Gender Affirmation Surgery Male to Female

Goals of Surgery Procedure Information Implants Risks & Complications Procedure Pricing

MTF ‘top’ surgery is a gender-affirming surgical procedure for transgender women and transfeminine individuals who wish to enhance the size and shape of their breasts to achieve a more traditionally feminine chest appearance.

Unlike FTM top surgery, which removes breast tissue, MTF top surgery typically involves breast augmentation using implants or, in some cases, fat grafting.

Dr Aggarwal is one of the only Sydney Plastic Surgeons who has completed further fellowship training in dedicated Breast Cosmetic and Reconstructive Surgery and is an expert at Breast Aesthetic surgery.

Goals of Male to Female ‘Top’ Surgery

Create an aesthetic feminine contour
Increase breast volume
Position and size the nipples in a more feminine configuration.
Improve gender congruence and alleviate gender dysphoria.
Eliminate the need for chest padding

Criteria to have MTF ‘Top’ Surgery

Transgender women must meet the following criteria in order to have top surgery

A letter of support from a qualified mental health professional
If significant medical or mental health concerns are present, they must be reasonably well controlled
Capacity to make a fully informed decision and to consent for treatment
Age over 18 years

Feminising hormones are not a pre-requisite for surgery, but if you are starting these hormones it is best to wait at least 12 months from commencement to allow any breast growth to stabilise, and therefore achieve the best results from surgery

The best candidates for MTF ‘top’ surgery are persons who:

Are physically and mentally healthy
Have realistic expectations
Are willing to accept the scars associated with surgery
Are of stable weight

MTF ‘top’ surgery may not be suitable for persons who:

Have not lived in their preferred gender identity for less than 12 months
Have fluctuations in physical or mental health
Are very overweight or obese (BMI >35) – ideally your BMI should be less than 30 for best results
Have multiple medical problems
Are on blood thinning medication
Are actively smoking

Dr Aggarwal

Dr Aggarwal is a well regarded, respected, highly skilled and experienced Specialist Plastic Surgeon. Graduating at the top of his class throughout his training, Dr Aggarwal has completed fellowship training at some of the world’s most prestigious reconstructive and cosmetic plastic surgery institutions in Canada and the USA. He continues to publish research is prestigious plastic surgery journals, and is actively involved in the training of future plastic surgeons.

What sets Dr Aggarwal apart from others is his personal, affable and warm nature. Not only does he pay attention to detail, to producing natural, beautiful results but he ensures that the patient’s journey is just as special as their outcome. Dr Aggarwal looks after patients at one of Sydney’s most prestigious public hospital campuses (POWH/SCH/RHW), and operates privately on Sydney’s North Shore. Dr Aggarwal has treated thousands of patients throughout Sydney and beyond who have achieved outstanding results under his care.

Procedure Snapshot

Anaesthetic: GA by accredited anaesthetist
Time: 1-2 hours
Duration of stay: Day Surgery
Hospital: Offered at Hunters Hill Private, Castlecrag Private or SAN Day Surgery
Medicare/Health Fund Rebate: No

Recovery: Most people can do most things at the end of the first week. Upper body exercise is disallowed for 6 weeks and strenuous exercise for 3 months. Avoid swimming in a pool or beach for 2 weeks.
Results: One of the most satisfying procedures for patients but it is important to note that results vary from patient to patient largely due to variation in anatomy and breast size and asymmetry prior to surgery.

MTF ‘Top’ Surgery / Breast enlargement Procedure

The procedure is always performed under general anaesthesia given by an accredited anaesthetist in a fully accredited and licensed facility (usually one of the North Shore’s premier private hospitals). The procedure takes one to two hours and most patients will be discharged the same day (some elect to stay overnight however).

Incision location

– A small inconspicuous incision is made to access the area under the breast where a pocket is created for the breast implant

Inframammary

– This incision is placed in the fold under the breast and is the most common incision used by Dr Aggarwal for breast augmentation

– This incision allows the best access to create the pocket for the breast implant and best control of long term shape of the breast

– It also allows the cleanest access for implant placement preventing long term contamination of the implant which can contribute to risk of capsular contracture

Peri-areolar

– This incision is placed around the nipple and areola

– It is less often used by Dr Aggarwal as the risk of contamination of the breast implant is higher

Trans-axillary or trans-umbilical

These incisions are placed in the armpit and around the belly button respectively.

These incisions are almost never used by Dr Aggarwal as they are less suitable for silicone implants, and offer less control of pocket creation for the breast implant and therefore less control of the breast shape.

Pocket placement

Breast implants may be placed in a pre-pectoral (in front of the muscle) or submuscular (under the muscle) pocket.

