However, it would be reasonable to say that the following method is usually followed: 

• The patient and surgeon agree on the desired size, shape and look of the augmented breast.    
• The type (smooth or textured), shape (round or anatomical) and size (measured in cc of volume) of implant is selected.  The implant may contain saline, silicone gel, or some other filler.  
• The incision site is determined; this can be nipple (areolar), armpit (transaxillary), under the breast (inframammary) or navel (transumbilical).    
• The site of implant placement is decided; this is usually above the muscle (subglandular, with a variant called subfascial) or below the muscle (submuscular), however since c.2010 a compromise placement (dual plane) has become very popular for transwomen.

Breast augmentation by a transsexual women is usually undertaken in order provide the largest and most beautiful and natural looking breasts possible	Incisions are made to keep scars as inconspicuous as possible, in the breast crease, around the nipple, or in the armpit. Breast tissue and skin is lifted to create a pocket for each implant.	After surgery, breasts appear fuller and more natural in tone and contour. The scars will fade with time but won't disappear completely.

Transwoman Kate after breast augmentation to a C-cup.  Unfortunately the breasts are not symmetrical and the cleavage looks slightly strange.

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. 

Some 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 folds. 

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.

To 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' ribcages 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. 
 

Material

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
These are bags of silicone gel, i.e. they are silicone gel (a soft-solid substance) inside a smooth or textured elastomer shell also made of silicone.  

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 into 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.  

An Independent Review Group sponsored by the UK Government undertook a detailed study of silicone gel breast implants in 1998-2000 and their findings concluded:

• There is no histopathological or conclusive immunological evidence for an abnormal immune response to silicone from breast implants in tissue.        

• There is no epidemiological evidence for any link between silicone gel breast implants and any established connective tissue disease. If there is a risk of connective tissue disease, it is too small to be quantified. The IRG cannot justify recommending further epidemiological studies to investigate this hypothesis.     

• Good evidence for the existence of atypical connective tissue disease or undefined conditions such as ‘silicone poisoning’ is lacking. It is possible that other conditions such as low-grade chronic infection may account for some of the non-specific illnesses noted in some women with silicone gel breast implants.

Saline Filled Implants
Saline-filled breast implants have been available since the late 1960s but they were largely viewed as an "alternative" breast implant in a market dominated by the popular gel-filled device.  Saline filled implants have only become popular since 1992 when the FDA decided to restrict the use of silicone gel-filled breast implants, and they now dominate the market in the USA (though not elsewhere).

Saline filled implants are simply bags of water.  The water is salt water, osmotically equal to the natural salt content of the body and completely harmless.  The saline is contained within what's technically called a silicone elastomer shell.  If the bag breaks, the body safely absorbs the saline that leaks. 

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)
These implants consist of two lumens, or envelopes, one inside the other.  In some models, the inner envelope is pre-filled with silicone gel, and the outer envelope is filled with saline at the time of surgery.  In other models, the relationship is reversed and the inner envelope is filled with saline. Some studies suggest that the double-walled model results in a softer, more natural appearance because it reduces the incidence of capsular contracture, also the amount of saline can be adjusted at the time of surgery to the optimum fill.

Model Andreja Pejic came out as a transsexual woman in July 2014, after having both GCS and breast augmentation. Small anatomically shaped breast impants are obvious in this photo from August 2015.

Hydrogel Filled Implants
Technically hydrogel is composed of 92% Saline and 8% Polysaccharides, i.e. it's a mixture of salt, water and sugar.  The Hydrogel implant is claimed to have the safety of standard saline implants but with all the benefits of a gel that will simulate the firmness and suppleness of natural breast tissue. 

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, most 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 
The polyvinylpyrrolidone (PVP) has long been used in tablets and other medical applications and is considered biocompatible.  Water-soluble, PVP-Hydrogel can be safely excreted through the kidneys in the event of traumatic rupture, it will not be metabolised by the body.  The implant manufacturer suggests PVP implants have improved radiolucency over silicone gel-filled or saline-filled implants, allowing clearer visualization of the breast tissue during a mammography. 

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
Plant oil filled implants have developed from the concern over health safety issues relative to the silicone gel-filled implant.  These breast implants filled with a natural vegetable oil promised greater safety for women.  They also reportedly have more natural feel and appearance than saline implants, but little is yet known about the long-term effects or problems associated with these.  They are available throughout most of the European Union but are still undergoing clinical trials in the US and Canada. 

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. 

Comparison
A comparison of the three most popular type of implant filling materials:  

* Requires special approval from the Therapeutic Goods Administration on an individual patient use basis. Strict criteria on use.
 

