Breast Enlargement for Gender Affirmation Surgery Guide

What can a breast enlargement for gender affirmation achieve?

The goal of breast enlargement for gender affirmation (sometimes called 'MTF top surgery') is to increase the size and change the shape of the breasts to make them look more feminine. Many individuals may consider this surgery after they have used hormone therapy to help increase the size of their breasts. If hormone therapy alone does not create the desired result, some patients may consider having a breast enlargement.

The surgeon may suggest that patients have at least 12 to 18 months of hormone therapy before having surgery. This allows for breast tissue to develop before increasing the size of the breasts with implants.

There are two hormones that have an effect on the size of the breast:

• Oestrogen – This helps increase fat levels in the breasts, hips and buttocks.
• Progesterone – This helps the milk glands growth of milk glands and the rounding off of the breasts into an adult shape. It also matures and darkens the areola around the nipple.

What does breast enlargement mean to you?

It's important to know there is no strict order, checklist, or "right" way to approach surgery for gender affirmation. Your identity is not made more or less valid by the surgery you choose to have; this is simply an aspect and reflection of your individuality and identity.

Each individual has a different relationship to gender affirmation surgery, and your priorities may be very different from those of your peers. Therefore, you should only consider breast enlargement if/when you feel you want to increase the size of your breasts.

At the moment, the only gender affirmation surgery currently offered by Medbelle is breast enlargement. Consequently, this overview only focuses on increasing breast size and not other treatments associated with gender affirmation.

Who are the best candidates for this surgery?

The ideal candidate is a healthy transgender woman or transfeminine individual who wants larger breasts and/or someone who has not achieved their breast size goals from hormone therapy alone. Though not a prerequisite, many trans individuals will have been on hormone therapy before looking into having breast surgery. Hormone therapy can help increase the size of existing breast tissue which can make it easier for a surgeon to increase breast size with implants.

Other features of ideal candidates for surgery include those who:

• Are over the age of 18
• Are medically and emotionally healthy
• Have access to ongoing psychological support
• Have strong social support from friends and/or family
• Are at a stable weight
• Have a healthy BMI
• Have a referral letter from a specialist health professional

Why have breast surgery?

Breast surgery is a popular option to help any individual achieve a specific look to their breasts, including transgender women and transfeminine individuals. For transfeminine individuals, breast surgery can be especially powerful with regard to easing gender dysphoria or body dysmorphia, though patients may be motivated by simply wanting to increase the size or alter the shape of their breasts. No matter the reason, breast enlargement can help many patients feel much more comfortable with their body.

It is vital patients tell their surgeon what they hope to achieve from surgery during the consultation. They will discuss all aspects of the procedure with you and recommend the best course of treatment to get you the results you want.

How is breast enlargement surgery performed?

Breast enlargement surgery generally lasts 60 to 90 minutes. Prior to having surgery, patients will have an in-depth consultation with their surgeon. The patient will discuss what they wish to achieve from the treatment.

The surgeon will also give information about what the procedure itself will involve. They will also give strict instructions on eating and drinking before and on the day of your surgery.

Consent

Before treatment, the patient will need to sign a consent form. Before signing this, it is important that they understand the benefits and potential risks of the procedure. The surgeon will go through these. It is important the patient asks any questions if they are unclear about anything. The surgeon will then draw guidelines on your chest to mark where the incisions will go.

Anaesthesia

On the day of your procedure, patients will meet their anaesthetist. This is the doctor who is responsible for putting them to sleep or numbing them during the operation.

Incisions

Surgeons aim to minimise scarring as much as possible. Generally, the surgeon will improve the aesthetic appearance of your breasts by placing incisions in the most hidden places. This may include making incisions in the following areas:

1. Periareolar incision (around the border of the areola)
2. Inframammary incision (just underneath the breast in the inframammary fold)
3. Transaxillary incision (in the armpit)

The surgeon will discuss which option is best and discuss the risks and benefits of each type of incision.

Implant placement

The surgeon can place the implant in three different positions as seen in the diagram below: Over the muscle, under the muscle, or a combination of both.

The position that the surgeon will decide to use depends on which one will produce the best results for the individual patient. The options your surgeon can use are:

Over the muscle (Subglandular or Submammary)

An implant that is over the muscle can help improve the shape of the breast as it is nearer to the surface of the skin. Implants in this position can also lead to less postoperative pain in the first few days. The implants are also less likely to move when the chest muscles are flexed. They are, however, more likely to be visible and more likely to interfere with future mammograms.

