Abstract
Background:
Gender affirming top surgery is becoming increasingly common, with greater diversity in the patients receiving top surgery. The purpose of this study was to examine national trends in patient demographics, characteristics, wound complication rates, and concurrent procedures in patients receiving gender affirming top surgeries
Methods:
Patients with gender dysphoria who underwent breast procedures, including mastectomy, mastopexy, breast augmentation, or breast reduction by a plastic surgeon between 2013 and 2022, were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. These procedures were considered to be gender affirming “top surgery”. Univariate analyses were performed to examine trend changes in the patient population and types of additional procedures performed over the last decade.
Results:
There was a 38-fold increase in the number of patients who received top surgery during the most recent years compared to the first two years of the decade. Significantly more individuals receiving top surgery in recent years were non-binary (p<0.01). There was a significant decrease in percentage of active smokers (p<0.01) while there was an increase in percentage of patients with diabetes (p=0.03). While there was a significant increase in the number of obese patients receiving top surgery (p<0.01), there were no differences in postoperative wound complications between the years. Significantly more patients received additional procedures (p<0.01) and had about a 9-fold increase in distinct number of additional CPT codes from 2013–2014 to 2021–2022.
Conclusion:
Our study found that there has been (1) a significant increase in the number of top surgery patients from 2013 to 2022 overall, and (2) a particular increase in patients with preoperative comorbidities, such as a higher BMI and diabetes. Understanding current and evolving trends in patients undergoing surgical treatment for gender dysphoria can inform individualized care plans that best serve the needs of patients and optimize overall outcomes.
Keywords: gender dysphoria, gender-affirming surgery, top surgery, transgender
Introduction
Roughly 1.9 million Americans identify as transgender, gender non-conforming, and non-binary, and this is likely a significant underestimate.1–3 Gender-affirming care plays an essential role for transgender individuals experiencing gender dysphoria to emotionally and physically align with their expressed gender identity.4 Of the many medical treatments that currently exist, gender-affirming surgery (GAS) has become increasingly common. GAS encompasses various procedures that include craniofacial, top (performed on the chest) surgery, and bottom (performed on the genitalia) surgery.5,6 Surgical treatment plans are often customized to fit the patient’s preferences and goals of care. Gender-affirming top surgery continues to be the most common type of GAS for the transfeminine, transmasculine and non-binary populations.7,8
Feminizing top surgery commonly includes an implant-based breast augmentation, however it may also include a mastopexy, liposuction or fat grafting or a nipple reconstruction. Masculinizing top surgery often includes a simple mastectomy, and is frequently accompanied by pedicle based nipple repositioning, nipple grafting, or suction lipectomy. Gender non-conforming and non-binary patients may prefer breast reduction techniques over mastectomy, in an effort to better conform with their gender identity.9 It is well known that the prevalence of gender affirming top surgery is increasing overall, however, it is less clear which procedures are increasing in prevalence and whether there has been a change in the concurrent procedures accompanying these top surgeries. Furthermore, changes in the prevalence of various patient populations with gender dysphoria seeking top surgery, as well as their preoperative comorbidities, has been relatively unexplored. A better understanding of these trends and current prevalence could guide surgical care of individuals seeking gender affirming top surgery, and provide important insights to better anticipate their needs. The purpose of this study is to examine national trends in patient demographics, characteristics, wound complication rates, and concurrent procedures in patients receiving gender affirming top surgeries between 2013 and 2022 using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) Database.
Methods
This study was determined to be exempt by our Institutional Review Board. ACS-NSQIP is a surgical database used to measure 30-day outcomes of surgical interventions whose methods have been previously established.10,11 Patients with gender dysphoria who underwent “top surgery” from 2013 to 2022 performed by plastic and reconstructive surgeons were identified using the principal Current Procedural Terminology (CPT) codes.