Implants come in two shapes:

• "Round" - The majority of breast augmentations use implants of this form.

• "Anatomical" - A shaped implant contoured to resemble the shape of the breast of a woman in vertical position.

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.   

Most breast implants are round (below left) or anatomical (below right). The shape of the implants will affect the shape of the augmented breasts. Both types of implants increase breast size.  The girl or woman can usually select the type depending on the look and outcome she wants to achieve.

Round implants make the upper part of the breast very prominent and can provide a striking appearance with push up bras, low cut tops or when wearing a bikini.  But the appearance when topless can be unnatural and breast augmentation obvious.

Anatomical implants are contoured or teardrop.  They provide less upper breast "fullness" because the top of the implant is shaped and sloped like a natural breast.  They lack impact of a round implant, but a small implant can be almost undetectable topless.

A transwoman with the common give-away of small areola, however the appropriately sized anatomical implants make her breasts seem quite natural.

The main advantages of an anatomical implant over a round implant are:

• It is not as wide as a round implant and therefore does not go out under the arm as much. 

• It is filled tighter than round implants thus maintaining the fullness in the upper parts of the breast, even in the upright position. This is made possible due to its anatomical shape.

• Folds and ripples and wrinkles are less common than in textured round implants.

• The overall shape is improved. 

• In some women it may improve the balance between the breasts and hips, creating an overall hip-slimming effect and a more desirable figure.

Pamela Anderson in Baywatch

However, many transsexual women prefer the very prominent breasts that result from having large round implants - as Pamela Anderson iconically demonstrated after having round breast implants before starring in the 1990's TV series Baywatch.

A transwoman after high quality breast augmentation using round implants. She has small areola which are positioned slightly high, but the overall appearance is good.

Also, one medical study controversially concluded that the natural appearance sought by women having anatomical implants 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 actually more natural in appearance than the anatomical because this retains its teardrop shape in this position, whereas a round implant can droop because the filling is under less pressure. 

Overall, it would seem that for 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 some women.

Surface

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
The outside of the implant is covered with a textured (rough) surface.

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 walled implants have an outer membrane or shell with a smooth feel. 

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.

Comparison
A comparison of the three alternative saline-filled implant shapes and surfaces:  

Anatomical Textured Saline	Round Saline Textured	Round Smooth Saline
Appears to have the most forward projection of the breast for any given volume.	Appears to have slightly less forward projection of the breast for any given volume.
Narrower breast, with least bulging out under the arm.	A little wider breast on the chest giving a round look.
In theory, less pocket creation out under the arm could pose less risk to damage to the sensory nerve to the breast.	The sensory nerve to the breast is at risk of damage as the pocket is created.
Most natural appearance with nice slope to the top of the breast.	Some bulging at the top of the breast at first and later may become somewhat concave.
Rather firm feel to the breast.	Softer feel to the breast.	Softest feel to the breast.
Occasional ripples.	Most prone to ripples.	Ripples are very rarely a problem.
Planning and placement requires extra care. It is important to prevent the implant turning around by careful pocket preparation. Texturing helps to fix the implant in position.	Requires careful surgical planning and placement, because texturing tends to fix the implant in place. It does not matter if the implant turns around, but the texturing makes this unlikely.	Standard surgical planning and placement. It does not matter if the implant turns around.
Texturing may help reduce the incidence of capsular contracture.		Capsular contracture may be slightly more likely.
Post-operative breast massage to reduce capsular contracture is not normally recommended by implant manufacturers (it can void warranty) or surgeons.		Post-operative breast massage to reduce the incidence of capsular contracture may be recommended.
Surgeons will usually recommend placing all these implants under the pectoralis major muscle (submuscular) for best results with most women.

 

Size

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:

• Increasing an A cup to a C cup required a total of 391cc, or 196cc per cup size.

• Increasing an A cup increasing to a D, cup required 437cc, or 145cc per cup size

• Increasing a B cup to a D cup required a total of 448cc, or 224cc per cup.

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.

Fairly successful large implants like Jennifer's are uncommon.

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.

Jaqueline started hormones at age 23.  She had small  (200ml) implants a few years later, which are almost impossible to detect visually in her B cup size breasts.

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 ribcage 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.

 

This transsexual woman had (top) 770cc saline submuscular implants with a periareolar incision, giving her a 36C bra cup.  She had these replaced with inflatable implants filled to 1000cc (bottom) and is hoping to eventually reach 1400cc to give her a full E or EE cup.

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.

