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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.
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