for the control group. Compared to control patients, treated patients had significant improvement in sensation at the nipple (p ≤ 0.0002), areola (p = 0.0001), and peripheral breast skin (p = 0.0001). For treated patients, there was no statistically significant difference in sensation between pre-operative and post-operative sensation in all tested areas at final follow-up. The authors concluded that this proof of concept (POC) study suggested that immediate reinnervation of the NAC following mastectomy enhanced recovery of NAC sensation in patients undergoing female-to-male mastectomy and may be further generalized to women undergoing post-mastectomy breast reconstruction. These researchers stated that immediate targeted NAC reinnervation has the potential to herald the “next frontier” in breast reconstruction, while also improving outcomes in transmasculine patients undergoing gender-affirming mastectomy.
The authors stated that the drawbacks of this study included the small study size (n = 10). They focused on objective sensory outcomes based on monofilament and temperature testing, although subjective outcomes, such as sexual arousal and self-esteem, are also important clinical endpoints. Furthermore, the placebo effect was a potential bias, as knowledge of neurotization may have impacted the treated group’s perception of sensation. To avoid this potential bias, future studies could employ a prospective, single-blind, randomized-controlled study design comparing transmasculine patients undergoing mastectomy with and without neurotization to evaluate sensory outcomes. Alternatively, future studies could examine differential sensory recovery of the chest in patients receiving unilateral nipple neurotization. Comparison of sensory recovery in patients who undergo nipple-sparing mastectomy (NSM) versus free nipple grafting (FNG) is also an interesting line of inquiry that can be addressed in future investigations.
Deptula and Nguyen (2021) stated that NSM is commonly performed when oncologically feasible. Although the NAC is preserved, patients are left with significantly altered nipple sensation after mastectomy. To optimize breast reconstruction outcomes, the NAC as well as its sensation should ideally be preserved. These investigators examined outcomes of NAC neurotization in patients undergoing mastectomy for both gender-affirmation and oncologic indications. They carried out a retrospective chart review on patients who underwent nipple reinnervation procedures from 2016 to 2019. Two groups of patients were identified who underwent nipple reinnervation during gender-affirming mastectomy or NSM and immediate autologous reconstruction. Patient demographic information and sensory assessments were recorded. Sensation was assessed for nipple, areola and peripheral breast skin (2 cm from the areola edge) sensation using Semmes-Weinstein monofilaments. A total of 10 patients underwent gender-affirming mastectomies with NAC reinnervation. NAC neurotization patients reported significantly better sensation at the nipple (p = 0.0001), areola (p = 0.0001) and surrounding breast skin (p = 0.0001) compared to a control group; 7 patients underwent reinnervation group after NSM and autologous reconstruction. NAC neurotization resulted in higher levels of sensation in the reinnervation with flap group compared a control group at the nipple (3.9 versus 4.9, p = 0.04) and areola (4.84 versus 5.68, p = 0.04). The presence of neuroma or hypersensitivity of the NAC were not observed in any patient undergoing neurotization (0 %). The authors concluded that the NAC has a valuable sensory function that is worth preserving after NSM. NAC neurotization is a viable technique in 2 patient populations: transmasculine patients undergoing gender-affirming mastectomy and breast cancer patients undergoing NSM and immediate autologous reconstruction. Moreover, these researchers stated that further study is needed to understand patient satisfaction and QOL outcomes with nipple reinnervation.
The author stated that the main drawback of this study was its retrospective design. While these investigators managed to identify control groups, they were not an equivalent substitution for a randomized controlled trial (RCT) to compare outcomes. Another drawback was the relatively small sample size (n = 10). The lack of statistical significance in some of these findings may have been related to an under-powered study. This trial was focused on the sensation of the NAC after neurotization. These researchers stated that further study may include a detailed analysis of sensation quadrate specific mastectomy skin as well as the effect of multiple coaptations when surgically feasible. While the authors employed objective and repeatable assessments of sensation, they did not carry out patient-reported outcome assessments. As these researchers continue to refine their NAC neurotization techniques, efforts will focus on patient reported outcome assessments using validated instruments such as the BREAST-Q and the BODY-Q chest module.
