Since gender incongruence is now categorized as a sexual health condition, Florence X. Doo, Alexander S. Somwaru, and colleagues at Mount Sinai West in New York City contend that all subspecialties must be prepared to identify radiologic correlates and distinguish key postoperative variations in the three major categories of gender affirmation surgery: genital reconstruction, body contouring, and maxillofacial contouring. For trans-females, pelvic MRI remains the most reliable modality to evaluate the two most common complications arising from vaginoplasty: hematomas and fluid collection. Although vaginoplasty typically preserves the prostate, it may have atrophied from adjuvant hormonal therapy with estrogen and progesterone, so regular prostate cancer screening guidelines should still be followed. When evaluating urethral complications from phalloplasty in trans-males, for confirmation of stricture with abnormal function tests and for fistula evaluation, a retrograde urethrogram or voiding cystourethrogram can be obtained.
Should a patient desire erectile potential with the fully-healed neophallus, an implant may be placed, which is prone to infection, attrition, malposition, and constituent separation. Related to gender affirmation surgery, silicone or saline breast implants in trans-females often evidence as incidental notations on chest radiography, CT, and MRI, yet the most common body contouring gender affirmation surgery is subcutaneous mastectomy. Since the nipple-areola complex is preserved, retaining malignant transformation risk, Doo et al. recommend trans-males submit to regular postsurgical breast cancer screening. Likewise, trans-female patients who have undergone neoadjuvant hormone replacement therapy have an increased risk for breast cancer and should be routinely screened. Illegal silicone injections, long targeted toward all transgender populations, typically register incidentally on imaging studies, as do facial augmentations achieved via neurotoxin injections or fillers, such as calcium hydroxylapatite or hyaluronic acid. As Doo and Somwaru explain, “postoperative imaging is not typically obtained because external aesthetic results can be adequately evaluated by the surgeon,” unless unique complications—bony erosions from impaction of alloplastic silicone prostheses or bone and cartilage autografts, embolization from injection or filler materials, etc.—present themselves.