Breast construction
Having a clear understanding of the breast construction options available will help you make an informed choice.
Breast construction (also called breast augmentation) is a gender-affirming surgery that creates, enlarges or shapes one’s breasts by placing implants underneath natural breast tissue or muscle. The goal is to have breasts and nipples with sensation, a larger cup size and minimal scarring.
Depending on what you discuss with your surgeon, incisions will be made under the breasts, in the armpit and/or around the areola. Implants can be placed just under the breast tissue or under the muscles of the chest.
Sometimes breast construction is a two-part process. In the first surgery, breast tissue expanders are inserted to stretch the skin, so that it will be able to accommodate the implant. Saline is injected into the tissue expander. This process will gradually fill the breast tissue expander until the desired volume is achieved. This can take a few months. Once the skin has stretched enough to fit the implants, another procedure is done to remove the breast tissue expander and insert the breast implants.
Breast construction is usually an “outpatient surgery,” meaning the patient gets discharged from the hospital later the same day.
Surgical options
There are two types of procedures for breast construction: implants and fat grafting. Implants (which are either saline or silicone) are the most common procedure used for gender-affirming procedures.
saline implants
Filled with sterile salt water, these implants come with a smooth or textured outer surface (known as a shell). Some implants are pre-filled with a specific amount of saline, while others are filled to the desired volume once the shell is in place. They vary in firmness and feel different to the touch compared to a silicone implant. Your surgeon will let you touch the different options to help you decide.
Potential issues with saline implants include:
A “sloshing” sound as the implants move during vigorous activity.
A “ripple effect” which is visible on the skin. Many factors contribute to rippling including the shape of implants, size of the implant pocket, size of the scar capsule that develops around the implant and amount of fluid in the implant.
silicone implants
These implants are filled with silicone and come with a smooth or textured outer surface (known as a shell). They vary in firmness and feel different to the touch compared to a saline implant. Your surgeon will let you touch the different options to help you decide.
Fat grafting
Fat grafting is the least common type of breast construction procedure. It involves removing body fat from one area of the body via liposuction and then injecting it into the breast in small quantities.
This procedure is not often recommended for gender-affirming breast construction because the results are less predictable, complications are more common and, generally, it requires multiple surgeries with an incremental “take” of the grafted fat with each procedure.
Complications associated with fat grafting include:
- Fat does not stay where it’s been placed; it’s not uncommon to lose up to 50 per cent of the volume in the breast within the first year of surgery.
- Risk of lumps due to necrosis (death of the fat tissue)
Implant size
Implant size is measured in ccs, millilitres or grams, not cup sizes. This is because cup size measurement is a concept based on the size of your body and ratio of your breast volume to your body shape.
Usually, you and your surgeon will choose a size range (including the height and width of your implants) beforehand. During your surgery, the surgeon will use their judgment and experience to narrow down to the ideal size of implant for your goals and anatomy.
Implant placement
Placement of the implant can depend on a number of factors but are typically either under the pectoral muscle or under the glands.
under the pectoral muscle ( subpetoral)
Most implants are placed under (or partially under) the pectoral muscle and under the glands of the breast. This placement may lessen the possibility of capsular contracture, a complication that can occur after surgery. This positioning may push the implant to the side of the chest. Finally, you will notice movement of the implant when the pectoral muscle is contracted, which will temporarily distort the implant.
under the breast tissue ( subglandular)
Another option is to have the implant placed above the pectoral muscle and under the glands of the breast. This placement may result in breasts that are positioned more towards the centre of the chest (versus closer to the sides). It may also create a more rounded appearance.
Incision location
Surgeons will typically make the incision in one of three locations. These locations are intended to reduce the visibility of scaring, but some scarring may still be visible.
below the breast (inframammary fold)
The incision is made where the breast connects to the chest. The incision is partially concealed in this fold, but the scar may still be visible.
near the armpit (axilla)
The incision is made to the side of the breast. The incision is partially concealed in the armpit, but the scar may still be visible.
around the areola (periareolar)
The incision is made all the way around the outside of the areola, partially concealing the scar in the edge and texture of the nipple and areola. The scar may still be visible.
Potential risks and complications
Like any surgical procedure, breast construction surgery involves risks. It’s important that you understand these risks so that you can make an informed choice about surgery.
A discussion of possible risks and complications is not intended to scare or deter you from having surgery but rather to ensure you have all the information you need to make a decision about surgery. Ask your surgeon which complications are more or less common and how they would be managed if they occur.
Potential risks
The primary risks from breast construction include:
- Anesthesia issues — Some people experience a negative reaction to anesthesia
- Cardiovascular issues — Such as blood loss, blood clots and artery blockages
- Results that don’t meet expectations — When the shape or size of your breasts don’t align with your hopes
In extreme cases, some of these issues can result in serious injury or death. However, your surgical team will take a number of steps to prevent and minimize these risks. The team will monitor you closely and will be ready to respond quickly. They will also talk to you about what you can do to minimize your risks before surgery.
Potential complications
Complications that can occur as a result of a breast construction surgery include:
- Scarring — All incisions cause a scar. Although incisions are usually located in a way that reduces the visibility of scarring, they may still be visible to varying degrees. Scars can become thickened, hypersensitive, and may even affect the shape of your breasts. Severe scarring may require surgical revision. You can mitigate the risk of this complication by following your surgeon’s advice for recovery.
- Capsular contracture — Scar tissue that develops around the implant may become tight or painful. This may change the shape of the breast. Sometimes the capsular scar tissue may need to be removed and the implant may either need to be removed or replaced. Your surgeon will give you postoperative instructions to follow that will help reduce the chances of this happening.
- Complications with the implant — The implant may break (rupture), leak or deflate. If this happens, it will need to be replaced.
- Migration or dislocation — The implant may migrate (move) or change position (rotate) in the breast.
- Skin necrosis — Poor blood supply may result in death of the skin surrounding the implant.
- Implant extrusion — The skin around an implant may break down, resulting in the implant being visible through the skin. If this happens, the implant will need to be removed temporarily, then replaced a few weeks or months later.
- Calcification — Calcium deposits can form in the scar tissue that surrounds the implant. These may feel firm and even painful. If you develop any bumps or lesions, contact your surgeon or primary care provider. Any bumps and lesions need to be examined to determine whether they may be a normal bit of calcium buildup, or a sign of breast cancer.
- Changes in sensation — You may experience changes in sensation in the skin of the breast and in your nipples. This may be an increase in sensation, a reduction in sensation or areas of complete numbness. These changes may be temporary or permanent.
- Tenderness and inflammation — Sometimes veins under the breast become inflamed and clotted (also called superficial thrombophlebitis). This can result in a tender lesion that looks and feels like a vertical cord beneath the skin. This is often a temporary complication.
- Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) — This is a rare form of non-Hodgkin lymphoma which may occur next to the implant. To learn more about this, see Trans Care BC’s handout about Textured Breast Implants and BIA-ALCL.