The breasts are a very visible and important aspect of every transsexual woman's "womanhood" and beauty - indeed such is the importance of breasts that breast augmentation is often the first surgery that she has.
Whilst every transgender woman hopes that female hormone treatment will result in satisfactory breast growth, this is unlikely even in the most promising circumstances. For example teenage transgender icon and singer Kim Petras began taking oestrogen hormones in 2006, age just 13. She had some breast development and stated in October 2012, age 20, "I am an A cup .. and will never get implants". However her breasts did not obviously grow any more, and when she re-launched her musical career five years later, photos showed that she had suddenly metamorphosed from a rather flat chest'ed girl to a buxom and generously endowed woman - thanks to a breast augmentation.
If the woman is already past puberty when she starts treatment, the resulting breast development can range from satisfactory to very disappointing - although even in the later case it should be remembered that modern bra's, "push-ups" (see a typical advert, right) and breast enhancers can still do wonders appearance wise and that breast augmentation should not be an automatic choice given the costs and risks always associated with any surgery.
A majority of transsexual women eventually seek augmentation mammoplasty (breast implants), 50-60% is commonly quoted in research papers. A Dutch study of 200 transsexual women found that they usually sought a distinctly "feminine figure" and that two-thirds had had breast augmentation - in some instances repeatedly if the initial augmentation had not been outspoken enough!
In some countries transsexual women form a non-trivial proportion of the total breast augmentation market. For example, according to the BAAPs, about 10,000 breast augmentation operations are undertaken in the UK per year. The NHS performs about 100 breast augmentations per year on male to female transsexuals, and a much larger number are privately funded. Perhaps 2-3% of all breast augmentations in the UK are performed on genetic men - predominantly transsexual women and shemale prostitutes, but also intersex women, drag artists, a few homosexuals and transvestites, and on at least one occasion a man just doing it to win a bet!
Disappointingly, despite the demand, very few surgeons cater properly for transsexual women and their special needs and desires, and those that do often charge excessively.
What is Breast Augmentation?
While it can vary over time and with fashions, the perfect breast will always be symmetrically balanced and proportionate to the rest of the body. Breast augmentation, technically known as augmentation mammoplasty, is a surgical procedure to enhance the size and shape of a woman's breast by inserting an implant behind each breast. The usual goal of breast augmentation is to achieve the most beautiful and natural looking breasts possible - although some women do not always desire a natural look!
To create an aesthetic and symmetrically balanced breast using implants to enhance them is not an easy task. However breast augmentation is a very well established and straightforward procedure that is capable of producing excellent results - it's certainly no secret that many top models and actresses have had breast augmentation.
Excessively large implants or poor-quality surgery make the breast augmentation very obvious, indeed it is important to emphasise that breast augmentation is always detectable via scaring, shape, appearance, movement and/or feel. Good quality surgery, an appropriate implant size, and a well-fitting bra will often result in a clothed appearance that (even with a low cut top) that is indistinguishable from any woman with natural breasts, and is totally passable. The very best augmentation results are hard to identify even when the transwoman is wearing a skimpy bikini top, however some problems are almost certain to become obvious visible if she then makes the next step of going topless. Unclothed, augmentation is impossible to hide from an intimate partner.
Anyone considering breast augmentation must take in to account that it is a fairly significant surgical procedure and that complications often result (as shown below). Also, breast implants have a finite life - typically they need replacing after 7-12 years. A transsexual woman choosing to have breast implants thus faces the cost and trauma of having replacement surgery every ten years or so for the rest of her life. The only slight positive is that recovery from a replacement procedure tends to be a shorter and less painful period than from the initial augmentation procedure.
For an understanding of breast implants, it's important to first consider how a breast gets and maintains its shape.
The female breast is made up of fatty, glandular and fibrous tissues. Within it are blood vessels, milk ducts, fat, glands and sensory nerves. A layer of fat surrounds the breast to give it a soft consistency and contour. Beneath the breast there is the pectoralis major, a large muscle that assists in arm movement.
Women's breasts vary greatly in both size and shape. The size of the breasts are determined by the amount of breast tissue and fat present in them. The actual shape of the breast is determined by the shape of the skin envelope, not by the shape of breast tissue within that envelope. The breast tissue acts as a "filler" which is shaped by the skin envelope; if it were removed from the envelope it has no shape of its own. Hence, the basic shape of a breast following augmentation will be similar, but with a fuller volume, than before the procedure. The shape is also affected by factors such as age, genetics and skin elasticity. The shape of the breasts of genetic women can also change dramatically as a result of pregnancy and breast-feeding. Even breasts on the same body can vary, one being slightly different from the other, such variations in size and shape are normal and they occur in most women.
Breast cleavage is largely produced by a bra. Very few breasts naturally point directly forward off the chest wall, the usual breast position being slightly "down and out" with little apparent cleavage. Without a bra, the upper profile of the breast in side view is usually straight, regardless of the size of the breast. Excessive outward bulging with an outwardly curving contour in the upper breast is a tell-tale sign of excessive augmentation.
The space between the breasts also varies widely from woman to woman, but it is generally on the large size for transsexual women due to their above average rib cage size combined with below average breast size.
It's Not All About Size
Most transsexual women tend to think only in terms of their bra cup size when considering their breasts and breast augmentation. For instance, if they're a 36A after hormone treatment, then their main concern may simply be becoming a 36C bra size after augmentation.