Under the muscle (Submuscular or Subpectoral)

Implants that are placed under the muscle have a much lower risk of being visible after insertion. This is because the chest muscle provides brilliant extra soft tissue padding over most of the implant. Implants in this position are also less likely to interfere with mammograms.

Dual plane

In some individuals, surgeons may opt to use a combination of both approaches mentioned above. This involves your surgeon placing the top of the implant below the muscle and the bottom of the implant in direct contact with the breast tissue.

Breast Implant Type:

There are three different implant types that are currently available. During the consultation, the surgeon will discuss these three types and suggest which one will best suit each patients’ needs.

The three breast implant types are:

Saline

A saline implant is made up of an outer silicone shell filled with sterile salt water (saline). The silicone shell is inserted into the breast empty and then filled with saltwater through a valve. Saline implants are no longer often used as they are at a higher risk of rupturing and do not produce very natural-looking results.

Silicone Gel

These implants are made up of a silicone outer shell that is filled with a viscous silicone gel. Silicone gel implants look and feel more natural than saline implants. They are also less likely to rupture.

Highly-Cohesive Silicone Gel

These are the most natural-looking and feeling type of implant. These implants contain a firm silicone gel that gives them a more stable form. Highly cohesive silicone gel implants are the least prone to rupture, and even when they do, the contents do not leak out as readily.

Implant shape

Breast implants come in two shapes as seen in the diagram below: round or teardrop (also called anatomical)

The surgeon will recommend which implant shape can help create the look the patient wants to achieve.

Round implants

Round breast implants add volume to the lower and upper parts of the breast. It is for this reason that they are considered to be best for patients wanting to add overall volume to their breasts.

They are particularly suitable for patients who want to increase the volume in the upper pole meaning the upper part of the breast above the nipple.

Teardrop implants

Teardrop implants, also known as anatomical implants, add volume mainly to the lower pole meaning the lower portions of the breast below the nipple. This shape generally provides a more natural-looking final breast shape.

Closing of incisions

After placing the implants into your breast, your surgeon will close the incision with sutures.

Return to the ward

When waking up from the anaesthetic, patients will be taken back to the ward to recover. Patients may be able to go home the same day or may need to spend an extra night in the hospital. This will be communicated before having surgery. After the breast enlargement is complete, the surgeon will give specific aftercare instructions which patients must follow.

What should I expect from my gender affirmation breast enlargement consultation?

If you think that breast enlargement is right for you and your transition, you will need a consultation. This is usually a 15 to 60-minute meeting with a surgeon. In this consultation, you will discuss your motivations and expectations of breast enlargement surgery. Your surgeon will also ask you some questions, which may include the following:

• Do you have any current medical conditions?
• Are you taking any regular medications? (Including herbal remedies and vitamins)
• Do you currently smoke?
• Do you currently drink alcohol or use recreational drugs?
• Is there anything you are allergic to?
• When did you begin your transition?
• Are you currently on hormone therapy?
• What would you like to achieve from the surgery?

Your surgeon will take into consideration your answers to these questions, examine your breasts and then recommend the best treatment plan for you. They may also take some photos of your breasts for your medical records.

How will my surgeon decide what implant size is right for me?

After discussing your desired breast size with your surgeon, they will take measurements of your breasts and recommend an appropriate implant size. Some surgeons will have implant sizers available during the consultation. You can try these different sizers during the consultation to help you make your decision.

Some surgeons also have 3D imaging available, which can also help with your decision. This device takes pictures of your breasts from different angles and formulates a computer image of what they would look like after surgery. The breast size in the images can be altered to show you what different sized implants may look like on you.

Although breast sizers and 3D imaging can help give you an idea of what your breasts might look like after surgery, these techniques are not 100% accurate and you should be aware that the final results may be different.

What questions should you ask during your consultation?

It is important that you are fully informed about the procedure and the potential risks it carries before you go ahead with the surgery. We, therefore, recommend that you jot down a few questions to ask your surgeon during the consultation. A few questions that may be useful to ask include:

• Do you think what I want to achieve is realistic?
• What can I do to get the best results possible?
• What will my final scars look like?
• Have you done this surgery before? Are there any photos I can see?
• How long will my recovery take?

If you think of any other questions, write them down and take them with you to your consultation.

What are the main risks of a breast enlargement procedure?

As with any surgical procedure, a breast enlargement carries some potential risks and complications. These may occur during or after the operation. It is important that you are aware of these in order to make a fully informed decision before you go ahead with the surgery. Your surgeon will talk you through the gender reassignment of male to female risks and complications. The gender reassignment male to female risks can include, but are not limited, to the following:

Capsular contracture

Capsular contracture is the most common long-term complication associated with breast implants. This occurs when your body creates a layer of scar tissue called a “capsule” around the breast implants. This scar tissue has a tendency to contract. The degree of contraction varies greatly from patient to patient. For some, this may result in a hard or painful feeling in the breasts.

