Breast augmentation, also known as augmentation mammaplasty or top surgery in the specific case of transgender women, is a plastic and reconstructive surgery procedure with the goal of creating a feminine and aesthetically accurate breast, harmonious with the patient’s body in order to make it congruent with their gender identity.
It is improper to call it a cosmetic surgery since its goal is different from that of a cosmetic procedure; it is by all means a surgical therapy for the treatment of gender dysphoria, which is the distress experienced by the patient who find theirself in a body and with a gender assigned at birth which is different from their gender identity.
The breast is one of the main external indicators for gender identification. For this reason, breast augmentation for MtF transgender patients represents a turning point in their transition, facilitating and improving their gender identification in social settings, improving gender dysphoria symptoms and helping the patient being at ease with their own body.
Table of Contents
Criteria for breast feminization surgery
The criteria set for breast augmentation by the Standards of Care 7th edition of the World Professional Association for Transgender Health (WPATH) are the following:
- Persistent and well documented diagnosis of Gender Dysphoria by a mental health professional.
- In full possession of one’s faculties. Able to make a fully informed decision and to give consent for treatment.
- Age of majority in a given country.
- The absence of absolute medical contraindications (medical conditions which would make it too risky to undergo surgery).
Hormone replacement therapy (HRT) is not a criterion or prerequisite for this surgery. However, it is highly advisable undergoing breast augmentation only after having started feminizing HRT and after taking it for at least one continuous year. The reason for this is to maximize the natural and physiological breast tissue growth stimulated by the hormones to obtain a superior aesthetic result.
The surgeon will collect the medical and family history (anamnesis), will perform a physical examination, check the vitals and will prescribe ECG, lab tests and medical imaging as deemed appropriate.
Based on the surgeon and on the clinic, the patient might have to stop hormone replacement therapy with estrogens due to the fact that it increases the risk of thromboembolic events during and after surgery. This stop will be decided by the surgeon and the anesthesiologist and can vary between 2-4 weeks before surgery and 2-4 weeks after surgery.
Smoking and nicotine are to be avoided 2-6 weeks before and after surgery; quitting smoking lowers substantially the risks of complications and speeds up recovery by improving tissue healing.
Blood thinning medications, such as aspirin, are to be avoided in the week prior to surgery.
In some cases, when patient’s skin is not elastic enough or if the volume of the chosen implant requires it, it might be necessary to undergo two procedures: during the first surgery two tissue expanders will be placed in position and in the following weeks they will be inflated increasing volume giving adequate time to skin and tissues to adapt. During the second surgery the expanders will be removed, and the surgeon will proceed with the breast augmentation.
Difference between male and female chest
Biological males and females have chests with different characteristics. These differences make breast augmentation on a cisgender woman not alike a breast augmentation on a transgender woman; hence, the surgeon will have to possess the knowledge and experience on this specific population in order to be able to obtain satisfactory results in the reconstruction and make the chest aesthetically similar with that of a biological female. For this reason, it is advised to choose a surgeon with experience performing surgeries on transgenders and not just a surgeon with experience in breast augmentation.
The main differences between male and female chest, for what concerns the features that influence the results of the mammaplasty, are the following:
- Female bodies have round curvy lines, males have sharp angled lines.
- Female bodies have a higher body fat percentage compared to males.
- The nipple and the areola are smaller in males
- Female nipples are located on the most projected point of the breast, at about the height of the midpoint of the humerus
- Male chest is larger compared to the female one which is also more cone shaped.
- Female breast extends from the second or third rib to the sixth or seventh rib.
- The pectoralis major muscle is more developed in men.
- The distance between the nipple and the inframammary line is smaller in women.
- Nipples are located more laterally in men.
- Transgender women don’t suffer from breast ptosis as much as biologic woman do.
- The intermammary cleft is larger in transwomen than in biologic women.
- Breast development due to feminizing hormone replacement therapy produces a wide array of results, depending on the individual characteristics of each patient. In general though, the breast that develops in a transgender woman is different from that of an adult cisgender one. It is actually more similar to that of an adolescent girl, cone shaped, pointy, with not much glandular tissue and usually low overall volume; only in rare cases it is possible to achieve complete development comparable to that of a post-puberty cisgender woman.
