I'm just beginning the process of looking into the details of breast augmentation. I understand the following trade offs exist with the various common incision types...

• inframammary incision: better access and therefore possibly better symmetry, incision should mostly be hidden but not always (i.e., lying down), must get implant size right because changes in breast size can affect scar location and visibility (i.e., changing to lighter or heavier implant at a later time, or even more likely if breast tissue growth in the area changes the location of the inframammary incision scar).

• transax/transaxillary (armpit) incision: hidden scar, breast area looks untouched, lying down will not reveal a scar, incision location can generally only be used once (further work would require, say, inframammary or periareolar incision), there is risk of numbness in arms/hands (most especially if done without an endoscope), achieving breast symmetry with armpit approach can be more challenging, requires smaller implant generally speaking.

• periareolar incision (Areola incision): avoid inframammary incision/scar, incision is well camouflaged if performed appropriately along the circumference of the areola, despite surgery prep using betadine there is still risk of infection due to bacteria hiding in the ducts of the nipple (can lead to capsular contracture), sometimes required as a non transax option, scar may not heal well, can damage one's ability to breast feed.

• Considerations of subglandular (over muscle) and submuscular (under muscle) placement of implants.

One thing which stands out to me is the very common inframammary incision which leaves a scar in the inframammary crease area. It seems that would be visible when lying down but others have hinted that's not necessarily true.

Another thing is that, if one changes implant sizes later on down the line, I hear there's (likely) risk that any existing inframammary incision scar will no longer reside optimally in the inframammary crease area due to changes in breast weight affecting the crease location. This means that in the rare but not unheard of event that one changes implant size, the inframammary incision scar can move either to the breast area or to the body (depending on weight changes, heavier or lighter).

Connected with that inframammary scar location potential, I wonder about a person at 1 year HRT who might experience some small growth and how that may affect weight and the inframammary incision scar location.

The over/under muscle placement of an implant is also puzzling to me... seems most testimonies and doctor-related comments online mention under-the-muscle being the most common. Most doctors seem to say it can depend on the patient's case but I see more under results than over. There are some doctors who focus on over-the-muscle and do fine work, so it doesn't seem bad.  I still haven't figured out the key to what's best here beyond inferring that most MTFs go under not over ... but not all MTFs... so why?

All these options related to incision location, implant placement, and implant type are available and used to achieve an optimal breast augmentation result for a particular patient's anatomy and goals.

I recently had breast augmentation surgery.  In choosing a surgeon, I looked for someone who was willing and able to choose from all the various surgical methods and products in making a recommendation appropriate for my unique situation.  It became clear that there are tradeoffs that have to be considered. 

I began my search thinking that I wanted transaxillary (armpit) incisions to avoid visible scars on my breasts.  I ended up agreeing to inframammary (breast fold) incisions.  Why?  Because after 3 years on HRT, my natural breasts topped out at a small B cup.  I wanted natural looking C-cup breasts.  My surgeon recommended shaped silicone implants to achieve this.  He also recommended a slightly larger size for a better looking result given my body frame.

He recommended under the muscle (subpectoral/dual-plane) placement so that I would have enough tissue thickness covering the implants to assure that their outline would not show through the skin.  These decisions meant that transaxillary incision were not possible.  Highly cohesive shaped silicone (gummy bear) implants are best inserted through an oversized breast crease incision for accurate pocket creation and implant orientation.

To determine where to make the inframammary incisions, the surgeon has to estimate where the breast crease will end up after the implant is in place and settled to its final location weeks into recovery.  Sometimes the incision scar will not coincide exactly with the new crease.  Depending on how far off it lies, the scar could be more or less visible.

My 2" scars one month post-op are about 1/4" above the breast fold.  With practically no sag at all (I don't pass the pencil test), the scars can be seen on the underside of my breasts fairly easily.  Since gummy bear implants are not expected to drop much at all (they fuse with surrounding tissue), I can't depend on developing breast sag to hide them any time soon.  Fortunately, the incisions are healing very nicely, and in time are expected to be nearly invisible.

Quote from: Ashley3 on October 10, 2016, 09:53:32 PM
Another thing is that, if one changes implant sizes later on down the line, I hear there's (likely) risk that any existing inframammary incision scar will no longer reside optimally in the inframammary crease area due to changes in breast weight affecting the crease location. This means that in the rare but not unheard of event that one changes implant size, the inframammary incision scar can move either to the breast area or to the body (depending on weight changes, heavier or lighter).

As you stated before, inframammory incision is pretty common, so this is a good hint about the suitabilty of the procedure.

