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Long-term Follow-up and Trends in Breast Augmentation in 527 Transgender Women and Nonbinary Individuals: A 30-year experience in Amsterdam

  • Isha Sijben
    Affiliations
    Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands

    Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
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  • Floyd W. Timmermans
    Affiliations
    Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands

    Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
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  • Oren Lapid
    Affiliations
    Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
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  • Mark-Bram Bouman
    Affiliations
    Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands

    Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
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  • Wouter B. van der Sluis
    Correspondence
    Corresponding author: Wouter B. van der Sluis MD PhD. Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
    Affiliations
    Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands

    Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
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Open AccessPublished:April 19, 2021DOI:https://doi.org/10.1016/j.bjps.2021.03.107

      Summary

      Background

      Transgender women and transfeminine spectrum nonbinary individuals may opt for breast augmentation. The aim of the study is to analyze the complications, surgical trends, and long-term follow-up of breast augmentations in this population over the past 30 years.

      Methods

      All transgender women and nonbinary individuals who underwent breast augmentation at our center between 01-1990 and 01-2020 were retrospectively identified. A retrospective chart study was conducted, recording individual demographics, implant characteristics, surgical timing, postoperative complications or other reasons requiring reoperation, and implant survival. A literature search was performed in MEDLINE on clinical outcomes and revision surgery of this procedure.

      Results

      A total of 527 individuals were identified. Median clinical follow-up time was 11.2 years (interquartile range 3.3-17.5). Median implant size increased significantly over the last years (1990-1990 median 275cc, 2000-2009 252cc, 2010-2019 375cc, p<0.01). Most individuals underwent breast augmentation and genital gender-affirming surgery in one-stage. Reoperations due to short-term complications were infrequent (hematoma (0.4%) or infection (0.4%)). Reoperations due to long-term complications comprised: implant rupture (5.7%), capsular contracture (4.9%), aesthetic problems (3.8%), low-grade infection (0.4%), or seroma (0.6%). In total, 2.5% of individuals requested larger implants. After performing the literature search and manuscript screening, 9 out of 115 identified studies were included for review. Follow-up time ranged from 30 days to 5.5 years. Reported complications requiring reoperation were capsular contraction (range 0.0-5.6%), asymmetry (3.6%), hematoma (range 0.0-2.9%), infection (range 0.0-0.9%) and implant rupture (0.7%),

      Conclusion

      Implant-based breast augmentation is a safe procedure in transgender individuals.

      Key Words

      Introduction

      The reported prevalence of transgender and nonbinary people seeking medical and surgical care increased in the past decades.
      • Arcelus J
      • Bouman WP
      • Van Den Noortgate W
      • Claes L
      • Witcomb G
      • Fernandez-Aranda F.
      Systematic review and meta-analysis of prevalence studies in transsexualism.
      This trend is also observed in The Netherlands.
      • Wiepjes CM
      • Nota NM
      • de Blok CJM
      • et al.
      The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets.
      Gender-affirming surgical procedures in transgender women and transfeminine spectrum nonbinary individuals comprise breast augmentation (top surgery), orchiectomy, gender-confirming-vulvoplasty or vaginoplasty (bottom surgery), and other feminizing procedures, such as facial gender-confirming surgery and chondrolaryngoplasty.
      Before any gender-affirming surgical procedure is performed, transgender women and nonbinary individuals have to meet criteria set by the World Professional Association for Transgender Health (WPATH). These include persistent and well-documented gender dysphoria, legal ability to provide informed consent, being of legal adult age, and other medical or mental problems, if present, should be well controlled. Breasts are associated with femininity and may therefore be an important aspect for some transgender women and nonbinary individuals. Feminizing hormone therapy often only results in moderate breast growth.
      • de Blok CJM
      • Staphorsius AS
      • Wiepjes CM
      • Smit JM
      • Nanayakkara PWB
      • den Heijer M.
      Frequency, Determinants, and Satisfaction of Breast Augmentation in Trans Women Receiving Hormone Treatment.
      Therefore, some individuals may opt for surgical breast augmentation to achieve a satisfactory result. Generally, it is recommended to be on feminizing hormone therapy for at least one year before opting for breast augmentation surgery.
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconfirming People, Version 7.
      Satisfaction with breasts, psychological well-being, and sexual well-being are known to improve after breast augmentation in this population.
      • Weigert R
      • Frison E
      • Sessiecq Q
      • Al Mutairi K
      • Casoli V
      Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals.
      Currently, information on long-term follow-up of transgender women who underwent breast augmentation is scarce.
      • Miller TJ
      • Wilson SC
      • Massie JP
      • Morrison SD
      • Satterwhite T.
      Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes.
      Large-volume studies, especially with long follow-up times, are lacking. The aim of this study is to provide information and long-term follow-up of implant-based breast augmentation in transgender women and nonbinary individuals. An up-to-date overview of relevant literature on this subject is also provided.

