Introduction
The purpose of gender-affirming surgery is to help alleviate distress associated with anatomical structures which (1) cannot be altered or eliminated by medical treatment, (2) have not changed enough with medical treatment, or (3) require the patient to take additional medication to maintain their body in congruence with their gender. Not all individuals who identify as transgender (or gender diverse) want or need surgery. However, surgery is a powerful potential tool to help an individual reach their gender goals.
Some surgical and related procedures can be minimally impactful on a person’s athletic activities, in the case of injectable medications such as fillers, or these procedures can be significantly impactful on a person’s daily functioning as well as athletic activities, as in the case of genital reconstructive procedures.
This chapter is provided to help act as a guide to help individuals and providers anticipate the potential course and impact of several common gender-affirming procedures. It is not fully comprehensive, nor should it serve to replace the role of effective communication between patients and their surgeons or between practitioners caring for a patient. Individual practices may vary, so be sure to maintain open communication with individual surgical providers.
Preparing for surgery
Every surgical protocol is different, but some guidelines for preparing for surgery are as follows.
Tobacco, marijuana, and their components
Many plastic surgeons require discontinuation of nicotine products prior to elective procedures [ ]. Tobacco smoking and nicotine in general is known to impair wound healing [ ]. Thus, it is recommended that all forms of nicotine be discontinued prior to surgery.
Cannabis use has also gained in popularity. There is some evidence that cannabis smoke can impair wound healing [ ]. The most well-studied cannabinoids are D9-tetrahydrocannabinol (D9-THC) and cannabidiol (CBD); their effects on wound healing are not well-appreciated. Studies of bone healing suggest CBD may have a positive effect on bone health and metabolism, whereas D9-THC may have a negative effect [ ]. D9-THC has been found to have a significant antiinflammatory effect, which may negatively affect wound healing [ ], as the inflammatory response is a normal part of initial wound healing. Regular cannabis use can also decrease the effect of opioid pain medications, raise anesthetic requirements, and withdrawal can result in hyperemesis [ ]. Taken together, there is some evidence to suggest avoidance of marijuana smoking before and after surgery, and, potentially, to avoid THC use before and after surgery. It appears that it may be safe to continue CBD products before and after surgery. However, there is great need for additional study of these substances.
Immunomodulators
Systemic corticosteroids and disease-modifying antirheumatic drugs (DMARDs), among other medications, are well known to interfere with wound healing [ ]. Systemic corticosteroids should be discontinued safely prior to surgery and timing for surgery should be coordinated with providers managing DMARD administration (typically timing surgery to be after at least one half-life of the medication) [ ]. Failure to discontinue these medications can lead to dysfunctional wound healing, including wound separation, delayed wound healing, poor scarring, and other problems. As always, specific cases should be navigated with the patient’s specialists and surgeon.
Hormone therapy
Hormone therapy is frequently used to help alleviate gender dysphoria in gender diverse individuals. For individuals designated male at birth (DMaB) seeking “feminizing” therapies, this treatment consists of some formulation of estrogen as well as a medication specifically to suppress testosterone production by the body, often spironolactone. For individuals designated female at birth (DFaB) seeking “masculinizing” therapies, hormone treatment often consists of some formulation of testosterone, but can include other medications to provide contraception, to help the cessation of menses, and to reduce some potentially undesired effects of testosterone [ , ].
Hormone replacement therapy with estrogen is known to increase risk of development of a deep vein thrombosis (DVT) or pulmonary embolism (PE). The formulation of estrogen and the route of administration can play a role in its thrombogenicity [ ]. There is controversy over the need to discontinue estrogen therapy prior to major surgery.
Some surgeons require discontinuation of estrogen therapy 2 weeks prior to major surgery to decrease the risk of DVT/PE. This can lead to perimenopausal symptoms in some patients. The need to discontinue estrogen before therapy should be a discussion with the operating surgeon. Factors that might contribute to needing to discontinue estrogen include the patient’s medical history, body mass index (BMI), duration of the planned procedure, travel time before and after surgery, mobility status, family history, and other considerations.
