Procedures

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Breast Construction

Breast Construction – Procedures

Breast construction (breast augmentation) is a gender-affirming, upper body surgery that creates, enhances or shapes one’s breasts by placing implants underneath natural breast tissue and/or muscle. The goal is to have breasts and nipples with sensation, a larger cup size and minimal scarring. This surgery is done by a plastic surgeon.

There are different surgical techniques and types of implants that can be used. The technique and the type and size of implant used depends on several factors, including your goals and your anatomy. Your surgeon will provide recommendations that are suited to your body shape and goals. You will be part of this discussion.

What your surgeon tells you may not be what you had hoped for. When this happens, you may want to reach out to your support people for help to come up with a new plan. You can also ask for a second opinion, or reconnect with your initial surgeon.

The section below is intended to provide information about the different considerations that your surgeon will talk about. It is not intended to suggest that each technique is available for each person. There may be options that are not listed below.

Here are some of the considerations your surgeon will speak with you about:

Size of implants

This is an important decision to make. Implants are measured in terms of ccs, millilitres or grams, not cup sizes (this is because “cup size” is a concept based on the size of your body and ratio of your breast volume to your body shape). It can be helpful to bring in photos of what your goals are.

Often times you and the surgeon will choose a range, and at the time of surgery, the surgeon will use their judgment and experience to find the ideal size of implant for your goals and anatomy. You will also discuss the ideal height and width of your implant as well.

Type of implant

Saline

May have smooth or texture silicone shell
some are pre-filled with a specific amount of saline, while others are filled to the desired volume once the shell is in place
More common to experience“ripple effect”, which can be visible on the skin (many factors contribute to rippling, including shape of implants, size of the implant pocket, size of the scar capsule that develops around the implant, and amount of fluid in the implant)
May make a “sloshing” sound during vigorous activity
If under filled, may be a bit “noisy”, like gurgling water

Silicone

May have smooth or texture silicone shell
Options vary in firmness and have a different feel than saline implant

Gel-saline expander breast implants

Implants consist of two envelopes: one envelope is pre-filled with silicone gel and the other envelope is unfilled
The second envelope is filled with saline overtime until the final desired volume is achieved

Fat grafting

Less commonly done
Liposuction is done on one area of the body and then fat is injected back in small quantities in to the breast
Common complications include not all the fat staying in place, and it is not uncommon to lose up to 50% of the volume within the first year of surgery
Theoretical possibility of adipocyte derived stem cells transforming in to other cell types
Risk of fat necrosis causing lumps
Risk of oil cysts
Less predictable than an implant and generally requires multiple surgeries, with an incremental “take” of the grafted fat with each procedure

Placement of implants

Subglandular

Implant is placed above the pectoral is major muscle and under the glands of the breast.
This positioning may result in the breasts being positioned more towards the centre of the chest (vs positioned closer to the sides). This may also create a more rounded appearance.

Subpectoral

The implant is placed below the glands of the breast and under (or partially under) the pectoral is major muscle.
This positioning may lessen the possibility of developing capsular contraction. This positioning may also push the implant to the side of the chest.
You will notice animation of the implant when the pectoral is major is contracted, which will temporarily distort the implant.

Incision locations

Though the incisions are intended to be placed in away that reduces the visibility of scarring, they may still be visible to varying degrees.

Inframammary fold

Incision is below the breast, where the breast connects to the chest.
Though the incision is partially concealed in this fold, the scar may still be visible.

Axilla

Incision is in the armpit area, to the side of the breast.
Though the incision is partially concealed in the armpit, the scar may still be visible.

Periareolar

Incision is made all the way around the outside of the areola.
Though the incision is partially concealed in the edge and texture of the nipple and areola, the scar may still be visible.

Type of silicone shell (implant surface)

Smooth shell

Can move within the capsule that forms around the implant, which may create more natural movement.
The risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is much smaller with this option

Textured shell

In 2019,Health Canada found that the rate of BIA-ALCL is significantly higher inpatients with macro-textured breast implants compared to other implants.
Since the potential risks associated with textured implants outweigh their benefits, Health Canada has suspended the licenses for Allergan’s Biocell breast implants (the only macro-textured implants available in Canada).
To learn more about this, see Trans Care BC’s handout Information about textured breast implants and BIA-ALCL.

Breast Construction – Complications

Here is a list of possible complications that can be experienced after breast surgery. Your surgeon will give you a detailed list of possible complications.

