Firm and shapely breasts provide a woman with a sense of attractiveness and have a significant impact on her sexuality. Surgical breast correction is one of the most frequently performed surgeries of gender reassignment. In trans women breast surgery consists in enlarging them with implants or autologous tissues.
It is recommended that women undergo feminizing hormone therapy (for a minimum of 12 months) before breast enlargement. The aim is to maximize breast growth for better surgical and aesthetic results.
The operation can make it much easier for patients to experience life in the role of the gender compatible with their identity. Usually this experience is required for 12 months before the "bottom" operation (vaginoplasty). As experience has shown, for some transgender people the "top" surgery (breasts) becomes the only surgical step taken during their transition.
For most women, breast enlargement (or "reconstruction" of the breast) significantly increases the subjective feeling of femininity. Breast plastic surgery provides the body with a more feminine profile, making it easier for the body to adapt to gender identity and to increase the incentives associated with their attractiveness. In our patients' experience, we observe a significant increase in satisfaction with the appearance of both the breasts and the whole body, as well as an improvement in the quality of psychosocial life and greater satisfaction with sexual life, even shortly after the procedure, and in the long term after it.The changes that occur after years of oestrogen therapy are well described. They create a feminine appearance in a biologically masculine body. Hormone therapy does not affect the voice, the appearance of hands and feet, or the size of the shoulders. Breast formation occurs naturally, but for many patients it is not enough. Unfortunately, no studies have yet been carried out to determine the exact minimum duration of hormone therapy that must be completed before breast surgery. Most surgeons recommend a 12-month period of feminizing hormone therapy before breast augmentation to maximize breast growth and get better surgical (aesthetic) results.
Mammogenesis (breast development) in trans women taking oestrogens follows a pattern similar to that of female mammogenesis described by Marshall and Tanner. From research we know that breast development is not only dependent on the dose of oestrogen, and in 67-85% of women requires plastic surgery to enlarge the breast, because hormone treatment produces only a pointed breast as in young girls or a small conical breast as in teenagers.
Breast enlargement with implants is a common procedure in plastic surgery. Although many surgeons are involved in breast augmentation, they differ in their skills and the degree of experience in treating trans people, and for this reason the results of treatment are different. In our experience we take into account certain specific features of transgender women.
Breast implants are usually implanted in trans women who have already developed breasts similar to those in young teenage girls. We inform patients that some complex shapes of full female breasts or age-related transformations cannot be accurately reproduced with synthetic implants. Sometimes the results of breast enhancement plastic surgery in women with minimally developed glands induced by hormones may be unsatisfactory. Based on our experience, we pay attention to anatomical differences: a sometimes wider "male" chest, stronger chest fascia, more developed chest muscle and smaller nipples and areolas. Our patients usually choose larger volume implants. We point to the fact that sometimes the presence of a slightly wider neckline may be difficult to avoid with a larger implant. The nipple and areola should be located centrally on the implant, and their excessively centralized position may cause the divergent positioning of the nipple and an unnatural appearance of the breast.
How are breast implants inserted?The breast enlargement procedure with implants is performed under general anaesthesia and usually takes between 1.5 to 2 hours.
- In our clinic, implants are placed in the space between breast and muscle tissues through one of the three available surgical approaches:
- a breast cut 3-5 cm long, located in a fold under the breast,
- incision in the axillary region using endoscopic technique,
- incision along the edge of the areola of the nipple.
What is endoscopic breast enlargement?
The procedure of breast augmentation using endoscopic technique, which enjoys great interest in our clinic, consists in making an incision of about 3-5 cm in the armpit area, through which surgical instruments and a special camera are introduced.
Under the camera’s control, the surgeon, using the same incision, makes a pocket between the tissues of the chest muscle, just above the ribs, and inserts a chest implant.
One unquestionable advantage of this method is a small degree of interference in the natural structure of the breasts. But the most important thing is that the location of the surgical scar in the fold of the armpit area makes it almost invisible. For this reason, breasts enlarged by armpit technique are referred to by patients as "flawless breasts".
What is the best implant position for me?
In our clinic, the vast majority of implants are placed in an inter-tissue pocket created under the larger breast muscle. Breasts are more natural to the touch, and there is less risk of shrinkage of the capsule surrounding the implant.
You can also place the implant over the muscle, directly under the breast. This option is sometimes recommended for patients with atypical chest anatomy or patients who practice strength sports. Another possibility is the so-called dual-plane introduction. This solution is used to obtain a natural breast filling, even allowing you to forego the breast-raising surgery called mastopexy. A more detailed discussion of each arrangement, as well as the selection of the best option, takes place during the consultation visit.
Which breast implant should I choose?