Troung et al (2023) recently described targeted nipple reinnervation (TNR) during female-to-male gender-affirming mastectomy with FNG using either direct nerve coaptation or nerve allograft. The objectives of TNR are to improve sensation (including erogenous sensation) and prevent numbness, paresthesia, chronic pain, and phantom sensation. These investigators described their modified technique, which has evolved to use autologous ICN branches as donor nerves for re-innervation if direct nerve coaptation cannot be achieved. During TNR, the T3 to T5 sensory branches are preserved and coapted to the repositioned NAC. In patients with donor nerves that were inadequate in length to allow for direct coaptation, autologous ICN branches were not used for coaptation (branches present along the chest wall that would otherwise be lost) or one of the T3 to T5 branches were harvested. An end-to-end nerve repair between the autograft and donor nerves was performed, and the donor nerve/autograft complex was coapted to the NAC. Targeted muscle re-innervation was carried out after autograft harvest to prevent neuroma formation. TNR with ICN autograft is technically feasible in female-to-male gender-affirming mastectomy with FNG when direct coaptation is not possible. Chest re-innervation using autologous ICN branches as donor nerves is another option for re-innervation when the nerves are too short for direct coaptation. The authors stated that because the collection of long-term data is ongoing, the effectiveness of NAC re-innervation using the new technique will be described in a future publication. Moreover, these researchers stated that long-term follow-up data are needed to examine the sensory outcome and patient satisfaction following autograft nerve repair. Furthermore, it will be important to better understand the post-operative time to sensory return and compare the effectiveness of direct coaptation versus autograft and allografts for TNR.
Remy et al (2024a) stated that TNR is a novel technique to preserve and reconstruct ICN to improve post-operative sensation; however, there is little evidence on relevant anatomy and outcomes. These investigators analyzed the anatomy and sensory outcomes of TNR in gender-affirming double incision mastectomy with FNG. A total of 25 patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient reported questionnaires were completed pre-operatively, and at 1, 3, 6, 9, and 12 months post-operatively. A total of 50 mastectomies were carried out. Per mastectomy, the median number of ICN found and used was 2 (1 to 5). Axon and fascicle counts were not significantly different between ICN branches (p > 0.05). BMI of 30 kg/m2 or greater and mastectomy weight of 800 g or greater were associated with significantly worse pre-operative sensation (p < 0.05). Compared to pre-operative values, NAC sensation was worse at 1 month (p < 0.01), comparable at 3 months (p > 0.05), and significantly better at 12 months (p < 0.05) post-operatively. Chest sensation was comparable to the pre-operative measurements at 1 and 3 months (p > 0.05), and significantly better at 12 months (p < 0.05) post-operatively. NAC sensation was significantly better when direct coaptation was performed compared to use of allograft only (p < 0.05), and with direct coaptation of 2 or more branches compared to direct coaptation of 1 branch (p < 0.05). All patients reported return of nipple and chest sensation at 1 year post-operatively and 88 % reported return of some degree of erogenous sensation. The authors concluded that TNR allowed for restoration of NAC and chest sensation within 3 months post-operatively; and the use of multiple ICN branches and direct coaptation resulted in the best sensory outcomes.
