The Most-Cited Publications in Gender-Affirming Surgery: A Cross-Sectional Bibliometric Analysis

Abstract

Background: Gender-affirming surgery is becoming more common among reconstructive surgeons. Bibliometric analyses are statistical evaluations of published scientific correspondence and are a validated method of measuring influence in the scientific community. As no such bibliometric analysis has been done as of yet, the purpose of this study is to identify the characteristics of the 50 most-cited peer-reviewed articles on gender-affirming surgery. Methods: The Scopus abstract and citation database was utilized in April 2020 to search for English-language publications related to gender-affirming surgery. The 50 most-cited publications that met inclusion criteria were reviewed for various metric tabulations. Results: The 50 publications have been cited a total of 4402 times. Thirty-one (62%) were published in 2000 or later. Phalloplasty was the most discussed surgical technique, and 18 of the articles focused on female-to-male (FtM) patients. Case series (46%) and review articles (24%) were most common and there were no Level I or Level II studies. The Netherlands contributed the most, with 13 articles. Among the most frequent keywords in the 50 abstracts were “flap” and “complication”. The earliest author keywords used were “transsexual” and “sex reassignment”. Conclusions: The keyword usage in these abstracts over time seems to follow the trend of a more socially inclusive lexicon. A focus on studies with a higher level of evidence may optimize surgeon education and more appropriately guide clinical practice. This study reveals that the most influential and commonly referenced studies may not be sufficient to appropriately guide clinical practices.

Introduction

As visibility of transgender populations increase, awareness of their unique challenges is becoming increasingly important. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), gender dysphoria prevalence is 0.005% to 0.014% of those assigned male at birth and 0.002% to 0.003% of those assigned female at birth. ¹ Currently, gender reassignment is considered the most effective treatment for transgender and nonconforming patients who suffer from gender dysphoria, which includes psychosocial interventions, hormonal therapy, and gender-affirming surgeries. ² In 2020, of the 6,878,486 reconstructive procedures performed by board-certified plastic surgeons, 16,353 of these were gendr-affirming procedures. ³ These procedures include penectomy, vaginoplasty, clitoroplasty, labiaplasty, orchidectomy, facial feminization/masculinization surgery, tracheal cartilage reduction, breast reduction or augmentation, metoidioplasty, urethroplasty, hysterectomy with bilateral salpingo-oophorectomy, vaginectomy, phalloplasty, and scrotoplasty, among others.^2,4 These procedures present unique reconstructive challenges, and as such, it is imperative that reconstructive surgeons are aware and abreast of the contemporary surgical challenges and techniques that are specific to this reconstructive patient population.

Bibliometric studies are used by academic physicians to determine the impact of certain publications in their respective fields.^5,6 Bibliometric analysis refers to the quantitative statistical evaluation of literature that can be used to assess the impact of researchers, institutions, and countries on the development of certain fields according to the number of and frequency of citations of publications. ⁷ There have been many citation analyses published in the field of reconstructive surgery.^8,9,10 These studies serve as reference tools that provide insight into the characteristics of the most-cited works and key publications that have helped shape the field of interest, as highly cited works can provide important information about the current understanding of a topic.^11,12 The aim of this study was to identify and conduct a qualitative and quantitative analysis of the 50 most-cited articles in gender-affirming surgery to help researchers gain a better understanding of the existing prominent literature and make better use of present resources. A bibliometric analysis will help to determine past and current understanding of gender-affirming surgery, and identify areas for further research and technical improvements in clinical practice. As such, findings of the present bibliometric analysis could be used to advocate for the health rights and coverage for transgender and gender minority patients. ⁶

Methods

Database

This cross-sectional study was performed by querying the Scopus (Elsevier, the Netherlands) abstract and citations database using previously described methods.^5,11 Scopus is the largest abstract and citation database of peer-reviewed literature and covers more than 41,000 source titles. All journals covered in Scopus are reviewed each year to ensure that the high-quality standards are maintained. ¹³ Queries using Boolean searches that resulted in the greatest number of English-language articles were conducted in April 2020 (Figure 1). The Boolean phrases used were [surgery AND (“gender affirming” OR “gender reassignment” OR “transgender” OR “transsexual” OR “sex reassignment” OR “sex affirmation” OR “gender affirmation”)]. No restrictions were placed on the searches relating to publication date, journal of publication, or country of origin.

