Gender-affirming and plastic surgeries

Gender Reassignment and Plastic Surgeries

Dr. Rachael Lattanzio

Objectives

  • Definition and Indications

  • Types of Surgeries

  • Nursing Considerations

  • Complications and Management

Gender Reassignment Surgery

Definition

  • Transgender:

    • Relates to a person who identifies with a gender that differs from the one assigned at birth.

Gender Affirming Care

  • Statement: Everyone deserves access to care.

    • Emphasis on inclusive healthcare practices for all individuals regardless of gender identification.

Gender Affirmation Surgery

  • Known As: Sex reassignment surgery.

  • Requirements:

    • Under 18: Must meet specific medical criteria.

    • Over 18: Must provide informed consent.

Types of Gender Affirmation Surgery

  1. Transwoman (Male to Female)

    • Surgical modifications aimed at aligning physical attributes with gender identity.

  2. Transman (Female to Male)

    • Surgical options to convert female physiological features to male characteristics.

Diagnostic Criteria

  • Medical Diagnosis: Established if a person expresses a profound desire to live and be accepted as a member of their identified gender.

  • Criteria:

    • Persistent sense of discomfort regarding one’s sex.

    • A strong wish to eliminate one’s genitalia.

    • Desire to live as a member of the opposite sex.

    • Experiences continuous discomfort for 2+ years and has been on hormone therapy for at least 1 year.

    • Absence of a mental disorder.

Hormone Therapy

  • Initial Approach: Puberty Blockers used first if the patient is in youth.

  • Medical Interventions:

    • Male to Female: Treatment includes estrogen along with antiandrogens.

    • Female to Male: Treatment includes testosterone.

Gender-Affirming Hormone Therapy: Key Considerations

  • Mental Health: Continuous counseling recommended before and during treatment.

  • Body Composition: Expected changes during virilization or feminization.

  • Bone Health: Typically stable, critical in adolescents or adults with low compliance.

  • Oncological Risks: Awareness of anatomical realities necessary.

  • Cardiovascular Health: Monitoring should occur similar to cisgender individuals, focusing on risks associated with:

    • Diabetes Mellitus type 2

    • BMI (Body Mass Index)

    • Arterial Hypertension

    • Polycythemia

    • Sedentary lifestyle

    • Hypercholesterolemia

    • Smoking

Perioperative Considerations

  • Preoperative Labs: Including but not limited to:

    • H&H (Hematocrit and Hemoglobin), LFTs (Liver Function Tests), Lipid Profile, Potassium, CBC (Complete Blood Count), Kidney Function Tests, Prolactin levels.

  • Other Considerations:

    • Pregnancy testing, privacy, venous thromboembolism awareness, anatomical considerations, room assignments, and psychosocial concerns.

Male to Female Surgeries

  • Types of Surgeries:

    • Genital Reconstruction to create a vagina including:

    • Penile inversion

    • Recto-sigmoid colon vaginoplasty

    • Vaginoplasty

    • Orchiectomy: Removal of the testicles.

    • Penectomy: Removal of the penis.

    • Breast Augmentation.

Female to Male Surgeries

  • Procedures:

    • Clitoral Enlargement due to hormone therapy.

    • Phalloplasty: Construction of a penis.

    • Metoidioplasty: Utilizing the existing genitalia to form a penis.

    • Mastectomy: Removal of breast tissue.

    • Vaginectomy: Removal of the vagina.

    • Labia Minora Reassignment: Utilization for penis skin.

    • Vagina Reassignment: Used for urethra reconstruction.

Other Surgeries

  • Tracheal Shaving: Decreases the size of Adams apple in males.

  • Facial Aesthetics:

    • Cheek Injections: Commonly for enhancing cheekbone structure.

    • Chin Procedures: Softening edges or enhancing definition.

    • Jaw Modifications: Shaving or fillers for jaw enhancement.

    • Rhinoplasty: Reshaping of the nose.

Nursing Considerations

Pre-Operative

  • Informed Consent:

    • Validate that patients understand and have signed consent for the surgery.

    • Document the informed consent process in detail.

  • Preoperative Preparation Tasks:

    • Assist with skin cleaning, hair removal, and administration of preoperative medications.

    • Surgical site marking is imperative.

Intraoperative

  • Responsibilities:

    • Assist in patient care including positioning on the OR table, urethral catheter placement, maintaining airway, and monitoring vitals.

Post-Operative

  • General Considerations:

    • Monitor for anesthetic complications in PACU (Post-Anesthesia Care Unit).

    • Ensure pain management is addressed.

    • Surveillance for bleeding and infection.

    • Manage medication and provide patient education on postoperative care including wound care and follow-up appointments.

Recovery Guidelines

  • Cheek and Nose Surgery: Swelling may last for 2 to 4 weeks.

  • Chin and Jaw Surgery: Most swelling subsides within 2 weeks, complete resolution may take up to 4 months.

  • Chest Surgery: Swelling and soreness usually last for 1 to 2 weeks; vigorous activity should be avoided for at least 1 month.

  • Bottom Surgery: Patients might need 6 weeks before resuming usual activities; follow-ups required weekly for a few months.

Post-Operative Complications

  • Potential Issues:

    • Regret over surgical decision.

    • Urethra Injury.

    • Nerve Damage to the surgical area.

    • Infection and Bleeding risks.

Nursing Considerations for Transgender Individuals

  • Pronouns: Use proper pronouns (They/Them, She/Her, He/Him).

