Transfemale (transgender male to female ) breast augmentation poses its own unique set of challenges. Unlike the female chest the congenital males chest has tighter tissues, stronger sternal attachments of the pectoralis major muscle, a wider sternal gap and a more inferolateral position of the nipple areolar complex. In addition the nipple-areolar complex is usually smaller. While it is true that feminizing hormone supplementation can soften the tissues and even add some amount of breast tissue development, it can not change the nipple-areolar position. (although it may increase its size a bit)
As a result it is important to recognize the effect of breast implant augmentation on the nipple-areolar position and the final aesthetic result. Regardless of implant size chosen the surgical goal is not to position the implant so that the nipple-areolar complex is centric. While this may be more effective in a cis-female, doing so in transfemales will very likely have the implant end up too low and too far to the sides. (you have to factor in tissue relaxation and resultant implant drop that will occur months after the surgery) While such a laterally positioned breast implant is not unrecoverable by secondary surgery it is far easier and more predictable to lower a breast implant than it is to raise it back up.
An implant placed to feminize the chest must open up/violate the lateral pectoral border as the breast mound does not completely sit over the pectorals major muscle. Thus almost every submuscular breast augmentation results in a dual plane implant position. (partial submuscular and partially subcutaneous) This effect becomes greater the larger the implant size is or the smaller the size of the chest wall. The surgical challenge is in how much to dissect laterally to open up beyond the lateral muscle border with the unpredictability as to how much the implant will drop after surgery. (if any) In some cases the size of the breast implant, when larger, will dictate what the extent of that dissection is to just get the implant to fit. In smaller breast implants there is more room for flexibility in the pocket dissection.
As a result every transfemale breast augmentation runs the risk of an implant that either sits too high or too low/too far to the side. That risk may be greater than cis-female breast augmentation due to the anatomic differences that the transfemale chest wall has. In addition the nipple-areolar complex may never achieve an ideal position on the breast mound. While there are procedures to change that position (nipple-areolar medialization) these effects are limited.
Dr. Barry Eppley
World-Renowned Plastic Surgeon