Remy et al (2024b) analyzed the quantitative and qualitative sensory outcomes following gender-affirming mastectomy (GAM) with TNR. A total of 60 patients were prospectively enrolled -- 30 subjects undergoing GAM with TNR were compared to 30 matched controls who underwent GAM without TNR and 30 cis-males who did not undergo surgery. Quantitative sensory testing including monofilament testing, temperature detection threshold, pressure pain threshold, 2-point discrimination, pin-prick, and vibration, as well as patient-reported questionnaires were completed pre-operatively and at 1, 3, 6, 9 and 12 months post-operatively. Monofilament values, cold and warm detection thresholds, pin-prick and pressure detection threshold were comparable to pre-operative values in subjects (p > 0.05) but remained significantly worse in controls (p < 0.05). Vibration and 2-point discrimination remained similar to pre-operative values in both subjects and controls (p > 0.05). Subjects reported significantly better nipple, temperature and erogenous sensation compared to controls (p < 0.05). Chest pain was significantly higher in controls versus subjects until 6 months post-operatively (p < 0.05). Phantom sensation and phantom pain were significantly higher in controls compared to subjects (p < 0.05). Nipple hypersensitivity was significantly higher in subjects compared to controls until 6 months post-operatively (p < 0.05). The authors concluded that restoration of mechanical (light touch and pressure), temperature and pain detection, as well as erogenous sensation were significantly improved with TNR, which was associated with significantly less phantom sensation and chest pain. Patients should be counselled on transient NAC hypersensitivity.
Current UpToDate reviews on “Gender-affirming surgery: Female to male” (Ferrando et al, 2024), and “Gender-affirming surgery: Male to female” (Ferrando, 2024) do not mention nerve grafting/neurotization for breast reconstruction.
Facial Recognition Neural Networks for Confirmation of Success of Facial Feminization Surgery
Chen et al (2020) noted that male-to-female transgender patients desire to be identified, and treated, as female, in public and social settings. Facial feminization surgery entails a combination of highly visible changes in facial features. To study the effectiveness of facial feminization surgery, these investigators examined pre-operative/post-operative gender-typing using facial recognition neural networks. In this study, standardized frontal and lateral view pre-operative and post-operative images of 20 male-to-female patients who completed hard-tissue and soft-tissue facial feminization surgery procedures were used, along with control images of unoperated cisgender men and women (n = 120 images). Four public neural networks trained to identify gender based on facial features analyzed the images. Correct gender-typing, improvement in gender-typing (pre-operatively to post-operatively), and confidence in femininity were analyzed. Cisgender male and female control frontal images were correctly identified 100 % and 98 %of the time, respectively. Pre-operative facial feminization surgery images were misgendered 47 % of the time (recognized as male) and only correctly identified as female 53 % of the time. Post-operative facial feminization surgery images were gendered correctly 98 % of the time; this was an improvement of 45 %. Confidence in femininity also improved from a mean score of 0.27 before facial feminization surgery to 0.87 after facial feminization surgery. The authors concluded that in the 1st study of its kind, facial recognition neural networks demonstrated improved gender-typing of transgender women from pre-operative facial feminization surgery to post-operative facial feminization surgery. This showed the effectiveness of facial feminization surgery by artificial intelligence (AI) methods. Level of Evidence = IV.
In a commentary on the afore-mentioned study by Chen et al (2020), Zuo and Forrest (2021) noted some of the confounding variables, such as hormonal therapy and use of make-up, which may affect the distinction between male and female. Zuo and Forrest (2021) also pointed out that the study by Chen et al (2020) was a very small study (n = 20). Moreover, they noted that as suggested by Chen et al (2020), future studies could also examine the marginal impact of individual facial feminization surgery procedures on facial recognition technology performance to determine which procedures elicit the greatest effects.
In a scoping review, Ahmadi et al (2023) examined the use of ML in the facial cosmetic surgeries and procedures. Electronic search was conducted in PubMed, Scopus, Embase, Web of Science, ArXiv and Cochrane databases for the studies published until August 2022. Studies that reported the use of ML in various fields of facial cosmetic surgeries were included. The studies' risk of bias (ROB) was examined using the QUADAS-2 tool and NIH tool for before and after studies. From 848 studies, a total of 29 studies were included and categorized in 5 groups based on the objective of the studies: outcome evaluation (n = 8), face recognition (n = 7), outcome prediction (n = 7), patient concern evaluation (n = 4) and diagnosis (n = 3). A total of 16 studies used public data sets. ROB assessment using QUADAS-2 tool revealed that 6 studies were at low ROB, 5 studies were at high ROB, and others had moderate ROB. All studies assessed with NIH tool showed fair quality. In general, all studies showed that using ML in the facial cosmetic surgeries was accurate enough to benefit both surgeons and patients. The authors concluded that using ML in the field of facial cosmetic surgery is a novel method and needs further studies, especially in the fields of diagnosis and treatment planning. Due to the small number of studies and the qualitative analysis conducted, these researchers could not draw a general conclusion regarding the impact of ML in the field of facial cosmetic surgery. Level of Evidence = IV.