Pre-pectoral

This is where the implant is placed above the muscle but under the breast gland

This pocket is less commonly used as it offers less coverage of the implant by soft tissues and therefore the implant may be more visible

However in certain patients it has several advantages such as:

– Better cleavage in patients with good soft tissue cover

– Less risk of lateral displacement of the implant

– Reduced animation (i.e. movement of the implant with muscle contraction)

– Faster recovery

– Suitable for patients with reasonable soft tissue thickness over their chest

Submuscular

This is where the implant is placed under the muscle and the breast gland

Submuscular or subpectoral pocket placement allows the following advantages:

– Additional coverage of the implant imparting a more natural look to the result especially the upper pole

– Offers reduced rates of capsular contracture long term

– Less risk of the implant migrating downward (or inferiorly) as the pectoralis major and pectoralis minor muscles sandwich the implant, maintaining its position as they contract during routine muscle activity.

After your Female to Male Top Surgery

Dr Aggarwal will place waterproof dressings over the incisions. You will also be placed in a surgical bra that you must wear for the first 6 weeks. This helps to reduce swelling, pain and discomfort as well as controlling the position of the implants in the early post-operative period as the area heals.

You will be able to get the area wet after 48 hours and go back into the surgical bra after your shower. You will not be allowed to swim in a pool or beach for at least 2 weeks after surgery.

You will be given a script for antibiotics by Dr Aggarwal which you must continue until the box runs out

You will also be given pain relief medications although most patients only report minor amounts of post-operative pain that is responsive to simple oral analgesia.

You will not be allowed to go back home on your own – you must have someone accompany you home, and it is best to have someone look after you for the first few days as you recover. You should not drive for at least 24 hours after having an anaesthetic nor operate heavy machinery although after breast implant surgery we generally advise to avoid driving for the first week.

While most sedentary activities can be resumed in the first week, you must not do any exercise for the first few days after surgery that could raise your blood pressure. You will also not be allowed to do any heavy lifting or upper body exercises for the first 6 weeks.

Dr Aggarwal will see you a week after your procedure to inspect how the wound is healing. You will be given instructions how to look after the wound as it continues to heal. You will be able to ask questions about what you can and cannot do.

Generally we will see you at 1 week, 2 weeks, 8 weeks, 3 month, 6 months and 1 year post surgery.

Implants

Dr Aggarwal only use the highest quality implants from the leading manufacturers (Mentor or Motiva) who back their implants with lifetime guarantees. At Mode Plastic Surgery we will never employ cut price or cheap implants that have not had the most rigorous testing or safety profile

Silicone “Gummy Bear” Implants

Modern breast augmentation uses current generation of silicone implants which have advanced significantly since being introduced decades ago. Unlike older generation implants, modern silicone implants are form stable/highly cohesive meaning that:

They offer greater stability of breast shape
If they rupture, the silicone retains its shape much like a ‘gummy bear’. It is therefore rare for even the breast to change its shape in the event of a rupture usually being detected on breast imaging.
Modern silicone implants have a tough outer shell which has very low rupture rates.
There is much lower incidence of gel bleed/ silicone seepage

It was older generation silicone implants that had less cohesive silicone so if the implant ruptured the silicone could leak into the breast tissue, form silicone cysts, and migrate to the axilla (arm pit). This does not usually happen with modern generation implants.

Implant Shape

Round Implants

These are used in women who:

Already have an excellent shape to their breast with reasonable tissue thickness
Do not require the shape of a tear-drop implant to produce an excellent shape
There is a concern that the implant could rotate
These implants are available in less firmer gels and can therefore feel softer to touch. However due to the softer gel, they can be more prone to rippling which can be visible and palpable in patients with thin overlying tissues.
Round implants come in different projections.
Have concern surrounding ALCL
Dr Aggarwal uses round implants from Motiva and Mentor.

Anatomical Implants

Anatomical or ‘tear drop’ implants are fuller at the bottom than the top resembling the shape of a native breast. These are useful in women who:

Have less thickness to their tissues and therefore less likely to hide the underlying implant shape
Desire a more natural looking result
Have a shape to their chest requiring difference in width and height of the implant (as anatomical implants come in different widths and heights)
Have tuberous breasts, or significant breast asymmetry
Have a degree of droop (ptosis) to their breast and want to avoid a breast lift

Anatomical implants are always textured though the degree of texturing varies between different implant manufacturers. At Mode, we utilise anatomical implants from Mentor (CPG).

Smooth or textured?

