Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results

Abstract

Background: A growing number of transgender women present to plastic surgeons seeking breast augmentation. Despite some advocating their technical similarity, the authors have found substantially different planning and techniques are needed to obtain aesthetic results in transgender patients versus cosmetic breast augmentation. The authors sought to develop an approach for operative planning and technique to elucidate these differences and obtain consistent results. Methods: All patients who underwent breast augmentation at the Johns Hopkins Center for Transgender Health were included in this study. Anthropometric assessments were obtained and comparative statistics between operative and nonoperative cohorts were calculated. Outcomes were analyzed and a patient-reported survey was performed to evaluate patient satisfaction. Results: Fifty-nine consecutive transfemale patients presented for evaluation. Anthropometric measurements included base width (median, 15.0 ± 2.1 cm), notch–to-nipple distance (median, 22.0 cm), nipple-to-midline distance (median, 12.0 cm), areolar diameter (median, 3.5 ± 1.5 cm), and upper pole pinch (mean, 1.8 ± 1.1 cm). Thirty-six patients underwent augmentation mammaplasty. Postoperative complications (8.3 percent) included a minor hematoma and grade III capsular contracture in two patients. Patients were asked to complete a brief outcomes survey and reported an improvement in psychosocial well-being and high satisfaction rate (100 percent) with the overall cosmetic result. Conclusions: Transgender female patients represent a unique patient population requiring special consideration of anatomical differences in key planning decisions. The authors delineate the first systematic algorithm that addresses these differences, emphasizing maneuvers such as routine inframammary fold lowering. This can allow experienced augmentation surgeons to obtain excellent aesthetic and patient-reported outcomes in this population. As with cosmetic breast augmentation, patient satisfaction rates are high. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Breast augmentation in the transgender patient: narrative review of current techniques and complications

“…Other authors report that more than half of their patients would select larger implant sizes if not for anatomic and operative restrictions (26). On average, implant size for our transfeminine patients is 448.1 cc (SD 121.4 cc) (Figure 2A,B).…”

“…In inframammary incisions, the new inframammary fold (IMF) should be placed lower than the native line to accommodate the future downward implant settling (27). This is especially important in transfeminine patients since failure to lower the IMF results in excessive upper pole fullness and a downward facing NAC (26). Mallucci and Branford proposed a simple, prospectively validated method for calculating the ideal location of the IMF incision.…”

“…Implant plane placement based on pinch test results helps to reduce concerns with postoperative malposition or animation deformity. The pinch test has recently been adapted into a transfeminine-specific algorithm for plane selection (26). This updated algorithm suggests using the prepectoral plane in patients with a "pinch test" >1.5 cm and skin softening coupled with signs of androgen exposure Mallucciexcess sternal bone width and pectoral hypertrophy (26).…”

“…The pinch test has recently been adapted into a transfeminine-specific algorithm for plane selection (26). This updated algorithm suggests using the prepectoral plane in patients with a "pinch test" >1.5 cm and skin softening coupled with signs of androgen exposure Mallucciexcess sternal bone width and pectoral hypertrophy (26). Of note, their group recommends that patients who have a history of silicone injections should receive dual-plane subpectoral placement regardless of tissue characteristics (26).…”

“…This updated algorithm suggests using the prepectoral plane in patients with a "pinch test" >1.5 cm and skin softening coupled with signs of androgen exposure Mallucciexcess sternal bone width and pectoral hypertrophy (26). Of note, their group recommends that patients who have a history of silicone injections should receive dual-plane subpectoral placement regardless of tissue characteristics (26). In our practice, we routinely use the prepectoral plane for patients with Tanner stage IV or V breast development, due to lower postoperative pain levels (27).…”