Breast Augmentation

Breast Augmentation

In general, transgender women who receive estrogen treatment will have a certain amount of breast development, but not usually enough for prominent breast growth compared to biological women. Therefore, most transgender women tend to undergo breast augmentation surgery with a silicone implant. Although the surgical technique is similar to breast augmentation in female patients, the implants must be placed subpectorally because most transgender women do not have sufficient breast tissue to cover the implants.

Criteria for male-to-female GAS for Breast Augmentation

1. Must have a diagnosis of gender dysphoria
2. Aged 20 (Patients aged over 18 but less than 20 must also provide parental consent).
3. Must have sufficient understanding of the surgery and competence to sign the consent.
4. No comorbid conditions preventing surgery or anesthesia.
5. Individuals with a concomitant psychiatric disorder must be treated until the symptoms are well controlled prior to surgical intervention.

Feminizing hormonal therapy before breast augmentation surgery is not mandatory. However, we recommend that patients be on hormonal therapy for at least 12 months before surgery to maximize growth of breast tissue and to ensure a more natural-looking female appearance post-operatively.

Female-to-male GAS

Male chest contouring is the most widely used surgery in transgender men so that they no longer need chest binding to hide their breasts in public. Long-term chest binding may result in the loss of breast skin elasticity, the feeling of discomfort, inconvenience of daily breast wrapping, and fungal infection or pressure sores. Techniques of male chest contouring vary depending on the size and amount of breast tissue and each individual surgeon’s technique. Male chest contouring can be divided into three main categories, as follows:

• Subcutaneous mastectomy, areolar incision
• Breast amputation with or without free nipple grafting
• Endoscopic subcutaneous mastectomy

Male chest contouring: subcutaneous mastectomy/breast amputation

1. Must have a diagnosis of gender dysphoria, certified by one psychiatrist.
2. Aged 20 (Patients aged over 18 but less than 20 must also provide parental consent).
3. Must have sufficient understanding of the surgery and competence to sign the consent.
4. No comorbid conditions preventing surgery or anesthesia.
5. Individuals with a concomitant psychiatric disorder must be treated until the symptoms are well controlled prior to surgical intervention.

During male chest contouring

The surgeon will remove the entire breast tissue, with only a portion of breast fat remaining to prevent uneven skin texture after surgery. In general, patients with small breasts (no larger than cup B) could undergo the surgery using small incisions. This procedure's advantage is that it creates just a small scar hidden at the areolar area, and nipple sensation remains. A concentric circular periareolar incision can be performed if simultaneous areolar size reduction is needed.50 However, a drawback of this procedure is that skin sagging may occur after surgery and requires around three to six months of continuous chest wrapping post-operatively.

Patients who have large breasts (larger than cup C) or have done chest binding for so long that the skin loses its elasticity tend to require a larger incision, together with nipple repositioning. The advantage of this procedure is that it flattens the chest area within a single stage of surgery. However, drawbacks are the presence of longer scars on the chest wall and loss of nipple sensation. In patients whose breast size falls between cup B and C, the surgical procedure employed is selected based on skin quality. Surgery through a small incision may be done in patients with high skin elasticity in combination with chest wrapping after surgery.

However, patients with significant skin sagging due to prolonged chest binding may require surgery through a larger incision to limit the presence of extraneous skin post-operatively. Endoscopic subcutaneous mastectomy techniques are similar to gynecomastia surgery in male patients. Breast tissue is removed via trans-axillary instrumentation. This procedure is suitable for patients with small breasts and small and male-like nipple-areolar complexes. Since this is a trans-axillary approach, there will be no scars on the actual chest wall and breasts. Limitations are higher costs and that the procedure needs to be performed by experienced centers. Therefore, this procedure is not currently widely used for gender affirmation surgery.

Complications that may arise from male chest contouring include

• postoperative bleeding, seroma
• infection and partial nipple-areolar complex necrosis (frequently seen).

For patients who underwent small incision surgery, a second operation may be needed to correct the remaining skin sagging. For long incision surgery, a keloid may appear at the surgical incision.