      Methods

       Design

      All transgender women and nonbinary individuals who underwent breast augmentation with or without genital gender-affirming surgery (gGAS) from January 1990 to January 2020 were identified from the hospital registry. Some included individuals were described in earlier studies.
      • Kanhai RC
      • Hage JJ
      • Asscheman H
      • Mulder JW.
      Augmentation mammaplasty in male-to-female transsexuals.
      • Kanhai RC
      • Hage JJ
      • Mulder JW.
      Long-term outcome of augmentation mammaplasty in male-to-female transsexuals: a questionnaire survey of 107 patients.
      • Kanhai RC
      • Hage JJ
      • Karim RB.
      Augmentation mammaplasty in male-to-female trans-sexuals: facts and figures from Amsterdam.

       Time path analysis

      Individuals who underwent both gGAS and breast augmentation, either at our or another institution, were included for time path analysis. They were classified as: augmentation first, gGAS first or augmentation, and gGAS in one stage.

       Surgical outcomes

      For the retrospective analyses on surgical outcomes, only transgender women and nonbinary individuals who underwent primary breast augmentation at our center were included. The following data were recorded:
      • -
        Individual demographics: age at implantation, body mass index, medical history (hypertension, diabetes mellitus, HIV), history of smoking, and alcohol abuse.
      • -
        Surgical characteristics: incision site, implant pocket location.
      • -
        Implant characteristics: brand, size.
      • -
        Date of breast augmentation and gGAS.
      • -
        Complications or other reasons requiring reoperation.
      • -
        Implant survival: time to explantation of implant.
      • -
        Clinical follow-up, defined as the time between breast augmentation and the last visit at our transgender clinic.

       Setting

      The Amsterdam University Medical Center, location VUmc is the largest gender surgery center in the Netherlands with a high-volume presentation of transgender and nonbinary individuals who wish to undergo gender-affirmative treatment. It is the only hospital in the Netherlands which provides the full range of surgical procedures for both transgender men and women. Consequently, the majority of transgender individuals in The Netherlands receive their treatment at our center.
      • Wiepjes CM
      • Nota NM
      • de Blok CJM
      • et al.
      The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets.

       Follow-up protocol

      After breast augmentation with an uncomplicated course, individuals are discharged the day after surgery. A scheduled postoperative visit is planned two and six weeks after surgery or on indication, depending on the occurrence of postoperative complications. Long-term complications were diagnosed ‘only on presentation of a complaint’ at the outpatient clinic. Generally, individuals follow multiple (medical and surgical) simultaneous treatment trajectories at the plastic surgery department and different transgender specialties in our hospital, which allows for a long clinical follow-up time.

       Literature search

      A systematic literature search was performed in MEDLINE on all available literature on breast augmentations in transgender women and nonbinary individuals. The search was performed in November 2020. Studies reporting clinical outcomes and/ or revision surgery were included. Exclusion criteria were case-reports and studies reporting cancer as clinical outcomes. No restrictions were imposed with regard to publication date. The search string consisted of the following search terms:
      • -
        (Mammaplasty[MESH] OR 'breast implantation'[MESH] OR 'breast implants'[MESH] OR breast augmentation) AND ('Transgender Persons'[mesh] OR 'gender dysphoria'[mesh] OR transgender* or transsexual* or trans-sexual*).
      All full-texts of identified manuscripts were screened by two authors (IS, WvdS) for eligibility.

