From now until sometime in Spring 2023, we’ll be writing about gender affirming surgeries and procedures. We’re starting with bottom surgeries and will end with office visit procedures such as fillers and botox. Two weeks ago, before a short break to get political, we talked about changing your shape with body contouring, and this week we’ll discuss breast augmentation. That’s right, top surgery for adding curves and volume!
Content advisory: we will be using anatomical terms and discussing surgical procedures in this article and this series. External sites that we link to may contain graphic images.
What Is Breast Augmentation?
Breast augmentation (often referred to as BA) is a surgical procedure to add volume and change the shape of breasts. It is one of the most common gender affirming surgeries. It’s also commonly known as top surgery.
There are many pages and many websites dedicated to breast augmentation. MTFsurgery.net has a 101 page. The American Society of Plastic Surgeons also has a section devoted to top surgery. If you only have time to read one, Dr. Mosser’s Gender Confirmation Center breast augmentation section may be the most comprehensive. We won’t strive to write a better article, so we’ll do a high-level overview here.
There are several decisions to make when deciding on top surgery. Throughout this series, we have referred to form and function when discussing options for surgeries. For gettin’ curvy with breast augmentation, most decisions are aesthetic, and a detailed conversation (or three!) with your surgeon will help make those decisions. There is a risk for loss of nipple sensation with all types of BA.
What you want your breasts to look like will inform these decisions, and your choice at any point may narrow down your options for other choices.
The main decisions will be:
What kind of implant?
- saline, silicone, or “gummy” silicone?
- round or tear-drop shaped?
- low, medium, or high profile?
- smooth or textured
What about nipples and areolas?
Where is the incision?
- transaxillary (armpit – thin solid line)
- periareolar (edge of the areola, or the darker pigmented skin around the nipple – thick solid line)
- inframammary (the bottom curve of the underbreast where it meets the chest wall – dotted line)
Where do the implants go?
- subglandular (inside the breast, over the pectoral muscle)
- submuscular (under the pectoral muscle)
What about fat grafting?
Fat grafting may be used in addition to implants or instead of implants to add volume to the breast. Fat grafting removes fat from one area of the body and adds it to another. It is done via liposuction. The primary disadvantage to fat grafting is that the fat might not stay in the breast.
More Information on Breast Augmentation Choices
What kind of implant?
Saline is salt water. A saline implant is generally placed empty, then filled with sterile salt water during surgery. The outside of a saline implant is silicone. Pros and cons to saline implants are:
- if they leak, saline will be absorbed by your body
- saline implants can use a smaller incision
- more choice in incision placement
- are less expensive
- are more prone to rippling
- may feel less like body tissue than saline
Silicone implants are silicone forms filled with a silicone gel. Pros and cons to silicone implants are:
- they may feel more like body tissue (silicone is thicker, more like fat, but feel softer to pressure)
- less prone to rippling
- are more expensive
- require a larger incision
- this incision must be in the armpit or under the breast
- if they leak, silicone may be harmful to the body
“Gummy” silicone is a thicker gel than “normal” silicone. It may provide a denser-feeling breast.
What shape of implant?
Round implants are generally placed under the pectoral muscle.
Tear-drop shaped implants are generally placed over the pectoral muscle.
The choice for round or tear-drop will depend on your existing breast tissue and your desired size and and shape. A tear-drop implant adds fullness to the bottom breast. A round implant adds fullness to both the top and bottom of the breast.
Low, medium, or high profile will affect the height of the breast at the nipple.
Breast implants are sized by volume rather than cup. A C-cup on a 46″ bra holds significantly more volume than an C-cup on a 38″ bra! A surgeon with extensive experience in trans breast augmentation will be more skilled at helping you choose a volume that will help achieve your desired look and be proportionate to your frame. Typical implants range from 150 ccs to 600 ccs but can go up to 1000 cc or more.
Smooth or Textured?
Implants are available with a smooth or textured outer surface. Here’s some important points:
- tear-drop shaped implants are generally textured
- the outer texture helps tissues attach to the implant and keep it in place
- round implants are generally smooth (although they can be textured)
- textured implants have been linked to a rare cancer
- the risk of this cancer is considered to be 1 in 3,000*
- this cancer is highly treatable (by removal of the implants and surrounding tissue)
- monthly self-screening to look for swelling, lumps, or other tissue changes is recommended for individuals with textured implants
- textured implants have not been removed from the market, however, one brand of implants which was linked to the majority of cases recalled that style of implant
- scientists continue to study this cancer and suspect the underlying causes may be infection and genetics
Nipples and more!
Your choice of implant placement can affect how your nipples sit on your new breasts. Talk to your surgeon about what you want your nipples to look like and your desires for cleavage, nipple positioning, and areola size. You can choose to have your areola resized during breast augmentation. Post-surgery medical tattooing can also change the appearance of your areola. We recommend looking at lots of pictures and bringing pictures of people with similar body types and the look you want to your consultation appointment(s).
Note: nipple resizing and movement can result in more scars, a longer and more complex surgery, and may have a higher risk of loss of sensation.
