TG Breast Augmentation

  By Cerise Richards, M.D.

 Since the beginning of Art History, the Breast has played a
 central role in defining the Feminine figure, both as a sign
 of fertility and beauty. In the MtF TG and TS community, the
 centrality of a presentable feminine figure is both
 necessary and desirable for our body image. After taking HRT
 for one to two years a majority of the MtF population may
 still have not achieved satisfactory breast development
 defined as a B-cup or greater. Therefore a large number of
 TS's seek additional breast enhancement through plastic
 surgery before completing the two years necessary for
 maximum hormonal effect.

 Since non-genital or cosmetic surgery are not proscribed by
 the Benjamin Standards, it is much easier to find a Plastic
 Surgeon who is willing to perform Breast Augmentation (BA)
 or Mammaplasty without completing the necessary
 psychological evaluation for SRS. It has always been held,
 since a paper by Dr. Edgerton, that BA should precede SRS
 since it is completely reversible and will allow the
 transitioning person to have a positive body image.
 Nevertheless, today BA and SRS are frequently performed at
 the same surgery.

 The Plastic Surgeon who performs this surgery should be
 experienced in operating on the male chest even though it
 has undergone some hormonal changes. Anatomically the male
 chest is broader, longer and more muscular with less
 subcutaneous fat. So the longer one stays on HRT prior to
 the insertion of prosthetic implants the better, since the
 hormones will provide more fat and glandular tissue to cover
 the devices. In the US, twelve months of HRT is considered
 the minimum time for BA surgery and in Europe it is eighteen
 months.

 The surgery consists of inserting a Silicone elastomer shell
 below each breast. The shell is then filled with Saline
 (sterile salt water) in the US or filled with Silicone-Gel
 in Europe. The Silicone-Gel has been banned in this country
 since 1992 because of the controversy of Silicone leakage
 causing Autoimmune disorders and silicone emboli. Under
 local or intravenous anesthesia, the procedure is usually
 performed in an outpatient setting. You may have a fixed
 volume implant or an implant which can be expanded
 additionally postoperatively. Both have different valves
 which are used for filling after the implants have been
 inserted in their deflated position. Therefore both can
 deflate partially postoperatively or rupture completely with
 trauma requiring replacement. The manufacturer quotes a 3%
 leakage/rupture rate in women, but this is responsible for
 one-third of the reoperations in BA.

 The surgical incisions are either below the
 breast (inframammary) on the chest wall or on
 the nipple border line (periareolar) or on the
 side within the arm pit (axillary.) The implants are then
 either inserted below the glandular tissue or below the
 pectoral (chest wall) muscle. The inframammary subglandular
 approach is preferred in Europe, but the scar can be visible
 for years and the tissue covering the implant may be too
 thin resulting in skin sloughing and extrusion in rare
 cases. The periareolar approach may result in decreased
 nipple sensation and again inadequate tissue covering. The
 axillary submuscular approach is now preferred for TS's in
 this country, but since more dissection and bleeding are
 encountered, endoscopic instruments are used to lessen
 complications. Because the pectoral muscle is stronger in
 males, the upward dislocation of the implant may occur
 unless the muscle is partially divided. The muscle will also
 tend to compress the circular implant into a spherical shape
 which in the male with a broader chest is helpful. This in
 turn decreases the cup size and therefore a larger volume of
 saline is needed (approximately 450 ccs). The dissection
 must continue towards the midline or the intraglandular
 space between the breasts will be too wide with no cleavage.
 Do you notice that most of our skinny runway models have
 that problem after BA? But the frequent complication of scar
 tissue forming a hard capsule around the implant is much
 less common with the submuscular approach and the use of
 antibiotics intraoperatively and postoperatively. The
 postoperative course is usually uncomplicated except for
 chest discomfort and discoloration lasting about one week.

    While it is the desire of every Plastic
 Surgeon to give you perfectly symmetrical
 breasts conforming to your wishes, he
 will also give you a lengthy informed consent which
 describes all the complications of dislocation, infection,
 skin tissue death, etc. Do not be discouraged! Just ask him
 How often do these complications occur in your practice�
 There is no scientific evidence that breast augmentation
 increases the risk of breast cancer. The presence of breast
 implants, however, makes it more technically difficult to
 take and read mammograms. Therefore New Ultrasound or MRI
 might be necessary to assess your breast tissue. Since
 breast cancer is increased with anyone taking Estrogens or a
 family history of breast cancer, annual followup is
 necessary. Breast cancer has been reported in four TS's
 following mammaplasty.

 What must be remembered is it that breast implants will not
 last a lifetime. They are mechanical devices foreign to your
 body which will need to be replaced and adjusted as you
 mature. The device is warranted for a lifetime, but the cost
 to replace them is not. One Plastic Surgeon on the FDA Web
 site said, "Who knows, they may last 6 months or 60 years."
 But there are people with retained prostheses for over ten
 years.

 Best Wishes for your New Future.
 Cerise Richards, MD