Proper implant selection is one of the key conditions for obtaining a beautiful breast with a natural look. In our clinic we use only silicone implants of the latest generation from the world's best manufacturers.
They are made of a certified medical material: silicone elastic coat and firm gel inside, thanks to which enlarged breasts are very natural to the touch. The special design minimizes the risk of tearing or shrinkage of the connective tissue bag surrounding the implant.
Our clinic offers a wide range of implants. Usually we can choose between round or anatomical, drop-shaped implants, in different sizes, with different surface structure and emphasis (high, medium, low). A more detailed discussion of each of the given parameters, as well as assistance in choosing the most optimal prosthetic takes place during a consultation visit.
My surgical scar...
Every surgical intervention creates a scar. After breast enlargement, scars are generally hardly visible and their location depends on the implant placement technique used.
Breasts after endoscopic enlargement with access through the armpit are called "flawless breasts" by patients because the scar is almost invisible. In the case of around-the-bell and subcutaneous access - after about 6 months and provided that you follow the care instructions of our clinic – the scars are difficult to distinguish from the surrounding skin.
What can I expect from the surgery?
After surgery, the patient usually stays at the clinic for a day. Visits are possible after consultation with medical personnel. It is necessary to wear a special postoperative bra. Sometimes postoperative chest pain persists for several days during which the recommended painkillers should be used. Edema and hypersensitivity in the operated area may also persist for several weeks.
The day after the operation, after the examination and discussion of the recommendations for the following days, the patient is discharged from the clinic. During subsequent visits we help the patient, adjust the position of implants, inform what to pay attention to, how to take care of the breasts, the physiotherapist shows you how to help yourself in reducing ailments.
What are the limitations after surgery?
Depending on the nature of your job, you will usually return to work after 7-14 days. The recommended period for heavy physical work is 4 weeks. Return to physical activity, including low-intensity cardio sports, is possible even after 7-14 days.
A return to high-intensity sports activities (e.g. running, swimming) and stressful sports activities is recommended after 6 weeks. It is necessary to wear a special postoperative bra during this time.
In the early postoperative period, the breasts should be handled gently, avoiding intensive and strong kneading or pushing. Only gentle massages and gentle touch are recommended. It is also forbidden to carry heavy objects for a minimum of 6 weeks. This is why it is important to organise appropriate conditions at home and support during the convalescence period.
Are breast implants "forever"?
When deciding to use breast implants, it is important to bear in mind that despite their very good biomechanical properties and high biocompatibility, breast implants undergo structural changes over time due to wear and tear.
Sometimes tearing or cracking can occur. In our clinic we use the latest generation silicone implants, which, according to the latest scientific research, are characterized by a very low risk of rupture for at least ten years after surgery.
Moreover, even in the event of a tear in the implant shell, the special structure prevents leakage to the outside, which makes the whole event asymptomatic. However, manufacturers of breast implants recommend replacing them every 10-15 years (depending on the manufacturer).
Autologous fat tissue transplantation
Fat transplantation or lipofilling is a technique in which fat is obtained by a procedure similar to abdominal or thigh liposuction. The fat is then properly prepared to separate the oil, fluid and blood. The result is a concentrated, purified sample that can be injected subcutaneously. In women who already have a certain volume of breasts after hormone treatment, a fat graft may be a good option to provide moderate breast augmentation so that implants are avoided. We inform patients that a variable percentage of the injected fat is re-absorbed and a second or even third procedure may be necessary to obtain sufficient breast volume.
However, more often we use fat transplantation as a supplement to breast enlargement with implants. Fat is injected into the subcutaneous plane to make the implant less visible and palpable. Fat tissue transplantation can be used to narrow down the wide neckline between the breasts.
The medical literature describes as the main (but rare) complications after breast augmentation such as hematoma, symmastia, capsule contraction, reduced sensation in the nipple and/or part of the breast, implant rupture (more often observed in implants filled with physiological salt than in cohesive silicone gel) and abnormal positioning of implants. Galactorrhea is another very rare disease that can occur both before and after surgery. It requires extensive hormonal diagnostics with particular emphasis on the examination of the pituitary gland.
Post-operative observationFrom our point of view, postoperative observation visits are obligatory for all patients after breast enlargement. Breast cancer can occur in transgendered persons with exposure to sex hormones between 5 and 70 years of age. Patients receive oral estrogens for a longer period of time to preserve the secondary female characteristics. The incidence of breast cancer is comparable to that of breast cancer in men and therefore lower than in the female population. Good quality screening and observation are essential. We know from experience that breast tests are very well accepted by transgendered women, so we should encourage patients to participate in appropriate screening protocols. Screening for genetic predisposition (e.g. BRCA mutations) should be considered in patients with familial breast and/or ovarian cancer.
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