Rainbow Health Ontario’s Breast Augmentation Surgical Summary Sheet provides a detailed list of potential complications, including ones that are specific to breast surgery, some that are related to surgery in general, and some that are related to having general anesthesia.

Complications specific to breast construction surgery

Dissatisfaction:

While many people are very happy with the results of their breast surgery, it is possible that the outcome of your surgery may not be what you pictured. For example, you may notice changes in the skin, or that your breasts, nipples or areolas are asymmetrical in size, shape or position.It is very common for someone to have some breast asymmetry in general(regardless of whether or not someone has had surgery). Significant asymmetry may require further surgery. Breast construction does not fully re-shape the chest, so breasts may be spaced in a way that does not create a lot of cleavage.

Some tattoo artists specialize in ‘areola restoration’, meaning that they may be able to tattoo the breast (after it has healed) to add more detail to the nipple. This can include making the nipple appear more pronounced, or increasing the appearance of the size of the areola.The anatomy of your breasts does dictate the position of the implants.

Scarring:

All incisions cause a scar. Although incisions are usually located in a way that reduces the visibility of scarring, they may still be visible to varying degrees. You can take steps to prevent severe scarring by following your surgeon’s advice about getting rest, avoiding the sun, doing massage exercises and using silicone/recommended ointments. Scars can become thickened, hypersensitive, and may even cause distortion. Severe scarring may require surgical revision. Some tattoo artists specialize in ‘skin/scar camouflage’, meaning that once the scars have fully healed, they may be able to make them appear less noticeable by blending them into the surrounding skin.

Lifespan of the implant:

A breast implant generally has an average lifespan of 10-15 years (it is rarely going to be in the body for life). There is a high chance it will need to be replaced at some point. This means that patients will likely need surgery later in life- either to replace the implant, or to manage a complication.

Capsular contracture:

Scar tissue that develops around the implant may become tight or painful. This may change the shape of the breast. Sometimes the capsular scar tissue may need to be removed and the implant may either need to be removed or replaced. Your surgeon will give you post-operative instructions to follow that will help reduce the chances of this happening.

Complications with the implant:

The implant may break (rupture), leak, or deflate. If this happens, it will need to be exchanged.

Migration or dislocation:

The implant may migrate (move) or change position (rotate) in the breast.

Skin necrosis:

Poor blood supply may result in death of the skin surrounding the implant (very rare).

Implant extrusion:

The skin around an implant may break down, resulting in the implant being visible through the skin. If this happens, the implant will need to be removed temporarily, then replaced a few weeks or months later.

Calcification:

Calcium deposits can form in the scar tissue that surrounds the implant. These may feel firm and even painful. If you develop any bumps or lesions, contact your surgeon or primary care provider. Any bumps and lesions need to be examined to determine whether they may be a normal bit of calcium buildup, or a sign of breast cancer.

Changes in sensation:

You may experience a loss of sensitivity in the skin of the breast and/or in your nipples and the

skin of your breast. This may be a reduction in sensation, or areas of complete numbness. Sometimes these changes may be temporary (sensation improves in the month after surgery) or permanent.

Tenderness & inflammation:

Sometimes veins under the breast become inflamed and clotted (also called superficial thrombophlebitis). They can look like thick vertical chords. This is often a temporary complication.

Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL):

This is a rare form of non-Hodgkin lymphoma which may occur next to the implant. To learn more about this, see Trans Care BC’s handout Information about textured breast implants and BIA-ALCL.

Other information about breast construction surgery

Breast construction is usually an “outpatient surgery”, meaning the patient usually gets discharged from the hospital later the same day.

Sometimes breast construction is a two-part process. In the first surgery, tissue expanders are inserted to stretch the skin, so that it will be able to accommodate the implant. Saline is injected into the tissue expander. This process will gradually inflate the tissue expander until the desired volume is achieved- this can take a few months.

Depending on what was discussed with your surgeon, incisions will be made under the breasts (inframammary fold), in the armpit(axilla) and/or around the areola (periareolar).

Once the skin has stretched enough to fit the implants, another procedure is done to remove the tissue expander and insert the breast implants. Implants can be placed just under the breast tissue (subglandular) or under the muscles of the chest (subpectoral).

ATTENTION: This section is to supplement what you receive from your surgeon. If there are any differences, you should follow the advice provided by your surgeon.