Definition of Gender and Gender-Affirming Top Surgery
Several criteria were used to identify and classify patients with gender dysphoria who underwent top surgery. Patients who underwent breast procedures – including mastectomy, mastopexy, breast augmentation, or breast reduction – were identified. Those with a postoperative diagnosis of “other gender identity disorder,” “gender dysphoria of childhood,” “gender dysphoria in adolescence and adulthood,” “sexual and gender identity disorders,” or “transsexualism” were identified and included using International Classification of Diseases, Ninth Revision (ICD-9) or Tenth Revision (ICD-10) codes (see Table, Supplemental Digital Content 1).
Prior to 2019, sex variable did not include additional gender descriptions and by 2019 NSQIP subsequently expanded the sex variable options to include non-binary as a gender entry option. As such, this study did not utilize assigned sex for gender classification. To consistently define the gender population across all years examined, patients were instead classified into three gender cohorts based on principal procedures they had performed as all patients in this population had some postoperative diagnosis of gender dysphoria. Transmasculine was defined as any patient diagnosed who underwent any type of mastectomy (19300, 19301, 19302, 19303, 19305, 19306, 19307, and 19308) with the assumption of a chest masculinization surgery. Transfeminine was defined as any patient who underwent breast augmentation (19325). Non-binary (assigned female at birth) were the remaining individuals diagnosed with gender dysphoria but did not seek a full chest masculinization surgery – instead seeking a breast reduction (19318) or mastopexy (19316).
Primary Outcomes of Interest
Primary outcome of interest was the trend in utilization of top surgery over a ten-year period, divided into five 2-year cohorts. Preoperative characteristics including age, Body Mass Index (BMI), and past medical history were examined. Outcomes at postoperative day 30 were analyzed and categorized by wound complication types, which included superficial surgical site infections, organ space or deep surgical site infections, and wound dehiscence. Trends of concurrent procedures performed at the time of top surgery were also examined.
Statistical Analysis
All analyses were performed using JMP® (version 17, SAS Institute Inc., Cary, North Carolina). Normally distributed, continuous data was reported as means and standard deviations. Categorical variables were reported as frequencies and percentages. Chi-Squared (χ2) tests were performed for categorical data and for continuous data, Analysis of Variance tests were performed, when appropriate. Significance was set at p≤0.05.
Results
Demographic trends are highlighted in Table 1, separating years 2013–2022 into five groupings each consisting of two consecutive years. The year 2021–2022 had the highest cases with 3403 patients, an approximately 38-fold increase from 2013–2014 and 3-fold increase from the former years of 2019–2020 (Figure 1). The proportion of transfeminine patients decreased from 52.27% (2013–2014) to 25.98% (2021–2022) while the non-binary population increased from 4.55% (2013–2014) to 34.26% (2021–2022) (Figure 2). The average age of patients receiving top surgery was significantly lower in the recent two years of the decade (29.08 years) versus the earlier two-year time period (36.20 years). This significant reduction in age at the time of top surgery was observed both in transmasculine (p=0.01) and transfeminine patients (p=0.02).
Table 1.
Trends in Patient Demographics and Procedures in Top Surgery
| Year | 2013–2014 | 2015–2016 | 2017–2018 | 2019–2020 | 2021–2022 | p-value |
|---|---|---|---|---|---|---|
| n=5,665 | 88 | 354 | 664 | 1,156 | 3,403 | - |
| Gender Population Defined by CPT Codes, n (%) | ||||||
| Transmasculine | 38 (43.18) | 101 (28.53) | 251 (37.80) | 558 (48.27) | 1344 (39.49) | <0.01 |
| Transfeminine | 46 (52.27) | 155 (43.79) | 238 (35.84) | 342 (29.58) | 883 (25.95) | |
| Non-binary | 4 (4.55) | 98 (27.68) | 175 (26.36) | 256 (22.15) | 1176 (34.56) | |