       Statistical analyses

      All statistical analyses were performed using IBM SPSS software Version 26.0 (IBM Corp., Armonk, N.Y.). Descriptive statistics were calculated for all variables. Continuous Gaussian variables were presented as means and standard deviations (SD), continuous non-Gaussian variables as medians and Q1-Q3 interquartile ranges (IQR). Categorical data were presented as frequencies and percentages. The Kruskal–Wallis test was performed to assess change of implant size over periods of ten years and the Mann–Whitney U test for independent observations to compare median implant size. Breast implants survival outcomes were presented as Kaplan–Meier curves. The censored outcomes are defined as the last visit or lost to follow-up of participants. The endpoint is explantation of implants. P-values of < 0.05 were considered significant.

      Results

       Study population

      A flow chart of study participation is presented in Figure 1. A total of 1388 individuals underwent gGAS in the study time period (1328 vaginoplasty, 17 no-depth vaginoplasty, 43 orchiectomy), of whom 653 (47%) underwent breast augmentation. These individuals were included for time path analysis. With exclusion of 141 individuals who underwent breast augmentation elsewhere, and inclusion of fifteen individuals who underwent breast augmentation without a form of gGAS, a total of 527 individuals were included for surgical outcome and trend analyses. All gGAS procedures were performed in our center, except for one gender-confirming vulvoplasty and two vaginoplasty procedures. Individual demographics are presented in Table 1.
      Figure 1
      Figure 1Flow chart of study participants and corresponding analyses.
      Table 1Demographics of included individuals.
      DemographicValue
      Total number of included individuals, n (%)527 (100)
       History of vaginoplasty507 (96.2)
       History of no-depth vaginoplasty3 (0.6)
       History of orchiectomy2 (0.4)
       No history of gGAS15 (2.8)
      Median age breast augmentation (y); IQR35; 27-45
      Mean BMI at surgery (kg/m2) ± SD23.3 ± 3.5
      Pocket, n (%)
       Subglandular372 (70.6)
       Dual plane139 (26.4)
       Subpectoral15 (2.8)
       Unknown1 (0.2)
      Incision, n (%)
       IMF494 (93.7)
       Axillary27 (5.1)
       Periareolar1 (0.2)
       Unknown5 (0.9)
      Documented history of intoxications, n (%)
       Alcohol abuse26 (4.9)
       Smoking269 (51.0)
      Co-morbidity, n (%)
       Hypertension47 (8.9)
       Diabetes Mellitus18 (3.4)
       HIV25 (4.7)
      Median clinical follow-up (y); IQR11.2; 3.3-17.5
      IMF = Inframammary fold, BMI = Body mass index, gGAS = genital gender-affirming surgery

       Trends in time path: breast augmentation and gGAS

      An overview illustrating the chronological order of surgical procedures in included individuals is presented in the online-only Supplementary Data 1. The overview of the time path also included transgender women and nonbinary individuals who underwent breast augmentation or gGAS elsewhere (Figure 1). In total, 653 transgender women and nonbinary individuals underwent both breast augmentation and gGAS (vaginoplasty n=647, gender-confirming-vulvoplasty n=4, or orchiectomy n=2) between January 1990 and January 2020. Of 653 included individuals, 85 (13%) underwent gGAS before, 417 (64%) in the same session and 150 (23%) after breast augmentation. The median time between augmentation and gGAS in individuals undergoing breast augmentation before gGAS was 16.4 months (IQR 10.9 – 27.6) and the median time between surgeries in those undergoing breast augmentation after gGAS was 20.4 months (IQR 8.6 – 39.9). Whereas breast augmentation and gGAS in the same session was the most prevalent in earlier years, a trend is observed toward undergoing breast augmentation at a later stage then gGAS.

