Applying concurrent multidisciplinary care to gender affirmation in transgender women: A case series

Abstract Gender affirmation surgeries, though important for many transgender persons, can be numerous. Combining surgeries, as presented in this case series, affords many benefits to patients without increasing risk or complications.

had no prior gender-affirming surgical procedures. All were nondiabetic, and BMI ranged from 21.6 to 38.1 kg/m 2 . See Table 1 for demographic information.
Preoperatively, the patients were seen at our multidisciplinary transgender health center. These patients endorsed gender dysphoria, clinically significant distress, related to both voice and physical appearance and thus were evaluated by both a plastic surgeon and speech-language pathologist specializing in gender-affirming care.
Penile inversion vaginoplasty was planned by the plastic surgeon, and all three patients were deemed to be candidates for voice modification therapy. Initial voice evaluation included a measure of voice-related quality of life with the Transsexual Voice Questionnaire for Male-to-Female Transsexuals (TVQMtF) as well as baseline recordings for the patient's current voice and speech characteristics. 4 Fundamental frequency, the objective correlate of pitch, was collected using the Multidimensional Voice Profile program from Pentax Medical's Computerized Speech Lab (Pentax Medical). Patients were instructed to sustain the sound "ah" in a comfortable speaking pitch for approximately 5 seconds. This task was not modeled so as to not influence habitual pitch production. After six months of voice training without complete satisfaction, they were considered for voice modification surgery, as is offered as an option for increasing pitch.
Feminizing glottoplasty was performed endoscopically under general anesthesia. The endoscopic approach has been found to have high patient satisfaction rate and ability to increase the fundamental frequency of the voice by creation of an anterior web and fusion reducing vibratory length. 5 The patients were intubated with a small endotracheal tube, internal diameter of 5.5 mm or less, allowing for easier manipulation of the vocal folds and causing less disturbance of their natural position than a larger tube. Using an operating laryngoscope, a potassium titanyl phosphate (KTP) laser was used to remove the epithelium from both sides of the anterior commissure of the vocal folds, extending back approximately 40% of the glottal length. These denuded edges were then approximated by injection of carboxymethylcellulose gel, a temporary augmentation material, to facilitate web formation between the two sides. Small absorbable endoscopic sutures were placed to further ensure that the two raw surfaces remained in direct contact through the process of scar formation. This permanently shortens the vocal folds by creating an anterior web, reducing the vibratory length, and increasing the fundamental frequency of vibration (Figure 1). Concurrent to FG, the patients underwent PIV using standard techniques to create a neovagina from inverted penile skin in the fascial space between the bladder and rectum with subsequent tissue rearrangement to create feminine external genitalia. 6 In this case series, surgical times ranged from 353 to 553 minutes. By comparison, mean surgical time for a cohort of patients undergoing PIV alone at our institution (n = 21) was 457 minutes (SD 114).
As is standard for PIV patients, the patients in this series remained in the hospital for seven-to-ten days following surgery. Following FG, patients were required to refrain from using their voice for one week after voice surgery to prevent postoperative trauma and dehiscence of the fusion. At oneweek postsurgery while still inpatient, the speech-language pathologist initiated voice rehabilitation to support healing and prevent vocal strain, using a gradual reintroduction of voice in a prescriptive manner. Vocal exercises such as resonant voice and semi-occluded vocal tract exercises were taught to promote strain-free production and support healing of the vocal folds. 5,7 No complications arose specific to FG. One patient did experience postoperative venous thromboembolism. All followed up for continued voice and communication therapy after discharge and had post-PIV follow-up with plastic surgery. At three-month follow-up, all patients had patent, functional, well-healed neovaginas, increased mean fundamental frequency, and decreased TVQMtF scores ( Table 2).

| DISCUSSION
This case series describes our multidisciplinary approach to evaluation and treatment of transgender women seeking gender confirmation. We preliminarily showed that combining PIV and FG is safe, effective, and does not add significantly to operative time or hospital stay. It also affords the benefits of fewer operative visits and exposures to general anesthesia as well as reduces travel and recovery periods for patients, which can lower cost and minimize time away from work. The combined approach allows for voice therapy to be initiated in-person in the hospital and for adherence to strict voice restriction guidelines in the immediate postoperative period. Based on our findings, there are potential benefits to this combined approach.
In the appropriate setting in which multidisciplinary care can be offered, such as our academic hospital-based gender affirmation program, PIV and FG can be safely and effectively combined. Further investigation to evaluate long-term outcomes and results in a larger cohort of patients is warranted, though great promise is shown based on the patients in this series.