Implants indeed add volume to the total breast tissue and the larger the desired cup size, the larger the volume (measured in "cc's") of the implant. However, breast augmentation is not just about bigger breasts; it's about shape and balance. The real goal of augmentation surgery is to have beautiful and attractive (sexy!) breasts.
Beautiful breasts come in all sizes cup size is not the only consideration. There should also be concerns about breast shape, proportions and overall body figure. There are many factors that are the basis for determining "beautiful" breasts.
Factors to Consider
Whilst surgeons half-heartedly say that it is not all about size, many of their patients clearly disagree. Half of all breast augmentation patients want breasts of a D or DD/E size - about 650cc total volume. In the typical transsexual women this correlates to implants of roughly 400cc - a very substantial and hard to disguise implant given the lack of existing breast growth.
Nevertheless, every woman has a different body shape which should influence the contours of the enhanced breast. Different breasts and body contours will determine the size and style of the implant and in some cases the location of the incision as well.
Breast width is an especially important dimension, because it determines how much cleavage there is between the breasts. Breast width also determines the outside curve of the breasts, which helps balance the hips and narrow the waist.
Two Points of View
Even after considering professional advice, the reality is that what many transsexual women desire and regard as "beautiful breasts" is not what their surgeon (or indeed a photographer of topless models) would regard as "beautiful breasts", or least the best and most natural looking achievable for the woman. For every girl seeking small implants (perhaps just 100cc) and hopefully almost undetectable implants to help fill out her breasts to at least a modest size for her build, there is another seeking large implants (over 500cc) and obviously unnatural looking breasts - Pamela Anderson in her heyday being an ideal.
One common problem is that all too often girls who have the least natural development, and thus are most unsuited for large implants, are the one's seeking the largest augmentation. To avoid unnecessary dissatisfaction and repeated surgery, the British Association of Plastic Surgeons sagely advises its members: "For a male-to-female transsexual patient to appreciate the outcome of augmentation mammaplasty, the surgeon should tolerate and address this patient's urge for a distinctly feminine breast configuration." Transsexual girls wanting very large implants (over 1000cc is not unusual) face great problems finding a reputable surgeon willing to perform the procedure.
Breast Augmentation Procedure
Different surgeons, depending upon their preferences and prior experiences, perform the breast augmentation procedure differently. Also, the method of inserting and positioning the implant will depend on the patients' anatomy and the desired size and shape of breast.
However, it would be reasonable to say that the following method is usually followed:
While breast augmentation will reliably make the breasts larger, it will not change the underlying basic shape of the breasts, a factor that may vary significantly from patient to patient. The shape of the breasts after implant enlargement or augmentation mammaplasty is mostly determined by the breast shape before surgery, the post-op augmented breasts will generally appear to be a larger version of the original breasts. A careful examination of the woman is thus very important since her physical characteristics will have a great bearing on the final shape of the enlarged breast. Factors determining the augmented breast appearance include the shape and symmetry of the ribcage and muscles, the shape and depth of the breastbone, the volume of the existing breasts, and the character of the existing breast skin. The position and symmetry of the existing breast folds and nipples, and the woman's height and weight also have a significant impact on the achievable appearance.
degree of breast asymmetry is normal, volume and size differences of the
breasts often can be corrected by implant volume adjustments, for
example as saline filler is added is added to saline implants.
But often it is not possible to correct many of the asymmetries that are
commonly seen, such as different heights of nipples or infra-mammary
Types of Implant
All breast implants have an outer pliable envelope enclosing either a liquid (usually saline) or soft-solid gel like substance (usually silicone gel). The surface of the implants has traditionally been smooth to the touch, but now there is another option, a textured surface.
help meet each woman's individual needs, various sizes and shapes of
implant are available. Some are specifically intended to benefit
transsexuals with rather large upper-body proportions - most transsexual
women have 'male-sized' rib-cages and tend to have their natural breasts
located somewhat further apart than on a natural-born XX woman, this
makes the breasts look subjectively smaller and lacking a well-defined
cleavage. Shaped implants can remedy this situation by adjusting
the shape of the breasts to produce a subjectively larger cleavage.
A breast implant is essentially a silicone elastomer shell - a rubber-like membrane or envelope. To achieve fullness and create the most natural breast-like feeling possible, this shell is filled with some suitable material - but finding a material that exactly but safely duplicates the feel and movement of breast tissue has been a long running challenge. Currently, the vast majority of implants are either silicone gel or saline filled; however some other fillings have recently appeared.
Silicone gel filled implants were the most common type for some 30 years, but have been avoided in the USA since the early 1990's due to unproven but suspicious health problems associated with the gel. Saline implants are considered to be totally safe and are now usually preferred, but unfortunately they give a less natural feel than silicone gel. Saline implants are currently (2001) the only type approved by the Food and Drug Administration for use in the USA, although silicone gel implants are still available in special circumstances. Other alternatives to silicone gel include hydrogel and plant oil filled implants have been recently developed, but their long term safety is still unproven, for example the UK's Medical Devices Agency advises against these fillings, recommending only silicone gel or saline implants.
Silicone Gel Filled Implants
Silicone gel implants were first developed in the early 1960s after it was discovered that injections of silicone, which had previously been used for breast enlargement, could lead to unacceptable complications. Silicone gel has an excellent texture as a filling material because it is soft and pliable and allows for very natural breast feel and movement.