| Age, mean (SD) | ||||||
| Overall | 36.20 (11.20) | 31.99 (11.35) | 30.17 (11.18) | 29.11 (10.08) | 29.08 (10.05) | <0.01 |
| Transmasculine | 30.53 (6.20) | 27.04 (7.91) | 26.51 (8.49) | 25.82 (7.82) | 26.23 (7.64) | 0.01 |
| Transfeminine | 41.70 (12.06) | 36.50 (12.90) | 36.19 (12.70) | 35.84 (11.87) | 35.70 (11.70) | 0.02 |
| Non-binary | 27 | 29.98 (8.86) | 27.23 (8.68) | 27.20 (7.14) | 27.37 (8.82) | 0.06 |
| Body Mass Index, n (%) | ||||||
| <18.5 | 0 (0) | 9 (2.54) | 13 (1.96) | 14 (1.21) | 88 (2.59) | <0.01 |
| 18.5 – 24.9 | 32 (36.36) | 128 (36.16) | 215 (32.38) | 324 (28.03) | 961 (28.24) | |
| 25.0 – 29.9 | 32 (36.36) | 92 (25.99) | 194 (29.22) | 361 (31.23) | 930 (27.33) | |
| 30.0 – 34.9 | 14 (15.91) | 55 (15.54) | 121 (18.22) | 271 (23.44) | 710 (20.86) | |
| 35.0 – 39.9 | 8 (9.09) | 50 (14.12) | 63 (9.49) | 115 (9.95) | 389 (11.43) | |
| >40.0 | 2 (2.27) | 20 (5.65) | 58 (8.73) | 71 (6.14) | 325 (9.55) | |
Abbreviations: CPT, Current Procedural Terminology
Figure 1.
Number of Top Surgery Cases Performed in Gender Cohorts from 2013 to 2022.
Figure 2.
Proportion of Top Surgeries Performed by Gender Cohorts from 2013 to 2022.
In terms of patient BMI, the majority of patients consistently fell into two BMI categories, specifically 18.5–24.9 or 25.0–29.9. However, there was a significant increase in obese patients (BMI ≥30.0) receiving top surgery throughout the years (p<0.01) (Figure 3). Preoperatively, there was a significant decrease (p<0.01) in patients with active smoking status in the most recent two years (Table 2). The 2015–2016 cohort had the highest percentage of tobacco smokers with 26.84 percent, while the 2021–2022 cohort had tobacco smokers of 12.17 percent. On the other hand, significantly more patients had diabetes at the time of surgery in recent years (p=0.03). While there were no patients with active diabetes in 2013–2014, 3.73% of patients had active diabetes in 2021–2022. Postoperatively, there were no significant differences in wound complications throughout the decade, including superficial SSI, deep SSI, organ or space SSI, and wound dehiscence.
Figure 3.
Trends in Proportion of Obese (BMI ≥ 30.0) Patients Receiving Top Surgery from 2013 to 2022.
Table 2.
Trends of Patient Past Medical History and Wound Complications
| Year | 2013–2014 | 2015–2016 | 2017–2018 | 2019–2020 | 2021–2022 | P-Value |
|---|---|---|---|---|---|---|
| n=5,665 | 88 | 354 | 665 | 1,156 | 3,403 | - |
| Past Medical History, n (%) | ||||||
| Smoking Status | 16 (18.18) | 95 (26.84) | 119 (17.92) | 171 (14.79) | 414 (12.17) | <0.01 |
| Diabetes | 0 (0) | 4 (1.13) | 22 (3.31) | 34 (2.94) | 127 (3.73) | 0.03 |
| Hypertension | 6 (6.82) | 18 (5.08) | 40 (6.02) | 64 (5.54) | 203 (5.97) | 0.93 |
| Wound Complications, n (%) | ||||||
| Superficial SSI | 0 (0) | 4 (1.13) | 7 (1.05) | 9 (0.78) | 45 (1.32) | 0.50 |
| Deep SSI | 0 (0) | 0 (0) | 0 (0) | 1 (0.09) | 6 (0.18) | 0.69 |
| Organ/Space SSI | 0 (0) | 0 (0) | 2 (0.30) | 0 (0) | 3 (0.09) | 0.31 |
| Wound Dehiscence | 0 (0) | 0 (0) | 0 (0) | 1 (0.09) | 4 (0.12) | 0.86 |
Abbreviations: SSI, Surgical Site Infection
Table 3A presents trends in additional procedures that patients received in addition to their primary gender-affirming top surgery. There was a significant increase in the percentage of patients who received one or more additional concurrent procedures (p<0.01). For transmasculine patients, the greatest increase in additional CPT code use was seen in the year of 2017–2018. For transfeminine patients, the greatest increase in codes was seen in the year of 2021–2022. There was an approximately 9-fold increase in the number of distinct additional CPT codes seen in recent years compared to the first two years of the decade (Table 3B). The increase in the distinct number of additional CPT codes was consistent across all gender categories. Supplemental Table 2 (see Table, Supplemental Digital Content 2) outlines primary and additional CPT Codes for some of the most common concurrent procedures performed in patients undergoing top surgery.
