Gender Reassignment Surgery – Male to Female Breast Augmentation Surgery

  • Reference Number: HEY-433/2016
  • Departments: Breast Services

This leaflet has been produced to give you general information. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion. If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

Introduction

You will have been given an appropriate referral from the Gender Identity Service, supported by a second specialist confirming your diagnosis. The referral confirms that funding is now in place for your surgery. This leaflet has been produced to reinforce the information that has been given to you about your surgery. Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and your doctor but if, after reading it you have any concerns or require further explanations, please discuss them with a member of the healthcare team caring for you.  

What is Breast Augmentation Surgery?

Breast augmentation surgery is an operation to change and enhance the physical form of your breasts by using implants to provide a proportionate, feminine shape.

Your Initial Consultation

You will be seen by the consultant and asked various questions about your general health, as well as being given a physical examination that will include several measurements of the breasts being taken and recorded.  Consent will be required for clinical photography, involving before and after surgery pictures, to complete an accurate visual record.

Prior hormone treatment, usually for a period of 18 months or more, may have increased the amount of breast tissue available, which would be advantageous – but individual assessment is of the main importance. In particular, any asymmetry (uneven appearance) of the chest is noted, as any element of asymmetry will need to be taken into account regarding how it may affect the final result of augmentation. You are strongly advised to stop smoking, due to increased risk of capsular contracture (a tight, fibrous capsule that forms around an implant).

Details of surgical options will be discussed regarding the most appropriate method and the range of breast implants available. This discussion will include identifying possible risks/advantages/disadvantages of each, as relevant to the individual. This consultation provides an opportunity to examine samples of different implants, shapes and sizes etc. You can see pictures of pre and post-operative surgery results, ask questions and discuss any concerns fully with your consultant. This ensures that you understand all the potential issues about the surgery.

Augmentation surgery cannot provide totally natural breasts, so it is important to have realistic expectations and not pre-conceived ideas of perfection regarding the final appearance.

 Implant type – there are saline-filled expander implants and silicone gel implants available. The different types will be discussed fully, as to which would be the most appropriate and give the best result to each individual. If there is insufficient breast tissue/skin available to accommodate implants, it is possible to use saline expanders prior to the silicone gel implants being used. This would involve several inflation procedures post-operatively over a few weeks, in order to expand the skin enough, dependant on individual requirements, in readiness to replace with the appropriate size of silicone gel implants. This would require a second operation, several months later.

Implant size and shape – consideration of the individual’s particular wishes are taken into account and discussed fully. Between 125-150mls of volume will increase the bra size by one cup size. Other considerations will be discussed including the shape of the implant and the base size of the implant. A round shape implant will provide a fuller appearance in the upper part of the breast. An anatomically designed shape – teardrop – implant will give less pronounced fullness in the upper part of the breast, providing a more natural looking shape.

The advantages and disadvantages of the different types of surgery will be discussed prior to making any decision.

In order to obtain an approximate idea of the required size of implant, it is suggested that the ‘rice bag’ test be carried out: – take one cupful of rice and cook as normal. When cold, put some of the rice into a plastic, resealable freezer bag and mould it into a round, flat shape – and measure the amount used. Fit this into your bra to get an idea of the extra size, add more rice or take some out – until happy with the overall effect. Remember to measure and record the final amount of rice used; this gives a good indication as to the implant size required.

Positioning of the implant – the implant can be placed either directly under the breast tissue, above the chest muscle (a subglandular position) or under the muscle of the chest wall (a subpectoral position). Every patient presents as an individual and the various advantages and disadvantages of each approach will be considered carefully and discussed accordingly.

Can there be any complications or risks?

As with all surgery there can be complications or risk.  Your consultant will go through these in detail with you as part of your consultation; however we have listed some of these below for your reference.  If you have additional concerns regarding risks or complications, please do not hesitate to discuss these with your consultant.

General complications and risks could include:

