Two-stage Augmentation Vs Dual-function Device?

Could someone speak on the tradeoffs of doing a two-stage augmentation (tissue expander and later actual implants), compared to a single augmentation in which a dual-function expandable device is used (e.g., silicone plus an expandable pocket for saline) ? (I am MTF with some existing tissue, but likely not enough for a plain single-stage augmentation to safely achieve the fullness I would prefer.)

Doctor Answers 4

Two stage vs one stage augmentation

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Usually MTF can have an augmentation in one stage. The tissue stretches commonly.  If it is tight certainly a tissue expander can be placed first.

New York Plastic Surgeon
4.2 out of 5 stars 30 reviews

Two stage breast augmentation almost never indicated.

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Two-stage placement of implants is for breast reconstruction and almost never for breast augmentation.

Breast augmentation in one versus two stages using a tissue expander

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In both transgender as well as genetic female patients, such as those with constricted breasts, whose tissues won't accommodate the desired size of implants, there will need to be some type of gradual expansion of the tissues to the ultimately desired size.  This can be accomplished with dual lumen devices, like the Becker implant with a silicone outer lumen and saline inner lumen, or an expandable saline implant like the Spectrum, or with a tissue expander that is then exchanged at a later time for a permanent implant, whether saline or silicone gel filled.  In the first option, the expandable device often serves as the definitive implant, and thus there is only one procedure needed as long as the injection port stays in.  These devices come with a small port, or rubber valve, through which the implant is gradually filled with saline, usually weekly, until the desired volume is reached.  The ports are often located laterally under the breast or toward the armpit.  While they can be left in, they are often palpable, and will need to be removed.  This is usually done under local anesthesia, but it leaves a second scar, small as it may be, on the body wall.  These implants have a higher long term leakage rate too, as opposed to single lumen devices, especially silicone gel, and that may be a disadvantage as well.  Contrast that with a two stage approach, which does require two procedures, but the second of which can often be done under local anesthesia too.  In my opinion, this method more often gives us the most control over the ultimate result, and thus the best shot at accuracy.  The expander is still filled gradually over time, usually on a weekly basis, but then it can be exchanged for a silicone implant which gives a softer, more natural result, and it is more durable too.  Additionally, in the event that the pocket is not formed exactly like we want with the expansion phase, we will know this, and with our planned second stage, any necessary adjustments can simply be planned into that procedure.  All of this is done through the same incision typically, and there is no need for an additional incision to remove a port.  That is the quick run down on your question.  A consultation with a board certified surgeon experienced in this type of breast surgery, especially in the transgender population, will help you to make your final decision on how best to proceed to reach your goals.  Best of luck in becoming who you really are!

Joseph L. Grzeskiewicz, MD
San Diego Plastic Surgeon

More data and photos would be useful

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Without photos, measurements, and desired implant size it's really impossible to make a determination or recommendation. I rarely would reccomend a tissue expander in a ccosmetic patient and would rather place a properly sized (meaning correct base width) implant, albeit smaller volume that you may desire, allow you to live with that for 3-6 months as a trial and then come back and swap that device out for a larger higher pprofile device if you so desired. You still have two surgeries but compared to an expander the first implant will look and feel good. An expander will look "bolted on" and is rock hard. I would recommend a second opinion from a board certified plastic surgeon doing at least 200 cosmetic breast cases a year. 

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