Surgical approaches for prosthesis placement in transgender patients: A narrative review

Breast augmentation is among the most common gender-affirming surgeries for transgender women, yet no standardized recommendations exist regarding the optimal surgical approach.

A retrospective review was conducted through PubMed, MEDLINE, and the Journal of Plastic and Reconstructive Surgery. Of 81 articles screened, 37 met inclusion criteria. Data were extracted on incision type, implant pocket selection, implant volume, complications, and patient satisfaction.

The inframammary approach represents the most used approach, reported in more than 80% of recent cohorts and meta-analyses. It is used for its surgical exposure, precise creation of pockets, and ease of creation of the new inframammary fold. The transaxillary approach allows for scar concealment but is technically demanding and less frequently performed, while the periareolar incision is limited by the small size of the areola and higher scar dehiscence rates. The choice of pocket was variable: the subglandular pocket was favored for aesthetic reasons but associated with higher rate of capsular contracture in cisgender women; the choice of subpectoral and dual-plane pockets offered better tissue coverage and are increasingly adopted in transgender populations. Implant volumes were consistently larger in transgender women than in cisgender cohorts, with a progressive increase over time. Complication rates, including capsular contracture and hematoma, were comparable between transgender and cisgender women, though malposition and infection may be slightly more frequent in transgender patients.

The inframammary incision remains the preferred approach for transfeminine breast augmentation. Pocket selection should be individualized according to anatomy and patient preference. Prospective multicenter studies are needed to establish evidence-based guidelines.