       Trends in implant-based breast augmentation

      In total, 527 transgender women and nonbinary individuals underwent primary breast augmentation in the study time period in our center. The number of performed breast augmentation procedures over the years is presented in Figure 2.
      • -
        Trends in implant size
      Figure 2
      Figure 2Number of transgender women and nonbinary individuals who underwent breast augmentation in our center per year. In the time period 2006–2016, breast augmentation was not reimbursed by public medical insurance companies.
      The median implant size was 290cc (IQR 230 - 340). The median implant size used during the last decade increased significantly as compared to median implant size reported in 1990 – 1999 (median difference + 100cc, P < 0.001) and 2000 – 2009 (median difference + 123cc, P < 0.001) (Figure 3).
      • -
        Trends in implant brands
      Figure 3
      Figure 3Median implant size per year. In the time period 1990–1999, a median implant size of 275 cc was used, in the time period 2000–2009, 252 cc, and in the time period 2010–2019, 375cc.
      The brands of the breast implants used in our center changed over the past decades (online-only Supplementary Data 2). In the 1990s, frequently used brands were: Mentor/Siltex, Nagor, and PIP. Later on, the majority of breast augmentations were performed with the brand Allergan (McGhan, Inamed, CUI, Inspira, and Natrelle). Currently, predominantly Motiva is used.
      • -
        Implant Pocket
      Breast implant pockets were subglandular (n= 372 (70.6%)), subpectoral (n= 15 (2.8%)), or dual plane (n= 139 (26.4%)). Between 1991 and 2007, the subglandular pocket was more common. After 2007, the majority of implants were placed in the dual plane pocket (online-only Supplementary Data 3).

       Complications and implant survival

      An overview of complications requiring reoperation is presented in Table 2. Short-term complications were uncommon and comprised infection (2/527, 0.4%) or hematoma (2/527, 0.4%). Long-term complications comprised mainly capsular contracture (26/527, 4.9%, after a mean time of 6.8 ± 4.7 years) and implant rupture (30/527, 5.7%, after a mean time of 12.9 ± 6.5 years). Implant survival, defined as ‘the original breast implant that was in place at the time of follow-up’, is presented in Figure 4. In 141 of 150 individuals, the first time of explantation was also the first reoperation. No distinction was made between explantation of one or both breast implants within one individual.
      Table 2Clinical outcomes of breast augmentation in 527 included individuals.
      First reoperation, N (%)Mean time to reoperation, years ± SD
      Short-term complications (<3 months)
      Hematoma, for which retake to theater2 (0.4%)Day: 1; 3
      Infection, for which explantation2 (0.4%)Day: 7; 11
      Long-term complications (>3 months)
      Rupture30 (5.7%)12.9 (±6.5)
      Capsular contracture

       For which capsulectomy

       For which implant exchange
      26 (4.9%)

      7 (1.3%)

      19 (3.6%)
      6.8 (±4.7)

      2.5 (±1.8)

      9.2 (±5.3)
      Excessive seroma, for which explantation3 (0.6%)0.6 (months: 2.6, 7.7, 12.9)
      Low-grade infection, for which explantation2 (0.4%)11.0 (±2.6)
      Aesthetic problems
      Aesthetic problems: dislocation, malposition, asymmetry, rippling, cleavage tenting, or double bubble sign of implants.


       For which reoperation

       For which implant exchange
      20 (3.8%)

      7 (1.3%)

      13 (2.5%)
      4.8 (±4.6)

      1.5 (±2.8)

      6.6 (±4.8)
      Other reasons
      PIP recall
      PIP implants were at risk for rupture10.
      52 (9.9%)11.7 (±1.3)
      Request larger size13 (2.5%)5.0 (±5.9)
      Request for explantation
      Transition regret, neck and shoulder problems, health complaints they attributed to implants, temporary explantation due to family who did not accept transition
      8 (1.5%)9.5 (±7.6)
      low asterisk Aesthetic problems: dislocation, malposition, asymmetry, rippling, cleavage tenting, or double bubble sign of implants.
      low asterisklow asterisk PIP implants were at risk for rupture
      • Wazir U
      • Kasem A
      • Mokbel K.
      The clinical implications of poly implant prothese breast implants: an overview.
      .
      low asterisklow asterisklow asterisk Transition regret, neck and shoulder problems, health complaints they attributed to implants, temporary explantation due to family who did not accept transition
      Figure 4
      Figure 4Survival of breast implant, as depicted per brand. The survival analysis included the following brands: Motiva, Mentor/ Siltex, Allergan (Inamed/ McGhan/ CUI/ Inspira/ Natrelle), Nagor, PIP, and others (Dow corning, Silimed, and unknown). Implant rupture occurred in the following brands: Inamed (n= 5), McGhan (n= 1), PIP (n= 6), Nagor (n= 3), Mentor (n= 14), or unknown (n= 2).