Adjustable Implants
When relatively large implants are desired then 'inflatable' adjustable fill implants have become increasingly popular. (Adjustable implants are sometimes referred to as "Spectrum Implants", after the popular brand from Mentor Corporation)

It's uncertain that these pictures are actually of a transwoman as claimed, but they are still interesting. Age: 28, Height:  5'1" Implants:  425-510cc, smooth, round, Mentor Spectrum adjustable Placement:  Submuscular, inframammary incision Bra cup size:  34A to 34D

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.

Transwoman "Barbie" opted for adjustable implants to increase her from a hormone induced B.  Over a period of a year she went from an initial D cup (left) to a G (centre), before reducing to a more natural E/F (right) when she had the valves removed.

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.  

A modern anatomical tissue expander with integral filling port.

Tissue Expanders
Tissue expansion-augmentation was originally developed for female breast reconstruction after a mastectomy, being intended to expand the limited remaining tissue and create a breast pocket for a long-term breast implant, but the technique also offers several advantages over standard breast augmentation methods when significant augmentation is required with little breast tissue to work with.  

Tiffany Andrews, aka Holly Sweet.  Her claim to be an E cup seems to be an underestimation!  However the nipples are high and - as is so often the case with transwomen - the areolae are relatively small.

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 technique offers several important advantages over standard breast augmentation methods when significant augmentation is required.  It is increasingly favoured by transsexual women because of:  

• The natural final appearance of even very large breasts. 

• Many of the shape problems normally encountered with large volume implants can be overcome by the slow stretching method.

• The stretch marks normally associated with large implants are reduced or even avoided. 

• There is normally a size limit to submuscular augmentation, if a woman with "AA to A" cup breasts wishes a significant augmentation (greater than 400 cc), then this is the method of choice.  Volumes of greater than 1000 cc can be possible with this method. 

• Scar tissue from prior procedures can inhibit a good result with ordinary implants.  Expander implant can overcome these problems. 

• The ability of the women to have very direct influence in the final size and shape of her breasts, without additional surgery.

• Significant differences in the size of the two breasts can be equalised.

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: 

• Only saline-filled implants can be used as adjusters, and saline implants are generally considered to have a less natural feel and sag than silicone gel or other alternative fillers.  Saline expanders can later be replaced by silicone implants, but this means more surgery.

• Every time the implant port is accessed - for injection or removal - there is a small risk of an infection. 

• Back problems are associated with very large breasts.  A lot of women have at least temporary back problems, which usually but not always subside after a few weeks. 

• Once the valve of an adjustable implant is removed, the implant cannot be deflated and re-inflated as can the standard smooth round saline implant.  This would be necessary if a capsule contracture were to occur, or the pocket needed to be repaired due to stretching of malposition of the implant due to problems with the pocket, e.g., the implants settling in too low, etc.  They would have to be removed intact, which requires a longer incision and scar, and risks injuring the implant.

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. 

Implant Incision

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 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. 

Periaerealor (Nipple)
Probably the most common incision method (called "periaereolar") is around the lower edge of the areola, at the junction of the dark and light skin around the nipple.  Both above the muscle and submuscular implants can be done this way and the method allows good placement of the implant with consistency. This approach can only be used if the areolae are quite large, which is not the case for most transsexual women.  In woman with small areolae, the method may be impossible because the incision needs to be at least 1.5 cm long, and preferably at least 2 cm long, for inserting even a relatively small implant of 200 cc volume through it.  This technique is best used for relatively small implants and so many transsexual women seeking large breasts avoid this approach.

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.

Bianca, shown: 1. Age 19, before starting oestrogen hormones 2. Age 22, after two years on hormones 3. Age 25, after breast augmentation using the inframammary method.

Transwomen Larissa Summers.  Her breasts seems natural in the main picture, but other pictures show the outline of implants and scars in the breast fold.

Inframammary (Breast fold)
Probably the second most popular incision.  An incision is made above the fold of the underside of the breast.   Both above the muscle (submammary) and below the muscle (submuscular) implants can be done this way and again the method allows easy access to the tissues to make a pocket to receive the implant, resulting in consistently good placement of the implant.  The main disadvantage is that the scars can often be very visible when the woman is lying down topless, or even when wearing a skimpy halter-top or a bikini - the surrounding skin is all one colour which highlights the scar.  The procedure is most preferable on woman whose natural breasts droop enough that the skin of the breast is touching the skin of the chest wall when standing, but this is rare in transsexual women.

Korean transwoman Ha Ri-Su.  The scar of her transaxillary breast augmentation is obvious in this picture.  The shape and edges of slightly over size implants are also observable.

