PROCEDURES   Augmentation Mammaplasty
	Augmentation mammaplasty, or breast enlargement is available for male to female transgendered patients. Sometimes hormone administration results in only a small increase in breast size, or a size not satisfactory to the individual. This procedure, along with hormone administration, will enhance the appearance of the new female breasts. The procedure is performed using saline inflatable breast prostheses (implants) and is performed on an outpatient basis, usually under general anesthesia. The procedure may be performed in conjunction with SRS, or at anytime in the course of transition, however it is best to wait until maximum hormone effect is achieved. There are various options available to patients. There is an option as to placement of this incision. If the areolae are large enough, implants can be place through a periareolar incision (an incision along the skin areola border on the lower half of the areola). This has the advantage of concealing the resultant scar in the color change between normal skin and areola. Sometimes, in the genetic male, the areolae are quite small and using this incision makes the surgery more difficult. Another option is the inframammary incision (an incision in the lower portion of the breast). This allows easy access to the tissues to make a pocket to receive the prostheses and inflate it to the proper size. Its disadvantage is that the scar lies on the normal skin and may be more noticeable. It does, however, lie on the lower portion of the breasts which is somewhat concealed when the breasts are enlarged. The third option is the axillary (armpit) incision. This has the advantage of concealing the scar in an area outside of the breast area. It has the disadvantage of being distant from the operative site, possibly making it difficult to visualize the site and control bleeding. Also, this scar may become thickened and quite noticeable when the arms are raised. Options are available as to the nature of the implant. Though saline implants are mandated by law, they come with different types of shells (coverings) and different shapes. There are smooth shells and textured shells. My experience suggests that there is increased risk of rippling of the skin with textured implants. Their theoretical advantage is that there is less risk of capsule contracture (internal scarring) and firmness. I have not found this to be the case. Implants are available in different shapes and sizes. They may be "anatomic" or designed after the shape of the natural breast, or they may be round. I have found that the round implants work quite well and do not have the risk of altering the appearance of the breast with minor shifts in position. The appearance of the breast does not seem to be less attractive with round implants. As to size, it is important to discuss with your surgeon your wishes and expectations. It is your surgeon's responsibility to discuss the benefits and risks. Together you come to a consensus of what can and will be done. Another consideration is placement of the implant above or below the pectoral muscle. The theoretical advantage of placing the implant below the muscle lies in the supposition that the covering layer of muscle will provide more cover for the implant and apply constant massage to the implant with muscle activity, leading to less change of firmness. This may be the case for those who have minimal natural breast tissue. My experience placing the implant below the gland and above the muscle works quite well in cases where there is a moderate amount of breast tissue. When using this method, pectoral muscle attachments do not have to be divided and there is less chance of the muscles pushing the implant down and outward. Capsule contracture and firmness represent a possible risk regardless of which procedure is used. Recovery from this procedure is relatively simple and uncomplicated. The dressings include a small bandage over the incision and a sports bra for compression and support of the breasts. Sutures are removed on the 7th postoperative day. Minimal to moderate pain is expected and appropriate medications are prescribed. Mild to moderate bruising may be expected but resolves within 7 to 10 days under usual circumstances. Normal activities can usually be resumed after one week, and workouts or strenuous activities can be resumed or taken up after 3 to 4 weeks. Sometimes breast massage is recommended to help preserve the softness of the breasts. Your surgeon will discuss the timing of this technique. Your first impression of your enhanced breasts may be startling. This is a new appearance and adjustment to a new body image may take a week or even longer. Don't be alarmed by this feeling; it is quite normal. You must also be aware of the risks involved in this operation. Fortunately the incidence of complications is quite small. One of the possible complications is hematoma formation, or a collection of blood under the skin. Should this occur it usually does so with hours of the operation. It is not life threatenting but must be dealt with to be sure healing occurs properly. It is removed at surgery and bleeding controlled. If dealt with it will not affect the final result. Infection is a remote possibility with this surgery. Patients receive intravenous antibiotics as the surgery begins and at the end of the operation. Should an infection occur it is treated appropriately, but may require the removal of the implant on the infected size for adequate treatment. Another prosthesis can be reimplanted in 4 to 6 months. Again, this is a very rare complication. Sensory changes may occur but are usually temporary. However a permanent change may result, either diminished sensation, heightened sensation, or even a lack of sensation. This is rare and unrelated to the placement of the incision. As mentioned earlier, the fibrous (scar) tissue that naturally forms around the implant may become thickened and contract, making the breasts feel firm and possibly even distorting its shape. This can be improved surgically should it occur, but it may recur. It is just an uncommon occurrence that may result from this operation. Another rare occurrence is leakage of saline from the implant. This is harmless as the saline will be absorbed by the body. However, the breast will decrease in volume and the implant will need to be replaced. The implant manufacturers do provide a form of warranty for patients. If the implant leaks because of a manufacturing problem, they will replace and provide some funds for the surgery required to reimplant the new prosthesis. This operation tends to have a high degree of patient satisfaction and has a low incidence of complications. It provides an added femininity for male to female trangendered patients who are candidates for augmentation mammaplasty.   LIPOSUCTION Suction assisted lipectomy (liposuction) may be appropriate for some individuals to help flatten the abdomen and narrow the waistline. This may especially benefit those transitioning from male to female. The procedure is a body contouring operation, not to be used for weight loss. It involves marking out areas of localized fat excess in the abdominal wall and along the flanks, or waistline. Solutions of saline mixed with local anesthetic are instilled into this area to minimize blood loss and to facilitate the removal of fat. The fat is extracted through very small incisions placed in the groin or lower abdomen using small cannulae (metal tubes) connected to a strong suction. Careful technique must be employed to try to avoid cosmetic deformities of the skin such as wrinkling or dimpling. The procedure is performed under general anesthesia and is of relatively short duration. It is routinely done on an outpatient basis at an accredited surgical center. I believe that general anesthesia affords the most comfort for the patient and the best opportunity to achieve adequate fat removal and contouring. Postoperative binding is necessary to allow the skin to naturally contract over the new body contour and to minimize the amount of swelling and bruising that may occur. Though this procedure appears to be relatively simple, it does require care and experience on the part of the surgeon. The complication rate is small but does exist. Complications such as bleeding and hematoma (a collection of blood under the skin) are extremely rare, though some degree of bruising is common. Infection is a remote possibility. Sensory changes may occur temporarily but the possibility of them remaining permanently is again remote. The risk of cosmetic residual deformity must be considered by each patient. These can range from skin dimpling, wrinkling, or folding to the presence of residual excess fat. Fortunately these are also rare occurrences, especially in liposuction performed on the abdominal wall and flanks. Pain following this procedure ranges from mild to moderate after the first few hours and lasting up to seven to ten days. There are exceptions of course. Pain management is a part of the care of the patient and resolves rather rapidly. Liposuction of other areas, such as the hips, thighs, arms, and buttocks can also be performed if indicated by the presence of contour deformities due to localized excesses of fatty tissue. It is important that any prospective patient have realistic expectations of what liposuction may accomplish for them. Again, it is not a weight loss procedure, but a body contouring procedure. It works well in the lower abdomen and often the flanks; it does less for the upper middle abdomen though improvement can be expected there also. Liposuction may be performed in conjunction with other operations such as augmentation mammaplasty (breast enlargement) or other cosmetic procedures.
	RESOURCES
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