       Breast implant-associated anaplastic large-cell lymphoma

      Anaplastic large-cell lymphoma (ALCL) was diagnosed in one transgender woman, which has been published elsewhere.
      • de Boer M
      • van der Sluis WB
      • de Boer JP
      • et al.
      Breast Implant-Associated Anaplastic Large-Cell Lymphoma in a Transgender Woman.
      ALCL was diagnosed after a long trajectory of multiple reoperations and different prostheses.

       Regret

      During the study time period, five (0.9%) of 527 people who underwent breast augmentation developed transitional regret, of which three opted for implant explantation. One person underwent explantation of implants due to rupture, before the date of regret. One person did not yet undergo explantation at time of analysis.

       Literature search

      A total of 115 studies were identified. After full-text screening, a total of nine studies on surgical outcomes and/ or revision of breast augmentation in transgender women and nonbinary individuals were included. Most studies on this subject were of retrospective design. An overview is presented in Table 3. Follow-up time ranged from 30 days to 5.5 years. The reported complications requiring reoperation were: capsular contraction (range 0.0-5.6%), asymmetry (3.6%), hematoma (range 0.0-2.9%), infection (range 0.0-0.9%), striae distensae (0.7%), implant rupture (0.7%), abscess (0.4%), scarring (0.0%), hypersensitivity (0.0%), and numbness (0.0%). Studies reporting satisfaction of breast augmentation in transgender women and nonbinary individuals used different kind of patient-reported outcome measurements (PROMs).
      Table 3Overview of literature on surgical outcomes of breast augmentation in transgender women and non-binary individuals
      AuthorsYearNgGAS before, during or after augmentationImplant sizeComplicationsRequest larger sizeSatisfaction measurement and outcomeFollow-up
      Kanhai et al.
      • Kanhai RC
      • Hage JJ
      • Asscheman H
      • Mulder JW.
      Augmentation mammaplasty in male-to-female transsexuals.
      *
      1999201NRIncreased from mean 165 to 287 ccReoperation n=21 (10.4%):

      n= 11 (5.5 %) Capsular contraction

      n= 11 (5.5%) not specified
      NRNRNR
      Kanhai et al.
      • Kanhai RC
      • Hage JJ
      • Mulder JW.
      Long-term outcome of augmentation mammaplasty in male-to-female transsexuals: a questionnaire survey of 107 patients.
      *
      2000107During (n=85) Before (n=22)Mean 258 cc Range 130-450NRn= 17 (16%)Semi-structured, self-developed, non-validated questionnaire

      75% satisfied,

      25% dissatisfied: majority about breast size (too small), other reasons were pain and aesthetic problems.
      5.5 years

      (range 1.3-17)
      Kanhai et al.
      • Kanhai RC
      • Hage JJ
      • Karim RB.
      Augmentation mammaplasty in male-to-female trans-sexuals: facts and figures from Amsterdam.
      *
      2001201During (n=159) Before (n=42)Mean 255 cc

      Range 120-450
      NRn= 11 (5.5%)NRMean 3.8y Range 0.04-16)
      Weigert et al.
      • Weigert R
      • Frison E
      • Sessiecq Q
      • Al Mutairi K
      • Casoli V
      Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals.
      201335BeforeMean 327 ± 61 ccNo complications or reoperationsNRBREAST-Q

      satisfaction with breasts, sexual well-being, and psychosocial well-being improved significantly at 4 and 12 months after surgery
      Median 20.7 Range 12.0 - 39.6
      Fakin et al.
      • Fakin RM
      • Zimmermann S
      • Kaye K
      • Lunger L
      • Weinforth G
      • Giovanoli P.
      Long-Term Outcomes in Breast Augmentation in Trans-Women: A 20-Year Experience.
      2019138NR1995-1999

      221 ± 44

      2000-2004

      250 ± 49cc

      2005-2010

      348 ± 113

      2011-2016

      363 ± 97 cc
      Reoperation n= 12 (18%):

      n= 5 (3.6%) Asymmetry

      n= 4 (2.9%) Capsular contracture

      n= 1 (0.7%) Striae distensae

      n= 1 (0.7%) Hematoma

      n= 1 (0.7%) Rupture
      n= 13 (9.4%)Retrospective chart review and subjective extrapolation of satisfaction.

