As with non-transgender women, breast augmentation in transgender women involves implant-based augmentation mammoplasty. A prosthetic implant comprised of a silicone shell, with saline or cohesive silicone filler, is placed underneath the breast tissue (subglandular implant) or under the pectoralis muscle (subpectoral implant).
Initiation of estrogenic and antiandrogenic therapy stimulates the development of breast tissue in transgender women. In the absence of solid evidence for an optimal length of time on feminizing hormone therapy prior to augmentation, some sources recommend a minimum of 6 months of hormone therapy prior to surgery, to allow hormone-related breast development to progress.[1,2] Realistically, a minimum of 2-3 years is more likely to maximize hormonal breast development.
The choice of implant, type, and position is governed by the woman's preoperative body habitus and wishes, in consultation with a board-certified breast or plastic surgeon. Subglandular implant placement may be preferred when there is adequate breast and subcutaneous tissue to cover the implant, and prevent visible implant seams and rippling. Subpectoral implant placement may be preferred when saline implants are used, or in the absence of adequate soft tissue to disguise the shape of the implant. There are no objective outcomes data to support the use of saline vs. silicone filler, other than aesthetic considerations and preference on the part of the surgeon and patient. Since many transgender women have inadequate breast development, subpectoral silicone implant placement is the typical approach used.
Breast augmentation procedures are often performed as a "same-day," ambulatory procedure under general anesthesia; operative time is approximately 2 hours. Recovery is fairly rapid over the course of several weeks, though some patients may experience prolonged soreness, swelling, and mild bruising. A small incision is made along the new inframammary crease and a space for the implant is created in the subglandular or subpectoral planes described above. The incisions are closed with several layers of sutures and the patient generally feels well enough to go home the same evening.
In general, results are durable and complications are rare for feminizing augmentation mammoplasty. Complications are typically divided into early (less than two to four weeks) or late complications (more than four weeks). Surgical data on augmentation mammoplasty specific to transgender women [2,5] are limited; some data are extrapolated from data published on non-transgender women undergoing this procedure. In one study, 75% of transgender women reported satisfaction in long-term follow-up with implant-based augmentation, with the majority of dissatisfaction related to subjective aesthetic outcome (primarily inadequate breast size) rather than technical surgical complications.
Postoperative complications in the primary and urgent care setting
Any concern for an early postoperative complication (as detailed in sections below) should be expeditiously referred to the operative surgeon.
A plastic surgery referral is also appropriate for a patient presenting late after augmentation mammoplasty with new symptomatic or objective breast complaints related to prior breast augmentation (e.g. swelling, pain, erythema, significant deformity/asymmetry, and implant deflation). Benign and malignant breast tumors are always in the differential diagnosis and should be worked up appropriately. Breast cancer screening should be up-to-date prior to referral. If a fluid collection or implant rupture is suspected based on history or exam, it is helpful to confirm this with an ultrasound or MRI prior to seeing the plastic surgeon.
Women who present with subjective dissatisfaction after previous breast augmentation may require a second surgical consultation or referral to another plastic surgeon. Elective secondary revision of augmented breasts is not uncommon. Prior to any referral for breast surgery, patients should be medically, psychologically, and socially stable, up-to-date in regard to breast cancer screening if indicated), and have reasonable postsurgical expectations.
Anesthetic complications particular to gender-affirming feminizing mammoplasty
In addition to standard anesthetic complications, patients undergoing feminizing mammoplasty should be assessed for risk factors for venous thromboembolism,and appropriate mechanical and chemoprophylaxis measures applied based on individual risk factors. Management of perioperative estrogen therapy and estrogenic risks of venous thromboembolism are discussed elsewhere in this protocol.
A hematoma typically presents early (within 1-2 weeks) after augmentation mammoplasty, typically as a localized or unilateral swelling accompanied by pain and bruising at the surgical site. In the absence of breast trauma, delayed hematomas are rare.
Close adherence to postoperative care protocols is necessary to prevent early postoperative hematomas. Specifically, the patient should be counseled to avoid strenuous activity and situations where the chest could be exposed to external trauma. Additionally, strict medical adherence (especially in regard to withholding anticoagulant, antiplatelet, and certain herbal medications and compliance with antihypertensive medications) can decrease incidence of postoperative hematoma.
Hematomas are typically treated with surgical re-exploration, evacuation with identification of the bleeding source, and reclosure, with or without exchange of the prosthetic implant. Small hematomas can occasionally be managed expectantly. An untreated large hematoma can result in secondary complications, such as infection, capsular contracture, or implant malposition.
A sterile postsurgical fluid collection is expected to form periprosthetically and typically is resorbed after the early recovery period. Unless there is reason to suspect that there is concomitant infection or that the fluid collection is in danger of causing incisional breakdown and implant exposure, there is no reason for concern or need for further radiographic evaluation with an early postoperative fluid collection. There is no evidence in the plastic surgery literature to support the routine use of drains in augmentation mammoplasty. A delayed seroma is generally abnormal, and should be evaluated by a plastic surgeon.