Figure 1.

Record selection strategy

All publications were presented in descending order according to the number of citations. Titles and abstracts of these publications were then reviewed independently by the authors to identify the studies that exclusively pertained to gender-affirming surgery. Any disagreements were resolved by discussion. Articles were excluded if the primary focus was not gender-affirming surgery, even if this topic was tangentially discussed. If this content could not be accurately determined by the title or abstract, the full article was obtained for further screening. Publications discussing information on the surgical and functional considerations of gender-affirming surgery outcomes, indications, techniques, procedural descriptions, and complications were included for study, including studies discussing the psychosocial outcomes and patient satisfaction following these surgeries.

Bibliometric Analysis

Data pertaining to authors, year of publication, journal, country of origin, and institutional affiliation were exported from Scopus to Microsoft Excel for tabulation and descriptive statistics. Notably, Scopus counts the number of publications for each country based on author affiliation regardless of the position of the author in the author list. Consequently, there may be an overlap in the number of publications assigned for each country. From these exported documents, the 50 most-cited publications were identified and the abstracts were reviewed independently by the authors for the type of study (eg randomized controlled trial, nonrandomized controlled trial, cohort study, case–control study, case series, case report, review article, and descriptive article), content pertaining to surgical topics, and level of evidence for clinical studies, based on the American Society of Plastic Surgeons (ASPS) guidelines. ¹⁴ Citation density, defined as the number of citations per year, was also reported for each of the 50 most-cited articles presented.

The author keywords were visualized using the VOSviewer program which is available for free download. ¹⁵ Keywords were included for visualization based on a minimum of 5 occurrences in the 50 abstracts. The size of each keyword node corresponds to the frequency of occurrence in the 50 abstracts, where larger nodes indicate higher frequency of occurrence. Keyword occurrences were tabulated using a binary method where the absence or presence of a keyword was counted. To exclude general terms, VOSviewer assigns a relevance score to these keywords as outlined in the technical manual. ¹⁶ VOSviewer can map keywords in a variety of ways. In this study, keyword mapping was performed using the average citation score to identify how the most frequent keywords changed as the number of citations increased. Keyword mapping was also performed using average citation year score to identify how the most frequent keywords changed over time.

Ethical Consideration

No Institutional Review Board (IRB) approval was required due to the absence of human subjects and the public availability of the data.

Results

Citation Analysis

The initial Boolean search on Scopus yielded 2296 full-length, English-language articles. The 50 most-cited publications relating to gender-affirming surgery are listed in Table 1. The 50 most-cited gender-affirming surgery articles were published between 1968 and 2016, with 31 published in 2000 or later. The number of citations per publication ranged from 54 to 200, with an average of 88.0 citations per article. The study by Cohen-Kettenis et al. from 1997 had the most total citations (200), followed by the Smith et al. study from 2005 with 191 total citations.^17,18 These 50 publications have been cited a total of 4402 times altogether, averaging 91.7 total citations per year. The greatest number of articles (6) was published in the year 2005, followed by 4 articles in 2011 (Figure 2). Correspondingly, the greatest number of citations (722) was recorded in 2005. The 2011 study by Cuypere et al. had the highest citation density of 21.1 citations per year, followed by the 2015 study by Horbach et al. with 20 citations per year.^19,20

Table 1.

The 50 Most-Cited Transgender Surgery Articles.