Transaxillary (Armpit) 
This technique involves an incision in each armpit (axillary) and also uses the endoscopic method of placement. 

This method is used primarily for those who don’t want scars on the breast and who don’t wish to have the surgery done through the navel.  It has the disadvantage of being distant from the operative site, possibly making it difficult to visualize the site and control bleeding.  While axillary scars usually can't be seen, there are nevertheless small and sometimes thickened scars in the armpits which may be quite noticeable when the arms are raised while wearing sleeveless clothing.  

Studies have also shown that there is  a higher possibility of permanent loss of feeling in the nipples than other incision methods, and the method can also interfere with the nerves near the arm, resulting in numbness in the arms occurring temporarily or permanently.

Transumbilical (Navel)
The Trans Umbilical Breast Augmentation technique (usually abbreviated to TUBA or "transumbilical") provides insertion of breast implants through a small incision made in the belly button.  The method cannot be used for large implants or pre-filled implants (e.g. silicone gel type), its restricted to saline implants.

The procedure is illustrated below:

Insertion through the umbilicus makes it hard to position the implant accurately, and is even harder if it is submuscular rather than subglandular, it also puts significant stress on the implant with a risk of streching or damaging the envelope.   Surgeons are not able to get as consistently good results this way as if they were working through an incision right on the breast. 

As positive, this method eliminates any scarring in the area of the breast (although unsightly scaring in the abdominal area can occassionally occur instead) and recovery can be much shorter because there are no stitches near the arms and breast, and less healing of scars and internal tissue that would be cut to pass an implant through the areola or inframammary area. 

Because of the difficulties in placement of the implant, the transumbilical method only makes sense if just small implants are required and avoiding any visual scaring of the breasts or armpits is a critical consideration, e.g. for young women seeking a modeling career.  Perhaps the main risk is having to make a normal (i.e. periarealor or inframmary) breast incision if the TUBA placement does not work out, however it can be argued that that the possibility of having no scars at all was worth the try.

Selecting the Right Incision Method
As can be seen above, each incision method has advantages and disadvantages.  

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
The final outcome and shape of breasts after implant enlargement or "Augmentation Mammaplasty" is in large part determined by the relationship of the implants to the pectoralis muscles of the chest wall.  Generalising, implants are usually placed above (over) the pectoral muscles, or beneath (under) the muscles, but there are variants and different prefered placements routes.  These all have different potential advantages and compliactions. The long-term problems associated with breast augmentation can be mitigated by the surgeon and patient considering and adhering to good principles that include limiting risk of capsule contracture, limiting the "round" look of implants, preventing visible rippling or wrinkling of the implants, preventing "bottoming out" of the implants, and - most importantly - preventing compromised mammography after augmentation.  Unfortunately short-term desires and wishful thinking often takes priority.

Possible Placements

There are four possible placements for breast implants, and all of them have very different with pros and cons:

• Submuscular
• Subglandular
• Dual plane
• Subfascial

Each placement is considered in more detail below: 

Subglandular (above the muscle)
This means placement of the implant directly below the mammary gland, above the pectoral muscles.  This placement is also sometimes referred to as retroglandular or submammary. The implants are usually inserted via a periareola incision.

When using this method surgeons recommend using silicone gel implants.  Saline implants need to be avoided as they are water filled, and the implant does not feel or move like breast tissue - silicone implants are far better in this regard. 

Advantages of the technique are the simple (thus low cost) surgical procedure, ease of placement, and minimal post-op discomfort since only skin and fat have been cut.  The approach also allows the insertion of oversize implants - ridiculous sizes being reached by some porn stars.  This type of placement is also particularly successful for transwomen with tuberous breasts or other problems.

A major disadvantage is that placing the implants often causes damage to the breast nipples, nerves, tissue and milk ducts.  This is undesirable for cis women planning to breast feed one day.  Also, if the breast tissue, skin, and subcutaneous tissue are too thin, their are substantial other disadvantages.  These can include visually very obvious implants,  damage to the mammary gland and breast tissue, marked interference with mammograms, clear visibility and feel of implant edges, visible and palpable rippling of the skin over the implants (especially with textured implants), a higher rate of capsule contracture, a high rate of later implant downward migration or "bottoming-out", and the high likelihood of eventual breast ptosis problems - which will be difficult to resolve.

A submuscular implant. A layer of muscle protects and separates most of the breast implant from the breast tissue

Submuscular (below the muscle)
The implants are placed behind beehind both the breast tissue and chest wall muscle.