Smooth implants

In Dr Aggarwal’s practice smooth implants are less commonly used as they have less stability of position and are more prone to implant malposition especially down and out when placed in a subpectoral/submuscular position.

However their benefits can include:

Lowest Risk of ALCL
May be possible to insert these via a smaller incision

Textured

Textured devices are more commonly used because as the tissue heals around the implant it produces a Velcro effect with the implant surface adding to maintenance of implant position.

Benefits of textured implants include:

Better maintenance of implant position
Lower capsular contracture rate especially in the subglandular position
Option to use anatomical implants with firmer gel consistency offering better maintenance of long term shape, and less rippling

The degree of texturing of implants varies and can be described as:

Macrotexturing: this is a very coarse texture imparted to the device during manufacturing. It was thought that texturing was a big reason why textured implants had reduced capsular contracture rates (see capsular contracture in complications) in breast augmentation. However this has lost favour recently whereby macrotextured implants from multiple manufacturers (eg. Allergan) have been associated with higher rates of ALCL.
Microtexturing: this is degree of texturing that is much finer than macrotexturing. We regularly use implants from Mentor which offer microtexturing. Mentor implants are available in smooth and round, and we employ them for both reconstructive and cosmetic breast surgery. Microtextured implants have a much lower rate of ALCL (see ALCL tab).
Nanotexturing: with increased innovation and research around ALCL, a new category of texturing has been recently developed. This texturing is so fine that the implant almost resembles a smooth implant whilst still offering the benefits of texturing. It is thought that given the reduced association of microtexturing with ALCL that these implants will have an even lower risk of such issues. Dr Aggarwal uses implants from Motiva which feature nanotexturing.

Saline Implants

Saline implants were popular overseas especially in North America as that continent went through a period of not using silicone implants.
In Australia these are rarely used as they carry a higher risk of rupture and rippling. If they rupture they lead to complete loss of breast shape.
The touted benefits of saline implants are thin capsule formation around the implant and if it was to rupture the content being saline which is simply absorbed by the body.
However with modern generation silicone implants being of extremely high quality the benefits of these silicone implants clearly outweigh those of saline implants.

Mentor Implants

Mentor is probably the biggest implant manufacturer in the world with the longest safety track record of any manufacturer.
At Mode Plastic surgery we routinely use Mentor implants for both our reconstructive and cosmetic surgery patients.
Available in both round and anatomical device shapes, smooth and textured, we are able to select the best device for a particular patient.
Furthermore their microtexturing offers lower risk of ALCL than other manufacturers that employ macrotexturing to their devices (see our information on ALCL).
Mentor implants come with a lifetime warranty.

Motiva Implants

The newest manufacturer on the block is Motiva however their implants are backed by years of research and extensive experience overseas.
Motiva implants also offer other benefits not seen before in other implant manufacturers’ devices, which is why we at Mode have employed their use:
- Microchip technology – which can be scanned externally by a Q-reader. This allows instant detection of serial number, size and type of implant to be detected allowing for safer record keeping. If a patient was to ever see a surgeon decades down the track this information can be essential, and particularly if there was ever an issue with the implant device.
- Nanotextured technology – delivers the benefits of textured devices with safety profile of smooth implants.
- Ergonomix implant technology – a special category of ‘round’ implants that have a softer gel imparting a natural feel to the breast, and also behaving like ‘anatomical’ implants with the effect of gravity.

MonoBloc construction – the outer shell and inner content are not two separate things but the implant is constructed as one unit.
Offer of 5 year extended warranty period (for surgical fees) and lifetime implant protection – Like Mentor Motiva offer a lifetime guarantee for their implants. This means should the implant ever become faulty the company will replace them free of charge. However patients can still be faced with surgical, anaesthetic and hospital fees for an operation in the event of device failure – Motiva offers the option to purchase extended warranty for 5 years during which period they will also contribute towards the cost of other fees associated with the operation, offering a complete peace of mind.

Motiva implants are slightly more expensive than the Mentor round implants however Motiva Ergonomix implants being comparatively priced to Mentor anatomical devices. Motiva implants are currently only available to our cosmetic surgery patients.

Lifespan of implants

Modern generation silicone implants are of very high quality but as with all foreign bodies they have a lifespan and must eventually be replaced.
Currently we state that the implants will last 10-15 years. However this does not mean that you will definitely need to sign up for surgery at the 10 year mark.
Dr Aggarwal will examine you every year following breast implant surgery. This is to ensure there are no changes in the breast shape as well as integrity of the implant.
If there is any suspicion of implant integrity or the implants are over a decade it may be worthwhile obtaining imaging at that stage. If imaging detects a problem with the implants or there are other reasons for surgery (e.g. scar revision, breast lift, etc) you will be offered surgery for exchange of implants.