Articles	No. of Citations (Citation Densitya)	Subject Matter	MtF, FtM, Both	Type of Surgery
Cohen-Kettenis PT, et al 1997. Sex Reassignment of Adolescent Transsexuals: A Follow-up Study.	200 (8.7)	QoL (psychosocial)	Both
Smith YLS, et al 2005. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals.	191 (12.7)	QoL (psychosocial)	Both
Dhejne C, et al 2011. Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden.	190 (21.1)	QoL (psychosocial)	Both
Cuypere GD, et al 2005. Sexual and Physical Health After Sex Reassignment Surgery.	182 (12.1)	QoL (incl. physical/sexual function)	Both
Monstrey S, et al 2009. Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique?	127 (11.5)	Surgical Technique	FtM	Phalloplasty
Smith YL, et al 2001. Adolescents With Gender Identity Disorder Who Were Accepted or Rejected for Sex Reassignment Surgery: A Prospective Follow-up Study.	124 (6.5)	QoL (psychosocial)	Both
Lawrence AA. 2005. Sexuality Before and After Male-to-Female Sex Reassignment Surgery.	113 (7.5)	QoL (psychosocial)	MtF
Ainsworth TA, et al 2010. Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery.	112 (11.2)	QoL (incl. physical/sexual function)	MtF	Facial feminization
Wierckx K, et al 2011. Quality of Life and Sexual Health after Sex Reassignment Surgery in Transsexual Men.	110 (12.2)	QoL (incl. physical/sexual function)	FtM
Kuiper B, et al 1988. Sex reassignment surgery: A study of 141 Dutch transsexuals.	108 (3.4)	QoL (psychosocial)	Both
Pauly IB. 1968. The Current Status Of The Change Of Sex Operation.	108 (2.1)	Review of Techniques	Both
Weyers S, et al 2009. Long-term Assessment of the Physical, Mental, and Sexual Health among Transsexual Women.	104 (9.5)	QoL (psychosocial)	MtF
Selvaggi G, et al 2005. Gender Identity Disorder: General Overview and Surgical Treatment for Vaginoplasty in Male-to-Female Transsexuals.	101 (6.7)	Review of Techniques	MtF
Horbach SE, et al 2015. Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques.	100 (20.0)	Review of Techniques	MtF	Vaginoplasty
Selvaggi G, et al 2011. Gender reassignment surgery: an overview.	99 (11.0)	Review of Techniques	Both
Gilbert DA, et al 1987. New Concepts in Phallic Reconstruction.	92 (2.8)	Surgical Technique	FtM	Phalloplasty
Felici N, et al 2006. A new phalloplasty technique: the free anterolateral thigh flap phalloplasty.	91 (6.5)	Surgical Technique	FtM	Phalloplasty
Biemer E. 1988. Penile construction by the radial arm flap.	91 (2.8)	Surgical Technique	FtM	Phalloplasty
Krege S, et al 2001. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients.	87 (4.6)	Review of Techniques	MtF
Perovic S, et al 2000. Vaginoplasty in male transsexuals using penile skin and a urethral flap.	84 (4.4)	Surgical Technique	MtF	Vaginoplasty
Rehman J, et al 1999. The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.	83 (4.0)	QoL (incl. physical/sexual function)	MtF
Fang R, et al 1999. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases.	83 (4.0)	Review of Techniques	FtM	Phalloplasty
Bettocchi C, et al 2005. Pedicled pubic phalloplasty in females with gender dysphoria.	81 (5.4)	Surgical Technique	FtM	Phalloplasty
Meyer JK. 1979. Sex Reassignment.	79 (1.9)	Review of Techniques	Both
Klein C, et al 2009. Continuing Medical Education: Sexual Functioning in Transsexuals Following Hormone Therapy and Genital Surgery: A Review (CME).	78 (7.1)	QoL (incl. physical/sexual function)	Both
Berg JEA, et al 1997. Long Term Follow up After Sex Reassignment Surgery.	77 (3.3)	QoL (psychosocial)	Both