Your choice of implant type and size can affect where your incision can be.
Saline implants are often placed empty, then filled once placed inside the breast. The incision needed to place them can be much smaller than the incisions needed for silicone implants, which are placed already filled.
Incisions for saline implants may be periareolar (around the edge of the areola, which is the darkened skin surrounding the nipple,) or transaxillary (through the armpit) as well as inframammary, which is an incision along the bottom of the breast where it meets the chest wall.
Silicone implants usually require an inframammary incision.
Some surgeons offer umbilical incisions, where the incision is made in the belly button for minimal visible scarring.
The Implant Pocket: Over or Under?
Implant placement inside the breast is described as subglandular or submuscular
Subglandular implants are positioned under the glandular tissue that lies beneath the nipple, but above the pectoral muscles. They may be a good choice for individuals who have large pectoral muscles. Healing time is shorter, and may be less painful. There is less tissue above the implant, so outlines or ripples in the implant material may be easier to see and feel. Silicone implants are generally recommended for subglandular placement.
Submuscular implants are placed under the pectoral muscle. Healing and recovery may be harder and more painful because muscles are moved in the surgery. However, as the implant is underneath more tissue, rippling and edges of the implant are harder to see. Submuscular implants are often recommended for individuals who have less glandular breast tissue. Images by Cody C. (@Sake-bunbun on Twitter.)
If you want a significant change of size, or your skin is not very elastic, your surgeon may recommend using an expander prior to implants. This is a multi-stage process that requires regular visits to increase the expander volume.
The expander is a medical device that is placed under the skin. Once it is placed, the patient returns for office visits regularly, where saline is added to the expander, making it bigger. As this is done slowly, the skin above the expander stretches and grows to fit each increase in size.
When: Preparation and Recovery for Breast Augmentation/Top Surgery
Dr. Mosser’s Gender Confirmation Center has very detailed pre-surgery and post-surgery pages including information about resuming exercise and his nutrition recommendations for after surgery.
We recommend reviewing our surgery preparation blog, and asking your surgeon for their specific recommendations. Your surgeon may want you to wear compression garments until at least your first follow-up visit, and will likely teach you how massage your breasts.
Prior to surgery, you will likely have a physical exam and lab work to make sure your health is optimized. If you are a smoker, you will be required to quit a few weeks before surgery. You will have lifting and movement restrictions after surgery, so you may want to arrange for household support. You should expect to take up to three or four weeks off of work, depending on how physical your job is. If you have a desk job, you may be able to return after a week.
How: Insurance and Surgeon Requirements
Like other gender affirming surgeries, you will likely need one letter from a mental health provider for your surgeon, along with a letter from your or hormone provider. Your insurance company will likely also want one mental health letter and one hormone letter.
The current WPATH SOC 8 recommendation is at least six months of hormone use, or longer if required for the desired outcome, unless hormones are not desired or are medically not appropriate. Many surgeons prefer that you have had a full year or more of estrogen use prior to breast augmentation. This is to ensure that your breasts are developed enough for augmentation.
Some insurance policies may require that you document your support and housing plans during recovery. If you’re a smoker, most surgeons will require you to stop smoking for a few weeks before surgery. If you have diabetes, your blood sugars will need to be well-controlled. Your surgeon or hormone provider will do a wellness exam prior to surgery to ensure that your health is optimized and you have the best chances for good healing and recovery.
Also interested in body contouring or orchiectomy? You may be able to have multiple procedures done during the same surgery. Ask your surgeon.
Don’t know what your insurance covers? We’ve published several blogs on navigating insurance and we also provide care navigation appointments.
Who: Finding a Surgeon
Many plastic surgeons offer breast augmentation. You are most likely to have a better experience and outcome with a surgeon who does a lot of gender affirming top surgeries. The techniques used for trans breasts are different from cis breasts, so your surgeon’s work history matters.
How to find a surgeon (note – we’re most familiar with West Coast surgeons!)
- talk to others in the community
- gender care centers at academic institutions such as OSHU, UCSF, UW
- well-known private practices such as the Gender Confirmation Center, MozaicCare, Align Surgical, Crane Center, etc.
- WPATH Provider Directory
- OutCare Health
- The r/TransSurgeries wiki on Reddit
Breast Augmentation Terms To Know
Capsular Contracture – scar tissue forms around the implant inside the breast. If the body produces a lot of scar tissue, or the scar tissue pulls, it can change the shape of the implant. This is called capsular contracture.
NAC – Nipple Areola Complex. The NAC is the structure of glands and ducts that lead to the nipple and areola inside the breast. This structure is directly affected by estradiol, and is often less developed in people who did not go through an estrogen-dominant first puberty.
Inframammary Fold – this is the line where the undercurve of the breast meets the lower chest wall. In breast augmentation, this line often needs to be moved down so that there is more room for a fuller bottom breast.
Double Bubble – what happens when the inframammary fold is not moved lower and the implant peeks out from under the original breast-meets-chest line.
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