I Am a MtF Transgender Wanting Breast Implants - Options?

I have been doing transgender breast augmentations for over two decades, so hopefully I can offer some useful thoughts.

First of all, transgender or not, below the muscle does NOT automatically imply "longer" or "more difficult" recovery. This is true for all augmentations, not just transgender patients. Careful surgical elevation of the pectoralis major muscle with precise control of bleeding points (as well as use of IV Decadron, oral Robaxin, oral Celebrex, and Marcaine in the breast implant pocket) makes this operation as "easy" (or hard) as submammary placement. Activity restrictions are identical in my practice for either implant placement position.

For a physically tall and probably wide breast base woman, particularly if you have thick or strong pec muscles and tighter, youthful skin, you need large implants to be proportionate. Although physical examination is needed to make a proper determination, you may wish to consider two-stage surgery, with placement of crescent-shaped tissue expanders below the muscle (inferomedial fibers divided), outpatient expansion, and then second stage placement of adequately-sized silicone gel implants (round, smooth, cohesive 5th generation). These will be teardrop-shaped when upright, but round when reclining, whereas shaped implants are textured to "stay in place" and remain teardrop-shaped when reclining (unnatural, IMHO). Not to mention, they don't move like real breasts because of the textured adherence to your tissues.

Although this seems like two guaranteed operations (it is) and no guarantee that revisions will be necessary (also true), I have looked at two decades of data and found a rather unfortunate tendency of so-called "single-stage" augmentations (in our transgender population) that ended up with 2, 3, or even 4 operations to get the final size, shape, and position required to look proportionate and natural for your height. Or, you can get the single-stage "Betty Boop" firm, tight, too-small look that leads to those multiple re-operations.

This 2-stage approach is not needed by every M-F transgender augmentation patient, but I find it beneficial in about half of my patients and they are happier for it as a result. Click on the link below for examples of my patients. Best wishes!

It is very difficult to determine the exact size and shape implant you will require to best match your ideal breast image without an examination by a board certified plastic surgeon. Not just any board certified plastic surgeon, but one with many years of frequently performing breast augmentation surgery for MTF patients including different approaches, techniques and implant choices. This is because several measurements not to mention your breast characteristics are needed to determine the optimal implant size to obtain your goals. Without knowing these dimensions it would be difficult to make this determination. For example, the existing base width of your breast will determine, in many cases, the maximal volume per implant profile that you can accommodate. To illustrate; a 100 cc difference may make a significant difference with a narrow base width breast, but much less of a difference if you have a wide chest wall and wide breast “foot print”. Therefore, just because your friend may have a great result with let’s say a 350 cc implant to make her go from a “A” cup to a “C” cup size does not mean that you will have the same result with the same size implant. . Further simply placing implants in a bra to determine the size best for you is not always accurate as the bra often distorts the size, is dependent on the pressure the bra places plus the implant is outside your breast and not under it among other variables. Computer software morphing programs that automatically determine the best implant size can be helpful in some but not all cases (e.g. doesn’t work well in my experience with existing implants, sagging or asymmetric breasts). Using “want to be” photos however are useful if simply provided to the surgeon as I will further explain the below link.

Generally speaking the advantages of going over the muscle are very few.  The recovery from sub muscular breast implants is not significantly different, but the longterm advantages are many.  I would suggest a sub muscular implant, even in patients that work out.  You need to try sizers on to determine which would be best for you.