Puckett CL, et al 1978. Construction Of Male Genitalia In The Transsexual, Using A Tubed Groin Flap For The Penis And A Hydraulic Inflation Device.	76 (1.8)	Surgical Technique	FtM	Phalloplasty
Leriche A, et al 2008. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism.	73 (6.1)	QoL (incl. physical/sexual function)	FtM	Phalloplasty
Monstrey S, et al 2008. Chest-Wall Contouring Surgery in Female-to-Male Transsexuals: A New Algorithm.	72 (6.0)	Review of Techniques	FtM	Chest masculinization
Selvaggi G, et al 2007. Genital Sensitivity After Sex Reassignment Surgery in Transsexual Patients.	71 (5.5)	QoL (incl. physical/sexual function)	Both
Lawrence AA. 2006. Patient-Reported Complications and Functional Outcomes of Male-to-Female Sex Reassignment Surgery.	69 (4.9)	QoL (incl. physical/sexual function)	MtF
Kim SK, et al 2003. Long-Term Results in Patients after Rectosigmoid Vaginoplasty.	69 (4.1)	QoL (incl. physical/sexual function)	MtF	Vaginoplasty
Karim RB, et al 1995. Refinements of Pre-, Intra-, and Postoperative Care to Prevent Complications of Vaginoplasty in Male Transsexuals.	67 (2.7)	Review of Techniques	MtF	Vaginoplasty
Ross MW, et al 1989. Effects of adequacy of gender reassignment surgery on psychological adjustment: A follow-up of fourteen male-to-female patients.	67 (2.2)	QoL (psychosocial)	MtF
Laub DR, et al 1974. A Rehabilitation Program For Gender Dysphoria Syndrome By Surgical Sex Change.	67 (1.5)	QoL (psychosocial)	Both
Monstrey S, et al 2011. Sex Reassignment Surgery in the Female-to-Male Transsexual.	66 (7.3)	Review of Techniques	FtM
Altman K. 2012. Facial feminization surgery: current state of the art.	65 (8.1)	Review of Techniques	MtF	Facial feminization
Lindemalm G, et al 1986. Long-term follow-up of “sex change” in 13 male-to-female transsexuals.	64 (1.9)	QoL (psychosocial)	MtF
Rohrmann D, et al 2003. Urethroplasty in Female-to-Male Transsexuals.	60 (3.5)	Surgical Technique	FtM	Urethroplasty
Karim RB, et al 1996. Neovaginoplasty in Male Transsexuals.	60 (2.5)	Surgical Technique	MtF	Vaginoplasty
Perovic S, et al 2003. Metoidioplasty: a variant of phalloplasty in female transsexuals.	58 (3.4)	Surgical Technique	FtM	Phalloplasty
Hage J, et al 1993. Review of The Literature on Techniques for Phalloplasty with Emphasis on The Applicability in Female-to-Male Transsexuals.	58 (2.1)	Review of Techniques	FtM	Phalloplasty
Bouman MB, et al 2014. Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function.	57 (9.5)	Review of Techniques	MtF	Vaginoplasty
Gross M. 1999. Pitch-raising surgery in male-to-female transsexuals.	57 (2.7)	Surgical Technique	MtF	Feminizing laryngoplasty
Hage JJ. 1996. Metaidoioplasty: an alternative phalloplasty technique in transsexuals.	57 (2.4)	Surgical Technique	FtM	Phalloplasty
Hage JJ, et al 1995. Chest-wall contouring in female-to-male transsexuals: basic considerations and review of the literature.	57 (2.3)	Review of Techniques	FtM	Chest masculinization
Luk Gijs, et al 2007. Surgical Treatment of Gender Dysphoria in Adults and Adolescents: Recent Developments, Effectiveness, and Challenges.	55 (4.2)	Review of Techniques	Both
Morrison SD, et al 2016. Phalloplasty: A Review of Techniques and Outcomes.	54 (13.5)	Review of Techniques	FtM	Phalloplasty
Hage JJ, et al 2006. Long-term outcome of metaidoioplasty in 70 female-to-male transsexuals.	54 (3.9)	QoL (incl. physical/sexual function)	FtM	Phalloplasty
Hoebeke P, et al 2005. Impact of sex reassignment surgery on lower urinary tract function.	54 (3.6)	QoL (incl. physical/sexual function)	Both

