MTF Transgender Breast Augmentation

There is some clinical evidence that incisions in the breast fold (inframammary) have the lowest risk of capsular contracture. However, some patients may prefer an incision along the areolar border, even if the capsular contracture risk may be slightly higher, in order to have a more blended scar. If areolar tattooing is being considered, the incision at the areolar border may allow for camouflaging the final scar. However, it is important to candidly discuss and learn the tradeoffs between different incision approaches in order to help you with your decision.

There is data from around the 1990s to suggest that capsular contracture rate is statistically less likely if implants have more tissue coverage, and consequently, surgeons in the United States began to preferentially offer augmentation under the muscle. In years since we have learned that the most likely culprit of capsular contracture is a phenomenon known as biofilm; think of this as a mixture of microbes, skin cells, proteins, and other material that can get onto the implant. There is evidence that incisions in the fold are less likely to expose the implant to biofilm materials than incisions near the nipple, where bacteria may live. Additional techniques, like the use of an implant “funnel,” irrigation of the breast pocket with antibiotics/antiseptics, and other handling approaches, may also reduce the risk.

Placement under the muscle may allow for a flatter upper breast slope. However, the implant will be more likely to move in potentially unusual ways with the movement of the chest muscles— a phenomenon sometimes called “animation deformity.” This can be bothersome to some patients.

For this reason and some others, going under the muscle is NOT the way most surgeons in other countries approach augmentation. Some of these reasons include the fact that under-muscle augmentation can be more painful, has a higher risk of bleeding, and involves working on the rib cage. Additionally, the muscle may hold up the implant in a higher position, which may be disadvantageous in transgender patients who naturally have a lower nipple position. If the implant is held up by the muscle but the natural breast tissue should descend and sag (in larger breasted individuals or those with higher weights), there can be an imbalance of the breast mound leading to what we call a “waterfall” deformity.

Dr. Sayed will review these and other considerations for you during your consultation for MTF augmentation.

Dr. Sayed uses a combination of surgical simulation software, sizing kits, clinical analysis, and above all, listens to the patient to craft a personalized approach. Dr. Sayed is comfortable using different implant styles, and as an expert in implant removal as well, he can have a very frank and informative discussion with you to help you understand the nuances of implant surgery.

Dr. Sayed prefers smooth round silicone implants for most patients. The likelihood of a stiff or unnatural appearing breast is lower with silicone implants, and the breast typically feels softer. Some patients are concerned about silicone leakage or the development of certain reactions to implants and would prefer a saline device. Dr. Sayed has extensive experience with both types of implants and can cater your surgical approach to your preferences.

Nipple enlargement can sometimes be achieved with injection of fillers, fat transfer, or grafting of cartilage and other materials. However, permanent nipple enlargement can be unpredictable. There are also nipple reconstruction techniques, which Dr. Sayed has used in hundreds of breast reconstruction patients, that may be appropriate in selected MTF breast augmentation patients.

Some breast lift techniques can be used to partially enlarge the areola (in fact, spread of the areola is one of the downsides of some lifting techniques, but can be utilized for this specific circumstance in some patients). However, medical tattooing by a qualified tattoo artist is the least invasive way to achieve a wider areolar appearance. Lifting techniques may increase the risk of loss of sensation in the nipple, whereas tattooing is less likely to do so.

Transgender patients tend to have thicker, stronger muscle, a short distance from the nipple to the fold, and a tighter skin envelope. This can lead to a higher likelihood of a low nipple position, a double bubble fold, or other cosmetic compromise, especially if very large implants are used. There may be some tradeoffs required for the MTF patient seeking augmentation, but in general, the results are highly satisfying in most patients.

Most patients will have preserved nipple sensation. Incisions in the fold are less likely to cause even temporary nipple sensory loss when compared to incisions around the areolar border. Breast lifts require incisions along the border, and this increases the risk somewhat, although most patients have preserved sensation long term.

Breast cancer in genetically XY individuals is uncommon but not impossible. The use of female hormones may increase the risk of breast cancer in transgender patients. You should confer with your primary care doctor and endocrinologist regarding the advisability of mammography in your case, particularly if you have a strong family history of breast cancer or a history of breast cancer in male relatives. MRI studies are recommended every few years by the FDA for patients with silicone implants in order to monitor for “silent leakage,” since the newer generations of implants are more cohesive than previous devices.