Infections are uncommon and typically present as early (1-4 weeks) complications following breast augmentation. The severity of infection can range from a mild incisional cellulitis to a purulent periprosthetic infection. The most common pathogens in periprosthetic infections are skin flora, and as a result, surgeons go to extensive lengths to avoid contamination.
A majority of postoperative infections will respond to medical treatment with antibiotics. However, most authors would advocate for implant removal in cases that fail to resolve, with delayed secondary augmentation performed in 6-12 months, once the patient has time to heal and fully clear the infection.
Incisional scarring is a late complication of augmentation mammoplasty. Patients should be cautioned on appropriate scar care, including sun avoidance in the early postoperative period. Patients with darker or oily skin types or a prior history of hypertrophic scar or keloid formation should also be aware of their increased risk for these complications.
In general, scarring from surgical incisions can be improved by following some basic tenets of postsurgical wound care. Firstly, reduction of mechanical stress and tension across the wound by following postsurgical activity restrictions is paramount to reducing scar width. Tension across the incision can result in minute wound disruptions, causing excessive or widened scar formation. Patients should be counseled that incisions predictably look the worst in the early stage of healing, up to 10 weeks postoperatively, before they begin to remodel over the next several months to up to one year. Hyper- or Hypopigmentation can also result in a more noticeable scar during this time of remodeling. We therefore recommend sun avoidance, or strong sunblock applied over a healed incision for the first year postoperatively. Scar compression has also been found to reduce hypertrophic scarring, although the mechanism is not known. This can take the form of gentle scar massage (beginning no earlier than 2 weeks postoperatively and after the wound is fully healed), taping, or silicone gels and sheets.
A break in the silastic shell of a saline  implant will be recognized immediately as deflation and loss of breast volume. Implants placed prior to the late 2000s contained a liquid silicone gel which was prone to leakage, both due to shell rupture and leaching. Potential complications include deformity, inflammation, and pain. Currently available silicone breast implants (4th or 5th generation implants, also termed cohesive gel implants), even a break in the outer shell of the implant will not allow free silicone gel to escape the implant. As a result, silicone implant rupture often goes undetected. Suspected rupture can be confirmed by MRI imaging. A long-term MRI study of implant integrity found that more than 90% of the current generation of silicone implants were intact at 10 years.
A 2011 report by the FDA recommended routine MRI screening for asymptomatic silicone implant rupture, initially three years after implantation and biannually thereafter, although there is no evidence base to support such a recommendation and an MRI may not be covered by insurance. Patients should receive preoperative counseling regarding this recommendation, as well the lack of objective evidence to support it.
Implant malposition and capsular contracture
Implant malposition can occur over time as the breast adapts to breast implant placement and aging. Nonpathologic capsule formation over the surface of the implant is expected. Pathologic fibrotic capsule formation, known as capsular contracture, can cause the implant to be hard and palpable, or cause implant displacement, breast deformation, or even breast pain related to the implant. Once symptomatic or disfiguring, implant removal and surgical excision of the capsule is indicated. Capsular contracture rates in modern implants are felt to be less than 10%, although long-term followup is needed. There has not been any link between breast implants or periprosthetic capsule formation and connective tissue diseases. While the U.S. Food and Drug Administration recommends screening for silicone implant rupture with MRI every 3 years, there is no evidence to support this practice in the absence of symptoms (pain, deformity), since the recommended approach to an incidental and asymptomatic implant rupture is non-operative observation.
Inadequate size and aesthetic deformities
A long-term study of transgender women who underwent augmentation mammoplasty found that 16% of the patients underwent a second augmentation procedure for breasts that were too small. These patients accounted for the majority of dissatisfaction related to augmentation.
A number of aesthetically unappealing complications can occur and result in dissatisfaction requiring revisional surgery and secondary augmentation. These complications are generally a result of a combination of technique and patient anatomy. Some of these complications can include a visible implant and implant folding or rippling, which occurs in saline implants or when the patient has inadequate soft tissue covering the implant. Other patients can develop asymmetry related to scar formation or displacement over time by the action of the pectoralis muscle (in the case of submuscular implants). These deformities will need to be addressed with secondary revision breast augmentation procedures.
Breast cancer epidemiology and screening in transgender women is covered elsewhere in this protocol. For those transgender women requiring screening or diagnostic mammography or breast ultrasound, both are possible with breast implants. However, mammography cannot detect implant-related complications, such as ruptures.
Breast soft tissue injections
Although autologous fat grafting is gaining acceptance in plastic surgery, its use in transgender women has not been widespread or well-described. Injection of silicone and other non-medical substances by unlicensed providers is covered in detail elsewhere in this protocol.
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