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!

For a tall, lean MtF transgender individual seeking breast augmentation, there are several factors to consider when choosing the best options for implants. Since you have relatively little natural breast tissue, it’s important to choose the right type of implant and placement to ensure a natural and aesthetically pleasing result. The most common approach is an inframammary incision with a submuscular pocket and typically a silicone implant. Silicone implants are preferred for a more natural feel and appearance. The decision between placing the implants over or under the muscle can be influenced by several factors, including your personal preferences, tissue coverage, activity levels, and the amount of overlying breast tissue.


If you are very physically active, you may be inclined to choose an over-the-muscle implant placement due to easier recovery. However, this choice might not provide as much tissue coverage for the implant, which can lead to visibility of the implant edges. Placing implants under the muscle can offer more tissue coverage, even though the recovery may take longer. It is essential to discuss your goals and preferences with an experienced plastic surgeon who specializes in transgender breast augmentation, as they can help guide you in choosing the right implant size, type, and placement based on your anatomy and desired outcome.


ABOUT DR. VYAS
Dr. Krishna Vyas, MD, PhD, MHS, is a highly trained plastic surgeon specializing in aesthetic surgery and breast surgery, including breast augmentation, reduction, lifts, and gender-affirming surgery (such as chest masculinization and feminization). With advanced training from institutions like Harvard, Mayo Clinic, and Johns Hopkins, Dr. Vyas is recognized for his expertise in breast and chest sensory nerve restoration. His PhD in clinical and translational science focused on stem cells, fat grafting, and improving outcomes in aesthetic surgery and breast surgery. Dr. Vyas has served on the editorial board for several medical journals and platforms and has over 200 research papers and talks. His research focuses on aesthetic surgery, regenerative medicine, stem cell biology, fat grafting, breast surgery, and gender-affirming surgery. Recognized for his expertise, Dr. Vyas was appointed an Instructor of Surgery at Mayo Clinic and served as an Assistant in Surgery at Harvard Medical School and Massachusetts General Hospital.


Dr. Krishna Vyas, MD, PhD, MHS
Harvard, Johns Hopkins, & Mayo Clinic Educated
Double Fellowship Trained
Aesthetic Plastic Surgeon
New York, New York

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.

At this current time, there are more options than ever before for breast augmentation.  There are saline (salt water) filled implants and silicone gel filled implants.  There are textured and smooth implants as well as round and, now, shaped implants.  So many options to choose from regarding implant types.  There are different options regarding technique as well.  For example, the incision to place the implants can be in the under-arm, around the areola, through the belly button, and in the breast crease.  The size of the implant depends on the broadness of your shoulders and the width of your breast.  Matching this to the shape of your body is another issue. Much will depend on the size you are requesting as far as the cup size.  Your surgeon should be able to help decide, with your input, the actual size of your implant.

It is hard to tell without looking at photographs. But from my experience with M to F going under the muscle is preferable for adequate coverage of the implant. I also agree that a silicone contour profile implant will give the most natural appearance.

Of course taking your chest measurements will help determine the size appropriate for you.

Good luck! 

dear 
I will start with a mild augmentation to give a chance to your tissue to settle on top of the implants 
Are you taking hormones?this could increase the wound complications , better to don't choose a heavy implants. For the size be assess by a qualified plastic surgeon, we will tell you the safest option. Under muscle is often mandatory,don't be scared , it doesn't change much!

The size of the implant will depend on many factors, including the width of your breast.  The approach needs to be individualized for each person.  

I have had the privilege of taking care of transgender patients in all different stages. I have used both saline and silicone implants in the submuscular position with nice results.. it depends on what the patient is looking for. Sometimes a staged procedure is necessary to achieve the final goal - for example, if a patient wants a larger look than we can achieve on the first surgery, we can re-assess the situation after 6-8 months to see if the body will allow for a larger implant.

I have zero experience with GID but it seems to me if your skin envelope is tight and you want to be as big as possible, would you consider wearing  a BRAVA to expand the envelope prior to augmentation and possibly to add fat to subcu space for better coverage?