Breast augmentation for transwomen

Breast augmentation is performed to enhance the size of a person’s breast.  It can be performed for a number of reasons:

• To enhance the body contour of a person, who, for personal reasons, feels their breast size is too small
• To achieve better symmetry when breasts are moderately disproportionate in size and shape

The best candidates for breast augmentation

Breast augmentation is usually carried out after transwomen have begun taking estrogen and after they have been presenting themselves socially as females for some time. Breasts will continue to grow naturally in transwomen for up to a year and a half after estrogen treatment is started, and it is best to wait until full natural growth has been achieved before performing an augmentation procedure. 

The physicians at UI Hospitals & Clinics follow the World Professional Association for Transgender Health (WPATH) standards of care that require one letter assuring readiness for surgery from a mental health provider. Though most individuals undergoing top surgery are 18 or older, younger individuals may be considered for the procedure if the patient, their legal guardians, and their mental health professional are in agreement that top surgery is appropriate.

Breast augmentation can enhance your appearance and your self-confidence, but it won’t necessarily change your looks to match your ideal, or cause other people to treat you differently. The best candidates for breast augmentation are people who are looking for improvement, not perfection, in the way they look. Before you decide to have surgery, think carefully about your expectations and discuss them with your surgeon.

Breast implants

The choice of implant filler, implant size, shape, and other features will be determined based on your breast anatomy, body type, and your desired increase in size. Your personal preferences, as well your plastic surgeon’s recommendations and sound surgical judgment, are also determining factors.

Breast implants are medical devices with a solid silicone, rubber shell. The implant shell may be filled with either saline solution (sterile salt water) or elastic silicone gel. There are now implants both with the traditional more liquid gel as well as a more solid gel that will not leak out of the implant should the outer shell rupture.  Both saline and silicone gel breast implants are approved by the U.S. Food and Drug Administration (FDA). Approval means that an implant has been rigorously researched and tested and reviewed by an independent panel of physicians for safety. Saline implants are FDA approved for augmentation in people 18 years of age and older. Silicone implants are FDA approved for augmentation in people age 22 and older.

The size of a breast implant is measured in cubic centimeters (ccs) based on the volume of the saline or silicone filler. Breast implants vary both by filler and in size, but there are additional features to consider:

• Texture: The implant shell may be smooth or textured.
• Shape: The implant may have a round profile or one that has a teardrop or tapered shape. (Shaped implants must have textured shells.)
• Profile: The implant may have a low, medium, or high projection (the depth of the implant from the base to the highest point of the implant curve).
• Diameter: The width of the implant measured across its base (the side of the implant that will be positioned over the chest wall).

You should be aware that breast implants are not guaranteed to last a lifetime, and future surgery may be required to replace one or both implants. Regular examinations for breast health and to evaluate the condition of your implants are important whether you have chosen saline or silicone breast implants.

All surgery carries some uncertainty and risk

Breast augmentation is normally safe when performed by a qualified plastic surgeon. Nevertheless, as with any surgery, there is always a possibility of complications, including bleeding, infection, or reaction to the anesthesia. You can reduce your risks by closely following your physician’s advice both before and after surgery.

The procedure does leave small but permanent scars, generally just under the breast. The scars fade with time but never disappear completely. Poor healing and less favorable scars are more common in smokers.  

Efforts are made to make your chest appear as natural and symmetric as possible, but sometimes contours can be imperfect, and the breasts can appear slightly different. Your nipple sensation will normally be unchanged, though occasionally there can be some loss or change in feeling. 

There are some surgical complications that can occur related to the presence of the implant. The most common problem is capsular contracture, which occurs if the scar or capsule around the implant begins to tighten. This squeezing of the soft implant can cause the breast to feel hard. Capsular contracture can be treated in several ways, and sometimes requires either removal or “scoring” of the scar tissue, or perhaps removal or replacement of the implant.

Occasionally, breast implants may break or leak. Rupture can occur as a result of injury or even from the normal compression and movement of your breast and implant, causing the manufactured shell to leak.

