Executive Summary

There is significant evidence that sub-muscular breast augmentation results in a potential loss of arm strength, increased post-surgical pain, and increased post-surgical recovery time. This evidence is not conclusive, due to the small number of tests and test subjects which exist in the literature, nor were any tests or studies performed upon transsexual women. The magnitude of this strength decrease may vary from roughly 10-20% overall, with specific movements and exercises being more or less impacted by the surgery. Not all women will suffer from this strength decrease, and women who are not normally athletic may notice less of a decrease than athletic women – if they notice it at all.

The two major placement locations of breast implants.

Report

Many transgender women who take steps to transition socially, legally, and physically (and thus become transsexual women) are either tempted by breast augmentation, or else choose to undergo it. The reasons for this are straightforward – as secondary sex characteristics go, breasts are a highly obvious indicator of femininity when viewed by the general public, or by the owner of said breasts. Most transsexual women over the age of 35 will not develop breasts of a sufficient volume, shape, and/or symmetry to meet their body morphology and appearance expectations, even after having been on hormone therapy for several years. While the situation is more positive for younger transsexual women, especially those who are so fortunate as to transition at puberty, the results of hormone therapy are by no means guaranteed.

And of course many cisgender women choose breast augmentation as a way to enhance their personal view of their appearance and their self-esteem.

A critical question, which arose as I considered my own breast augmentation, was whether the implants should be placed under or over the pectoral muscle of the chest? Asking the transgender “anecdote and rumor mill” resulted in a flurry of conflicting opinions, and reading the opinion of surgeons online indicates either an ignorance on the subject, or else an opinion not backed up by any specific study or fact. The first surgeon I consulted, who had performed hundreds of breast augmentations, claimed she had never even heard of any difference between the two techniques.

The zeitgeist of breast augmentation opinion tends to be this: you achieve better appearance with implants under the pectoral muscle (UM) or partially under the pectoral muscle (PUM) than over the muscle (OM). However, because the muscle wall is cut during a UM or PUM procedure, you can lose “from 10-20% of your arm muscle strength.” (The exact number varies depending upon the source). To me, this was a serious concern, as being a fencer and tennis player, plus a relatively shrimpy person who doesn’t have that much muscle to begin with, losing up to 25% of my arm strength would be a serious change in my quality of life.

As a result, I did what I do best, which was go to my university and slog through the medical research and summarize it, and I am sharing my results here with you, dear reader. Please note that while I am a professor and science researcher, I am not a physician, and I have not had medical training. I am not and cannot give you any medical advice, only do my best to present the results of my research.

Also please note, I’m not going to discuss the differences between silicone and saline implants, “gummy bear” versus other implants, or implant size. The focus of this research paper is to investigate the effects of placement UM or PUM, versus OM.

Differences in the Procedures

The three most common methods of breast augmentation (BA) are under the pectoral muscle (UM), or partially under the pectoral muscle (PUM, also called “dual-plane”), and over the muscle (OM). The PUM method has many sub-methods, which vary depending upon the level of muscle coverage desired. Subfascial implants are placed under the outer fascia or covering of the pectoral muscle, and are rarely done.

Breast implant placement examples.

There are myriad advantages and disadvantages claimed for each of the primary methods.

PUM or UM techniques are typically employed with silicone implants. These methods are said to not only create a more natural appearance, but to reduce the chance of capsular contracture (tightening or hardening of the breast, also called “encapsulation”). Surgery is slightly longer in duration, and the recovery time can be 6 to 8 weeks, with some patients reporting severe pain during recovery, due to the procedure being more involved and the pain associated with muscle healing. OM techniques are typically employed with saline implants, and are often used when the implants themselves are smaller and the starting “native” breast tissue is larger. Surgical recovery time from OM procedures can be half that of UM and PUM procedures, with a much lesser pain level during recovery. However, the chance of capsular contracture is greater. There is typically no difference in scarring between the two procedures, unless the OM option allows insertion via the nipple tissue.

Where the specific concern lies is here: to place an implant under the muscle to any extent, the muscle must be cut and “freed” from the chest wall, which means that it can no longer contract to exert pull in the direction perpendicular to the cut. This by definition means that the muscle cannot function the same as it did before the surgery. The dispute is whether or not the difference is noticeable – or if it is noticeable, if the difference is worth the potential benefit in terms of an improved appearance, and potentially lesser chance of encapsulation.

Why Do Surgeons Recommend One Procedure Versus Another?