Types of breast implants and the different surgical approaches in breast augmentation
As one of the most performed reconstructive and cosmetic surgeries, during the years have been developed several different surgical techniques as well as diverse range of implants that lead to various aesthetic and functional results. It is recommended to talk with the surgeon about the choice of the surgical technique and type of implant, discussing advantages and disadvantages of the different options addressing in particular those linked to the specific anatomical characteristics of the patient. Here’s in what ways breast augmentation can vary:
Implant placement: subglandular, submuscular and dual-plane
Breast implants can be placed in a pocket created by the surgeon either under the glandular tissue of the breast (subglandular or “over the muscle”) or under the pectoralis major muscle (submuscular or “under the muscle”); a third option is the dual-plane technique where the upper part of the implant is under the muscle, while the lower part of the implant is in subglandular placement.
Subglandular implant placement has the advantage of being a less invasive technique, with a faster post-op recovery, less risks and complications, less pain or discomfort post-op and allowing for implants of greater volume. The disadvantage of this technique is that if the glandular breast tissue is scarce in the patient, the edges of the implants might be visible, with an unnatural aesthetic result. The feeling to the touch will be the more unnatural the less glandular tissue is present in the patient.
Submuscular implant placement tends to give a more natural result, without the risk of the implant edges being visible due to the scarcity of glandular tissue covering it. It also has a lower chance of a complication that might arise after breast augmentation and known as capsular contracture. However, in the case of patients who are physically active and doing exercise, there is the risk of migration of the implant due to the activity of the pectoralis major muscle as well as the risk of temporary deformity when the muscle is contracted; the post-op recovery is longer with risk of having a reduction in athletic performance, with possibly less strength in the exercises involving the pectoralis major muscle and in some cases pain or discomfort while performing some exercises.
Dual-plane implant placement as stated above means that the upper part of the implant is placed under the pectoralis major muscle, hence being covered by both the muscle and the glandular breast tissue; the lower part of the implant is left free instead and covered just by the mammary gland. This type of implant placement carries most of the advantages of the previous two techniques, minimizing their disadvantages. It is possible to vary the surgical technique by dissecting and detaching the muscle to a varying extent, to address different anatomical features of different patients and improving the aesthetic result, by providing for example more or less lift in case of breast ptosis.
The shorter or longer post-op recovery period will present again when there will be the need to replace the implant; it is advised to change the implant 10 years after surgery or sooner in case of complications or if signs of wear or deterioration of the implant appear.
When it is necessary to undergo a mammogram, dual-plane and submuscular placement are those that allow for an easier execution of the imaging exam when compared to subglandular placement.
Implant filler material: saline vs silicone
All the breast implants are made by a silicone outer shell. This is because silicone has shown over the years to be the most biocompatible, longer lasting and safest material.
The differences in material are only about the filling of this silicone shell: the most widely used options are saline solution (sterile saltwater) and cohesive silicone gel.
The advantages of breast implants filled with saline is that it is inserted while still empty and then filled when in the right place through a specially designed valve. This allows for a smaller incision which will lead to a less visible scar and allows for surgical approaches not feasible otherwise, such as the transumbilical approach. Another advantage of this type of implant is that in the rare event of implant rupture what will come out of it is just saline, harmless and resorbable by the surrounding tissues. Among the disadvantages of saline breast implant there are the unnatural consistency, which is similar to that of a water balloon, the risk of bacterial contamination due to the added step of filling the implant during surgery, the possibility of filling the implant with some air bubbles too which in rare cases can be felt by patients when they move, the possibility of feeling the valve or the creases that might form on the shell surface in case of loss of volume and lastly in the event of implant rupture it will empty out quickly due to the fluidity of the liquid it contains.
The advantages of breast implants filled with silicone is the natural consistency to the touch, soft but solid, similar to the breast glandular tissue of cisgender women. Being completely produced in a medical manufacture it doesn’t pose the added risk of microbial contamination or liquid spillage during the filling process. Among the disadvantages there are the need for a longer incision, hence more visible, the fact that silicone is not a resorbable biomaterial so in case of implant rupture it needs to be surgically removed; nowadays there is a low chance of rupture, due to outer shells engineered to last longer and be more resistant. Silicone used for filling the implants also is not the same used until the early ‘90s, but it is now a highly cohesive gel that due to its viscosity in case of implant rupture doesn’t spill out of it. Moreover, silicone is radiopaque, meaning it blocks x-rays making it harder to execute a mammogram; in place of a mammogram, an MRI can be performed.