Scarring

As your surgeon will have to make an incision for this, scarring is unavoidable. Cosmetic surgeons aim to hide scars as much as possible, and for most patients, scarring is mild and fades over time.

Bleeding & bruising

Bleeding and bruising is common after this type of operation. In most cases, this is only mild; however, it can become quite significant. If you begin to experience any sort of bleeding or bruising that concerns you, you should notify your surgeon straight away. Adhering to your surgeon’s advice regarding medication will reduce the risk of bleeding.

Infection

If you develop an infection after surgery, it is important to take this seriously. Often, infections are minor, allowing your surgeon to treat them easily with antibiotics. If this is left untreated, however, it can spread and become very serious. It is therefore vital that you notify your surgeon if you notice any of the following:

• A temperature over 38 degrees
• Redness or swelling that is moving away from the incision site
• Foul-smelling discharge coming from the drains or incisions
• An increasing amount of pain or discomfort that does not go away after taking painkillers

Changes in sensation

It is quite common to experience some changes in sensation after surgery. These changes can include:

• An increase in sensitivity
• Numbness
• Pins and needles
• Pain

Changes in sensation can occur if your surgeon damages a nerve during surgery. If any of the above occur, they are often temporary, but they may take a while to subside. In some rare cases, however, the changes may become permanent.

Aesthetic

You should always keep in mind that you may be unhappy with your final results. You may not be happy with the final size, shape or symmetry of your breasts. This is the main reason why it is vital that you clearly communicate what you want to achieve to your surgeon, who will then tell you if what you want is achievable or not. In order to give yourself the best chance of being as happy with your final result as possible, you should choose a highly experienced and qualified BAAPS or BAPRAS surgeon.

Capsular contracture

The most common long-term complication of breast implants is capsular contracture. This occurs when a fibrous scar shell, or capsule, forms around the implant once it’s inside the breast. This capsule has a tendency to contract, which can lead to the breasts feeling very hard and painful.

Rupture

A rupture occurs when the shell of the implant is split open or broken, leading to the contents of the implant leaking out. This may occur due to direct injury to the breasts or damage to the implant itself before your surgeon inserts them into the breast. If a rupture occurs, you must have the implant removed or replaced.

BIA-ALCL

Breast Implant-Associated Anaplastic Large Cell Lymphoma is a rare type of cancer that is associated with breast implants. This association is still in the early stages of research. It is, however, important to be aware that this is a risk. Your surgeon will be able to discuss this in greater detail with you during your consultation.

Implant specific complications

There are a few more complications that can occur with breast implants. These include:

• Double-bubble
• Lateralisation
• Bottoming-out

You can find more information on these complications here.

Make sure you read through and understand all the gender reassignment of male-to-female risks and complications before you consent to have surgery.

How can I prepare for my gender affirming breast enlargement?

Breast enlargement is an invasive procedure, and it is important that you properly prepare for it. It is a good idea to put some things in order at home in the weeks and days before your surgery. We have put together a list of preparation tips below for you to consider before your gender affirmation breast enlargement. These tips may make your initial recovery at home easier.

Hormone therapy

Before having your breast enlargement, your surgeon may require that you be on hormone therapy for at least 18 months. There is a chance that the resulting breast development from hormone therapy will give you the size of breasts you want. However, If you are still unhappy with the size or shape of your breasts after taking hormones for over a year, then the breast tissue that developed will make it easier for your surgeon to increase their size via implants.

Household chores

You may find that seeing to some household chores prior to your surgery may make it easier for you to recover once you arrive back home. Some tasks you can take care of around the house include:

• Cleaning
• Taking out the rubbish
• Laundry

Food and shopping

You will be unable to lift heavy bags for a few days after your operation. Therefore, it may be a good idea to do a big food shop before you come into the hospital. Some individuals find batch cooking a few meals and keeping them in the freezer helpful as then you don’t need to worry about cooking when you get home.

In the weeks leading up to your operation, it is important that you eat a healthy diet. This includes eating lots of lean protein, fruits and vegetables. Where possible, you should reduce the amount of salty and fatty foods that you eat.

Furthermore, it is vital to stay well hydrated and drink lots of water and caffeine-free fluids. To further reduce the risk of complications, you should reduce your intake of alcohol while you heal.

