Gender-Affirming Breast Augmentation Using a Subfascial Plane: A Retrospective Review
Surgical approaches for breast augmentation have been well-described in the cisgender population. However, data on outcomes is limited for transgender patients. This study aims to characterize the outcomes and complications following implant-based gender-affirming breast augmentation using the subfascial plane.
Methods/Technique:
A retrospective chart review was conducted on transgender women that underwent subfascial breast augmentation from June 2017 to August 2024 at a single institution under the care of the senior author (E.R). Patient demographics, transition history, comorbidities, and postoperative outcomes were collected. Data was analyzed to assess predictors of short- and long-term complications as well as revision rates using IBM SPSS software (IBM Corporation, Armonk, NY, USA).
Results/Complications:
A total of 65 patients aged 19 to 79 years old (mean, 40.2 ± 14.6 years) were assessed. The average implant volume was 505.2 ± 156.9 cc (range, 200 to 850 cc). Within 30 days (n = 60), seven patients (11.7%) had at least one incident/complication with one (1.7%) of these patients requiring revision surgery. Two patients developed infection (one managed surgically, one managed non-surgically). Neither of these patients had other incidents/complications. Five (8.3%) of these patients developed malposition. Outside of 30 days (n = 51), 10 patients (16.7% of the total follow-up population, 19.6% of the >30-day follow-up population) had at least one incident/complication that required further management. These incidents/complications included 5 instances of malposition, 5 asymmetries, and 3 capsular contractures all requiring further management. Overall, five patients (7.6% of all patients, 9.8% of the >30-day follow-up population) underwent revision operations for incidents/complications. One patient, without any incidents/complications, underwent revision due to desire for larger breast implants.
Diabetes status was found to be significantly associated with malposition (p = 0.011), with 50.0% (n = 2) of those with type 2 diabetes mellitus developing malposition. Increased implant profile was significantly associated with asymmetry (p = 0.023), with 3 patients with extra-full implants developing asymmetry. Increased duration of hormone therapy was found to be significantly associated with capsular contracture (p = 0.001) with those developing capsular contracture being on hormone therapy for an average of 8.5 years longer than those who did not. No significant correlation was found between age and duration of hormone therapy. Average follow-up was 211.8 ± 350.7 days with the longest being 1,525 days.
Conclusion:
The subfascial plane theoretically offers a chest contour free from the lateralizing and flattening influence of the pectoralis major muscles, potentially allowing for a more feminine result for those seeking gender-affirming breast surgery. Use of the subfascial plane is a promising option for a wide variety of patients as safety is comparable to other techniques and outcomes reported in the literature(1). Fluctuations in endogenous hormones have shown changes in capsular contracture risk in previous studies, and may warrant investigation into hormone therapy (HT) as a risk factor(2). As this study was a retrospective review, it was limited by patient follow-up data in the electronic health record system. Several factors may have influenced short follow-up, including socioeconomic factors and insurance status; beyond the surgical global period (typically 90 days) covered by insurance, patients often only return if complications arise. Further prospective investigation with larger age, BMI-matched cohorts and longer follow-up may better facilitate analysis of outcomes between breast augmentation techniques, as well as the role of HT in capsular contracture and other complications.