Initially capsule contracture was a major problem with silicone gel implants, but the incidence rate is however much reduced with the latest implant types. Silicone implants do interfere with the standard mammography techniques, but this can usually be overcome by informing the radiologist about the presence of the implant so he or she can alter the technique to obtain the optimum result ("Eklund Distraction Technique").
Leakage or bleed of free silicone gel from the implant in to the breast, or elsewhere, may cause silicone granulomas to form. These are lumps of inflammatory tissue around small amounts of silicone. These lumps can often mimic the lumps which indicate breast cancer, but these silicone granulomas are not cancer and do not appear to increase the risk of cancer. There has been no evidence that silicone gel is related to connective tissue disease. In fact silicone appears to be one of the most inert materials known. However, the perceived - but not proven - safety concerns have stopped the unrestricted use of silicone gel implants in the USA, the Food and Drug Administration has restricted their use since April 1992. There is no sign of this ban being reversed despite many recent in-depth studies clearing silicone gel implants of any cancer risk, and the fact that many countries, including the United Kingdom, continue to permit their use.
Saline Filled Implants
Recently fixed-volume prefilled saline implants have become available, but most saline implants are inserted uninflated and then filled when in place, before removing the valve and closing the incision. This technique has the significant advantage over silicone gel implants (which are always pre-filled) that the incision the implant is inserted through can be much smaller (typically 2-3cm, against 4-5cm). Also the surgeon can adjust the filling level for a best appearance, including adding different amounts to the two implants to help correct any breast size difference.
Most surgeons and patients are of the opinion that silicone gel implants have a more breast like feel when compared with saline filled implants, which feel a little "watery" and firmer, and fall less naturally. However saline implants do have the advantages over silicone gel of less capsule contracture, smaller incisions required, and an overall reputation of greater safety. Both textured silicone and saline implants experience rippling, but in general saline implants ripple more and are more palpable, i.e. they can be felt and detected by feel more easily. Another major problem with saline implants is the leakage and deflation rate, which seems to be about 50% over a period of 10 years. In a matter of hours or days of a rupture the breast will become totally flat again.
Double Lumen Implants (Combinations of Silicone and Saline)
Hydrogel Filled Implants
Used in many areas of medicine for such devices as replacement tendons and arterial transplants, hydrogels are believed to be safe and completely biocompatible. In fact, the majority of our body tissue is made up of naturally occurring hydrogels. In the event of leakage or rupture, the body will safely absorb the implant content.
In December 2000 the Medical Devices Agency of the United Kingdom issued a safety warning against the use of the popular Hydrogel breast implants manufactured by Poly Implant Prosthesis (PIP). The MDA's review has identified that the manufacturer's (only one brand has been used in the UK) biological safety assessment of this product in inadequate, due to the lack of long-term toxicity data or clinical follow-up, together with methodological flaws in some of the pre-clinical tests.
PVP-Hydrogel Filled Implants
There are two styles of PVP-filled implants: prefilled and inflatable. Like other implants, PVP-filled implants all have a textured silicone elastomer shell.
Plant Oil Filled Implants
One of these new type implants, called Trilucent, contains triglyceride, an oil from soya beans that has been used for 40 years as a nutrient in intravenous feeding and as a drug carrier in injections. The manufacturers of Trilucent believe, the vegetable oil can be metabolised and excreted by the body like saline, but that it is also resistant to bacterial and fungal contamination whereas saline is not. Its lubricating properties also means that it should not rub the inside surface of the implant; this has been linked to leakage's in conventional implants. However, in June 2000 the Medical Devices Agency of the United Kingdom issued a safety warning against Trilucent breast implants because of health concerns and recommended their removal. There is no evidence of any serious medical problems but tests have shown that material produced if the oil breaks down in the body could potentially cause cancer or damage to a foetus.
Implants come in two shapes:
Round implants tend to provide more upper breast fullness while anatomical implants are contoured or tear-drop shape so they tend provide less upper breast fullness because the top of the implant is shaped and sloped more like a natural breast.
The main advantages of an anatomical implant over a round implant are:
However, many transsexual women prefer the Pamela Anderson look that can be best achieved with large round implants. Also, a recent study has [perhaps controversially] concluded that the result sought to be achieved by anatomical implants, that is, that the implant has a teardrop shape which is more natural in appearance, is achieved just as well by round implants. The study demonstrated that when a round implant is imaged within the breast in a woman who is standing, the implant takes on the same anatomical shape as the anatomical implant. The study also found that when lying down, the round implant is more natural in appearance than the anatomical because the anatomical implant retains its teardrop shape in this position whereas a round implant does not. It would seem that in at least some women, a round implants placed under the muscle can have a more natural appearance than anatomical implants, which may appear somewhat elongated in appearance in the same woman.
Almost all implant membranes (bags) are a silicone elastomer shell with rubber like characteristics. There are two types of outer surface: smooth or textured.
Textured Wall Implants
A persistent problem with breast implants is capsular contracture. A textured surface implant helps prevent the capsule, which naturally forms around the implant, from tightly squeezing the implant and thus making it unacceptably hard. Because of the way scar tissue forms around an implant, a textured surface is supposed to prevent scar tissue fibres from laying down uniformly in a parallel fashion and thus tightening up.