  • General surgery risks – bleeding, infection, bruising, scars. Steps are taken to reduce risks, such as injections to help prevent adverse blood clotting; use of compression stockings to help prevent deep vein thrombosis and antibiotic cover. 
  • Haematoma – (collection of blood) this may appear within the first 48 hours, associated with the sudden increase in breast volume with a tight and/or an uncomfortable feeling. Small haematomas can be managed without treatment and should settle. However, larger haematomas may need to return to theatre to be dealt with surgically. Generally, the breast area may become a little discoloured and this may spread down towards the abdomen. Your body will absorb this bruising in time and rarely needs any intervention but if worried, consult your surgeon.
  • Nipple/skin sensation – approximately 1 in 100 of those undergoing primary augmentation will have permanent alteration in sensation, on one or both sides. This can involve the nipple, areola or the skin on the breast; it may be less sensitive or feel totally numb. It would be considered permanent after a year’s time and not likely to return.
  • Ptosis (condition of breast/nipple drop) – over time, the presence of implants can cause this to happen.  Sometimes this can improve the natural look of the breast but this would depend on the individual. Initially, breast augmentation can correct mild cases but would cause additional scarring if further corrective surgery was undertaken.
  • Infection – the rate of infection is extremely low at less than 1 in 100 but if it occurs, it usually requires the removal of the implant for a period of time. Once the infection has cleared, it is possible to replace the implant but there is an increased risk of further infection with a second procedure.  Any signs of redness, heat, discharge or raised temperature needs to be reported to the doctor, consultant or the surgical ward. An earlier follow-up appointment can then be made to attend the ward or the breast clinic outpatient department.
  • Scarring – with any scar, there is always the risk of overgrowth of the scar tissue – known as overgranulation of the skin or keloid scarring. If the scar is hidden under the breast, this becomes less of a problem but it can still require special silicone dressings to treat the scar.
  • Granulomas – it is possible that small lumps may appear over the implant due to the body’s reaction to a foreign material such as silicone. However, any lump occurring in the breast, whether it has undergone augmentation or not, should be properly investigated by your GP or consultant.
  • Capsular contracture – is part of the body’s defence mechanism, it can form a tight, fibrous capsule around the breast implant causing it to become less natural looking. Approximately 25 out of 100 patients will develop some form of contracture around the implant, although most will not realise that there is a problem. Occasionally, the contracture becomes hard and looks misshapen and the implant may need to be removed.
  • Palpable Implants – occasionally, the top of the implant can be felt as a definite ‘ridge’ under the skin, especially if you are thin with little breast tissue. Placing the implant under the muscle (submuscular) may reduce this problem.
  • Rippling – ripples may be seen on the surface of the skin on the breast giving an uneven appearance (wave-like) particularly when leaning forward. This is due to the skin attaching to the underlying implant and can be reduced by placing the implant under the muscle. This option is also recommended when there is very little natural breast tissue to cover the implant.
  • Deflation/replacement – there is a risk of deflation with the saline implants; augmentation using these should not be regarded as long-term. They are exchanged usually for silicone gel implants. It is possible that at a later date, implants may need adjustment or replacement; although this could be in 10-15 years, or perhaps longer after the initial augmentation. This may be due to contracture or other cosmetic changes, rather than ‘deflation’ or gel ‘bleed’ (slow diffusion of silicone out of its covering). The ongoing development of implant designs mean that it is difficult to predict the implants expected lifespan.
  • Implants – The saline implants can deflate slowly or quite rapidly and would need removing if ruptured. However, the silicone implants are not so obvious; any loss of integrity (change of shape or a tear) in the outer shell is made up for by being kept within a sack-like capsule formed around the silicone (called an intracapsular rupture). The gel does not spread around the body; it may be forced into the surrounding tissue but only produces a localized area of inflammation. This is quite common with the older designs and is normally asymptomatic (no symptoms). The modern silicone implants are made with a cohesive gel, which would not move far from the capsule. An ultrasound scan would be done to confirm whether the implant is intact or not.

What will happen after your initial consultation?

After your initial consultation, you will be placed onto a waiting list. When a suitable date becomes available for your surgery, you will receive a letter with appropriate details including:

  • A date for your pre-assessment appointment.
  • A date for your surgery, times and where to attend.

Pre-operative admission to the ward – you will be seen by the doctor, anaesthetist and surgeon. After routine medical checks and obtaining consent, the breasts are marked with several measurements for the operation. Antibiotics are given before the procedure commences.

The operation

The operation is performed under general anaesthesia. The most common approach of placing the implant in position is by making an incision along the crease under the breast, called the infra-mammary fold. This means that the scar line will not be as noticeable due to being positioned beneath the breast.

Dissolvable sutures are used throughout the operation; the wound will be dressed with white adhesive strips called steri-strips with a waterproof dressing in place.

Post-operative (after your operation)

Recovery – when your operation has been completed you will spend time in the recovery room where you will be monitored until you are considered well enough to return to the ward.

Post operative pain management – if you are experiencing pain, please speak to a nurse who will ensure you are given appropriate pain relief.

 Antibiotics – are given during the procedure and may occasionally be given for a few days afterwards. It is important that you complete the full course given to you.

Discharge Home

You should be able to go home the next day. Usually, only an overnight stay is required if the implants are sub-glandular (under the breast tissue). An additional night’s stay in hospital may be required if the implants have been placed in a sub-pectoral position, (under the chest muscle) and dependant on the level of discomfort being experienced after surgery.

On Discharge

On discharge you will be given an information leaflet with advice about post operative care, pain relief and exercises, as relevant to your breast surgery. Bruising and a swollen appearance can be expected, which may take a few weeks to settle. Once home, you are advised to be careful with arm movements for the first couple of days and gradually return to normal activities/exercise within 5 – 6 weeks.  You are advised to continue wearing the lightweight, supportive bra supplied after the surgery for about 6 weeks.

Follow up Appointment

You will be reviewed in the breast outpatient clinic 7 – 10 days after the operation, when the dressings will be removed and the wound area checked. It will be recommended that strips of white tape (micropore) be used along the scar line for 3 months, as this can help minimise the scarring.

Contact Information:

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the  Breast Care Unit on telephone number (01482) 622679 or email hyp-tr.tgsinfo@nhs.net

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

  • you must be able to give your consent
  • you must be given enough information to enable you to make a decision
  • you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.