Table 3A.
Trends of Additional/Concurrent Procedures in Top Surgery
| Year | 2013–2014 | 2015–2016 | 2017–2018 | 2019–2020 | 2021–2022 | P-Value |
|---|---|---|---|---|---|---|
| Overall | 54 (61.36) | 52 (14.69) | 190 (28.61) | 478 (41.35) | 1356 (39.85) | <0.01 |
| Transmasculine | 10 (26.32) | 28 (27.72) | 151 (60.16) | 370 (66.31) | 812 (60.42) | <0.01 |
| Transfeminine | 44 (95.65) | 12 (7.74) | 22 (9.24) | 30 (8.77) | 136 (15.40) | <0.01 |
| Non-Binary | 0 (0) | 12 (12.24) | 17 (9.71) | 78 (30.47) | 308 (34.69) | <0.01 |
Table 3B.
Trends in Distinct Additional/Concurrent Procedures in Top Surgery
| Overall | 10 | 18 | 30 | 47 | 95 | - |
| Transmasculine | 1 | 8 | 14 | 14 | 30 | |
| Transfeminine | 9 | 9 | 17 | 29 | 66 | |
| Non-Binary | - | 4 | 4 | 11 | 24 |
Discussion
Our study found significant national trends in demographics, characteristics, wound complications, and concurrent procedures over the last decade. Top surgery continues to be the most common type of gender affirming surgery sought by patients who desire surgical intervention for gender dysphoria and its incidence is increasing annually.7,8 Its role in enhancing quality of life, increasing patient satisfaction, and improving patient outcomes is well established.12,13 Understanding the current and evolving trends in patients undergoing top surgery can inform individualized care plans that best serve the needs of patients and optimize overall outcomes.
Trends in Volume and Patient Age
There was a 38-fold increase in case volume over the decade examined, supported by prior research reporting an overall increase in the frequency of top surgery.4,14 This trend, when examined by the gender cohort receiving top surgery, however, reveals different patterns in the utilization of top surgery over time. Over the ten years examined, there has been an increased proportion of transmasculine and non-binary top surgery being performed with a relative decrease in the proportion of GAS patients seeking feminizing top surgery. Furthermore, the average age of patients receiving top surgery decreased significantly over time. These opposing trends may be multifactorial. Increasing visibility and social acceptance of transgender people may have likely promoted and encouraged patients to seek gender affirming care earlier in life, and at earlier onset of gender dysphoria with gender incongruence.15 In addition to increasing societal and medical acceptance, the Affordable Care Act (ACA), enacted in 2010, produced federal and state-level policies which increased gender-affirming care for transgender and other gender-diverse individuals.13,16,17 Currently, about half of state Medicaid programs cover GAS.18 Although some policies remained restrictive, there remains an increase in utilization of GAS, as represented in the shift in age prevalence of patients receiving gender-affirming care in our findings. Disparities still persist as stringent preoperative requirements for coverage result in a subset of patients paying out-of-pocket expenses for gender-affirming care.19,20–22 It is plausible that prior to the expansion of the ACA there was a significant number of patients desiring top surgery, but with limited to no access.23 We surmise that in the earlier years of our patient cohort, many older patients without previous access to top surgery underwent these procedures. The decrease in average age of patients receiving top surgery may also suggest and likely represent the true incidence of gender dysphoria diagnosis nation-wide. Lastly, the exponential increase in the most recent years may also be attributed to Covid-19, as many elective surgeries, including GAS, had a resurgence following the end of the pandemic.24
Trends in Patient Comorbidities and Wound Complications
Comorbid conditions such as tobacco smoking status, diabetes, and obesity increase the risk of postoperative complications.25–27 While some studies have associated high BMI with increased operating time, blood loss, and length of hospital stays, others have shown no correlation with outcomes, particularly in top surgery.28–30 Recently, Hassan et al. has found no significant differences across BMI classification in morbidity outcomes in top surgery patients, thus urging re-evaluation of BMI cutoffs for medical coverage of top surgery.31 Due to inconclusive consensus on risks associated with high preoperative BMI, patient selection for top surgery has been highly surgeon-dependent. Our findings might support the hypothesis that surgeons are developing a more expansive approach with BMI ranges used to determine preoperative risk for top surgery. These trends are reassuring as the incidence of wound complication has remained relatively similar over the years, despite the increasing prevalence of patients with higher BMI receiving top surgery. Consistent with more recent studies looking at the impact of BMI on top surgery, this suggests an acceptable safety profile even with a greater percentage of high BMI patients.