A survey of 508 breast augmentation (BA) surgeons found that they performed under the pectoral muscle (UM) procedures 63% of the time, partially under the pectoral muscle (PUM) procedures 25% of the time, and over the muscle (OM) procedures only 11% of the time. Subfascial implants, which are placed under the outer fascia or covering of the pectoral muscle, are rare, being performed only 1% of the time. (Reece)

Which procedure is best depends upon many factors, which the surgeon must evaluate, based upon the patient’s body and their needs. These include, in order of priority:

• Cosmetic result, combined with choice of implant. Surgeons tend to place only silicone implants under or partially under the muscle, whereas saline implants tend to be placed over the muscle.
• Decreased chance of capsular contracture (tightening or hardening of the breast, also called “encapsulation”).
• Patient preference.
• Decision changes in the middle of surgery.
• Specific anatomy of the patient.
• Potential mammography considerations. (Reece)

Note that “specific anatomy of the patient” is one of the least-common decision points. Indeed, it was cited by less than 1 in 6 surgeons – yet for transsexual women, who despite all our best wishes do not have the same bodies as women, this should be one of the most important decision points!

What if My Surgeon Won’t Perform the Procedure I Want?

You can attempt to explain to them the reasons why you are concerned, and refer to some of the studies listed in this article. However, in my experience most surgeons who are comfortable with a certain practice or who feel strongly about performing a certain procedure are not going to change their minds based upon patient input. Your ultimate option is to find a different surgeon.

I know how heartbreaking it can be to find a good doctor but be put in the dilemma of “I really need this procedure done, and I like the doctor, but I just do not want to do it this way!” Everyone will have to decide this for themselves. I will say this – once you go sub-muscular, it’s very difficult to repair the muscle later on should you change your mind. In addition, if you are an older transwoman you may consider how a lack of arm strength could impact your mobility as you approach old age, on top of the strength-sapping effects of estradiol and anti-androgens (or sex reassignment surgery).

Will you have enough strength to maintain an active life? Every bit counts over age 60.

No surgery is “simple” or “a piece of cake.” Any surgery has the potential to go wrong, or to simply take much of your energy and require a longer than expected recovery time. My very simple liposuction procedure floored me for months afterwards, despite all the adverts and first-hand testimony from shiny, happy people who claimed to be practically recovered the week after surgery. If you have doubts about which breast augmentation procedure to use…I recommend you wait and find a surgeon who will do what you want.

Size Matters

I’m not going to attempt to advise you on size, but I will give you some information I discovered during my interviews with many physicians as I was finding the right surgeon, as well as with many transgender women who underwent breast augmentation like I did.

• Do NOT assume that the surgeon knows what your cup size will be based upon your implant size! This is a false assumption of authority with many patients make. I found that every surgeon I spoke to was very off-base in terms of their “rule of thumb” for cup size as a function of implant size. One problem is that the way the implants rest within your body is actually somewhat variable, but another problem is simply the silly and inconsistent manner in which breast cup size is measured, and it depends highly upon your anatomy. Every surgeon I spoke to told me that a 400 cc implant would give me a B cup when I was done. I had 380 cc implants installed, and I’m officially a 33 D/DD or 34 D. That’s some difference.
• There are many factors which go into choosing a proper implant size, and if you want your breasts to look as natural as possible, make certain that your surgeon is taking into account the distance from nipple-nipple, the positioning of the nipples relative to the side of your chest, the width of your sternum, the natural angle of your nipples produced by your existing chest muscle and fatty tissue, etc. That old adage, “measure twice, cut once?” It applies here. A surgeon who takes a lot of measurements and spends a lot of time weighing options is a good thing.
• Make certain that your surgeon uses a Keller funnel or equivalent device to assist with the surgery, as these are generally agreed to significantly reduce the change of infection, and thus reduce the change of losing your implant or undergoing painful and potentially disfiguring capsular contraction.
• Please read the risks very carefully in the literature which your surgeon provides before you proceed, as well as any information available from the implant maker. Please consider that many of us will not ever regain full nerve sensation after the surgery, or if we do that it can take a year or more before all feeling returns. This is not due to cutting of the nerves, it’s due to trauma from stretching the nerves – thus, smaller implants mean a lesser chance of nerve damage.
• Understand that choosing a final size will be a very difficult decision for you. A smaller size will mean less pain, simpler healing, and potentially a more natural look – at the potential drawback of being “too small.” My surgeon gave me a range from 325-380 cc which she said was “conservative,” and not to brag but my results are absolutely perfect – natural and proportional to my frame (I chose 380 cc). Other surgeons said I could go as high as 480 cc, a size which would have made me look somewhat overbalanced and Barbie-like.
• You need to understand as well that even though you may want this surgery more than anything else in the world, EVERY transgender woman who is a personal friend of mine who has undergone breast augmentation absolutely freaked out right after surgery. Several ranted at their surgeon days later and demanded that the implants be removed – and so did I, I say in all honesty and humility. Thankfully, none of us actually had them removed, and we soon found peace with our “new bodies.” The freakout was due to three factors – first, suddenly having this huge mass on your chest which you’ve never had before, which is psychologically shocking. Try to prepare yourself for this, and if you have a spouse or significant other, tell them to expect that you could freak out. Shoot, tell your surgeon, too. Second, the effects of general anesthesia can produce unusual psychological effects for days to even weeks after surgery – I found I don’t seem to come off all the anesthesia hangover until nearly 2 weeks have passed. And third, you may very well be in tremendous pain, not only from the cutting itself, but the pain and discomfort from the skin stretching is…well, it’s unique, severe, and can be scary.

