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Transgender Breast Augmentation

Breasts are universally recognized as a symbol of nourishment, love, femininity and sexuality.

Breast augmentation is the second most popular cosmetic procedure performed (following liposuction), about 254,000 cases per year in the United States.

If you are a MTF transgendered patient, you should be on hormones for 2 years to max out your “home grown” abilities under which an implant will be placed. If you are a MTF transsexual, you will also need a letter of therapy clearance from a licensed therapist ideally with a doctoral degree.

Breast prostheses applicable for standard implantation are typically saline or silicone. Cohesive gel implants when cut on the laboratory bench maintain their shape and do not leak. Gel implants may require a larger incision. Prostheses come in difference profiles and some are anatomical in shape, i.e. tear dropped, being fuller in the lower pole.

The average expectancy of a saline filled breast prosthesis is about 16 years. However the likelihood that revisionary surgery will be performed within 5 years is about 25% across the board. The most common reasons for implant replacement are for request of size change 37%, leakage or rupture 24%, capsular contracture 18%.

Compare this with a 3% incidence of re operation in Dr. John Tebbetts series involving about 1662 patients with a 7 year followup. Careful matching of the implant to the unique anatomical features of the patient explains this.

Generally I subscribe to the Tebbetts formula for appropriate size. Oversizing creates many problems including early drooping (pendulous weight effect) and “double bubble.” A distortion when the base of the implant below is seen distinctly from the base of the natural breast, above, which is of lesser circumference.

Breasts as they occur naturally are not perfectly symmetrical, “sisters not twins.” Some balance can be achieved by differential filling and placement. Cleavage does not occur naturally and attempts to place implants so close as to achieve this may result in synmastia, the touching of one breast prosthesis against another.

The subpectoral approach is desired especially when pinched skin thickness is narrow in the upper pole (that breast tissue above the areola). This provides greater coverage of the implant. However, an implant is seldom entirely covered by the pectoralis muscle and is really bi-planar, partially sub-glandular in the lower outer quadrant where the pectoralis muscle is absent.

Athletes should avoid a subpectoral approach as it might impede pulling.

The two most popular in incisions are inframammary and periareolar. Other procedures include transaxillary (through the arm pit) or transumbilical.

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