Chest Feminization in Male-to-Female Transgender Patients: A Review of Options

Abstract

Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.

Keywords: chest feminization; gender affirmation; transwomen.

FIG. 1.

Transgender women experience variable degrees of breast development when taking hormone replacement therapy.

FIG. 2.

This thin patient had inadequate envelope to achieve her desired breast volume with an implant alone. She opted for a staged approach, here shown before and after a tissue expander was placed under the breast skin and fully inflated with saline. At a second stage, the permanent implant will replace the expander.

FIG. 3.

The typical adult natal male chest has nipple–areola complexes that are far apart, with a paucity of upper pole skin and high, flat inframammary folds.

FIG. 4.

There is sometimes a need to compromise between centering the nipple–areola complexes over the implants and avoiding too much space between the breasts.

FIG. 5.

Transgender female patients shown with effaced inframammary folds (arrows); a nonideal result that may require use of sutures or mesh to restore definition.

FIG. 6.

Three transgender women with implant-based breast augmentation are shown. The ideal feminine inframammary fold is curved and low enough to allow for adequate lower pole shape and volume.

FIG. 7.

Granulomas of the breast may result from injection of materials such as silicone. The patient shown had injections performed decades before and now is seeking breast reduction.

FIG. 8.

The first reported primary bilateral gender-affirming breast reconstruction using deep inferior epigastric perforator flaps (before and after).

FIG. 9.

Autologous flaps allow for more control over breast shape, including the inframammary fold position and upper pole skin envelope.

FIG. 10.

Latissimus dorsi myocutaneous flaps, typically with implants, provide another autologous alternative when skin envelope is inadequate.