So Which Procedure Should I Have?

I was accused of being too “wishy-washy” in this article, because I don’t just come out and say “do this.” I am not only not a medical doctor, I am not your medical doctor, nor you. In addition to that, this is a specific research topic which has not been broadly studied, much to the detriment of women considering breast augmentation surgery. I cannot ethically advise you which is best, I can only point out that despite the glossing over of the potential complications of sub-muscular implants, the evidence shows that there are some risks involved with respect to your future strength and mobility.

So Which Procedure Did *I* Have?

I have 380 cc silicone Sientra implants, over the muscle, installed with a Keller funnel, in a general hospital setting with an anesthesiologist and full surgical team. The total surgical time was about 90 minutes. During surgery, which was my first under general anesthesia, I underwent a severe and unusual drop in blood pressure, which made me very glad after the fact that I had chosen a full hospital setting. The anesthesiologist was able to bring my blood pressure up after trying 2 different methods, so my surgery was able to be completed. I lost almost no blood; the blood pressure drop was due to severe vasodilation.

The surgery changed me from a 33 A to a 33 D/DD (which are generally rounded up in bra terms to a 34 sub-A and 34 D, respectively). My results were perfect and well-proportioned for my frame, and the surgery made a huge positive impact to my self-image, confidence, and quality of life. I experienced severe numbness and loss of feeling, however, some of which has returned after a few months. My right breast has much more feeling than my left, for unknown reasons. I experienced a minor post-operative infection at the incision site of one breast, which was localized to the skin and treated aggressively by my surgeon with antibiotics and anti-fungals.

Why am I telling you all this? Simply to give you a real-world example of what you might face.

Specific Studies on the Long-term Impacts of Submuscular Implants

Now we get to the heart of the matter. Shockingly, studies on this procedure are rare, especially given the fact that almost 290,000 American women undergo BA every year and it is the most common cosmetic procedure performed in the United States. (ASPS) And I was unable to find a single study of this sort performed upon transsexual women, anywhere in the world. I did find a couple of case reports and anecdotes from physicians, but those were not group studies which controlled for error and contained before and after analyses.

It’s no surprise that most of the studies which do exist focus on female athletes, as they are a population which is not only most likely to be concerned about any potential loss of strength or mobility, but they are also the ones most likely to subjectively (or objectively, in the case of top athletes) notice any other physical impacts.