Most anatomical implants are textured because the implant is meant to have a top and a bottom (it is tear drop shaped), a textured surface on the implant causes the tissue to adhere to the implant enough to prevent its free rotation. Without the texture, the implant could "flip," leaving the implant upside down and misshapen in appearance. While this can be corrected manually or surgically, it is not an ideal happening!
One problem that causes many surgeons to avoid textured implants is the apparent increase in the chance of visible rippling compared with smooth implants. The same characteristics of the textured surface that cause the scar tissue to form irregularly around the textured implant also cause it to appear rippled in appearance. Also, due to their due to their thicker walls textured implants often have a less natural and harder feel than smooth implants, and can appear unnaturally solid.
Smooth Wall Implants
Smooth shell implants are less likely to cause visible rippling (especially if placed below the pectoral muscle) and are more natural to the touch because they are made with thinner walls than textured, anatomical implants. Also, unlike anatomical implants, round implants do not require texture because they can rotate within the capsule and pocket without any change in appearance.
Given these advantages and some controversy over whether textured implants actually reduce the rate of contracture significantly enough to warrant the potential disadvantages, many doctors prefer to use smooth, round implants, usually placed under the muscle which is also claimed to further reduce the incidence of capsular contracture.
Breast implants are available in a wide variety of volumes, normally ranging from as little as 120 cc to about 850 cc, although expanders go up to 1500 cc. Some porn stars have pushed their breast size to outrageous proportions over multiple augmentations, finally using custom implants sizes of 2000 cc or more!
One study found that in a natal woman an average of 189cc of saline was needed to change the size of a breast by one bra cup size:
The A to D finding seems rather small, but the overall finding that [roughly] every 200cc of implant size equated to a one cup increase seems accurate.
Although transsexual women generally prefer large implants (both in volume and breast width), unfortunately they often have insufficient existing breast tissue for adequate coverage of the desired size implant. If an unsuitably large implant is used then there will be an unnatural appearance with obvious implant give-away signs such as skin stretch marks (see below). Larger implants may also cause some pressure atrophy and thinning of muscle, subcutaneous fat and breast tissue or possibly even the ribs in the sub-muscular position.
With very large implants (800 cc and above), their weight and the effects of gravity cannot be ignored. Back pain is almost certain as a male type skeleton tries to deal with 2+ kg (5+ lbs) of weight added at a high and forward location, whilst the sheer weight of the implants will soon cause the breasts to sag and look far from satisfactory when not supported by a bra.
Smaller implants avoid or reduce the problems associated with implants - capsules, sagging, stretching of the breast skin, even breast cancer. For example, the smaller the implant the less likely that problems with capsule contraction will occur - relatively more breast tissue covers a small implant and it will therefore feel softer, and any distortion and firmness from capsule formation will be less noticeable.
When seeking breast augmentation, many transsexual women are faced with a conundrum as they typically have wide rib-cage and relatively little natural breast tissue even after several years on hormones. Small implants can be almost undetectable even nude, but result in breasts that are still unsatisfactorily small and excessively separated, with insufficient outside curve to match the body outline. But going for large implants means obviously augmented breasts, and an increased risk of complications.
Post-Operatively Adjustable and Expander Implants
Skin and other tissues when subjected to a gradual stretching force will not only stretch but will also actually grow and expand.
There are now two alternative techniques that make use of this fact for breast augmentation:
1. Adjustable Implants: This method uses an adjustable saline implants that can be enlarged step-by-step after surgery by the injection of saline into it.
2. Tissue Expanders: This uses temporary tissue expanders (very similar to saline breast implants) that are later replaced by permanent long-term implants.
The procedure is relatively simple. The desired breast size is discussed prior to the operation, remembering that the maximum volume of which cannot be changed after the procedure without further surgery. The surgeon then inserts - in a deflated or largely deflated state - the appropriate implants, usually under the pectoral muscle.
Breast expansion begins postoperatively after the implant has been placed. After the surgical incision has adequately healed (ordinarily about two to three weeks) the expander is gradually inflated in the surgeon's office through weekly injections of saline solution by way of a small needle placed through the skin. Over several months, the implant is slowly increased in volume by repeatedly injecting additional saline solution into the implant until the appropriate volume and symmetry is reached. For example, an implant in the range of 400 to 700 cc can be filled at the time of placement with about 120 to 300 cc, assuming the woman waits two weeks following surgery before beginning expansion and then inflates weekly with 100 cc, about seven weeks are required for full expansion.
Adjustable implants use what is known as a "remote filling port", a small button-like valve device placed beneath the skin adjacent to the expander and which is connected to the implant/expander by a small, soft tube. About 6 months after the original procedure another minor surgical procedure is performed to remove this rather noticeable device, but thus prevents any further adjustment.
The procedure is initially the same as for adjustable implants. After the expander "fill" period - which may last 2-3 months - there is a settling-in and stretching period of up to six months during which no more saline is added. This second period allows time for the expander to stretch the skin and the breasts to develop a natural looking sag. To speed this process up, the expandable implants is often overfilled by between 100-150 cc compared to that needed for the target breast size. Eventually another procedure is undertaken to remove the temporary tissue expander implants and normal long-term implants (i.e. typically saline or silicone) are inserted into the pocket formed by the expanders.
Like adjustable explants, tissue expanders (or simply "expanders") used to have a filling port. However removal of this remote filling port at the time of long term implant placement is difficult and requires an additional small incision, so most modern expanders have an integral filling port that consists of a metal lined pocket within the expander itself. The surgeon precisely locates the filling port prior to each injection so that damage to the expander does not occur. Removal of these expanders is thus greatly simplified when inserting the long term implants, and no additional incisions are needed to remove the filling port.
