Breast and Chest Surgery for Transgender Patients

Breast development and hormone therapy

Development of the breasts during the prenatal stage of life is independent of sex hormones and is, therefore, the same in males and females. During embryonic development, breast buds composed of networks of tubules develop from the ectoderm. In females, these tubules will eventually become the matured milk ducts. Until puberty, the tubule networks of the breast buds remain quiet. At puberty, male and female breast development diverges. In females, high levels of estrogen and progestins, in conjunction with growth hormone and insulin-like growth factor-1, result in growth and maturation of the tubules into the ductal system of the breasts. Estrogens are generally believed to induce breast proliferation whereas progestins result in differentiation. Progestins are not thought to have a significant role in breast volume. In contrast, in puberty of males, androgens (testosterone and dihydrotestosterone) increase about 10-fold higher compared to females, and estrogen is approximately 10-fold lower compared to females. The high levels of androgens strongly suppress the action of estrogen in the breast at puberty, resulting in lack of breast development in men.

The suppression of androgens and supplementation with estrogens can lead to breast growth in transwomen. Androgen blockade can be achieved with antiandrogens. Spironolactone is most commonly used in the United States, whereas cyproterone acetate is widely used in Europe. A major difference between the agents is that cyproterone also has progestogenic properties. As previously mentioned, it is not approved for use in the United States due to concerns of hepatotoxicity. Some centers use gonadotropin-releasing hormone analogs to suppress androgen production, but cost limits the use of these agents. Alternatively, orchiectomy is an effective means to decrease androgen levels.

Breast size typically begins to increase 2 to 3 months after the initiation of hormone therapy. Initially, tender breast buds begin to form and breast growth progresses over 2 years. For this reason, the SOC recommend hormone therapy for at least 1 year prior to breast augmentation. Response to therapy varies among individuals, but breast and nipple development in transwomen is rarely as complete as it is in cisgender women. Few studies have addressed the optimal hormone regimen to maximize breast growth in transwomen. While studies have demonstrated the efficacy of various hormone therapies, reported data are observational and subjective. The majority of available literature does not suggest that estrogen type or dose affects the final breast size in transwomen. In addition, current data do not provide evidence that progestins enhance breast growth. Some, but not all authors suggest that younger age, tissue sensitivity, and body weight may impact breast size. Furthermore, shoulder width may play a role in perceived breast size and adequacy of growth. Overall, data do suggest that final breast size with hormone therapy is unsatisfactory in many transwomen; 60% to 70% seek surgical breast augmentation.

Patients should be counseled on the degree of breast growth they may expect from hormone therapy and the appropriate options should they desire larger breasts. Some transwomen have unfortunately resorted to “pumping,” an illegal and dangerous practice of injecting liquid silicone into breast tissue to enhance breast size. Serious complications of pumping range from local inflammatory reactions to pulmonary embolism and death. Still, because it is a cheap alternative compared to approved treatments, this potential deadly practice continues.

Augmentation mammaplasty

Many transwomen who report inadequate breast growth with hormone therapy continue to wear external prostheses or padded bras. As such, augmentation mammaplasty may be requested. Breast augmentation can be performed at the same time as vaginoplasty; this can help decrease surgery time and cost in individuals who desire both procedures. In a retrospective survey of 107 transwomen, Kanhai et al. reported that 80% of participants had mammaplasty and vaginoplasty simultaneously. The percentage of patients undergoing both procedures at the same time is likely far lower and variable between clinical practices.

Anatomic differences between the male and female chest are relevant to implant selection, incision choice, and pocket location. The cis male chest is not only wider than the cis female chest, but the pectoralis major muscle is usually more developed. Furthermore, the cis male areola is smaller than the cis female areola, the distance between the nipple and inframammary crease is less, and there is less ptosis in the breasts of transmen, even after hormonal therapy ( Figs. 9.1 A, B and 9.2 A, B ).

While the principles of augmentation mammaplasty in transwomen are similar to that of cis women, the broader chest, larger pectoralis muscle, and shorter distance between the nipple and inframammary crease warrant additional consideration. These anatomic characteristics may require lowering the inframammary crease and releasing the lower sternal attachments of the pectoralis major muscle ( Fig. 9.3 ). When releasing the sternal attachments of the pectoralis muscle, the overlying pectoralis fascia is left intact. These maneuvers may assist with implant positioning relative to the position of the nipple-areola complex, and help to prevent lateral implant displacement. Due to the wider chest wall diameter in transmen, a wide interbreast width is common, even with the selection of larger implants.

The implants may be placed in either a subglandular or subpectoral pocket. This decision depends upon the degree of breast growth in response to hormonal therapy. Subglandular implants may be more palpable and may have higher rates of capsular contracture due to less soft tissue coverage overlying the implant. However, subpectoral implants may be more prone to displacement due to the activity of the overlying pectoralis major muscle. Overall, the subpectoral position remains the most common pocket location.

In terms of incisions, transaxillary, periareolar, or inframammary crease approaches may be used. The choice of incision is tailored to the requests and the anatomy of the individual. Due to the smaller size of the male areola and the use of larger implants, an inframammary crease approach is most commonly chosen. Trans axillary incisions are sometimes used, whereas periareolar incisions are infrequently utilized. With the increased use of form-stable implants, larger incisions are often required, which also favor an inframammary crease approach.

While both saline and silicone implants are available, recently, the authors have favored form-stable implants placed in a subpectoral pocket through an inframammary crease incision. In the authors’ opinion, this approach allows the surgeon to most effectively lower the inframammary crease, centralize the implant underneath the nipple-areola complex, and release the pectoralis major muscle.

Many transwomen prefer larger implants. Kanhai et al. reported that the average size of implants in transwomen nearly doubled in their practice from 165 mL in 1979 to 287 mL in 1996. In a long-term follow-up study of 107 patients, the authors reported that 25% of patients were unhappy with their mammaplasty. The most common reason for dissatisfaction was that that the breasts were too small. Further augmentation was reported in 19% of these patients.

In order to decrease the risk of venous thromboembolism (VTE), hormones are discontinued prior to surgery, and either fractionated or unfractionated heparin is administered subcutaneously upon induction of anesthesia. In our practice, estrogens are discontinued 2 weeks prior to surgery. Following surgery, a compression bra is worn for 3 weeks. The individual is also instructed to limit upper body exercise for the first several weeks following surgery to decrease the risk of implant displacement. Gentle breast massage is instituted approximately 7 to 10 days following surgery.

Third-party payer coverage

While there has been significant progress in third-party coverage for gender confirming procedures, many insurance providers continue to consider breast augmentation a “cosmetic” procedure and, therefore, do not provide benefits. However, the SOC point out that in some individuals, a “cosmetic” procedure can have a radical and permanent effect on their quality of life. In fact, research has suggested that gains in breast satisfaction, psychosocial well-being, and sexual well-being after breast augmentation in transgender individuals are statistically significant and clinically meaningful. Because insurance benefits vary, it is worthwhile to review benefits on a case-by-case basis to determine if augmentation mammaplasty is covered.