In the past other materials were used and tested, such as hydrogel and trilucent oil (soybean oil) but they were abandoned due to their aesthetic, functional and safety characteristics not on par with the other materials still in use.
Breast implant shape: round or anatomical (round vs teardrop)
Round breast implants were the first to be produced and utilized for breast augmentation surgery. They are symmetrical implants, with shape similar to a half sphere; its maximum projection point is located right at the center of the implant. Round implant rotation after placement, which is possible although not common, doesn’t cause any issue thanks to its symmetry. This type of implant increases the volume of the breast evenly to all the poles as opposed to the teardrop implant which fills more the lower poles. Round implants are chosen when there is no or minimal ptosis of the breast, when the nipple is located at the center of the breast and in general when the patient already has an ideal shaped breast. Moreover, this type of implant is less expensive.
Anatomical implants, also known as teardrop implants, were introduced in the market in more recent times and have immediately been a huge success, in part also due to the fact that they were the first to be filled with highly cohesive silicone gel, which guarantees a more natural feeling and overall result. The shape is that of a drop on a vertical surface; its maximum projection point is shifted to the lower part, making it not symmetrical. It is available in many different models with heights, widths, variable location of the maximum projection point, to give the surgeon the possibility to choose the best model based on the individual patient’s characteristics, such as their anatomy and physiological asymmetries. The teardrop implant is usually preferred when volume is needed in the lower poles and in the areolar region, or to correct ptosis of the breast (sagging), or when the breast is poorly developed, or when the breast lost volume due to breastfeeding or after weight loss, or in the case of tuberous breast or asymmetries between the breasts, or when the nipple points downward. The teardrop shape mimics the natural tendency of the breast to have the most volume at the level of the nipple and decreasing in volume going upwards or downwards. The anatomical implant shape provides a more natural result when the chest is vertical, but when the patient lies down it will retain the teardrop shape making it less natural looking than natural breast or round implants which redistribute their volume. Besides the higher costs of the implant itself, it could require longer surgery time and a more complex surgical technique, which contribute to an overall higher price of surgery.
The natural aesthetic result is not uniquely dependent on the implant shape, but on multiple factors. For this reason, it is improper to say that one shape provides a more natural result when compared to the other; the choice of the implant shape depends on the individual characteristics of the patient and on their expectation.
Smooth vs textured breast implants
Another difference among breast implants is about their outer shell which could be rough (textured) or smooth.
Smooth breast implants were the first to be introduced to the market and to be implanted in the ‘60s. The thickness of the shell is inferior when compared to textured implants, providing a more natural feeling to the touch and less rigidity to the implant. Smooth implants move more freely and follow the movements of the body since they don’t grip firmly to the surrounding tissues. However, if the pocket created by the surgeon is larger than the volume of the implant, the mobility becomes a disadvantage increasing the risk of implant migration during the healing process with suboptimal aesthetic result. Smooth breast implants are usually placed under the muscle, hence they need a more invasive surgical technique. The lower thickness of the outer shell allows for a smaller incision when compared to a textured implant placement.
Textured breast implants were introduced during the ‘80s. Their surface is rough, like sandpaper (but clearly not abrasive!). They were developed to prevent a complication known as capsular contracture following the theory that the growth of tissues in the microscopic spaces of the textured shell, would prevent the formation of collagen and other excess fibrous tissue around the implant. Textured implants have the advantage of sticking to the surrounding tissues, lowering the risks of implant migration, but at the same time their limited mobility gives them a less natural feeling. In the case of teardrop implant, the textured surface is required otherwise in case of rotation the aesthetic result would be unnatural. A patient with concave or convex chest has higher risk of implant migration; those with “pectus excavatum” or “pectus carinatum” are advised to choose a rough implant. Textured implant shells are thicker: this gives them a less natural feel to the touch, but also gives them more resistance with a lower risk of rupture and overall longer lasting implants.
Also in the case of the choice between smooth and textures breast implants there are multiple variables to consider; it will be the surgeon, after the surgical consultation, to advise what is best based on the patient’s individual characteristics and on his knowledge and experience, explaining the differences, the advantages and the disadvantages of both.
Profile or projection of breast implants: low profile, moderate profile and high profile
Breast implant profile, known also as mammary implant projection, defines how much an implant projects forward from the chest, especially evident on the side view. The main types of profiles are low, moderate and high, but there are also intermediate measures depending on the brand of the implant.