Risks & Complications

Every surgery carries risks, and therefore one must consider if risks outweigh the benefits for your own personal situation. If they do then the surgery may be well worth it. Dr Aggarwal will discuss the pros and cons of surgery with you during your consultation.

General Complications

Risks of anaesthetic – there are general risks of going under an anaesthetic such as a mild stress on the heart and lungs, risk of reaction to anaesthetic drugs and risk of blotting in the legs. These risks are generally low in patients who are otherwise fit and healthy.
Bleeding (1-2%) – any bleeding is controlled during surgery however unexpected bleeding can occur in the immediate postoperative period. If this occurs it will necessitate a return to theatre to control the bleeding.
Infection (<1%) – this is extremely rare given the precautions taken to prevent contamination of implants (read the 14 point plan). However you are given antibiotics during induction (when you are going to sleep), as well as a course of oral antibiotics after your surgery to keep this risk to a minimum.

Implant Complications

Implant palpability – it is possible to usually feel the implant at the lower, outer part of the breast in thin persons as this is where the coverage is the least. However in very thin individuals or those with small breasts or little soft tissue cover it may be possible to feel or see the implant elsewhere.
Rippling – softer gel implants are more prone to rippling than higher cohesive gels. Patients with thinner tissues are more likely to experience this where it can be possible to both see and feel the rippling of the implant. Rippling can occasionally be masked by fat grafting or by change to a firmer gel implant.
Rupture – rupture rates of modern day silicone gel implants are very rare. If they do occur they are picked up incidentally on imaging as the form stable implants maintain their shape despite the rupture. However given implants are foreign bodies they will lose integrity over time and will eventually need to be replaced.
Rotation – this is only an issue for anatomical (or tear drop) implants. To prevent this an exact size of pocket is created to match the size of an implant. If there is a concern regarding rotation, round devices obviate this risk.
Capsular Contracture – The body reacts to a foreign body such as a silicone implant by forming a layer called the capsule around it. In 5-8 % of patients this capsule can become hard over time changing how the implant feels, and sometimes how it looks. It can also become painful in extreme cases.
- Most of these cases occur in the first year after insertion of breast implants
- Most manufacturers cover this complication as part of their lifetime guarantee.
- Studies indicate that capsular contracture is lower with textured implants (especially when placed in subglandular plane or just below the breast and above the muscle), and lower with submuscular placement of implants
- More recent literature indicates that this may be related to contamination of the implants during insertion with a chronic response of the body to a ‘biofilm’ of bacteria on the implant surface causing the capsule to become hard.
- The treatment for capsular contracture involves removal of the implant, removal of the capsule and insertion of a new implant with care taken to prevent capsular contracture. However in some patients who have had recurrent capsules the only solution is to permanently remove the implants.

Soft Tissue Complications

Atrophy of tissues – a foreign object like silicone pushing against the normal breast causes it to thin. The bigger and heavier the implant the greater the degree to which this will occur. As the tissues thin implant visibility, palpability and rippling become more pronounced and the risk of implant malposition become higher. We therefore caution against selection of large implants and Dr Aggarwal will usually guide you as to what size will suit your frame whilst trying to minimise this risk.
Change in nipple sensation – this can occur in up to 15% of patients but is usually short lived and returns to normal after a few weeks to months.
Animation deformity – this is movement of the implant with muscle activation. This occurs in all patients having submuscular placement and for this reason for the first 6 weeks the pectoralis muscles should not be heavily used to avoid movement of the implant. Long term extreme use of the pectoralis muscles (such as heavy bench pressing) should probably be avoided altogether to avoid long term implant malposition. Some degree of implant movement with pectoralis muscles will occur in all patients and should be expected rather than seen as a complication.
Unusual breast shape – it is common for the initial shape of the breast to be unusual as the tight pectoralis muscles with a subpectoral implant take time to relax and for the implant to settle due to gravity. This can take approximately 6 weeks to 3 months. However occasional problems can occur including:
- Malposition
  - Implant moves either centrally, laterally (down the side), up or down, needing revision surgery for correction
- Asymmetry
  - Most women’s breasts are asymmetrical and breast augmentation can highlight small asymmetries that were not noticed previously
  - Significant asymmetries are aimed to be corrected by surgery
  - However there can be asymmetry of scars, shape, nipple position and it is important to discuss these before surgery with Dr Aggarwal.

Frequently Asked Questions

Do I need a referral for MTF ‘top’ surgery/breast enlargement?

It is now compulsory to obtain a GP referral for all plastic surgery procedures.