  • Culturally Competent Care: Understanding and sensitivity to the unique needs of transgender and gender non-binary individuals.

  • Psychological Support:

    • Prioritize mental health assessments to provide emotional support and resources.

Holistic Nursing Approach

  • Emphasizes addressing physical, emotional, and psychosocial aspects of care.

  • The goal is to provide patient-centered care that respects gender identity.

Affirming Opportunities in Nursing Language

  • Language Use: Encourage rephrasing statements to be affirming to the patients.

  • Debrief Importance: Affirming language builds trust and improves patient outcomes.

Common Plastic Surgeries Overview

  • Types:

    • Liposuction

    • Rhinoplasty

    • Breast Augmentation/Reduction

    • Facelifts

    • Abdominoplasties

    • Breast Reconstruction (post-mastectomy)

    • Skin grafts (for burns/wounds)

    • Cleft lip & palate repair

    • Facial trauma repair

    • Hand surgery

Nursing Considerations for Plastic Surgery

  • Discussion needed on primary nursing considerations for preoperative and postoperative care.

Specific Surgery Procedures and Recoveries

Rhytidectomy (Facelift)

  • Definition: Surgical procedure aimed at wrinkles and sagging skin due to aging.

  • Recovery: Complete by 2 to 4 weeks; can return to work afterward.

Blepharoplasty

  • Definition: Eyelid-reshaping surgery

  • Recovery: Usually resume public appearances within 10 to 14 days; swelling/bruising may take longer.

Browplasty (Brow Lift)

  • Definition: Tightens forehead skin to remove wrinkles and smooth creases.

  • Recovery: Normal activities can resume within 10 days but may take longer if combined with other procedures.

Rhinoplasty (Nose Job)

  • Definition: Reshape the nose for better facial symmetry.

  • Recovery: Bruising fades over 10 days.

Mastopexy (Breast Lift)

  • Definition: Elevates sagging breasts.

  • Recovery: Return to work within two weeks; full activity might take up to one month.

Breast Augmentation

  • Definition: Surgical enlargement of breasts.

  • Recovery: Most return to normal activity within 1-2 weeks.

Reduction Mammaplasty (Breast Reduction)

  • Definition: Removal of fatty tissue in the breast.

  • Uses: Cosmetic reasons or alleviation of physical discomfort.

  • Recovery: Typical return to work within two weeks.

Liposuction

  • Definition: Procedure to suction fat from targeted areas.

  • Types:

    • Tumescent Liposuction: Involves injection of numbing agents.

    • Ultrasonic-Assisted Liposuction (UAL): Utilizes ultrasonic energy.

  • Recovery: Return to work can vary based on extent of treatment but often within a few days.

Abdominoplasty (Tummy Tuck)

  • Definition: Removes excess skin and tightens the abdomen.

  • Recovery: Guidelines suggest normal activities resume in 2-3 weeks with possible extended limits pre-existing skin hang.

Pre-Operative Assessment Factors

  • Medical History & Risk Factors: Comorbidities like hypertension, diabetes, smoking, or clotting issues.

  • Psychosocial Assessment: Understanding patient expectations, body image issues, and support systems.

  • Nutritional Status: Assess for malnutrition which affects healing.

  • Medication Review: Identifying anticoagulants or NSAIDs.

Post-Operative Monitoring Checklist

  • Vital Signs: Be vigilant for hypotension or tachycardia.

  • Pain Management: Utilize PCA, opioids, or NSAIDs.

  • Incision & Drain Care: Inspect for signs of infection or dehiscence.

  • Compression Garments: Facilitates healing and reduces swelling.

  • Prevent DVT: Focus on ambulation.

Post-Operative Patient Education

  • Recommendations:

    • Smoking cessation critical for healing.

    • Maintain high hydration and nutrients; a high-protein diet is advisable.

    • Be aware of signs of infection.

    • Avoid strenuous activities specific to the surgical procedure.

Common Post-Operative Complications and Interventions

Early Complications:

  • Hematoma Formation: Monitor the site, apply pressure as needed.

  • Infection: Look for erythema, fever, and drainage.

  • Pain Management Issues: Addressing promptly is crucial.

Late Complications:

  • Scarring & Keloid Formation: Monitor and manage.

  • Delayed Wound Healing: Especially in smokers and those with diabetes.

  • DVT/PE Risk: Increased in longer surgical episodes.

Nursing Interventions for Pain and Comfort

  • Pain Management: Includes opioids, NSAIDs, and non-pharmacological methods like ice packs or elevation.

  • Positioning: In contexts of head elevation for facelift, or semi-Fowler's position for abdominoplasty to lessen tension.

  • Emotional Support: Encourage understanding when to seek help for excessive symptoms post-procedure.

Ethical Considerations for Gender Affirmation and Plastic Surgeries

  • Autonomy & Informed Consent: Patients should have a clear understanding of the risks and benefits.

  • Body Dysmorphia Awareness: Important to screen for unrealistic expectations and considerations.

  • Access & Equity: Discuss whether access to gender and plastic surgeries is equitable across populations.

    • Debate prompt: Should insurance cover reconstructive but not cosmetic surgeries?

Simulation Activity: "What’s the Priority?"

  • Objective: Teams categorize patient scenarios into priority orders of concern, enhancing critical thinking in urgent situations.

Additional Resources

  • Plastic Surgery Overview: https://www.verywellhealth.com/most-popular-plastic-surgeries-3157239

Thank You

  • Queries? Any questions posed after the session?