Augmentation mammoplasty (A.M.) has enjoyed a great deal of popularity as an elective surgical procedure since its inception in the early 1960s. Considerable improvement has been made in both the prosthesis itself as well as the technique. Perhaps the most important improvement was the removal of the patches from the back of the prosthesis coupled with the large "false bursa" concept. That is to say, changing from a small surgical pocket with a fixed prosthesis to a large surgical pocket with a freely mobile prosthesis has markedly improved the softness and natural appearance of the augmented breast.
In spite of all the improvements it is still not a perfect operation as contracture of the pocket resulting in loss of softness and a less than natural appearance can still occur.
The squeeze technique developed by Dr. James Baker of Orlando, Florida to rupture the fibrous pocket lining and reexpand the pocket has greatly helped in alleviating this problem, but again, does not always give a perfect result.
A.M. in the MTF patient does not present any unusual problems. Generally, there has been some breast enlargement from estrogen therapy and the patient presents herself with an appearance of a female with small to moderate breast development. In the case of large breast development the MTF is, of course, not a candidate for A.M. For suitable candidates the surgery can be done on an out-patient basis, usually under light general anesthesia or local anesthesia and sedation.
If the areola of the nipple has a great enough circumference, the prosthesis can be inserted through an incision around the edge of the areola. Usually, however, a small 1 1/4'" to 1 1/2" incision is made beneath the breast in the shadow area, just above the crease which allows a large pocket to be formed by separating the breast tissue away from the underlying muscle. Some surgeons have advocated building the pocket beneath the chest muscle in order to reduce the chance of contracture, however, this muscle is thicker and tighter in the male chest and it is my opinion the prosthesis will do better in front of the muscle rather than deep into it.
I prefer a gel prosthesis to the saline (salt water) inflatable prosthesis as I believe the former is more durable. If the inflatable prosthesis should leak the saline is quickly absorbed and the patient is without breast projection in a matter of hours. Should a gel prosthesis break, and this is NOT a common problem, the gel remains in the pocket and only +slight+ projection is lost. The broken implant feels "mushy" and replacement can be done under local anes- thesia.
Occasionally a larger prosthesis can be used depending on the expansion factor once the breast tissue has been released from the chest muscle. Final decision of prosthesis size is made during surgery and usually the largest prosthesis that will fit comfortably is used.