The profile must not be mistaken for the implant diameter which is the area of the base: these two are distinct and variable measurements and characteristics of each breast implant. The advice in this case is to look at the harmony of the overall end result, which as always depends from the individual characteristics of the patient; among the many variables the surgeon needs to look at the chest dimensions, the development of the breast following feminizing hormone therapy and the expectations of the patient who might want a more or less curvy result as well as a more or less natural aesthetic. The surgeon will take care of explaining the differences, making the patient understand the diverse range of possibilities and results, and advise the patient based on his clinical experience.
Breast implant incision placement
In the case of the cisgender woman there are many possibilities regarding the breast implant incision placement; in the case of the transgender woman, three are the incisions that are generally taken into consideration:
- Periareolar incision
- Axillary incision
- Inframammary incision
The last one is considered by many surgeons as the incision of choice; this is because transgender women have a smaller nipple-areola complex when compared to cisgender women, which makes it harder to insert the implant as well as it makes harder the pocket creation (tissues dissection) where the implant is placed. The axillary incision is generally not advised as the pectoralis major muscle is stronger when compared to the one of a biologic woman as well as it is different the structure of the lower pole of the breast, making the dissection harder and increasing the risk of malpositioning the implant and/or of implant displacement/migration. Moreover, the axillary scar is more visible, for example when raising the arms or when wearing just the bra, reason for which this surgical approach is not the best choice. The inframammary approach instead guarantees an easier procedure for the surgeon, which translates into a better aesthetic result and a lower risk of complication whatever the implant of choice is. The scar is hidden in the inframammary fold by the breast itself or by the bra when this is worn, making less recognizable the fact that the patient underwent breast augmentation surgery.
The dimensions (volume) of the breast implant
Most of the patients is familiar with the dimension of breast implants, one of the most known variables and most discussed in internet forums. The dimension of the implant is indicated by a number which defines its volume and whose unit of measurement is the cm³ following the international standards, but is most commonly indicated as cc or CC.
The dimensions of breast implants vary between about 120cc and 800cc. It is not possible to estimate the final dimensions of the breast based purely on the implant size as it varies also based on the patient’s specific anatomy, such as the chest dimensions, the distance between the side of the chest and the nipple and the distance between the two nipples, the amount of glandular tissue present and other features of the chosen implant itself. It should be reminded that the skin has to be able to stretch and fit the implant and that its elasticity varies among different individuals, as well as variable is the risk of stretch marks. It is wise to consider this information too when choosing the volume of the breast implant.
Among the different ways to understand the final aesthetic result by choosing different volumes, the surgeon could help by using a measuring tape to show the proportions, or with the use of special bras to wear with pockets where implant replicas are inserted and that give an idea of the final result under the clothes, or by showing the pre-op and post-op pictures of patients with similar anatomy, or more recently with the use of 3D simulation and modeling software that can create a virtual model of the patient’s body and can approximate the final result.
The higher the volume, the higher is the risk of losing sensitivity in the breast area, which can partially or totally be recovered for up to one year after surgery thanks to the natural healing processes of the nerve endings; this is due to the fact that the increased volume stretches the nerves and the larger the volume, the more is the stretch and the possible nerve damage.
Larger volume also generally translates into longer recovery, with more discomfort, and a less natural aesthetic result.
Hence, in the choice of this breast implant characteristic it is important to listen to the advices of the surgeon, which are based on his knowledge and experience in this specific surgery.
In some cases, when the implant dimensions require it, or when the skin is not elastic enough, or when the natural growth due to HRT is poor, it might be required to undergo a two-step procedure: during the first step a tissue expander is placed subcutaneously and its volume will be increased weekly by injecting saline in it; the second step is the breast augmentation and it can take place once the stretch will be sufficient to fit the implant.
Breast lipofilling or Fat transfer breast augmentation
A further and alternative technique for breast augmentation is the breast lipofilling, also known as fat transfer breast augmentation or autologous fat graft.
The technique requires the harvesting of adipocytes, the fat cells or commonly “fat”, in a similar way liposuction is performed; it requires an area where it is possible to harvest enough fat cells as per the patient needs. The fat is then processed before in can be used to fill the breast region. The harvested fat cells need to be viable and need to receive nutrients from the tissues where it will be injected in order to stay vital. If this doesn’t happen, it will be resorbed and eliminated in the following weeks. Survival rate is about 40-70% of the grafted volume, which depends on the harvesting, processing and reinjection techniques employed; combining PRP (platelet rich plasma) to fat grafting is showing an higher survival rate of the fat cells, in some studies this rises to 70% when compared to 40% in the control group.