Generally, there is weaker evidence for the discontinuation of testosterone prior to major surgery, however some surgeons do recommend or require it.
Blood thinners
Medications that promote bleeding are typically discontinued before surgery unless the benefits significantly outweigh the risks. Patients on blood thinners will need to check with their doctor and surgeon to assess the safety of discontinuing the medications prior to any procedure.
Aspirin should not be used as a pain medication within 2 weeks of surgery, due to its irreversible effect on circulating platelets. If aspirin is being taken for any other reason, there will been to be a discussion of the risks versus benefits of discontinuation.
There is some controversy over the role of nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen and naproxen. While they may slightly increase risk of bleeding, their benefit as a nonnarcotic pain medication. There is growing evidence that NSAIDs do not meaningfully contribute to postoperative bleeding [ ].
Herbal supplements
Some herbal supplements, such as gingko and garlic, can promote bleeding if taken in significant amounts. Other herbal remedies, such as St. John’s wort, can interfere with other medications. Patients should check with their surgeons if they feel they want to continue any herbal supplements.
Travel
Patients who have prolonged travel time for a surgical procedure may be at increased risk for venous thromboembolism (VTE) which can result in PE. PE can cause death, severe disability, or significant impact on exercise capacity. Patients traveling for several hours should plan for multiple breaks to walk around to decrease risk of VTE [ ].
Recovery between surgical procedures has significant variability. Patients should review with their surgeons how long they should remain in the area following their procedure.
Finances
Genital and chest surgery procedures may require activity modification for a prolonged period, which may preclude some patients from working in their normal job capacity. Patient should check their Short-Term Disability policies and/or ensure they have enough of a financial cushion to address expected and unexpected incidental costs, especially in the event of complications during recovery.
Support system
Patient should ensure they have an adequate and stable community of individuals who can provide physical and/or emotional support following major surgical procedures. This is especially important during genital surgery procedures. The patient make have functional limitations that require them to have assistance a couple or more times a day. Additionally, even during an uncomplicated postoperative course, patients can experience depression, anxiety, and other difficult emotions, and should be able to turn to friends or other support persons to help during those times.
Principles of wound healing after surgery
Events in wound healing are often described in three phases: inflammatory, proliferation, and maturation [ , ]. These phases are a continuous, blended, symbiotic process. Different segments of incisions or different incisions from the same surgery can be in different phases of healing simultaneously.
The inflammatory phase begins with hemostasis; the blood vessels in the area constrict and coagulation occurs to limit blood loss. Hemostasis is achieved in 6 hours. Over the next one to 6 days, blood vessel dilation and angiogenesis occur to permit all needed cells (keratinocytes, polymorphonuclear neutrophils, fibroblasts), antibodies, growth factors, and enzymes to reach the wounded area and restructure the basement membrane. During this time, the main cells at work are the phagocytic cells: neutrophils and macrophages.
Though a necessary part of healing, this rise in exudate levels can lead to erythema, heat, edema, and pain. If the exudate leaks in the surrounding area, maceration can occur. It can be managed with light activity, elevation, medications. Preoperative exercise status, nutrition intake, vascular supply and the baseline health of the patient play significant roles in promoting a improved postsurgical outcome.
The proliferation phase begins on day three and lasts for 3 weeks. The formation of granulation tissue and restoration of the vascular network occurs during this phase. Initially, fibroblasts produce abundant loose type III collagen and some type I collagen. Nearing the end of this phase, fibroblasts and type I collagen become primary. Evidence does not support inactivity and stasis as effective intervention. Instead, begin placing light stresses on tissues with gentle massage and movement. Simply walking can also assist in promoting healing.
The remodeling phase begins at 3 weeks and continues up to and beyond 12 weeks. Collagen is degraded and deposited in an equilibrium-producing fashion. Stronger type I collagen replaces type III collagen. Collagen is positioned in small parallel bundles, unlike the basket-weave collagen in the uninjured dermis. Organizational changes in collagen improve tensile strength, however, scar tissue will only achieve the 80% of the strength of intact, uninjured skin.