Note: ^aNumber of citations per year since publication.

Abbreviations: FtM, female to male; MtF, male to female; QoL, quality of life.

Figure 2.

Total number of publications per year.

Content

Of the 50 publications, 22 were quality of life (QoL) studies, 11 of which focused on psychosocial impacts of gender-affirming surgery, and 11 included considerations of postsurgical sexual and physical functioning (Table 1). The remainder of the publications focused on specific surgical techniques (12) or a review of techniques (16). The phalloplasty technique was the subject of 13 of the articles herein. Female-to-male (FtM) patients were the focus of 18 articles, male-to-female (MtF) patients were the focus of 17 articles, and 15 articles focused on both of these patient populations.

Authorship and Publication

A total of 170 authors were represented in the 50 most-cited articles, averaging 3.4 authors per document and 25.9 citations per author. De Cuypere and Monstrey of Belgium were the most active with 8 publications each in this 50 most-cited list (Table 2). Of the 5 most active authors, all were affiliated with the University Hospital Ghent, in Ghent, Belgium. The articles originated from 15 different countries (Figure 3). The Netherlands contributed the most (13), followed by the United States (10) and Belgium (9).

Table 2.

The Top 5 Authors of the Most-Cited Publications.

Author	No. of Publications	Affiliation	Country
De Cuypere, G.	8	Ghent University Hospital	Belgium
Monstrey, S.	8	Ghent University Hospital	Belgium
Selvaggi, G.	7	Ghent University Hospital	Belgium
Cohen-Kettenis, P.T.	4	Ghent University Hospital	Belgium
Weyers, S.	4	Ghent University Hospital	Belgium

Figure 3.

Total number of publications by country of origin.

Evaluation of study type revealed that case series was the most prevalent study type, comprising 23 of the 50 most-cited articles (Table 3). These were followed by review articles (12), where experts reviewed new or existing methods for performing various gender-affirming surgeries. Correlating with study design, Level IV studies were most prevalent, with 26 publications. There were 23 Level V studies, 3 Level III studies, and no Level I or Level II studies in this list. The most frequently occurring keywords grouped by average citation number are shown in Figure 4. The most frequently occurring keyword within the 50 abstracts is “technique” with 21 occurrences. The next most frequent keywords each occurred 15 times: “flap”, “complication”, and “treatment”. There were 22 total journals represented in the 50 most-cited articles (Table 4). Plastic and Reconstructive Surgery was the most active, publishing 9 of the 50 articles and 695 total citations. Archives of Sexual Behavior had the second most, with 7 of the 50 publications and 691 total citations.

Table 3.

Publications Classified by Study Type.

Type of Study	No. of Publications
Randomized controlled trial	0
Nonrandomized controlled trial	0
Retrospective cohort	3
Case–control	0
Case series	23
Cross-sectional	5
Review article	12
Descriptive article	7

Figure 4.

Keyword mapping by average publication date.

Table 4.

Journal of Origin of the Most-Cited Publications.

Journal of Origin	No. of Publications	Total Citations	Average Citations per Publication
Plastic and Reconstructive Surgery	9	695	77.2
Archives of Sexual Behavior	7	691	98.7
Journal of Sexual Medicine	5	452	90.4
Annals of Plastic Surgery	5	347	69.4
BJU International	5	387	77.4
Journal of the American Academy of Child and Adolescent Psychiatry	2	325	162.5
European Urology	2	116	58.0
Psychological Medicine	1	193	193.0
PLoS ONE	1	191	191.0
Quality of Life Research	1	114	114.0
Journal of Nervous and Mental Disease	1	108	108.0
Nature Reviews Urology	1	100	100.0
Journal of Plastic, Reconstructive and Aesthetic Surgery	1	92	92.0
Clinics in Plastic Surgery	1	91	91.0
British Journal of Plastic Surgery	1	84	84.0
Archives of General Psychiatry	1	79	79.0
Scandinavian Journal of Plastic and Reconstructive Surgery and Hand Surgery	1	77	77.0
Seminars in Plastic Surgery	1	68	68.0
International Journal of Oral and Maxillofacial Surgery	1	65	65.0
Journal of Urology	1	59	59.0
Journal of Voice	1	57	57.0
Annual Review of Sex Research	1	55	55.0

Trends

The oldest article included in this list was authored by Pauly in 1968 in the Journal of Nervous and Mental Disease. It characterized male transsexualism as a “preference for the feminine role” based on “conviction” and, upon review of 121 sex reassignment surgeries, determined that social and emotional success was enhanced when vaginoplasty resulted in a functional vagina. ²¹ Keyword analysis was conducted and presented in a network visualization map. The most frequently occurring keywords grouped by publication year are shown in Figure 4. The oldest keywords were “transsexual”, “sex reassignment”, and “gender”. The most recent article included was published in 2016 in Plastic and Reconstructive Surgery by Morrison, et al. It critically appraised the literature on phalloplasty, stating that some FtM “transsexuals” may desire this procedure as part of their transition. ²² Keywords such as “phalloplasty”, “patient satisfaction”, and “gender dysphoria” were the most recently used author keywords.