• If a saline-filled implant breaks, the implant will deflate in a few hours and the salt water will be absorbed and naturally expelled by the body.
• If a silicone-gel filled implant leaks or breaks, the elastic silicone gel may remain within the implant shell, or may escape into the breast implant pocket (a capsule of tissue that surrounds the implant). A leaking implant filled with silicone gel may not deflate and may not be noticeable except through imaging techniques such as an MRI.  

Following the placement of breast implants, mammography is technically slightly more difficult. Obtaining the best possible results requires specialized techniques and additional views. You must be candid about your implants when undergoing any diagnostic breast exam. In some cases, an ultrasound exam or MRI may be recommended in addition to mammography.

Planning your surgery

In your initial consultation, your surgeon will discuss what can be achieved with a breast augmentation procedure. Be sure to discuss your expectations frankly with your surgeon. The size and contour that can be achieved varies with each individual’s particular size and shape, and it is important that you have a realistic understanding of the results your surgeon can achieve.

The surgeon will examine your chest, and will probably photograph it for reference before and after surgery. He or she will discuss the variables that may affect the procedure—such as your age, the size and shape of your chest and body overall, and the condition of your skin. They may have you evaluate your appearance with different sized implants placed in a bra over your current breasts to judge how large an implant you would desire. Your surgeon will describe the procedure in detail, explaining its risks and limitations and making sure you understand the scarring that will result. Be sure to tell your surgeon if you smoke, and if you’re taking any medications, vitamins, or other drugs.

Most insurance companies do not consider breast augmentation to be medically necessary, and they do not cover the cost of this procedure. You will be given information regarding the cost of the procedure.

Preparing for your surgery

Your surgeon may require you to have a mammogram (breast x-ray) before surgery. You’ll also get specific instructions on how to prepare for surgery, including guidelines on eating and drinking, avoiding smoking, and taking or avoiding certain vitamins and medications.

While you’re making preparations, be sure to arrange for someone to drive you home after your surgery and to help you out for a few days if needed.

Where your surgery will be performed and type of anesthesia

Augmentation mammoplasty is performed in one of the hospital’s operating rooms under a general anesthetic so you are asleep for the entire procedure.  It generally takes approximately two hours. Most people go home the day of surgery.

The surgical procedure

Most commonly, an incision approximately 2 to 3 inches long is made in the fold underneath the breast.  A space is then developed underneath the breast, and generally the underlying muscle beneath it, for placement of the implant.  (The implant is usually placed underneath the muscle to create a more natural contour to the upper part of the breast.) The chosen type of implant is then positioned in the space that was developed and the incisions are closed. A small bandage and a supportive bra are applied.

After your surgery

You’re likely to feel tired and sore for a few days following your surgery, but you’ll be up and around almost immediately after your procedure. Breast augmentation is a painful procedure, but most of your discomfort can be controlled by medication prescribed by your doctor.

Your gauze dressings can be removed a day or two after your procedure, but you should continue to wear your surgical bra, at least most of the time, for the first 1-2 weeks after surgery. You may experience a burning sensation in your nipples for about two weeks, but this will subside as bruising fades. The swelling in your breasts may take three to five weeks to disappear.

Getting back to normal

You should be able to return to work within a few days, depending on the level of activity required for your job.

Follow your surgeon’s advice on when to begin exercises and normal activities. Your breasts will probably be sensitive to direct stimulation for two to three weeks, so you should avoid much physical contact. After that, breast contact is fine once your breasts are no longer sore, usually three to four weeks after surgery.

Your scars will be firm and pink for at least six weeks. Then they may remain the same size for several months, or even appear to widen. After several months, your scars will begin to fade, although they will never disappear completely.

Routine mammograms should be continued after breast augmentation for people who are in the appropriate age group, although the mammography technician should use a special technique to assure that you get a reliable reading.

Your new look

For many people, the result of breast augmentation can be satisfying, even exhilarating, as they learn to appreciate their fuller appearance.

Breast augmentation results in a very rapid body-image change that most transwomen enjoy. Like all gender affirming treatments, the goal is to treat gender dysphoria and improve overall quality of life.

However, as much as you may have desired these changes, you’ll need time to adjust to your new image—as will your family and friends. Be patient with yourself, and with them. Keep in mind why you had this surgery, and chances are that, like most transwomen, you’ll be pleased with the results.