Driving

You will not be able to drive straight after your operation. This means you must arrange for a friend or family member to take you home after your surgery. Your surgeon will be able to tell you exactly when it is safe for you to drive again.

Children and pets

It will be difficult for you to take care of young children and pets while you are recovering. In the few days immediately after your surgery, you may feel more tired than normal. As a result, you may benefit from asking a relative or friend to look after your children or pets to allow yourself to take the time you need to rest.

Clothing

Another gender reassignment male-to-female preparation idea is to make sure you have plenty of comfortable clothing for after the surgery. It may be easier to pick items that open easily from the front so that you do not strain your stitches. Slip-on shoes may also be useful so that you do not have to bend.

Rest and sleep

Initially, after surgery, you may find it more comfortable to sleep in an upright position. You may find that having extra pillows on your bed makes it easier for you to rest and sleep in this position. You should avoid sleeping on your stomach in the initial post-operative period, as this can impact your final results.

It is vital that you follow your surgeon’s specific advice regarding how to prepare for your surgery. If you have any questions, you can contact your patient care adviser, who will be at hand to help with any queries you have.

What can I expect after having breast enlargement surgery?

During your consultation, your BAAPS/BAPRAS surgeon will inform you of the aftercare process for your gender affirmation breast enlargement. Following your surgeon’s aftercare advice will help you get the best results possible and is just as important as the surgery itself. As you will have a very invasive procedure, it is vital to take it slow during the first few days.

Some important aftercare points you should consider include the following:

Post-operative appointment

After having your treatment, you will be given a post-operative appointment. During this appointment, your surgeon or nurse will assess how you are recovering, check your incisions and address any complications that may have occurred. It is vital that you attend this appointment to ensure that your recovery goes as smoothly as possible.

How will I feel after the operation?

If you are given a general anaesthetic, you may wake up after the operation feeling very groggy and drowsy. This is normal and should wear off after a few hours. If your surgeon uses a local anaesthetic, the treated area may feel numb for a while before the sensation completely returns to normal.

Your breasts are likely to feel swollen and look bruised. This is also normal and will subside over the next few days to weeks. If you are worried about the level of swelling or bruising present, you should notify your surgeon immediately.

How much time do I need to take off work?

This depends on what type of job you have. If you have a physically active role, then you will need to take a full week off work. For low-impact or office jobs, you should take around four to five days off to allow yourself to recover well.

You should refrain from even light duties for at least two to three weeks.

When can I start exercising again?

In the first one to three weeks, you should not do any form of exercise. This is because even a little bit of aerobic activity can increase the amount of swelling around your breasts. However, to prevent blood clots, we recommend that you do not spend all your time in bed. You should start light walking as soon as possible, every few hours whilst you’re recovering.

After week three, you can start sports that do not require any vigorous movements (e.g. cycling). You should continue to avoid other sports, especially contact sports.

After week six, all sports and exercises should be possible again.

Will I have to wear a post-operative bra after surgery?

You will need to wear a post-operative bra immediately after your surgery. The amount of time you need to wear this garment depends on what your surgeon specifically recommends.

In general, you may need to wear the bra day and night for the first week after surgery. After the first week, you may still need to wear the bra during the day for the next two to four weeks.

It is very important to listen to your surgeon's advice in order to ensure your healing progresses well.

Final results

You will have some scarring on your breasts after your treatment. As part of your gender reassignment aftercare advice, your surgeon may recommend some techniques that can aid in the healing of these scars. This may include the following techniques:

• Scar massage
• Silicone sheets, gels or creams

Your surgeon will also advise that you keep your scars out of direct sunlight to prevent them from darkening. Keeping your scars out of the sun will also protect the healing skin from skin cancer. If you do expose them to the sunlight, make sure that you wear a high-factor sunscreen to protect them.

For the first few days after surgery, your breasts may feel swollen, over-enlarged and tight due to the post-operative swelling. You may also find that your breasts feel very sensitive for several weeks, and it may take time for this to settle. It is worth noting that it can take two to nine months until everything completely settles and you can appreciate the final results.

All of the information found on our website is sourced from highly reputable experts, and government-approved authorities and is widely used by healthcare professionals.

• https://www.nhs.uk/conditions/gender-dysphoria/treatment/ NHS
• https://www.nhs.uk/conditions/cosmetic-procedures/breast-enlargement/ NHS
• https://baaps.org.uk/patients/procedures/1/breast_augmentation British Association Of Aesthetic Plastic Surgeons

Our content is written by our Medical Quality Managers and Patient Care Advisers, all of whom have medical backgrounds and training. Prior to publishing, all the information is reviewed by a surgeon specialised within the relevant field.