Discussion

The present study revealed that the level of evidence for the 50 most-cited articles is most frequently Levels IV (26) or V (23), thus illustrating the challenge of performing high-level surgical studies in transgender patients, as creating a control group or cohort of nonsurgically treated patients can present an ethical dilemma. ²³ It is unclear, however, if a higher level of evidence studies exist but have rather not been cited as frequently as the ones herein presented. Silvestre et al. reported that the Plastic Surgery In-Service Training exam consisted largely of questions supported by a low level of evidence, and may present biases in training. ²⁴ Future studies should be designed as Levels I, II, and/or III where possible. Then, as these stronger levels of evidence are cited more frequently, the clinical canon for gender-affirming surgery will include more concrete causative relationships.

The journal of publication and country of origin are influential in determining the number of times an article is cited. Plastic and Reconstructive Surgery and Archives of Sexual Behavior were the most productive journals represented in this study. As a publication focused on sexology and clinical psychology, Archives of Sexual Behavior published a large number of these functional and surgical outcomes articles. Until the release of the DSM-V in 2013, transsexualism and/or gender identity disorder were mental diagnoses. ²⁵ It follows that articles relating to the care of transgender patients were represented largely in psychological journals. As society has progressed, it has seen greater visibility and acceptance of transgender patients, increased quality and availability of gender-affirming care, and better recording of transgender identities by medical records.^26,27 As acceptance and recognition of transgender patients grows within medical and surgical spaces, research should be more fittingly disseminated.

The date of publication is also influential in determining how many times an article gets cited. Citation density corrects for this advantage by assessing the number of citations per year since publication. Previous studies have indicated that time provides a considerable advantage in terms of the total number of citations, given the fact that the articles have been available for longer.^28,29 However, the present study showed that 31 of the 50 articles listed were published in the year 2000 or later, while the time span was from 1968 to 2016. And, the articles with the 10 highest citation densities were from the years 2005 to 2016 (Table 1). There has been an increase in visibility over time of transgender patients and their unique surgical needs.^26,27 It follows that as the visibility of this patient population continues to increase, more data and research will accrue.

The current study showed that global contribution to the most-cited gender-affirming surgery research was limited to Europe, North America, Asia, and Australia, with the vast majority of research coming from Europe, following the rapid increase in visibility and identification of transgender individuals in Europe.^30,31 This may be due in part to perceived differences in the freedoms of sexual expression in Europe and the Americas in comparison to Africa and parts of Asia. ⁶ Over time, the keywords have changed as well (Figure 4). Words like “transsexual” and “sex reassignment” are among the most frequently occurring keywords and have been utilized in the most recently published article from this list. Today, these terms are largely outdated and do not reflect the lexicon of transgender medicine. ²⁵ Interestingly, while the phrase “gender affirming” has been recently adopted as medically inclusive language, none of the 50 most-cited articles included these keywords. ³² Academic surgeons and health care providers must be cognizant of the evolving terminology and endeavor to utilize inclusive language so that research work remains accessible, and the medical community continues to become more hospitable to transgender patients.

There are limitations that exist within citation analysis studies. One such limitation is the difficulty in assessing the potential bias of authors who cite articles from the journal in which they are targeting for publication. In addition, this study, as with the methods previously described, did not account for self-cited articles, which may benefit high-volume authors.^33,34 Textbooks, lectures, and academic presentations were not included in this analysis. Additionally, utilization of a database comes with inherent limitations. The Scopus database has its own classification system of publications, which is not available to users. This may have led to the potential omission of influential articles. Citation analysis may also be a victim to the “snowball effect”, which posits the possibility that authors may be likely to cite a study that has been previously cited in publications, regardless of the quality of the study. ³⁵

Conclusion

The majority of the most-cited articles in gender-affirming surgery are case series and review articles. There is an opportunity here for more widely performed, higher-level articles to help guide clinical practice. The literature continues to expand, as the majority of articles were published in the year 2000 or later. The authors must be mindful of the terminology, as some keywords may be anachronistic. This study may serve as a reference to researchers and academic surgeons who seek to understand the general landscape of reconstructive gender-affirming surgery in the literature. As the medical community continues to prioritize inclusive comprehensive care, the topics covered in these 50 most-cited articles may expect significant developments and higher level of study in the coming years.^36,37,38

This paper was previously presented as a poster at the ASPS Plastic Surgery Meeting in Atlanta, GA, USA in October 2021. It has not been published elsewhere.