Surgeon preference and comfort level in an individual’s preoperative risk profile might be attributed to improved management of other comorbid conditions such as glycemic control and smoking cessation. The prevalence of smoking demonstrates a downward trend, possibly a result of effective smoking cessation counseling, pharmacotherapy targeted to treat substance use, an increase in patient motivation to receive top surgery, or a combination of these factors. Even with the increased prevalence of diabetes in top surgery patients, stable wound complication rates likely reflect adequate management of or improvement in preoperative glycemic control, as hyperglycemia and hemoglobin A1C level, rather than mere presence of diabetes, have proven to be strong predictors of postsurgical complications.32–34
Trends in CPT Codes in Top Surgery
Previous studies have demonstrated great variability in aesthetic preferences and this may affect the types of additional procedures sought.35,36 In pursuit of individualized surgical care aimed at promoting patient psychological and physical well-being, there has been an evolution in which combined, concurrent surgeries are performed to optimize the cosmesis of masculinizing or feminizing surgeries.37 About 40% of top surgery patients in this NSQIP cohort received concurrent CPT codes. Nipple reconstruction, full-thickness skin graft, and suction-assisted lipectomy were common concurrent procedures performed with primary top surgery in our NSQIP cohort. Furthermore, the distinct number of additional CPT codes have increased by about 9-fold, with nipple reconstruction (19350 and 15200) representing the most consistent and increasingly performed concurrent procedure in transmasculine and non-binary patients. While a pedicled flap is possible for nipple preservation in chest masculinization procedures, according to our data, free nipple grafting has become increasingly common. Transmasculine patients also frequently sought suction lipectomy to create desired masculine contour, a procedure that is often concurrently done with mastectomy.38
There was greater variety and diversity in the concurrent procedures seen over the years, particularly in the transfeminine patient cohort. Breast implant removal (19328 and 19330) were common additional codes seen in this cohort, suggesting history of breast implants, desire for revision, or prior complication.39 Interestingly, concurrent gender-affirming bottom surgery with codes for complete amputation of penis (54125) and simple orchiectomy (54520) were increasingly performed over the years. Likewise, concurrent top and bottom surgery in transmasculine patients was also seen to be on the rise. With chest wall masculinization being the most requested gender-affirming surgery in transgender men, concurrent hysterectomies have been previously reported to be performed simultaneously with a modest to slightly increased risk of complications, the most common being hematoma/bleeding.40,41 Nonetheless, other studies have suggested that combined GAS can be a safe and effective means of optimizing surgical care for transgender patients while decreasing overall recovery time.40–42 Despite the expansion of healthcare, insurance policies guiding coverage and billing practices often vary, which may influence the concurrent procedures or CPT codes utilized in patients undergoing gender affirming top surgery.23,43 Changes in coding over time suggest that both chest wall masculinization and feminization are procedures that are not adequately described by simple or single codes originally designated for cis-gendered patients. Similar to many new procedure types in plastic surgery, future efforts may focus on defining codes that accurately describe the complex nature of these gender affirming procedures. This may aid in developing adequate guidelines and minimize inconsistencies in billing practices, while reflecting the considerable time, effort, and expertise that plastic surgeons provide.44
Limitations