Advantages of Adjustable's and Expander's
The final results are often absolutely outstanding, with incredibly natural looking large breasts. Indeed, some well-known shemale's have used them to achieve outrageous breast proportions.
However, there are several disadvantages:
Another disadvantage of the adjustable/expandable procedure is that it is more expensive than other augmentation methods. This is particularly true if temporary tissue expanders are replaced by long-term implants since clearly two sets of implants are involved and two surgical procedures are performed.
There are three common incision locations for inserting implants. The nipple (areola) incision is probably the most popular, followed by under the crease of the breast, and finally the the armpit. Another potential procedure is via the belly button (navel), but this has become rare due to the damage (e.g. internal bleeding) often resulting.
Other disadvantages of this method are visible scars on the breast itself, more traumas during surgery and longer and more painful recovery in some cases than incisions in either the navel or armpit. However the incision is relatively small and there is a natural colour change where the areola changes to breast skin which usually hides the scar well. For most patients the incision eventually becomes hardly noticeable unless they have a tendency to scar badly.
The areola approach is the only incision method that directly damages the breast tissue and is known to be more likely than to cause problems lactating and breast feeding than other methods.
The procedure is illustrated below:
Insertion through the umbilicus makes it hard to position the implant accurately, generally allows placement only above the muscle, and also puts significant stress on the implant. Surgeons are not able to get as consistently good results this way as if they were working through an incision right on the breast. Because of difficulties in placement of the implant, the transumbilical method really only makes sense if there is not already a scar on the breast. Also the method cannot be used for large implants or pre-filled implants (e.g. silicone gel type).
However, this method eliminates any scarring in the area of the breast (although unsightly scaring in the abdominal area can occur instead) and recovery can be much shorter this way because there are no stitches near the arms and breast and less healing of scars and internal tissue that would be cut to pass through the areola or inframammary area. Perhaps the main risk is having to make a normal (i.e. periarealor or inframmary) breast incision if the placement did not work out during surgery, however it can be argued that that the possibility of having no scars at all was worth the try.
Selecting the Right Incision Method
If the natural breast is small and perky (relatively common in transsexual women) the underarm transaxillary approach is often the optimum approach. It involves no incision on the breast, does not interfere with the breast tissue and can achieve a perfectly symmetrical result with only minimal and well concealed scarring - unless the woman is a dancer or for some other reason often has her arms in the air with the axillae exposed frequently. If you have had no previous breast augmentation surgery and avoiding any visible scars is very important, then the navel (transumbilical) method is an option, but it has the least consistent record as regards good placement of the implants and should only be done by surgeons who specialised in this technique. For women who have large areolae (relatively rare in transsexual women) the periaerolar incision is an attractive option which allows reliable implant placement, it can be used with any type and size of implant and is very versatile, allowing shaping of the breast tissue and muscle to form a natural shape around the implant. The incision made in the wrinkles of the brown skin round the areola generally heals with the only slightly visible scaring and is thus very popular. Finally, the inframammary incision allows good placement but leaves the most visible scaring except with pendulous breasts, it's best reserved for large and very large pre-filled implants.
In general the surgeon will make every effort to ensure that the incision (typically varying from 2 cm long for small unfilled saline implants to over 5 cm for large pre-filled silicone gel implants) is placed so that the resulting scars will be as inconspicuous as possible, given the women's circumstances and priorities. A big potential advantage of saline implants over silicone gel implants is small and well hidden scars - saline implants are usually filled after insertion so the incisions will be just 2-3 cm in most cases, and insertion techniques such as the transumbilical method can inconspicuously locate these small scars if desired.
At least 90 percent of all incisions, if properly closed, will result in an inconspicuous scar after maturation is complete - but unfortunately patients do differ in their healing characteristics and a very few may scar badly, and the possible scaring should be considered when selecting the implant method. E.g. If an ability to topless sunbath without showing off implant scars is important, then small implants via the transaxillary method may well be preferred over larger implants via the inframammary technique.
Breast Implant Placement
Chest Wall Anatomy and the relationship to Breast Implant Placement
(above the muscle)
While many surgeons prefer this method when using silicone gel implants, if saline implants are used then in many cases the results are suboptimal. This is because saline is water, and does not feel as much like breast tissue as silicone.
If the breast tissue, skin, and subcutaneous tissue are too thin, one can see the outline of the implant, actually feel the implant edges, and often see rippling in the skin. In these cases, it would be better to place the implant under the muscle.
Advantages of the technique are ease of the surgery, avoidance of a breast lift (mastopexy) for mild sagging or drooping (ptosis) of the breast, less post-op discomfort since only skin and fat are cut. The approach also allows insertion of oversize implants.
Disadvantages are marked interference with mammograms, clear visibility and feel of implant edges, visible and palpable rippling of the skin over the implants, especially with any textured implants, higher rate of capsule contracture, high rate of later implant downward migration or "bottoming-out", and difficulty correcting later ptosis problems when they occur. Saline implants over the muscle are avoided if possible.
Advantages include mostly separating the implants from the muscle, facilitating unobstructed mammography, a more natural look with a soft transition from the flat of the upper chest wall to the round shape of the implant, much less visibility and feel of the implant edges, usually no rippling (except textured implants), and low risk of capsule contracture, as long as the implants have not been contaminated by ductal germs while being passed through the breast tissues.
