%expand% %gdefine(pickone,'%arg(%rand(%num-args%))) %expires:(never) Cerise Richards - March 2001

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TG Breast Augmentation

Since the beginning of Art History, the Breast has played a central role in defining the Feminine figure, both as a sign of fertility and beauty. In the MtF TG and TS community, the centrality of a presentable feminine figure is both necessary and desirable for our body image. After taking HRT for one to two years a majority of the MtF population may still have not achieved satisfactory breast development defined as a B-cup or greater. Therefore a large number of TS’s seek additional breast enhancement through plastic surgery before completing the two years necessary for maximum hormonal effect.

Since non-genital or cosmetic surgery are not proscribed by the Benjamin Standards, it is much easier to find a Plastic Surgeon who is willing to perform Breast Augmentation (BA) or Mammaplasty without completing the necessary psychological evaluation for SRS. It has always been held, since a paper by Dr. Edgerton, that BA should precede SRS since it is completely reversible and will allow the transitioning person to have a positive body image. Nevertheless, today BA and SRS are frequently performed at the same surgery.

The Plastic Surgeon who performs this surgery should be experienced in operating on the male chest even though it has undergone some hormonal changes. Anatomically the male chest is broader, longer and more muscular with less subcutaneous fat. So the longer one stays on HRT prior to the insertion of prosthetic implants the better, since the hormones will provide more fat and glandular tissue to cover the devices. In the US, twelve months of HRT is considered the minimum time for BA surgery and in Europe it is eighteen months.

The surgery consists of inserting a Silicone elastomer shell below each breast. The shell is then filled with Saline (sterile salt water) in the US or filled with Silicone-Gel in Europe. The Silicone-Gel has been banned in this country since 1992 because of the controversy of Silicone leakage causing Autoimmune disorders and silicone emboli. Under local or intravenous anesthesia, the procedure is usually performed in an outpatient setting. You may have a fixed volume implant or an implant which can be expanded additionally postoperatively. Both have different valves which are used for filling after the implants have been inserted in their deflated position. Therefore both can deflate partially postoperatively or rupture completely with trauma requiring replacement. The manufacturer quotes a 3% leakage/rupture rate in women, but this is responsible for one-third of the reoperations in BA.

The surgical incisions are either below the breast (inframammary) on the chest wall or on the nipple border line (periareolar) or on the side within the arm pit (axillary.) The implants are then either inserted below the glandular tissue or below the pectoral (chest wall) muscle. The inframammary subglandular approach is preferred in Europe, but the scar can be visible for years and the tissue covering the implant may be too thin resulting in skin sloughing and extrusion in rare cases. The periareolar approach may result in decreased nipple sensation and again inadequate tissue covering. The axillary submuscular approach is now preferred for TS’s in this country, but since more dissection and bleeding are encountered, endoscopic instruments are used to lessen complications. Because the pectoral muscle is stronger in males, the upward dislocation of the implant may occur unless the muscle is partially divided. The muscle will also tend to compress the circular implant into a spherical shape which in the male with a broader chest is helpful. This in turn decreases the cup size and therefore a larger volume of saline is needed (approximately 450 ccs). The dissection must continue towards the midline or the intraglandular space between the breasts will be too wide with no cleavage. Do you notice that most of our skinny runway models have that problem after BA? But the frequent complication of scar tissue forming a hard capsule around the implant is much less common with the submuscular approach and the use of antibiotics intraoperatively and postoperatively. The postoperative course is usually uncomplicated except for chest discomfort and discoloration lasting about one week.

Typical Breast While it is the desire of every Plastic Surgeon to give you perfectly symmetrical breasts conforming to your wishes, he will also give you a lengthy informed consent which describes all the complications of dislocation, infection, skin tissue death, etc. Do not be discouraged! Just ask him, “How often do these complications occur in your practice?”. There is no scientific evidence that breast augmentation increases the risk of breast cancer. The presence of breast implants, however, makes it more technically difficult to take and read mammograms. Therefore New Ultrasound or MRI might be necessary to assess your breast tissue. Since breast cancer is increased with anyone taking Estrogens or a family history of breast cancer, annual followup is necessary. Breast cancer has been reported in four TS’s following mammaplasty.

What must be remembered is it that breast implants will not last a lifetime. They are mechanical devices foreign to your body which will need to be replaced and adjusted as you mature. The device is warranted for a lifetime, but the cost to replace them is not. One Plastic Surgeon on the FDA Web site said, “Who knows, they may last 6 months or 60 years.” But there are people with retained prostheses for over ten years.

Best Wishes for your New Future.
Cerise Richards, MD

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