      Very satisfied: 67%, satisfied: 15%, neither satisfied nor dissatisfied: 2%, dissatisfied: 15%, very dissatisfied: 2%
      Median 4.6y Range 2.0-13.3
      Miller et al.
      • Miller TJ
      • Wilson SC
      • Massie JP
      • Morrison SD
      • Satterwhite T.
      Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes.
      201934NRMean 520 cc (range 350-700)n= 1 (2.9%) Hematoma (reoperation)

      n= 1 (2.9%) Infection

      n= 2 (5.9%) Extrusion

      n= 1 (2.9%) Excessive scarring

      n= 1 (2.9%) Asymmetry
      NRSelf-developed, non-validated questionnaire

      93% was happier and more satisfied with their chest. 100% reported improvement in their gender dysphoria and expressed they would choose to undergo the operation again. 25% expressed the wish for revisionary surgery after augmentation
      Mean 15.9m Range 0.5-38.7
      Cuccolo et al.
      • Cuccolo NG
      • Kang CO
      • Boskey ER
      • et al.
      Epidemiologic Characteristics and Postoperative Complications following Augmentation Mammaplasty: Comparison of Transgender and Cisgender Females.
      2019280NRNRn= 3 (1.1%) Hematoma

      n= 1 (0.4%) Abscess
      NRNR30 days
      Chatterjee et al.
      • Chatterjee SS
      • Khanna M.
      Hundred and Eleven Cases of Subfascial Breast Augmentation in Trans Women-A Single-Center Experience.
      2020111Beforen=14 180-300cc

      n=76 300-400cc

      n=21 400-550cc
      n= 12 (10.8%) Capsular contracture, for which reoperation in one individual

      n= 1 (0.9%) Infection

      n= 11 (9.9%) Poor scarring
      n= 2 (1.8%)NRNR
      Coon et al.
      • Coon D
      • Lee E
      • Fischer B
      • Darrach H
      • Landford WN.
      Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results.
      202036NR530 ± 76n= 1 hematoma (2.8%)

      n= 2 capsular contraction (grade 3) (5.6%)
      NRSelf-developed, non-validated questionnaire

      Results: improvement in psychosocial well-being and high satisfaction rate with overall cosmetic result (79% very satisfied and 21% moderately satisfied)
      Mean 6m

      range 0- 22
      gGAS genital Gender-Affirming Surgery, NR Not Reported, m months, y years
      *= Overlap of included individuals can be expected in these same-author studies