Disadvantages include a bit more discomfort early post-op, technique a bit more difficult than over the muscle, and the loss of the lower pole support fascia which leave the implants supported by the same weak skin tissues as implants over the muscle, leading to later downward bottoming-out of the implants in a few patients as is frequently seen in implants over the muscle.
(under the muscle)
The advantages of this approach are ease of placement, natural breast shape no implant visibility, no rippling of the implant surface (except textured implants in thin women), lower capsule contracture risk, since the breasts are completely separated from the implant, and no ducts with germs are damaged while placing the implants, low mammography interference, good internal support, and no scars on the breast.
Disadvantages are the difficulty mastering the procedure, muscle discomfort post-op, and implants which tend early to be a bit full superiorly, until the support fascia stretches.
Advantages and Disadvantages:
Rippling - in women with little breast tissue, subpectoral or fully submuscular placement is likely to reduce the chances of visible rippling of the implant. This should be true regardless of the originating reason for the rippling (underfilling or textured surface, depending on the opinion held) because the implant is partially or fully covered by muscle, in addition to breast tissue.
Mammography - although technology increasingly makes better breast imaging possible with and without implants, placement of the implant below the muscle is thought generally to improve mammography by making it less likely that the implant will prevent proper imaging of all of the breast tissue. Subglandular (or above muscle) placement, on the other hand, is thought to be more likely to interfere with imaging. While implants containing alternative fills such as soy or peanut oil have been experimented with due to their being radiolucent (they allow imaging to pass through the implant), none have been approved for use so the above muscle placement of the implant still causes some concern with regard to mammography.
Appearance - Initially, and especially with silicone implants, implants were predominantly placed above the muscle (subglandular).
Most surgeons agree that where:
(i) the woman has adequate breast tissue to disguise the implant, and
(ii) there is no unfortunate rippling or contracture
then above the muscle placement results in the most natural looking result because the implant is behind only the tissue itself, and the tissue that is being augmented takes on the augmented shape. It is also preferable for women who work out their upper body a lot as their muscles can contract implants that are behind the muscle into a distorted shape with an unusual appearance.
However, for women with little to average breast tissue - which includes most transsexual women - under the muscle placement can help to avoid the "fake" look of implants that are apparent because they are closer to the surface.
Sagging - For fully submuscular placements, and to a degree subpectoral placement as well, the implant is better supported than in subglandular (above muscle) placement, resulting in less sagging (ptosis) of the augmented breast in the long term.
However, if a woman already has substantial breast tissue then a submuscular or subpectoral placement can be a problem because the pectoralis muscle tends not to sag. But placement of the implant behind the muscle means that the implant is likely in high on the chest. The passage of time can result in the sagging of the existing breast tissue, which increasingly looks like separate tissue hanging from the firmer, higher mound of the implant. A mastopexy (breast lift) can become necessary to restore the appearance.
Due most of the factors listed above, most surgeons prefer under the muscle placement, whether subpectoral or fully submuscular, but again, the patient's physical characteristics will affect the decision as well as the surgeon's preference.
Comparison of various implant positions:
During the first 24 to 48 hours after your surgery, you will experience the most discomfort. Your breasts will be swollen and very tender. Although every woman's recovery time is different, you should be able to resume many of your regular activities after about one week. You will need to wait at least one month before resuming any strenuous activities.
Should any problems occur after surgery, contact your doctor immediately. This is especially important if your temperature is elevated, or one of your breasts is noticeably more swollen and tender to the touch, painful, red or inflamed.
surgery, implants will ride high on the chest. It will normally
take 4-12 weeks for them to "drop" into place. The more natural
breast tissue you have and the smaller the implant, the more natural the
look. Keep in mind, most women wish they had gone larger!
Placing them under the muscle also allows for a more natural appearance.
As you age, your natural breast tissue will sag, the implant will not.
The implant manufacturer Mentor Corporation conducted clinical testing of its saline-filled breast implants to determine the most common short-term risks associated with their implants. The Saline Prospective Study (SPS) was a 3-year study to assess all complications with breast implants as well as patient satisfaction, body image, and self-concept. Patients were followed annually and data through 3 years are available. The SPS enrolled 1,264 augmentation patients, 76% of which returned for their 3-year visit. The results are tabulated as follows:
It's worth noting that more than 1 in 5 (21%) women experienced problems with wrinkling and ripples, and probably more than half experienced some form of problem, of greater or lesser significance, within 3 years of their breast augmentation. Clearly breast augmentation is still not a trouble free experience for many women, whatever some surgeons may try to imply.
Over half of all transsexual women eventually have breast augmentation and the results are well documented. Its informative to quote the results of one survey here to see if the pain, expense and complications are all considered worth it by transsexual women ...
It's notable that despite the desire of many transsexual women for large breasts, the two women with an augmented 40D and 48E bra size are clearly exceptional. The most common result is a moderate B cup and the average implant size is an also moderate 260ml, the largest being only 450ml. This, and the relatively high percentage of women feeling that their breasts were still too small, is unfortunately an indication of the limitations imposed on augmentation by the small natural breasts typical of pre-augmentation transsexual women. See the at the bottom of this page photo of an augmentation by the famous surgeon Dr. Douglas Ousterhout as a demonstration that even the best surgeon can only achieve so much with the material they have to work with.
