Special considerations for breast augmentation in trans women

Note: This post contains illustrations of breast anatomy.

Among trans women and transfeminine people, breast augmentation surgery is both frequently sought after and frequently received compared to the population of cis women. According to the 2015 U.S. Trans Survey, 8% of assigned-male respondents had received breast augmentation and a further 36% wished to undergo the procedure; in the Netherlands, 40% of trans women who received treatment at Amsterdam’s VU University gender clinic between 1972 and 2018 had undergone this surgery, and 85% reported that this was because they were unsatisfied with the degree of growth from hormone therapy alone. Conversely, only an estimated 1% of cis women in the United States have breast implants (Maher et al., 2020).

While the many different approaches to breast augmentation have long been a specialty centered on cis women’s bodies, these techniques are not necessarily as effective or appropriate for trans women’s bodies. A recent report by surgeons and physicians at the Johns Hopkins Center for Transgender Health (yes, that Johns Hopkins) reviews the particular considerations that must be taken into account when choosing surgical techniques for breast augmentation in trans women.

Coon et al. (2020) examined a group of 59 transfeminine patients evaluated for breast augmentation surgery, 36 of whom went on to receive this surgery. The authors observe that this surgery “is atypical in that the majority of cases are likely not performed by surgeons who perform a high volume of gender surgery”, and so these surgeons may not have experience with discerning which techniques are most suitable to trans women. All patients had been on HRT for at least one year, which is described as having “an essential role in maximizing breast growth and pocket expansion” – the volume of tissue and skin available to accommodate the implant.

In the patients who underwent surgery, 91.7% received lowering of the inframammary fold, the point where the bottom of the breast tissue meets the chest. The authors emphasize the key role of this step for trans patients: “Perhaps the most critical difference to appreciate in transgender augmentation is the need for routine inframammary fold adjustment, in contrast to cosmetic mammaplasty.” Without lowering and reconstruction of the inframammary fold, the implant could be positioned too highly and cause the nipple to point downward:

The authors also indicate that due to typically broader chest width in trans women, there are compelling reasons to choose the largest anatomically possible implants:

Over time, we have gravitated toward accepting patient desires for larger implants because of high satisfaction rates and lack of complications. Even so, approximately half of patients would select larger implants than we would permit if allowed. Perhaps most importantly, more substantial implants successfully fill the horizontally broad chest, addressing one of the most challenging parts of obtaining a good result.

In most cases, low-profile (wide diameter, less height) and high-profile (narrow diameter, greater height) implants are avoided in favor of medium-profile implants, with high-profile implants used only rarely in those few patients who have “narrow chests, substantial breast development on estrogen, and a desire for maximum size”. The authors also report that in their experience, shaped teardrop implants do not produce a visible difference compared to round implants, and carry a risk of improper positioning as well as the development of anaplastic large-cell lymphoma due to their textured surface.

Additionally, they recommend placement of implants beneath rather than above the pectoral muscle, as trans women’s breasts may have a “small diameter”, and placement directly underneath the mammary gland but atop the muscle can create the appearance of “an unnatural double mound” and “visible implant edges”. Subpectoral placement can also help avoid the outcome of an overly wide gap between the breasts, a risk for trans women with broad ribcages:

Aggressive release of the pectoralis with partial-thickness release of the thick sternal insertions (taking care not to fully release it) can help to address the problem of excessive cleavage gap from greater sternal bone width.

Among the patients treated at this surgical center, 79% reported being very satisfied with their overall cosmetic result, and 21% were moderately satisfied. Awareness of these factors can help trans women and their providers make the aesthetically optimal choice when planning an augmentation surgery. With these techniques, many of the concerns specific to trans women’s anatomy can be mitigated, resulting in a satisfying outcome that aids in the treatment of gender dysphoria. ■