Also, as you stated, displacing of the scar due to big changes in implant size is very very rare. Think about it, if same shape implants (but bigger or smaller) are placed in the exactly same location, scar would be always on the lower side of the breast. So, even if the scar is not exactly placed at the fold, odds it will be really noticeable are quite low.

Quote from: Ashley3 on October 10, 2016, 09:53:32 PM
Connected with that inframammary scar location potential, I wonder about a person at 1 year HRT who might experience some small growth and how that may affect weight and the inframammary incision scar location.

Again, not likely. Breast tissue growth is gonna happen over the implant in the areola/nipple area. So, even if your breast goes a cup up due to TRH, the tissue is gonna develop mainly in the front area of the breast.

Also keep in mind that visibility of the scars depends greatly upon the healing.

Quote from: Ashley3 on October 10, 2016, 09:53:32 PMI still haven't figured out the key to what's best here beyond inferring that most MTFs go under not over ... but not all MTFs... so why?

Under the muscle procedure is the regular choice when the patient does not have much breast tissue/size to begin with. That's why most MTF's go under and not over. Under-the-muscle gives a more natural result when there's not enough breast tissue to properly cover the implant.

My case:

I'm 5'7'' tall, 120 lbs, 30' under bust and 34DD breasts. I have 600cc high profile round silicone implants placed under the muscle through inframammory incision. Scar is not really noticeable and it is placed on the lower part of the breast very close to the fold.

Quote from: Clara Kay on October 11, 2016, 01:15:23 PM
... I recently had breast augmentation surgery.  ...  after 3 years on HRT, my natural breasts topped out at a small B cup.  I wanted natural looking C-cup breasts.  ...

He recommended under the muscle (subpectoral/dual-plane) placement so that I would have enough tissue thickness covering the implants to assure that their outline would not show through the skin.  ...

...
Fortunately, the incisions are healing very nicely, and in time are expected to be nearly invisible.

This is great info... thank you. And congrats on your positive experience and result.

So you were 3 years into HRT? That's two more years than where I am at today! Okay... I have to say, that hits me like a really sound way to go about it. Did you feel you could have easily done the same thing at two years, or did you feel that third year really made an important difference or was a planned thing? I ask that because, you probably know this, many physicians recommend a good two years to be safe from unexpected growth. I've also heard from doctors that some patients successfully do things earlier than two years HRT but that waiting until at least two is extra safe with less change expected... you were even more extra patient beyond the general safe two year recommendation.

I'm curious what you think about someone (or yourself had you done so...) venturing into it at one year HRT?

Quote from: Wednesday on October 11, 2016, 11:25:25 PM
... Think about it, if same shape implants (but bigger or smaller) are placed in the exactly same location, scar would be always on the lower side of the breast. So, even if the scar is not exactly placed at the fold, odds it will be really noticeable are quite low. ...

Quote from: Wednesday on October 11, 2016, 11:25:25 PM
... Again, not likely. Breast tissue growth is gonna happen over the implant in the areola/nipple area. So, even if your breast goes a cup up due to TRH, the tissue is gonna develop mainly in the front area of the breast. ...

In both cases... the risk of scar movement was truly not obvious to me so this is very good to know thank you.

Quote from: Wednesday on October 11, 2016, 11:25:25 PM
... Under the muscle procedure is the regular choice when the patient does not have much breast tissue/size to begin with. That's why most MTF's go under and not over. Under-the-muscle gives a more natural result when there's not enough breast tissue to properly cover the implant. ...

So is a small 38B considered not enough, making under a better option? I assume so. I guess at 38B one more year is going to be, maybe, a fuller or larger 38B... or maybe a small 38C if lucky. Are all those still outside what you'd consider to be not enough tissue such that under the muscle would be recommended? I realize nothing is certain but just curious what you opinion is. Thanks for sharing your experience and info.

Quote from: Ashley3 on October 12, 2016, 12:13:16 AM
So is a small 38B considered not enough, making under a better option? I assume so. I guess at 38B one more year is going to be, maybe, a fuller or larger 38B... or maybe a small 38C if lucky. Are all those still outside what you'd consider to be not enough tissue such that under the muscle would be recommended? I realize nothing is certain but just curious what you opinion is. Thanks for sharing your experience and info.

Also I was a small B cup before doing BA (on hormones for more than 5 years), so I think being a B cup qualifies for under-the-muscle placement. Even reaching a small C I think most surgeons would suggest you to go under.

Keep in mind that, while being slim, it is difficult even for many cis women to get past B cups without doing BA!