Common Implant Problems
When any type of breast implant is inserted, the body's immune system reacts by forming a protective lining made from collagen around it to protect itself from this foreign body. This is referred to as the "capsule" or "tissue capsule."
The formation of a capsule is normal and happens in everyone regardless of whether the implant is smooth or textured, silicone or saline. Under ideal circumstances, the capsule maintains its original dimensions and the implant rests inside it, remaining soft and natural appearing. However, for reasons that are unknown, in some women the capsule has a tendency to shrink, squeezing the implant. An implant that is compressed hardens like a balloon, i.e. the tighter the capsule becomes the firmer the breast feels. This problem is called "Spherical Capsular Contracture". It has been known since the very early days of implants and has always been considered to be the main problem with breast implants.
The degree of capsular contracture is measured on the "Baker Scale", from grade 1 to 4. Grade 1 means the breast looks and feels so soft that the capsule is virtually undetectable; while Grade 4 means the implant is painful and as firm as a grapefruit, and that it is being distorted in shape and squeezed out of position.
No matter the degree of capsular contracture, it is not the implant that gets hard, if the implant is removed it is as soft as when it was inserted, it is the interaction of the capsule with the implant that makes the breast feel firm. Capsular contracture alone does not cause implant rupture because the force is exerted evenly around the surface of the implant.
Encapsulation may occur immediately after surgery or many years later, and may occur on one or on both sides. The incidence of capsular contracture approached 100% in the 1970s, subsequent modifications in implant design and the surgical procedure have reduced this undesirable effect significantly, according to various studies and surgeons claims, the frequency of significant encapsulation (Grade 3 or 4) among women with saline-filled breast implants currently ranges anywhere from 5 to 18%.
It should be noted that a mild to moderate degree of contraction usually. Most encapsulation is of a mild degree (Grade 1 or 2) that doesn't detract from the quality of the augmentation result and is not considered clinically significant. Indeed, for some women a mild degree of firmness in their breasts, similar to a pubescent girl's, may actually represent a desirable outcome.
treatment of severe capsular contracture is usually surgical. In
an "open capsulectomy" the surgeon scores, or cuts, the capsule to
release its hold on the implant. In a "closed capsulectomy," the
entire capsule is surgically removed. The body then forms a new
capsule but the hope is that it does not contract as the old one did.
Capsulectomy is a more extensive operation than capsulotomy but has a
higher rate of success in correcting contracture. Only a
relatively small percentage of women with implants develop capsular
contracture severe enough to require surgical treatment. The
rare patient develops repeated capsular contracture but in the majority
of cases it can be successfully treated.
Implant Wrinkling and Breast Rippling
Some transsexual women insist on choosing excessively large and inappropriately shaped implants for their available breast tissue coverage in an unrealistic desire to achieve "Playboy" breasts. At best its very obvious that they've had breast implants, whilst in the very worst cases the implant can actually start to emerge through a hole in the skin at the bottom of the breast.
The most common visible problem with overly large breast implants is traction rippling. Rippling looks like someone had their fingers on the breast and left indentations, it is not a permanent rippling in most cases but a ripple occasionally as the implant moves and literally ripples, giving the skin a wave-like appearance instead of the smoothness you see in a normal breast. When you spot an actresses or lingerie model with obvious and over large implants, then you have probably seen this phenomenon. Some 20% of genetic women with implants experience problems with rippling, and the incidence is probably even higher in transsexual women who tend to over size their implants.
Every breast implant has at least a little bit of wrinkling, an irregularity of its surface. Some implants have very little, and some have a lot of it; if there is little, then it may not even be detectable. If there is more, it may be felt, and if there is a lot of wrinkling, then it can be felt and even seen as rippling. In general, the degree of wrinkling depends upon several factors that work to either hide or reveal wrinkling or rippling. The areas where rippling is usually most apparent are the outer side near the arm, along the bottom, and towards the cleavage, in that order. The rippling is most objectionable when it is visible at the top of the breast. For that reason, placing implants beneath the large pectoral muscle can be particularly advantageous with saline implants. The thickness of the muscle obscures whatever wrinkling there might be, in the same way that a thick carpet will hide uneven floor boards.
Saline implants tend to ripple more than silicone gel or other materials.
It is in the nature of saline inflatable implants to have wrinkling of
the shell. This is because the shell needs to be thick and strong
enough to last as long as possible, and because the saline (salt water)
fill shifts with changes in body position. In addition, if a
saline implant is not filled up to the optimum, which may require
overfill, there can be rippling at the top of the breast also.
Every saline implant has an optimum volume of saline fill, a volume that
gives the best balance between either wrinkling (caused by not enough
saline) or too firm/round (caused by too much saline). The
difference between inadequate volume and the optimum volume is
astonishingly small, around 10%, which may be only a couple tablespoons
of water! Women who are troubled with rippling because their
implants were not filled to the ideal optimal volume may need an
operation to add that critical tablespoonful of saltwater that makes all
A development since this article was originally written in 2001 has been the emergence and approval by medical authorities of so-called "gummy bear" implants. These are highly cohesive silicone gel breast implants - with the implication being that there is no containing envelope like traditional silicone or saline implants, and that the whole implant is effectively a jelly-like silicone compound that can't burst or leak. Post surgery it is difficult to tell the difference between traditional silicone implants and a "gummy bear", but the manufactures claim that it can't rupture is already disputed by patients.