The implants are usually inserted via an inframammary crease incision.  Another option is to use a transaxillary incision - entering the space under the muscle where it lies closest to the skin in the anterior axillary fold under the armpit.  This procedure minimises muscular damage and avoids any breast scaring.  However, it is a more difficult technique to master, and the pre-filled implant size is limited to between 300 to 400cc’s, which may be insufficient for some transsexual women.  It is thus far rarer.

The many advantages of this approach are a protective cover for the implants, an excellent support structure s which avoids bottoms, a natural breast shape, lower capsule contracture risk, no ducts are damaged while placing the implants, and low mammography interference. It also less likely that the implants are visually obvious or can be felt in the breast.

The submuscular placement is particularly recommended for slender patients and/or those with little existing breast tissue as it reduces the chances of rippling, which is when the edges of the implant fold and wrinkles of the breast implant can be seen through the skin. 

Post surgery, some muscle discomfort is inevitable until they stretch and the implants settle. 

 

A dual plane placement. A layer of muscle covers the upper half of the implant, only breats tissue and skin the lower half.

Dual plane (or subpectoral)
The dual plane placement is also sometimes also called subpectoral.  There are medical articles arguing that there are the differences, but these are far too technical for this website. 

The dual plane placement is best considered as a hybrid between the submuscular and subglandular placements.  The insertion involves placing the upper part of the implant under the pectoralis major muscle while allowing the lower part of the implant to sit directly under the breast tissue over the pectoral muscle. I.e., the lower half of the implant is not covered by muscle in this type of placement. 

The implants are usually inserted via a periareola incision or an inframammary crease incision. 

Most surgeons consider this insertion placement to result in the most natural looking appearance as the breast implant sits in an optimal position whilst its lower half adopts a rounded shape and fall as it's not constrained by overlaying muscles.  Another advantage of dual plane placement is that it reduces damage to the milk ducts, nerves, and breast tissue. 

The many advantages of this approach are the relative ease of placement, a natural breast shape without visually obvious implants, no rippling of the implant surface, lowered capsule contracture risk, no ducts are damaged while placing the implants, and low mammography interference. As such it is the most commmon BA procedure - about 75% of breast augmentations by cis-woman are subpectoral. It works particularly well with anatomical (aka teardrop) shaped breast implants.

However a problem is that the placement leaves the lower part of the implants supported only by the same weak skin tissues as subglandular implants, leading to the risk of later downward bottoming-out of the implants.   

A subfacial placement with the implant placed under a supporting fascia that covers it almost entirely.

Subfacial
In the subfascial breast augmentation procedure, the surgeon places the breast implants beneath the pectoralis fascia which is a thin tissue covering the chest muscles, but above the muscles themselves. This placement is also referred to as retropectoral.

The support fascia is an extension of the muscle envelope from the pectoralis muscles to the abdominal rectus muscles, and the finger shaped serratus anterior muscles to the sides.  This stout collagen sheet slowly stretches after implant placement and provides reliable long-term internal bra-like support to prevent "bottoming-out".

The placement combines most of the advantages of the subgalndular and submuscular placements.  These include separating the implants from the mammary gland facilitating unobstructed mammography, a natural appearance 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 a low risk of capsule contracture.  

The procedure also causes little injury to the breast tissue during the surgical procedure which usually results in a more comfortable healing and recovery process, however the placement inevitably causes disruption to the muscle support fascia in order to create a space for the implants - with a resulring risk of complications.

The biggest disadventage of this placments is that requires a very skilled surgeon with a very high degree of skill and experience, i.e. it's the most costly.

Advantages and Disadvantages:
Capsular contracture - Many surgeons believe, based upon clinical studies regarding placement of the implant and contracture rates, that placing the implant below the pectoralis muscle (subpectoral) or fully submuscular, reduces the rate of capsular contracture when compared to above the muscle placement of the implant.   Keep in mind that there is not total agreement as to whether this is truly the case.  One alternative that has been suggested to prevent capsular contracture is the textured implant which, even if placed above the muscle, is also supposed to reduce the rate of capsular contracture.  Whether this is true is also the subject of some debate.  Furthermore, many believe that textured implants are more likely to create visible rippling.  Surgeons who disagree with this view of textured implants claim that rippling is a result of improper filling of the implant and not at all with the surface of the implants.

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.

Premature breast implants, inadequately covered by hormone induced breast tissue, is a common problem

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.

Leslie, transwoman star of the now cult 1978 'B' movie "Let Me Die A Woman".  A critical examination of her initially very natural looking breasts shows that the implants have sagged to an oddly low position, although they seem to remain within the breast tissue.

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 to 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:

The image below is from a clinic advertising their breast augmentation surgery:

Part 2 of "Breast Augmentation"....