       Discussion

      In this article, trends, outcomes and long-term follow-up of transgender women and nonbinary individuals, who underwent primary breast augmentation, are presented. Short-term complications were scarce and consisted of hematoma or infection, both in 0.4% of cases. Implant rupture (5.7%) and capsular contracture (4.9%) were the most common long-term complications. Thirteen (2.5%) transgender women and nonbinary individuals underwent revision breast augmentation due to a request for larger implants.
      In current literature, the reoperation rate after breast augmentation in the described population ranges from 0% to 18%. However, great variation exists in reported clinical follow-up times and upheld definition of complications.
      • Weigert R
      • Frison E
      • Sessiecq Q
      • Al Mutairi K
      • Casoli V
      Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals.
      • Miller TJ
      • Wilson SC
      • Massie JP
      • Morrison SD
      • Satterwhite T.
      Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes.
      • Kanhai RC
      • Hage JJ
      • Asscheman H
      • Mulder JW.
      Augmentation mammaplasty in male-to-female transsexuals.
      • Kanhai RC
      • Hage JJ
      • Mulder JW.
      Long-term outcome of augmentation mammaplasty in male-to-female transsexuals: a questionnaire survey of 107 patients.
      • Kanhai RC
      • Hage JJ
      • Karim RB.
      Augmentation mammaplasty in male-to-female trans-sexuals: facts and figures from Amsterdam.
      ,
      • Fakin RM
      • Zimmermann S
      • Kaye K
      • Lunger L
      • Weinforth G
      • Giovanoli P.
      Long-Term Outcomes in Breast Augmentation in Trans-Women: A 20-Year Experience.
      • Cuccolo NG
      • Kang CO
      • Boskey ER
      • et al.
      Epidemiologic Characteristics and Postoperative Complications following Augmentation Mammaplasty: Comparison of Transgender and Cisgender Females.
      • Chatterjee SS
      • Khanna M.
      Hundred and Eleven Cases of Subfascial Breast Augmentation in Trans Women-A Single-Center Experience.
      • Coon D
      • Lee E
      • Fischer B
      • Darrach H
      • Landford WN.
      Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results.
      The prevalence of capsular contracture requiring reoperation ranges from 0.0% to 5.6%. Implant rupture was reported in one study in 0.7% of included individuals. The maximum reported follow-up was 5.5 years (Table 3). This could, at least partially, explain the higher rate of capsular contracture and rupture observed in our study when compared to other studies, since reoperations due to capsular contracture occurred after a mean time of 6.8 years and reoperations due to implant rupture occurred after a mean time of 12.9 years.
      Cuccolo et al. compared short-term complications of breast augmentation in cis- and transgender women. The reoperation rates were low in both.
      • Cuccolo NG
      • Kang CO
      • Boskey ER
      • et al.
      Epidemiologic Characteristics and Postoperative Complications following Augmentation Mammaplasty: Comparison of Transgender and Cisgender Females.
      Similar to studies published in the transfeminine population, studies reporting on postoperative complications after breast augmentation in ciswomen are variable in follow-up time and upheld definitions of complications.
      • Cuccolo NG
      • Kang CO
      • Boskey ER
      • et al.
      Epidemiologic Characteristics and Postoperative Complications following Augmentation Mammaplasty: Comparison of Transgender and Cisgender Females.
      Short-term complications requiring reoperation was infrequent in our study as well as in literature of ciswomen.
      • Hvilsom GB
      • Holmich LR
      • Henriksen TF
      • Lipworth L
      • McLaughlin JK
      • Friis S.
      Local complications after cosmetic breast augmentation: results from the Danish Registry for Plastic Surgery of the Breast.
      ,
      • Codner MA
      • Mejia JD
      • Locke MB
      • et al.
      A 15-year experience with primary breast augmentation.
      Long-term complication rates requiring reoperation defined as capsular contracture and rupture were lower in ciswomen, although their follow-up time was shorter.
      • Unger JG
      • Carreras JM
      • Nagarkar P
      • Jeong HS
      • Carpenter W.
      Allergan Style 410 Implants for Breast Reconstruction: A Prospective Study in Efficacy, Safety, and Symmetry.
      • McGuire P
      • Reisman NR
      • Murphy DK.
      Risk Factor Analysis for Capsular Contracture, Malposition, and Late Seroma in Subjects Receiving Natrelle 410 Form-Stable Silicone Breast Implants.
      • Heden P
      • Bronz G
      • Elberg JJ
      • et al.
      Long-term safety and effectiveness of style 410 highly cohesive silicone breast implants.
      The number of performed breast augmentations per year varied over the past decades. A decrease was observed in the period 2007–2016. An explanation for this decrease is most likely due to our national public medical insurance companies halting the reimbursement of breast augmentations between 2006 and 2016 (online-only Supplementary Data 4). The authorization of reimbursing by public medical insurance companies remained valid for one year, which explains the decrease after 2006. This underlines the fact that insurance reimbursement policy may affect the accessibility to surgical care of transgender individuals.