Although being and interesting and innovative technique, this is not a viable option for all of the patients. First off it is necessary to have a donor area where sufficient fat is present and that is possible to harvest. This is not possible in patients too slim. Secondly, it is not possible to make high volume augmentations with this technique, so it will depend also on the patient’s expectations. Nevertheless, it is an interesting surgical technique, especially to retouch some areas like the inframammary one when the two breasts are too wide apart after breast augmentation with implants; or it could be used to fill up small areas of which the patient might be aesthetically dissatisfied.
Fat transfer breast augmentation might also be indicated for patients who responded well to feminizing hormone replacement therapy, with satisfactory natural growth of the breast. Besides improving the aesthetics, this technique can also aid at improving the consistency of the breast to the touch. Lastly, this technique could be employed to correct some asymmetries.
It is of utmost importance when choosing this technique to choose a clinic and surgeon with specific experience and knowledge of current techniques and high satisfaction rate of the patients.
Surgery time, post-op recovery and advices
Surgery can be performed on a short in-patient stay or on an out-patient basis. It generally lasts 90-120 minutes. The anesthesiologist and the surgeon will prescribe medications to control post-op nausea and pain, but as for any other surgery some discomfort and fatigue might be felt during the first days of the recovery; the first two days will be the less pleasant due to the acute effects of surgery and anesthesia.
Swelling and bruising are to be expected and will be resorbed in the first weeks after surgery.
Based on the surgeon and procedure, the patient might be wrapped in protective elastic bandaging, or simply some surgical glue might be applied over the stitches. It might be advised by the surgeon to wear a post-surgical (compression) bra for two weeks both day and night and then day only for 4 weeks.
The patient won’t be allowed to raise their hands or lift heavy objects during the first days or weeks as advised by the surgeon.
It is usually not advised to take a shower during the first days post-op but listen to the specific advices from the treating surgeon. It is surely not advised though, to have long baths both in a bathtub or in a swimming pool, which could influence the healing process of the surgical wounds and which should be kept dry and clean. Sponging, wet wipes, shampoos at the hairdresser salon, are some of the ways to keep clean without getting completely wet.
It will be advised to sleep supine, on the back, with some pillows elevating slightly the chest position especially on the first week.
Getting out of bed early and walking is good both for healing and to decrease the risk of deep vein thrombosis (DVT), but it is very important to not get too tired and be careful as the effects of anesthesia and surgery might cause a fall, so it is better to have someone by the side; it is also important not to perform any movement which might cause bleeding, further swelling , bruising and pain.
Icepacks can help both in reducing the swelling and the discomfort.
On the first day post-op it might be advised to have a light or liquid diet, then based on personal feeling other foods can be reintroduced.
Smoking and drinking alcohol are to be avoided. This is a great opportunity to quit smoking, starting from a couple of weeks before surgery.
First check-up visit is usually scheduled within the first week post-op.
Two weeks post-op light activities can be resumed and often work can be resumed 1-week post-op.
6-8 weeks post-op most of activities can be resumed.
Ask the surgeon for advices on how to minimize scars, such as silicone sheets and creams. For at least one-year post-op avoid exposing the surgical scars to the sunlight, to minimize their visibility.
Risks and complications of breast augmentation in MtF transgender
Breast augmentation is one of the most performed procedures by plastic, reconstructive and cosmetic surgeons worldwide.
As any invasive surgery, breast augmentation carries some risks such as intra-op and post-op bleeding, infections and adverse reaction to the anesthesia.
Some of the specific risks and complications of this surgery are the following:
- Capsular contracture, which is the formation of fibrous scar tissue around the implant and which compresses it, causing distortion and unnatural aesthetics.
- Seroma, which is the collection of fluid between the implant and the capsule and that the organism is not able to resorb by itself.
- Implant migration, which is the shifting of the implant from where it was placed by the surgeon during the procedure.
- Implant rupture
- Loss of sensitivity which could affect the nipple, areola or the cutaneous region of the breast
- Prolonged pain after surgery
- Asymmetry of the breasts
- Dissatisfaction for the aesthetic results.
To correct these complications, further surgery might be required. 10 years post-op it might be advised to replace the implants.
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