When considering returning to sport, one must consider the strength of the wound. Myofibroblasts produce wound contractions through their numerous connections to collagen and help decrease the surface area of the developing scar. The wound continues to gain tensile strength, thickness, and organization with newly deposited type III collagen fibers [ ]. After 15–20 days, there is decreased risk of wound separation. Tissue strength at 3 weeks is approximately 20%–30% of the original skin. By week 6, the concentration of collagen fibers begins to resemble that of intact skin. The collagen matrix matures to become denser and more uniformly aligned.
Wound disruption is unlikely because the tensile strength of the wound is nearing 60%–70% of intact skin. Avoid resuming strenuous physical activity until 6 weeks postoperatively. By the 12th week post-op/injury a small gain in strength will result from the further aggregation of type I collagen fibrils into fibers. Maximal tensile strength is achieved at 80% tensile strength in the resultant scar versus that of the original skin. Throughout the first year, the alignment of those fibers will form an organized scar [ ].
Abnormalities of scar tissue healing can easily be observed on the skin surface [ , ]. Generally, two types of scar abnormalities are described, hypertrophic and keloid. Hypertrophic scars remain within the border of the incision. They have a static phase, followed by possible spontaneous regression. Keloid scars grow beyond the boundaries of the incision and do not resolve naturally. Keloids can result from repeated rewounding [ ]. There is a Keloid-triad hypothesis in the etiopathogenesis of keloids [ ]. The triad includes infection, genetic factors, and suture factors, which include rigidity and location in relation to skin lines of tension and rigidity of sutures. Keloid scars tend to form in the upper torso of the body, head (earlobes and mandibular ridge), neck, back, deltoid, and presternal areas. Contributing factors for abnormal scarring are, inadequately moist environment, excessive mechanical forces on the wound, wound infection, foreign body reactions and allergies.
Scar tissue adhesions arise from the failure of the tissues to form independent layering [ ]. There is a restriction of scar mobility with respect to underlying tissue with nonanatomic connections of fibrous tissue between normal tissue planes. Part of this is related to an imbalances in regulatory mechanical steps of the healing process, and some people are more prone to develop postoperative adhesions [ ]. Ischemia is thought to be the most volatile insult leading to adhesion development. Adhesions can limit range of motion and musculoskeletal strength and can alter proprioceptive input. Medical providers can assist with enhancing wound healing by promoting circulation with appropriate amount of movement with respect to the phases of healing and support with lifestyle changes, nutrition, and medications.
When discussing wound healing abnormalities in the context of gender-affirming surgery, a few procedures rise to the top. Keloids and hypertrophic scars in chest contouring surgery are commonly considered. There is a concern for keloid development in the inframammary incision. Keloids on the vulva may result from too much activity or too much sitting and poor swelling management. Intraabdominal adhesions in peritoneal or bowel vaginoplasty might occur. Adhesions are also a risk at the donor site for radial forearm flap phalloplasty and can significantly impair use of the hand and forearm related to independent motion in the multiple layers of muscle and tendons that move the wrist hand and fingers. Adhesions in the donor site of the anterior lateral thigh flap phalloplasty are typically less problematic due to the strength and bulk of the underlying structures.
Throughout the remainder of this chapter, we will highlight specifics for each surgical procedure. Overall, we consider that lifestyle, including appropriately-timed exercise, is important preoperatively and postoperatively. Additionally, mechanical stress is essential for the appropriate of tensile strength of a wound; mechanical force on a wound is required for angiogenesis and the migration of fibroblasts, which accelerates the gain in tensile strength with stimulation of growth factors, collagen production, and blood vessel growth.
Timeline of physiology and activity recommendations
| Week | Percent tensile strength | Healing mechanism | Clinical implications for promoting healing |
|---|---|---|---|
| Week 1 | 3% |
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| Week 2 | 7% |
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| Week 3 | 18% |
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| Week 4 | 34% |
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| Week 5 | 50% |
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| Week 6 | 68% |
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