      A shift in surgical timing of gGAS and breast augmentation was observed. In the 1980’s, breast augmentation was performed either during or after the gGAS procedure.
      • Kanhai RC
      • Hage JJ
      • Karim RB.
      Augmentation mammaplasty in male-to-female trans-sexuals: facts and figures from Amsterdam.
      In that time period, breast augmentation was rarely performed before or without the prospect of a vaginoplasty procedure, which may be a reflection of a more binary (surgical) gender view.
      • Beek TF
      • Kreukels BP
      • Cohen-Kettenis PT
      • Steensma TD.
      Partial Treatment Requests and Underlying Motives of Applicants for Gender Affirming Interventions.
      For some time now, it has been possible for the individual to choose for top surgery- with or without bottom surgery, in the order of their preference.
      The aforementioned study of Kanhai et al. reported a trend of increasing implant size over the years.
      • Kanhai RC
      • Hage JJ
      • Karim RB.
      Augmentation mammaplasty in male-to-female trans-sexuals: facts and figures from Amsterdam.
      This over-time increase of implant sizes has also been observed in a study by Fakin et al..
      • Fakin RM
      • Zimmermann S
      • Kaye K
      • Lunger L
      • Weinforth G
      • Giovanoli P.
      Long-Term Outcomes in Breast Augmentation in Trans-Women: A 20-Year Experience.
      Our data supports this observation as well. Thirteen (2.5%) transgender women and nonbinary individuals underwent reoperation following the request for larger implants. Three of these individuals were mentioned the same study cohort (1979 – 1997) performed at our center earlier. In that cohort, eleven (5.5%) of 201 transgender women and nonbinary individuals requested larger implants.
      • Kanhai RC
      • Hage JJ
      • Karim RB.
      Augmentation mammaplasty in male-to-female trans-sexuals: facts and figures from Amsterdam.
      The decrease in transgender women and nonbinary individuals requesting reoperations for larger implants could be explained by the increase of average implant size over the past decades, as well as the historically variable reimbursement policies by public medical health insurance companies.
      In practice, larger implant sizes are generally associated with wider based implants. These two implant characteristics, in our experience, results in a more harmonious result in relation to the broader chest seen in transgender women. Resulting, the choice for larger, wide-based implants allows for both cleavage formation and more appropriate nipple positioning on the breast. The lessons taught by our experience throughout the years have emphasized the necessity of informed decision-making on implant characteristics and proper expectation management to achieve patient satisfaction.
      Unfortunately, known studies reporting satisfaction of breast augmentation in transgender women and nonbinary individuals used different kinds of PROMs. The existing BREAST-Q was not developed to cater to the needs of transgender people.
      • Pusic AL
      • Klassen AF
      • Scott AM
      • Klok JA
      • Cordeiro PG
      • Cano SJ.
      Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q.
      An all-encompassing transgender-specific PROM is still being developed, which will also specifically address breast augmentation outcomes.
      • Klassen AF
      • Kaur M
      • Johnson N
      • et al.
      International phase I study protocol to develop a patient-reported outcome measure for adolescents and adults receiving gender-affirming treatments (the GENDER-Q).
      Strengths of this study comprise the study population size with long-term clinical follow-up. Limitations of this study comprise the lack of patient-reported outcomes, which was however mentioned in a recent study by our colleagues
      • de Blok CJM
      • Staphorsius AS
      • Wiepjes CM
      • Smit JM
      • Nanayakkara PWB
      • den Heijer M.
      Frequency, Determinants, and Satisfaction of Breast Augmentation in Trans Women Receiving Hormone Treatment.
      , and the retrospective nature of the study. For our systematic review, only the MEDLINE database was used. Therefore, the absence of multiple search methods is a limitation. Different implant dimensions available over the years and different surgeons performing augmentations in this single-center study may contribute to a certain amount of intervention bias with regard to the trend of increased implant sizes observed

      Conclusion

      The incidence of short- and long-term complications after implant-based breast augmentation in transgender women and nonbinary individuals is acceptable. The procedure may be regarded as safe. Over the years, implant size, brand, pocket, and medical reimbursements have changed.

      Conflict of Interest

      None declared.

      Funding

      None.

      Ethical Approval

      The study protocol was assessed and approved by the Ethical Review Board of the Amsterdam University Medical Center, location VU University Medical Center, and is registered under METC 2014322.

      Appendix. Supplementary materials

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