Archives of Gynecology and Obstetrics (2022) 305:1517–1524

https://doi.org/10.1007/s00404-022-06603-3

GENERAL GYNECOLOGY

Complications and satisfaction in transwomen receiving breast

augmentation: short‑ and long‑term outcomes
A. K. Schoffer1 · A. K. Bittner1 · J. Hess2 · R. Kimmig1 · O. Hoffmann1

Received: 22 February 2022 / Accepted: 27 April 2022 / Published online: 21 May 2022
© The Author(s) 2022

Abstract
Background To achieve long-term improvement in health care of transgender women, it is necessary to analyze all aspects
of gender-confirming surgery, especially the relation of risks and benefits occurring in these procedures. While there are
many studies presenting data on the urologic part of the surgery, there are just few data about complications and satisfaction
with breast augmentation.
Methods This is a retrospective study using parts of the BREAST-Q Augmentation Questionnaire and additional questions
for symptoms of capsular contracture and re-operations and analyzing archived patient records of all transwomen which
were operated at University Hospital Essen from 2007 to 2020.
Results 99 of these 159 patients (62%) completed the questionnaire after a median time of 4 years after surgery. Breast
augmentation led to re-operations due to complications in 5%. The rate of capsular contracture (Baker Grad III–IV) in this
population was 3%. Most patients (75%) rated high scores of satisfaction with outcome (more than 70 points) and denied
to have restrictions due to their implants in their everyday life. All patients reported an improvement in their quality of life
owing to breast augmentation.
Conclusion Breast augmentation by inserting silicon implants is a safe surgical procedure which takes an important part in
reducing gender dysphoria.

Keywords Transwomen · Breast augmentation · Capsular contracture · Satisfaction · Breast implants

Introduction breast augmentation [4]. Although gender-affirming surgery

(GAS) has become more common in recent years, there have
Many male-to-female transgender individuals (transwomen) been few studies addressing complications and satisfaction
seek surgical feminizing procedures throughout their lives of surgical breast augmentation [4–9]. Especially regard-
to improve their gender dysphoria and quality of life. An ing the fact, that transwomen are often older, have a higher
important part of feminization is developing natural shaped, BMI and suffer from pre-existing medical conditions, it is
feminine breasts [1] which psychologically plays a central very important to analyze risks and benefits of any surgical
role in the femininity, attractiveness and sexuality of women procedure [10]. In addition, there are specific risks associ-
[2]. However, cross-sex hormone therapy (CSHT), which ated with implant surgery, such as capsular contracture [11]
is often performed initially, usually results in inadequate or breast implant-associated lymphoma (BIA-ALCL) [12,
breast growth that often does not even correspond to cup 13]. Consideration should also be given to the potentially
size AA and does not change after the first six months of increased risk of developing breast cancer due to CSHT [14]
therapy [3]. Therefore many transwomen search for surgical and the limited validity of imaging due to the insertion of
silicone implants [15].
* A. K. Schoffer In recent years, patient-reported outcome measures
arianekatharina.schoffer@uk-essen.de (PROM) have been increasingly used to measure the benefit
of a surgical intervention. The BREAST-Q is a PROM that
1
Department of Gynecology and Obstetrics, University is available in three different modules for augmentations,
Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany
reconstructions and reductions of the breast [16] and has
2
Department of Urology, University Hospital Essen, Essen, been validated [17]. However, this questionnaire was created
Germany

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1518 Archives of Gynecology and Obstetrics (2022) 305:1517–1524