Nerve Grafting for Gender Affirming Breast Surgery
Gfrerer et al (2022) noted that restoration of breast sensation has become an important objective in autologous and implant-based breast reconstruction after cancer-related mastectomy. Although gender-affirming mastectomy with free nipple grafting (FNG) results in similar sensory deficits, chest reinnervation concepts have not been applied to this procedure. These researchers described a novel technique to reinnervate the FNG in patients undergoing double incision gender mastectomy. This technique differs from previously described reinnervation techniques in several aspects: First, the donor axon count is maximized by preserving the 3rd to 5th lateral cutaneous nerves for coaptation to the nipple areola complex. Second, the reinnervation approach varies and is based on patient anatomy. Third, the distal graft or donor nerve is split into fascicles to increase the reinnervation zone. Fourth, the split fascicles are coapted to the dermato-sensory peripheral nerve elements of the dermis. The authors concluded that chest reinnervation is technically feasible in patients undergoing double incision gender mastectomy with FNG.
Loughran et al (2024) stated that FNG makes sensory recovery challenging. Permanent decreased sensation to touch and temperature in skin-grafted skin is common. Direct neurotization of the nipple-areolar complex (NAC) graft has been described; however, quantitative data regarding degree of nipple reinnervation possible is unknown. These researchers quantified and qualified sensation recovery following nerve coaptation to reinnervate the NAC. Patients undergoing mastectomy for gender dysphoria from 2020 to 2022 were offered nerve allograft to restore nipple sensation. A lateral intercostal nerve was selected and coapted to allograft which was embedded beneath the nipple graft. Semmes Weinstein testing was used to evaluate nipple sensation. Assessments were made at visits of less than 1 year and over 1 year from surgery. Filaments used represented normal sensation, minor diminished sensation, diminished sensation, loss of protective sensation, and deep pressure sensation only. A total of 115 patients elected for direct neurotization. Semmes Weinstein testing was limited to 46 patients representing 46 encounters and 92 nipples in the less than 1 year group and 24 encounters and 48 nipples in the over 1 year group. Of the 92 nipples in the less than 1 year group, 17 (18.5 %) noted return of normal sensation and 37 (40.2 %) noted minor diminished or diminished sensation, indicating nerve reinnervation. There were 38 (41 %) nipples with loss of protective sensation or deep sensation only. There were 48 nipples included in the over 1 year group. Of the 48 nipples, 4 (8.3 %) noted normal sensation and 30 (62.5 %) noted minor diminished or diminished sensation, indicating nerve reinnervation. For the remaining 14 nipples, 14 (29 %) noted loss of protective sensation or deep sensation only. The authors concluded that sensory outcomes in NAC grafts used for reconstruction in patients undergoing double incision mastectomy remain poor. Sensation restoration beyond that expected from full thickness skin grafts can be achieved in the majority of patients with nerve allograft via direct neurotization.
The authors stated that this study was limited by loss to follow-up, especially in the greater than 1 year group. Despite this limitation, this study was the first of its kind to include a large patient cohort and to quantify degree of sensory recovery using Semmes Weinstein monofilament testing in patients undergoing direct neurotization of NAC graft after double incision mastectomy for gender dysphoria. All patients recovered a degree of return of sensation, with 71 % of patients demonstrating normal, minor diminished light touch or diminished light touch return of sensation after 1 year. This value is well beyond what would be expected in a full thickness skin graft. Furthermore, the authors were unable to provide a reliable control group for comparison in this study, as the vast majority of patients who elected for nerve grafting also elected for direct neurotization of the free nipple graft.