Despite the every effort of implant manufacturer's and surgeons, the look and feel of breasts with implants will be different (to some degree) from that of similar size real breasts. Have you ever paged through a lingerie catalogue and been sure that one of the models had breast implants? Well, that's probably because implants can make the breast look unnaturally rounded. Most implants are half spheres in appearance while natural breast shapes are more parabolic or U-shaped. Women with large implants may also get a "double breast." This is because the normal breast hangs, but the implants stick straight out from the chest wall. This makes the breast look like it has a hump in the middle when looking at it from the side. When pushed up, the implants' upper border will show through the skin. Two deeply curved upside down lines get etched in the skin. When pushed together, well... they don't push together. It is like putting too balls together; they meet in the middle and leave a gap on either side. This is in contrast to the straight line formed by natural breasts. When left alone, implants leave a flat valley-like gap where the breastbone (the sternum) is, between the implants. Natural breasts slope more gradually towards the centre.
Measure's can be taken to minimise and reduce all these problems, but they
cannot be completely eliminated with the current breast augmentation
When doctors say that implants feel the same as normal breasts, they are talking about how they feel to others touching the breasts, not about how they feel to the woman with the implants. Implants can make it harder to sleep on your stomach and they often feel cold. Silicone gel and plant oil-filled breasts have a good reputation for feeling comfortable and natural to the woman, but saline-filled implants don't have the same density as tissue so the weight of the breast feels odd for its size.
The body forms capsule tissue around the implants, in some women this causes the breasts to feel artificially firm or even hard.
The difference in the feel of the breasts can also have an impact on cancer screening. If the augmented breast does not feel the same as the natural breast, it can be difficult to determine if there is a change in the breast that should be checked out. Also, there are changes that will occur in the breast due to the implant that will have nothing to do with cancer, but these changes can cause alarm when they are first noticed.
Give-away's caused by over-large implants or other factors (including poor quality surgery) include:
Factors that increase implant give-aways:
Factors that decrease implant give-aways:
Transsexual women who "pass" successfully have usually taken the advice of their surgeon and settled for appropriately shaped small-to-medium implants which give them natural appearing augmented breasts of perfectly adequate size for their build.
There is a large body of medical literature dedicated to breast augmentation, but very little specifically related to breast augmentation in transwomen. Further, the majority of the literature dates back to the 1990s or earlier - and thus fails to reflect significant medical advances.It was therefore an important event when in April 2019 the magazine JPAS Open published the study "Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes", an online copy can be found here. The study itself opens with the introduction:
"Gender-affirmation surgery is essential in the management of gender dysphoria. For male-to-female transgender women (transwomen), feminization of the chest is a component in this process. There is minimal literature describing effective and safe techniques for breast augmentation in transwomen."
A summary of the key points and findings:
The study also noted:
The study concluded that "Breast augmentation in transwomen is safe and typically leads to high patient satisfaction with improvement of gender dysphoria".
The study included the photos below:
Breast Augmentation Examples
I attempt to show here a diverse range of implant results illustrative to the diverse range of procedures and implants types possible.
Hundreds more fully documented examples of breast augmentation, including "Before and After Photos" and a lot of other useful information, can be found at the "All about Breast Augmentation and Breast Implants Resource" and Nicole's huge "Breast Augmentation & Breast Implants Information Web".
The pictures below are provided by Leah. The left picture was taken soon after her breast augmentation in her late 30's. This involved a inframammary incision and the skin of breast is still very stretched and the outline of the profiled implants fairly clear. The right hand picture is taken several years later and the breasts have settled in to a more natural looking appearance, probably aided by some additional hormone induced tissue development. The exceptionally large areolae (for a transwoman) are slightly marred by the uneven stretching and the surrounding area seems to have a slight skin rash (just visible in the photo), possibly caused by the implants being too near the surface (i.e subglandular).
The following pictures show Larisa. An initially good impression (left) of her breast augmentation is countered (right) by the implants being obvious and a very unnatural in appearance when topless.
Next is Teddy Quinlivan - who out'ed herself as a transwoman in 2017. As shown in the left photo, her breast development age 22 was probably disappointing given that she had been taking oestrogen hormones for five years. After very careful consideration and a lot of research she had round breast implants of just 100 cc, which are obvious in the middle photo. The implants are very small for most patients but - as she undoubtedly hoped for - the appearance is usually ideal for her a skinny build and career as a model (age 24, right).
Before and after photos of a transgender woman who started hormones age 31 and had augmentation surgery age 34.
Before and after photos of the breast augmentation of a transgender woman published her by surgeon. He doesn't provide any details, but she was age 25.
Before and after photos of a 27 year transwoman. Obviously the profile of the breast has improved dramatically, but as usual the areola remains unusually small for the breast size and is a strong giveaway.
The photo below shows a transwoman after 600cc implants, they are excessive for pre-existing breast tissue. But if her goal is dressing and appearing as a very generously endowed middle aged woman, it's a success.
The following examples are provided by surgeons, as such they are probably particularly good results.
Some photos of transwomen 'before and after' breast augmentation. No details of the procedure are available. Note yet again the small nipples /areola that so often unfortunately distinguish the breasts of transwomen from cis-women.
Finally, you can read a little about my own breast augmentation and experiences by clicking here.
Additional contributions to this page are very welcome, your identity will
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