for genetic women, and a PROM developed specifically for symptoms for capsular contracture. This questionnaire was
the needs of transgender individuals does not exist to date sent to all 159 transwomen who had received surgical breast
[18, 19] As GAS increases worldwide, in 2018, a working augmentation using silicone implants at University Hospital
group from Canada, the United States, and the Netherlands Essen from 2007 to 2020. Of these 159 patients, 99 agreed
began a Phase I study and development of a GENDER-Q to participate in this study (62%). In addition, the archived
questionnaire [20], which is currently in the validation phase patient records of these 99 patients were reviewed and age,
and is expected to be available in 2022 [16]. BMI, pre-existing conditions, and surgical complications
The available literature measures satisfaction with surgi- were recorded.
cal breast augmentation either using the BREAST-Q [9] or Data were collected and analyzed using Microsoft Excel
with help of specifically designed PROMs [4, 18]. Kanhai 365 (Microsoft Corporation, version 2102, Redmont WA,
et al. and Weigert et al. demonstrated a high level of satisfac- USA) and IBM SPSS Statistics (IBM Corporation, 2020.
tion with the outcome of augmentation, but did not record IBM Statistics for Windows, version 27.0. Armonk, NY,
any surgical complications [4, 9]. Balakrishnan et al. con- USA). BREAST-Q was converted to the corresponding
ducted a study in which they asked a total of 42 transwomen Rasch sum score.
about their subjective satisfaction in a retrospective study To compare satisfaction scores by age, the Shapiro–Wilk
from 2007 to 2017 and then compared this with objectively test searching for normal distribution was first performed.
recorded parameters of cosmetic outcome. They showed a Since there was no normal distribution, the Mann–Whitney
significant correlation of the cosmetic outcome with the sur- U test was used. The significance level was set at p < 0.05.
veyed parameters [5], but this must be critically questioned,
as patients with psychiatric pre-existing conditions, nicotine
or drug use and other comorbidities (diabetes, hypertension, Results
vasculitis) were excluded from the study. Nauta et al. com-
pared 82 trans-women to 188 genetic women in America and The median age of the patients at the time of surgery was
were able to show differences in comorbidities and anatomi- 45 years (20–64 years, SD 11.63). Using a graphical repre-
cal conditions [10]. No study has yet succeeded in identify- sentation of the age distribution, two peaks can be identi-
ing risk factors for the occurrence of specific complications, fied, between 25 and 34 years and between 45 and 54 years
such as capsular contracture, in the context of surgical breast (Fig. 1).
augmentation for transwomen. At the time of the study, surgery had been performed a
median of 4 years ago (0–13 years, SD 3.22). The median
Aim of this study BMI of the patients was 24.9 kg/m2 (18.0–42.4 kg/m2, SD
4.74). 68.7% of patients reported not smoking, 30.3% were
The aim of this study was to interview all transwomen smokers, and 1% were unknown. 3% of patients suffered
who underwent breast augmentation at University Hospital from diabetes. 56.6% of the patients suffered from one
Essen between 2007 and 2020 using parts of the BREAST- or more pre-existing condition, the most frequently men-
Q Augmentation Questionnaire, which was supplemented tioned being hypertension (20.2%), asthma (9.1%), hypo-
by questions asking for re-operations and high-grade cap- thyroidism (8.1%), depression (7.1%), previous myocar-
sular contracture. In addition, the archived patient records dial infarction (5.1%), sleep apnea (3%), COPD (3%), and
were searched for comorbidities and surgical complications.
Another purpose was to investigate the occurrence of higher-
grade capsular contracture and try to identify risk factors.

Methods

First, the study design was approved by the ethics board

of University Hospital Essen and prior to participating, all
patients provided their informed consent. Subsequently, a
questionnaire was designed, which consisted of parts of
the postoperative BREAST-Q augmentation questionnaire
(Psychosocial Wellbeing, Sexual Wellbeing, Satisfac-
tion with Breasts, Physical Wellbeing: Chest, Satisfaction
with implants, Satisfaction with outcome) and was supple-
mented by questions about complications, re-operations and Fig. 1  Age distribution of our patients

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Table 1  Average implant sizes