Where can I see Dr Aggarwal?

You can see us at our main practice at Gordon, or at our other locations at Hornsby, Potts Point, Hunters Hill or Camperdown.

Where will I have my operation?

Usually Hunters Hill Private or SAN Day Surgery

What can I do to prepare for surgery?

Stop smoking at least 2 weeks before surgery
Cease fish oil, and other supplements such as Ginkgo, Ginseng.
Please discuss with Dr Aggarwal if you are on blood thinning medications as to when you should stop and recommence those.

After surgery, will I need to wear a special surgical bra?

Yes for a total of 6 weeks.
You should not wear any bras with an underwire during this period

Will I be able to exercise after surgery?

You should not do any exercise that raises your blood pressure for at least 72 hours after surgery to avoid the risk of an unexpected bleed
Heavy upper body exercise that activates the pectoralis major muscle should be avoided for 6 weeks
Extreme heavy duty upper body exercise such as very heavy bench pressing should perhaps be avoided permanently as this risks displacement of the implant from its ideal pocket location.
You should note that there will be some movement of the implants with exercise as they are commonly placed under the muscle

Will I need special medications after surgery?

Dr Aggarwal will provide you with the necessary scripts for antibiotics and pain relief.
For the future you should remember that if you are ever having dental work or other invasive procedures to cover yourself with some oral antibiotics as there is a small risk of bacteria entering the bloodstream with such procedures that can reach the implant cavity.

Will I need further surgery?

Yes. Once you have implants, you will require surgery at some stage to exchange them. As they are foreign objects they have a lifespan of roughly 10-15 years.

How will I know if my implants have ruptured?

Dr Aggarwal will offer to see you yearly and once implants are 10 years old it may be wise to image them to inspect whether there are any issues with their integrity.

Can I travel in an airplane after surgery?

It is safe to undertake air travel after having implants
However we always encourage patients not to be away overseas shortly after having a procedure, so that we can closely follow your recovery and address any concerns that may arise.

When will I be able to swim after breast augmentation?

You may swim in a pool or beach after 2 weeks as this is the time it takes for the incision to heal.

When will I be able to drive after breast augmentation?

It is best to not drive for several days and up to 1 week after surgery.

Do you offer twilight anaesthetic or sedation for breast augmentation?

No
All our breast augmentation surgeries are performed under general anaesthesia given by an accredited anaesthetist
The surgery is performed in an accredited private hospital
It is usually a day surgery procedure but you will need someone to pick you up and accompany you home after the procedure

Will breast implants change the sensation of my breasts?

This is uncommon but it is possible that there is a reduction in nipple sensation for a period after breast enlargement. In the minority where this happens, in most of those cases the sensation returns to normal weeks to months after the procedure. It can take as long as 12 months.
Permanent loss of sensation of the nipple is very rare.
If this is of significant concern to you, you should not have surgery on your breast.

Can implant cause cancer?

There is no association between breast implants and breast cancer
Textured implants more recently have been associated with a rare lymphoma called ALCL. The risk is extremely low (1/7000) and we still consider implants to be very safe way of augmenting the breast. Smooth implants, have no risk of ALCL at present.

Are there any alternatives to breast implants for augmentation?

Yes but none are as reliable, or cost effective
Fat transfer for a natural augmentation does exist but is limited by
- Areas of fat available for harvest: the skinnier you are the less likely it is that you will have fat deposits elsewhere to harvest
- Fat grafting is unpredictable and approximately 50% of the fat does not survive the transfer
- This means that it has to be ‘overdone’ to an extent – but all the fa must be in contact with tissues that provide it with good blood supply, otherwise it dies and can form hard cysts (fat necrosis).
- The procedure is time consuming and often needs to be repeated.
- The hours it takes to perform a single procedure and often a second means it is extremely expensive.
Dr Aggarwal does not offer fat transfer for breast augmentation.

Procedure Pricing

We offer different packages for breast enlargement, which includes
- Mentor or Motiva implants
- Surgical fees
- Hospital fees (our usual hospitals are Hunters Hill Private or SAN Day Surgery)
- Anaesthetist fees
- Initial period of follow up
Please note that the pricing usually does not include initial consultation fees.
- Preoperative consultation fees
- Anatomical implants (approximately $1000+GST extra)
- Breast lift (mastopexy) – an augmentation mastopexy procedure is quoted separately as it substantially increases the complexity of the procedure.
- Follow up fees after the defined period of our basic package
- Surgical fees for future implant revisions

A quote for this procedure will be provided to you after a consultation with Dr. Aggarwal. You can also call or email our office for our current indicative pricing.

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