• One study examined 20 female athletes, 7 that had UM or PUM implants, and 13 that had OM implants. Those who had UM and PUM procedures required an average of 7.2 weeks before they could resume their normal weight-room routines. Five of the 7 women who had UM or PUM implants reported they lost strength and were unable to perform their normal chest muscle-dependent exercises. One woman reported no change, and 1 woman reported increased ability. Two of 7 women in this group reported having so much pain post-surgery that they could no longer perform certain exercises. However, 5 of the 7 women said they would have implants placed in the same location again. Women who underwent OM procedures claimed they only required an average of 3.8 weeks before they could resume their normal weight-room activities. Five of 13 women reported an improvement in their chest and arm strength post-surgery and only 1 woman reported a decrease in ability. None reported pectoral pain during their exercise routine. Twelve of 13 said they would have implants placed in the same position again. (Sarbak)
• Another study focused on 20 women who were tested using a Biodex 3 System to assess strength performance, both before surgery and 2 and 6 weeks after UM or PUM breast augmentation. The women saw significant strength reductions 2 weeks after surgery, and by 6 weeks more than 75% of the patients had returned to their normal strength. Nine patients returned for long-term testing, and it was found that they kept their strength, or continued to improve. While some patients did not recover their full strength, the vast majority did, and as a result the researchers found little evidence to claim a permanent strength reduction. (Beals)
• A study of 650 UM breast augmentation procedures claimed that no decrease in arm strength was noted – however, the author also claimed “Any correlation between loss of muscle strength or function and the surgical technique is difficult to assess because many patients are overly cautious after surgery and underuse their chest muscles. The author believes that the procedure does not weaken the pectoralis muscles.” It then referred to the study by Beals et al. (Hendricks)
• A study of a single athletic swimmer found that after breast augmentation her swimming performance decreased by 20 percent. However, some of her decreased performance was arguably the result of her increased drag in the water due to her larger cross-sectional profile. Validation testing on non-augmented swimmers who wore prosthetically augmented swimsuits determined that perhaps half of the reduction in swimming performance suffered by the patient was due to hydrodynamic drag, leaving the other half potentially due to a loss of strength or flexibility. (Levine)
• A study of 10 women who underwent a complete unilateral skin-sparing mastectomy and UM breast augmentation, with 18 control subjects, found that those undergoing surgery had a net reduction in arm torque strength on the operated side of their body of 20.1%. This was a very useful study, as it measured specific strength differences in specific exercises. The least strength loss was 9.7%, which was for a movement where the arm was hanging down at 45 degrees in front of the patient, and pushing towards the back of the patient. The greatest strength loss was 31%, for holding the arm out at the side and raising it above 120 degrees from vertical down (see the next two graphics for more details). The problem with this study is that women undergoing a full mastectomy also undergo much more surgical trauma than women who are having a simple BA procedure, and some of the patients had considerable tissue and lymph nodes removed. (de Haan)
• Forty-seven women undergoing UM breast augmentation were evaluated pre-operatively and post-operatively at both 3 months and 6 months, in the areas of breast sensation, pectoralis muscle function, and body image. Small but non-significant decreases were found in terms of strength in flexion, extension, and adduction. However, some small but non-significant increases were also noted in some exercises, and all of the differences were quite small, leading the researchers to conclude that there was no net difference. However, qualitatively speaking at 6 months post-operation 8% of the patients felt like their strength had increased, while 16% of the patients felt like their strength had decreased. (Banbury)
• An Italian study found that among 172 patients evaluated over 10 years who underwent PUM breast augmentation that 43 patients (25%) suffered reduced muscular strength during some movements such as pushing down, arms adduction, or cutting bread into slices. The authors reference the study by Sarbak as further evidence of strength reduction, and then they report on a technique called tri-plane augmentation mammaplasty, where the muscle is not cut, but split to make a pocket for the implant. They reported that over 24 months they had good success, but there were no before or after strength tests, and no details of any of the patients. (d’Alcontres)

References

d’Alcontres, Francescosco Stagno, et al. “Triplane Augmentation Mammaplasty.” Annali Italiani Di Chirurgia 84.3 (2013): 305-310.

American Society of Plastic Surgeons. 2014 Plastic Surgery Statistics Report. http://www.plasticsurgery.org/Documents/news-resources/statistics/2014-statistics/plastic-surgery-statsitics-full-report.pdf

Banbury, Jillian, et al. “Prospective Analysis Of The Outcome Of Subpectoral Breast Augmentation: Sensory Changes, Muscle Function, And Body Image.” Plastic And Reconstructive Surgery 113.2 (2004): 701-707.

Beals, Stephen P., et al. “Strength Performance Of The Pectoralis Major Muscle After Subpectoral Breast Augmentation Surgery.” Aesthetic Surgery Journal 23.2 (2003): 92-97.

de Haan, Annemiek, et al. “Function Of The Pectoralis Major Muscle After Combined Skin-Sparing Mastectomy And Immediate Reconstruction By Subpectoral Implantation Of A Prosthesis.” Annals Of Plastic Surgery 59.6 (2007): 605-610.

Hendricks, Hans. “Complete Submuscular Breast Augmentation: 650 Cases Managed Using An Alternative Surgical Technique.” Aesthetic Plastic Surgery 31.2 (2007): 147-153.

Levine, Norman S., Robert T. Buchanan, and Katharine M. Barthels. “Decreased Swimming Speed Following Augmentation Mammaplasty.” Plastic and Reconstructive Surgery 71.2 (1983): 257-259.

Reece, Edward M., et al. “Primary Breast Augmentation Today: A Survey Of Current Breast Augmentation Practice Patterns.” Aesthetic Surgery Journal 29.2 (2009): 116-121.

Sarbak, John Michael, and James L. Baker Jr. “Effects of Breast Augmentation on Pectoralis Major Muscle Function in the Athletic Woman.” Aesthetic Surgery Journal (2004).