SP19. The LEGACY Project Surgical Outcomes: Cross-sectional Complications Following Gender-affirming Surgery in a Community Primary Care Population

PURPOSE: Current literature on complications of gender-affirming surgery (GAS) remains limited and generally reported from single-center, retrospective chart reviews. This has resulted in a wide range of published GAS complication rates. Surgeon-reported outcomes, which make up the majority of research on GAS complications, may suffer from publication bias or limited follow-up duration. Evidence from other surgical specialties demonstrates that complication rates differ depending on if the sample is primary care or surgeon-based. The LEGACY Project is a PCORI-funded multi-site study that examines how gender-affirming care impacts quality of life. It also examines GAS complications as reported by patients and primary care providers. METHODS: The LEGACY Project combines retrospective electronic medical record review and patient-reported outcomes from surveys administered to primary care patients at Fenway Health and the Callen-Lorde Community Health Center. Complications were reported by patients as free text in the LEGACY Project database. This text was reviewed and complications were coded in duplicate by two authors. Complications that were unclear were resolved by a third author. Descriptive statistics were calculated and the Fisher’s exact test was used to compare transmasculine versus transfeminine outcomes. RESULTS: A total of 1,116 gender-affirming surgeries were reported, the most common was chest masculinizing mastectomy (n=402, 36%). 198 complications were evaluated across 13 surgery types. There were 96 complications reported for chest masculinization surgery, the most common was hematoma (n=20, 20.8%) followed by scarring (n=15, 15.6%) and nipple graft necrosis or loss (n=14, 14.6%). Postoperative aesthetic concerns included standing cutaneous deformities (n=8, 8.3%) and chest wall deformity (n=2, 2.1%). There were 16 complications reported for hysterectomy, the most common was bleeding (n=5, 31.3%) followed by urinary dysfunction (n=2, 12.5%). Complications were classified as early healing, late healing, or aesthetic outcomes and were compared between transmasculine and transfeminine patients. Significantly more early healing complications compared to late healing complications occurred in transmasculine patients (n=98, n=37) as compared to transfeminine patients (n=15, n=12) (p=0.038). CONCLUSION: This large, multi-institution project assesses patient-reported surgical complications from primary care settings, capturing outcomes across multiple different surgeons and surgical centers and representing valuable population-level rather than surgical center-level data. This data therefore demonstrates a more representative complication rate of 17.2% for chest masculinization surgery, 17.6% for breast augmentation, 16.7% for vaginoplasty, and 7.4% for facial feminization surgery. It also shows that significantly more transmasculine patients experience early wound healing complications compared to transfeminine patients. Future research is needed to investigate why this difference may exist and whether it could be due to properties of the surgeries being investigated or potential differences in exogenous hormone effects.