The generalizability of our study results may be limited to patient populations that are NSQIP participating, calling for subsequent investigation in smaller hospital settings. Examining and comparing these trends in non-participating ambulatory surgery centers as well as private practice may offer additional understanding to validate our study’s findings. Though the NSQIP database adheres to strict data collection methods, large database studies can be biased by inaccuracies in information entry including, but not limited to, coding of procedures and postoperative diagnosis. As such, this heterogeneity across electronic medical records, may result in an underestimation of the number of gender-affirming procedures across various participating institutions. Given the ability to include non-binary as a gender option under sex was not available until 2019, our study was limited in how gender could be classified. As such, non-binary patients, assigned female at birth, were likely captured and included only if they received a breast reduction or mastopexy. Because the goals of surgical care differ in that non-binary patients assigned male at birth compared to non-binary, assigned female at birth, future research should evaluate trends in this patient population incorporating validated patient-reported outcomes through a multi-institutional approach. Finally, as previously mentioned, although the NSQIP database provides very specific data collection instructions, the extrapolation of gender dysphoria from a set of inclusion criteria based on principal CPT and ICD9/10 codes may not have captured all patients.
Conclusion
Gender affirming top surgery is becoming increasingly common, and patients receiving top surgery have become more diverse. Understanding current and evolving trends in patients undergoing surgical treatment for gender dysphoria can inform individualized care plans that best serve the needs of patients and optimize overall outcomes. Our study found that there has been (1) a significant increase in the number of top surgery patients from 2013 to 2022 overall, and (2) a particular increase in patients with preoperative comorbidities, such as a higher BMI and diabetes. While the average age was greater in the first several years of our study period, the more recent younger cohort is likely closer to the true incidence of GAS patients seeking top surgery. Nevertheless, the number of top surgery patients seeking surgical treatment annually may continue to increase as care hopefully becomes more accessible and socially acceptable. Understanding the distribution and changes in CPT code usage may inform future billing practices and help plastic surgeons accurately describe the complex nature of these gender affirming procedures. Given these findings, plastic surgeons should be prepared to care for a higher volume and greater diversity of patients seeking GAS, with an overall goal to improve access to care, improve patient quality of life and optimize outcomes.
Supplementary Material
Table 4.
Trends of Most Commonly Performed Concurrent Procedures in Top Surgery
| Year | 2013–2014 | 2015–2016 | 2017–2018 | 2019–2020 | 2021–2022 |
|---|---|---|---|---|---|
| Transmasculine | 19350 (100%) | 19350 (64.10%) 19499 (7.69%) 14000 (5.13%) |
19350 (74.23%) 15200 (9.79%) 15877 (7.22%) |
19350 (78.47%) 15200 (13.68%) 15877 (4.23%) |
19350 (78.24%) 15200 (8.55%) 15877 (5.37%) |
| Transfeminine | 14301 (25.93%) 55970 (18.52%) 57335 (18.52%) |
19316 (17.65%) 19330 (17.65%) 55970 (17.65%) |
19328 (18.75%) 19371 (18.75%) 19316 (9.38%) |
54125 (9.52%) 14041 (8.73%) 14301 (8.73%) |
19371 (7.78%) 54520 (7.25%) 54125 (6.30%) |
| Non-Binary | - | 19304 (62.50%) 19350 (18.75%) 19499 (12.50%) |
19350 (80.95%) 15877 (9.52%) 19380 (4.76%) |
19350 (76.52%) 15877 (5.22%) 19303 (5.22%) |
19350 (80.4%) 55980 (5.25%) 15200 (3.90%) |
Funding/Support:
Tufts University School of Medicine; The project described was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, Award Number T32TR004417. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Footnotes
Conflict of Interest: None.
Disclaimers: None.
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