Manufacturer Mean Min; max SD

Mentor/PIP (cc) 365 195; 650 104.4

Allergan (g) 363 210; 695 101.5
Rofil (g) 323 230; 470 128.6

previous thrombosis (3%). All other mentioned pre-exist-

ing conditions occurred in less than 3% of the patients.
91.9% of the patients stated that they regularly took one or
more medications, 7.1% stated that they did not take any
medications—although it is no longer possible to evalu-
ate whether this is due to an inaccurate medical history Fig. 2  BREAST-Q scores
and the patients did not consider their hormone therapy as
medication or really did not take any medication. 86.9% of As shown in Fig. 1, two age peaks can be identified in
the patients reported receiving estrogen for CSHT. the examined collective which therefore can be divided
At University Hospital Essen, textured implants are into two groups of approximately equal size: Patients who
used exclusively: 67.7% of patients received implants from were between 20 and 44 years old (n = 48) and patients
Mentor, 27.3% from Allergan, 3% from Rofil Medical, 1% who were 45–64 years old (n = 50) at the time of surgery.
from Poly Implant Prothése (PIP) and in 1% the manufac- The Mann–Whitney U test was used to determine whether
turer was unknown. the older patients were more satisfied with the outcome of
Table 1 shows the average implant sizes used. 74.8% of surgery. The results show, that the group of patients over
the implants were implanted prepectoral and 25.2% below 45 years old gave significantly higher scores for psychosocial
the muscle. well-being (p = 0.032) and physical well-being (p = 0.010).
A total of 10 re-operations were performed in Uni- Satisfaction with outcome also showed a tendency toward
versity Hospital Essen, the largest proportion (70%) of better satisfaction in the group of older patients with
which involved the replacement of implants from the com- p = 0.054.
panies PIP and Rofil Medical after it became public, that
these companies used inferior industrial silicone for their
implants [21]. 1% required relief of a hematoma, 1% devel- Discussion
oped a late hematoma after several months, and 1% devel-
oped bilateral Baker grade III–IV capsular contracture, The age distribution in this study is similar to that of com-
so that both implants had to be removed without replace- parable studies [22, 23], and the distribution curve with two
ment. 4% of the patients stated that they had undergone peaks is also found in other studies on GAS [23, 24]. While
further surgery in other hospitals. 1% had a seroma to be Jackowich [24] and Zavlin [23 attribute this mainly to eco-
surgically relieved, 1% had a dislocated implant, which nomic factors, the patient records of our population also
was replaced, and 1% had implants replaced for cosmetic showed another possible reason: During the psychological
reasons. This results in a reoperation rate due to surgical evaluation, many patients reported a desire to have children
complications of 5% for the presented collective. and the fear of not being able to realize this desire in a life as
When asked about symptoms of grade III–IV capsular transwoman. This also seems to be a possible explanation,
contracture, two patients responded that they had symp- why a large number of patients decided to live out their true
toms, and one patient stated that her implants had already gender identity openly later in life.
been removed due to capsular contracture. This results in The overall rate of re-operations is 14%. The largest pro-
a rate of 3% capsular contracture Baker grade III–IV. portion of this, however, is based on the replacement of PIP/
In addition, the patients answered selected questions Rofil implants, which accounts for a total of 8% of re-opera-
of the postoperative BREAST-Q questionnaire. Figure 2 tions and can certainly not be seen as a general complication
shows graphically the points remitted by the patients, of implant surgery, since it is a matter of poor product qual-
Table 2 lists all calculated values. ity of only a few manufacturers. 1% voluntarily underwent
There is no conversion for the questions on satisfaction another operation for cosmetic reasons to have their breasts
with the implants; patients can give 2–8 points here. 86.7% enlarged even further. All patients receive estrogen therapy
of the patients awarded a full 8 points. for at least one year to achieve pre-expansion of the skin and

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Table 2  Calculated values from n Mean Median SD Min max 1. Quartil 3. Quartil
BREAST-Q
Psychosocial wellbeing 98 81.2 86 17,587 39 100 68 100
Sexual well being 87 70.33 67 22,333 0 100 58 91
Satisfaction with breasts 99 73.72 74 15,402 36 100 64 85
Physical wellbeing: chest 99 92.49 100 10,756 34 100 91 100
Satisfaction with implants 98 7.66 8 1025 2 100 8 8
Satisfaction with outcome 99 83.51 89 18,442 26 8 69 100

maximum self-growth of the breast prior to surgery [25], also used to a large extent in our cohort, and furthermore the
yet the implants can only be large enough to still be cov- comparison period of 10 and 13 years is similar, these data
ered by skin, adipose tissue, and muscle if necessary. Thus, were considered to be the most meaningful and were used
initially, it is not always possible to meet patients' desires as basis. It should be noted, that Coroneos et al. [26] do not
for a very large breast. Fakin et al. [8] also reported 9.4% break down the described complication rates according to
patients (13 of 138) who underwent a second surgery due smooth or textured surface, whereas only textured implants
to the desire for a larger breast. 1% of our patients experi- are used at our clinic.
enced postoperative bleeding, 1% experienced late hema- A significantly higher rate of complications is described
toma, 1% experienced unilateral dislocation, 1% experienced by DeBlok et al. [7] in their study conducted on a Dutch
seroma after hospital discharge, and 1% developed capsular collective. There, 33% (102 of 308 patients) reported suf-
contracture, which also required reoperation. This results fering from health complaints associated with their implants
in a reoperation rate of 5% due to complications, which is [7]. Unfortunately, this statement is difficult to verify as the
slightly lower than the 8% non-elective surgery rate reported authors of the study do not provide a more detailed break-
by Fakin et al. [8]. Comparing these data to those collected down of what exactly constitutes health complaints and,
by Cuccolo et al. [6], who conducted the largest retrospec- although the study was conducted on a large collective (3074
tive data analysis comparing breast surgery in transwomen transwomen) and over a long period of time (1972–2018),
and genetic women, reveals a higher rate of complications. the response rate is only 25.14% with 773 completed ques-
Cuccolo et al. [6] report a rate of 1.4% re-operations in trans- tionnaires. Furthermore, it is likely that even worse implants
women (four cases in a total of 280 patients), accounted for were used in the 1970s and 1980s than is the case today, pos-
by hematoma (1.1%) and abscess (0.4%). However, when sibly leading to a falsely high complication rate. To derive a
looking at these data, it is important to note, that this is a correlation between the complications that occurred (post-
large database analysis in the U.S., and while it draws on a operative bleeding, late hematoma, seroma as well as unilat-
large number of cases, it only captures complications within eral dislocation) and risk factors, such as smoking, diabetes,
the first 30 days after surgery and does not capture any long- pre-existing diseases or long-term medication, too few cases
term complications. occurred within the scope of our study, to be able to derive
In comparison, the data collected by Miller et al. [18] a conclusion here.
show a higher complication rate of 17.6% (6 of 34 cases) 3% of patients reported receiving a diagnosis of capsu-
in which reoperation was necessary in 5.9% (2 of 34 cases). lar contracture, of which 1% had already had their implants
However, the significance of this should also be questioned, removed. Taking this 3% as the rate of symptomatic capsular
as only 34 cases were retrospectively examined in this study. contracture on average 5 years after surgery and compar-
The largest data analysis for genetic women is provided ing it, using the binomial test, with the 7.2% symptomatic
by Coroneos et al. [26], who were required to provide ret- capsular contracture at 7 years described by Coroneos et al.
rospective data collection for FDA approval of Mentor [26] yields a value of p = 0.071, showing a tendency toward
and Allergan breast implants and studied a total of 99,993 a lower rate of capsular contracture in transwomen. Similar
patients from 2007–2017, 56% of whom had received sili- findings are also provided by Fakin et al. [8], who reported
cone implants as part of a purely cosmetic procedure [26]. a capsular contracture rate of 2.9%. To further support this
Here, an overall reoperation rate of 11.7% at 7 years was theory, more studies on this topic should be conducted in
reported, which is higher than the 5% in transwomen col- future.
lected in this study. Coroneos et al. [26] also report a Baker Estrogen exposure seems to be the first possible reason
III-IV capsular contracture rate of 7.2% at 7 years for cos- for a lower rate of capsular contracture. This assumption
metic augmentations in genetic women. Since these data is supported by data presented by Dancey et al. [27], who
refer exclusively to implants from the Mentor and Allergan showed that in a cohort of 1400 genetic women who under-
companies and implants from these two companies were went cosmetic augmentation, those who became pregnant

