A common question I am frequently asked is "What are the differences in performing a breast augmentation in a cis-female and a trans-female?" The surgery itself is essentially the same, and with any breast augmentation several decisions are made, which include incision placement, type of implant, and locations of the implant: above or below the muscle. Studying the differences in genetic male and genetic female anatomy and examining each patient's own anatomy and the resulting changes from hormones are what help determine those answers.
Over 90% of my cis-females prefer the incision to be placed in the infra-mammary crease (below the breast). However, over 90% of my trans-females prefer a trans-axillary incision (through the armpit). Hiding the scar in a natural crease in the armpit allows a patient to avoid placing a scar on the breast itself. Once healed, the scar is completely hidden, and by looking at the breast alone, there is no indication that a surgery has been performed.
The style of implant is discussed with every patient. The options include saline, silicone, and highly cohesive silicone ("the gummy bear"). All of the implants are safe, but some have more advantages than others. Saline is usually most affordable and allows a smaller incision, because the implant is filled after it is placed in the body. Unfortunately, saline implants come with rippling, the risk of deflation, the highest rate of scar tissue formation, and without a doubt feel the least natural. Silicone is a great option and feels much more natural. Silicone implants have less rippling, do not deflate, and a lower rate of scar tissue formation, but the price often reflects these advantages. The "gummy bear" round implant in my opinion is the implant of the future. The highly cohesive gel has the least amount of rippling, the lowest rate of scar tissue formation, and the best upper chest fullness for cleavage. Once again, in my opinion it is the best implant available, but the company who manufacturers it must agree, as their pricing reflects all of these advantages. I allow all of my patients to see and feel the different types of implants during consultation, which often help them decide.
Size is surprisingly easy. The most important factor is that the width of the implant matches the patients chest size. No one wants to little hills with a big valley in the middle; nor do they want a "uni-boob". On average, my trans-females need wider implants than the average cis-female. If a cosmetic surgeon, does not pay attention to this detail, the patient can end up with a large gap between her breasts. If the patient prefers that look, that is ok; but most of my patients who are desiring augmentation want more cleavage. After the appropriate width is determined, I discuss with the patient the desired amount of projection off of the chest, and we choose an implant that meets her goals together.
The next decision is where to place the implant: above or below the pectoralis major muscle. This decision varies depending on the individual. Factors that must be taken into account include the patient's muscles thickness, breast tissue, and fat distribution. Many trans-females have more muscle than my average cis-gender patient. The amount of breast tissue and fat distribution varies greatly depending on the individual's response to hormones. Whenever possible, I prefer to place the implant below the muscle. By placing the implant below the muscle, the patient will have more of her own tissue covering the implant, giving a more natural feels and slope of the upper chest. Placing the implant below the muscle has also been shown to decrease the rate of scar tissue formation. However, if a patient has very thick muscle, it can look unnatural, and when the pectoralis muscle contracts, the implant may be pushed to the side. Due to these reasons, I spend a fair amount time during a consultation examining the patient and discussing her goals to make this decision.
In summary, the main differences in breast augmentation between cis and trans females has very little to do with the surgery, but much more to do with the treatment planning done during the consultation. I would like to thank my trans-gender patients because I feel that serving them has made me a better cosmetic surgeon. Many of my cis-gender patient's have benefited as much of cosmetic surgery is to make one appear more feminine or more masculine - whether it is a patient's nose, chin, or any other body part despite one's gender identity. Intently studying subtle differences in anatomy between genders has helped me to fine-tune my skills for all of my patients.