Remy et al (2025) stated that most patients undergoing breast surgery with FNG lose nipple erection (NE) function. These investigators examined the effect of nerve preservation and reconstruction with targeted nipple-areola complex reinnervation (TNR) on NE following gender-affirming mastectomy with FNG. Patients undergoing gender-affirming mastectomy with FNG were prospectively enrolled. Subjects who underwent TNR were compared with controls who did not undergo TNR. Post-operative patient-reported NE function was scored using a 4-point Likert scale. Objective NE evaluation consisted of the change in areola circumference and nipple height following cold application using a thermal device and 3-dimensional (3D) imaging. A total of 20 patients (11 subjects and 9 controls) with comparable age, body mass index (BMI), and mastectomy weight were included. At an average follow-up of 16.8 (± 7.0) months, significantly more subjects reported NE than controls (72.8 % versus 38.9 %, p = 0.03), with a higher median NE score (3 [range of 1 to 4] versus 1 [range of 1 to 2], p = 0.0005). Following cold application, subjects had a greater mean reduction in areola circumference (-4.16 ± 3.3 versus -1.67 ± 1.9 mm, p = 0.02) and a greater mean increase in nipple height (+0.86 ± 0.8 versus +0.37 ± 0.3 mm, p = 0.04) compared with controls. Improved patient-reported NE function correlated with better cold detection thresholds (p = 0.01). The authors concluded that TNR was associated with improved patient-reported and objective NE following gender-affirming mastectomy. These investigators stated that these findings suggested the importance of both afferent sensory and efferent autonomic intercostal nerve fiber functions in mediating NE and suggested the effectiveness of TNR in improving NE following breast surgery involving FNG.
The authors stated that the drawbacks of this trial mainly included its small sample size (n = 11 subjects) and that subjects were not blinded or randomized to the reinnervation intervention. In addition, the evaluation of NE function pre-operatively and then post-operatively at multiple follow-ups, or at least at the same follow-up period in all patients, would have provided additional information. Moreover, although age, BMI, and mastectomy were statistically comparable between both study groups, other variables which may have influenced outcomes were not analyzed, including pre-operative NAC size and surgeon experience and technique. Furthermore, patient-reported NE function did not distinguish NE in the context of cold sensation versus erogenous sensation, and objective NE function was only measured in the context of cold exposure. Lastly, these researchers did not examine patient pre-operative concern for NE function to understand the importance of preserving this function in patients undergoing gender-affirming mastectomy. These researchers stated that future studies should aim to stratify NE function based on different stimuli.
Appendix
DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents
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A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
- A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
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The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
There is no minimum duration of relationship required with mental health professional. It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written. A common period of time is three months, but there is significant variation in both directions.
Evaluation of candidacy for gender affirmation surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.
Characteristics of a Qualified Health Professionals (From SOC-8)
Qualifications of Mental Health Professional for assessing transgender and gender diverse adults for physical treatments (from WPATH SOC-8):
- Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
- Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
- Are able to assess capacity to consent for treatment.
- Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
- Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.
- Liaise with professionals from different disciplines within the field of transgender health for consultation and referral on behalf of gender diverse adults seeking gender-affirming treatment, if required.
Credentials of surgeons who perform gender-affirming surgical procedures (fromWPATH SOC-8):
- Training and documented supervision in gender-affirming procedures;
- Maintenance of an active practice in gender-affirming surgical procedures;
- Knowledge about gender diverse identities and expressions;
- Continuing education in the field of gender-affirmation surgery;
- Tracking of surgical outcomes.
Characteristics of health care professionals working with gender diverse adolescents:
- Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
- Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
- Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
- Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
- Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.
References
The above policy is based on the following references:
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