Quote from: Wednesday on October 12, 2016, 12:41:07 AM
Also I was a small B cup before doing BA (on hormones for more than 5 years), so I think being a B cup qualifies for under-the-muscle placement. Even reaching a small C I think most surgeons would suggest you to go under.

Keep in mind that, while being slim, it is difficult even for many cis women to get past B cups without doing BA!

I didn't know that was the norm... okay, so not far from a 1 year HRT small 38B. Curious... even though you went for BA at 5 years, what do you think of someone doing it at 1 year? I've only heard generally that some people do that, and I read some experience on this forum of someone doing it at 1 year without issues. Seems possible but want to gauge reasonable risks. I don't sense there's anything major, perhaps just slightly not as optimum for estimating implant size w/natural growth... maybe some other things.

Quote from: Ashley3 on October 12, 2016, 01:20:37 AM
I didn't know that was the norm... okay, so not far from a 1 year HRT small 38B. Curious... even though you went for BA at 5 years, what do you think of someone doing it at 1 year? I've only heard generally that some people do that, and I read some experience on this forum of someone doing it at 1 year without issues. Seems possible but want to gauge reasonable risks. I don't sense there's anything major, perhaps just slightly not as optimum for estimating implant size w/natural growth... maybe some other things.

I think going for BA at 1 year is a safe decision. One of my closests friends did it after 1 year on HRT and she's very happy with the result (and her breasts haven't grow noticeably since then).

In fact, I think doing BA even before HRT wouldn't be problematic. I prefer going a bit bigger than expected over going a bit smaller 

At 1 year, I had not reached my growth plateau.  However, the amount of growth beyond the first year was not so much that I would have regretted doing BA at the one year mark. 

A good percentage of the female breast is adipose tissue (fat).  HRT is supposed to cause fat redistribution to hips, butt, abdomen, face, and to the breasts.  So it's not just breast glandular growth that's important.  Fat redistribution takes time.

The other thing I want to mention is that late transitioning trans women often have broader chests than natal women.  That often means selecting an implant size which has a larger width to get a more natural looking result.  The width, however, should not exceed the width of your natural breast.  If this guideline is violated, one often ends up with boobs that appear fake. 

I waited the extra time to make sure I had reached my maximum breast growth before going for implants.  I also didn't put BA at the top of my surgery priorities.  In fact, it was last:

1) Facial hair removal
2) FFS
3) Hair transplant
4) GRS
5) BA

It wasn't hard for me to delay BA to my 3rd year.  Hurray for padded bras! 

Quote from: Clara Kay on October 12, 2016, 01:28:49 PM
At 1 year, I had not reached my growth plateau.  However, the amount of growth beyond the first year was not so much that I would have regretted doing BA at the one year mark. 

A good percentage of the female breast is adipose tissue (fat).  HRT is supposed to cause fat redistribution to hips, butt, abdomen, face, and to the breasts.  So it's not just breast glandular growth that's important.  Fat redistribution takes time.

The other thing I want to mention is that late transitioning trans women often have broader chests than natal women.  That often means selecting an implant size which has a larger width to get a more natural looking result.  The width, however, should not exceed the width of your natural breast.  If this guideline is violated, one often ends up with boobs that appear fake. 

I waited the extra time to make sure I had reached my maximum breast growth before going for implants.  I also didn't put BA at the top of my surgery priorities.  In fact, it was last:

1) Facial hair removal
2) FFS
3) Hair transplant
4) GRS
5) BA

It wasn't hard for me to delay BA to my 3rd year.  Hurray for padded bras! 

These are all really truly helpful points... had not known about fat redist affecting breast size in that way or watching to avoid implant sizes larger in width than natural size.

A while back I originally picked up padded bras for the same reason but immediately removed the pads in favor of forms which tend to create a weightier binding-like effect that gets in the way of evaluating things (size/comfort) while going about day-to-day tasks. I think this is because I would start to associate a good form size with that binding effect which I'm guessing is quite far from how the real implants feel. I've used pad-like material when going out only a handful of times... I just thought of the forms as more realistic weight-wise and beyond. This is sort of why I'm considering something earlier than waiting it out but I'm now little encouraged to go back give the pads a try... cannot hurt. I say this also in the spirit of evaluating a potentially viable long term work around.

Your priorities sound really perfect for your goals and generally for consideration by anyone. I see that "3rd year" again and it really seems wise... considering simply the two components of fat redist and breast growth itself it seems clear your final choices on things (implant size, approach and all that) after 3 years are going to be more certainly precise/sound.

Thank you!

  Thank you both... the clarifications/tips/info are really helpful!