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had an increased risk of developing capsular contracture The median satisfaction with the breast was 74 points,
(43.6% vs 23.9% capsular contracture, p = 0.008) [27]. Since which means that the patients in this study were significantly
there is also greater exposure to estrogen during pregnancy, more satisfied than those surveyed by Weigert et al. [9].
it is reasonable to suspect a central role in the etio-pathology When looking at the questions individually, many patients,
of capsular contracture. This is also consistent with data when asked how satisfied they were with the way their bras
collected by Persichetti et al. [28], according to which down- fit, expressed a certain dissatisfaction and stated, that it was
regulation of ER α leads to decreased contractility of myofi- very difficult to find bras at all, due to the larger breast cir-
broblasts. They also showed a negative correlation between cumference. While this is not a medical problem, it is cer-
ER β and the thickness of the capsule studied, suggesting tainly an industrial market gap.
that ER β has a more antiproliferative role [28]. Moreover, Furthermore, 30% of the patients were dissatisfied with
this study also showed a time-dependent correlation, which the fact that the breasts were not as close together without a
was also supported by Joseph et al. [29] in a study performed bra. This is a peculiarity of the anatomically male developed
in rats. Accordingly, the concentration of pro-proliferative upper body, which has a narrower, more oval and laterally
factors is significantly higher 30 days after implantation, seated nipple–areola complex (NAC) and more developed
than 90 or 180 days after implantation [29]. A perioperative pectoralis muscles than the female. In addition, the ster-
pause of CSHT in transwomen may decrease the develop- num is much wider and the distance between the nipple and
ment of capsular contracture. Maybe the administration (oral inframammary fold is much shorter [1]. Unfortunately, the
vs transdermal) or the active ingredient composition of the insertion of silicone implants cannot remedy this situation.
preparation also affects the development of capsular con- The high scores in relation to physical well-being indi-
tracture in transwomen. cate, that the patients have few impairments overall, such as
Prospective randomized studies should be performed on limitations in sports, lifting heavy objects or sleeping, due to
these influences in future, recording the exact estrogen prep- the implants or complications of surgery. This results clearly
aration, the duration of intake and the perioperative pause, differ from data collected by Weigert et al. [9], in which their
to investigate these influences in more detail and thus pos- patients gave a median score of only 76 points.
sibly provide further insights into the development and the In terms of satisfaction with the implants, patients gave
prevention of capsular contracture. a median of full 8 points, which underlines the satisfaction
In addition, studies should be performed to break down with implant surgery itself.
the rate of capsular contracture in transwomen after insertion Satisfaction with outcome was very high, with a median
of smooth or textured implants. Due to the rare occurrence score of 89 points, and 25% of patients awarded the maxi-
of BIA-ALCL after insertion of textured implants [30], some mum of 100 points. Particularly noteworthy is the question
authors generally do recommend not to use this implants any about the improvement in quality of life, to which 89% of the
more [31]. To date, only four cases of BIA-ACLC have been patients agreed completely. A further 11% stated that they
reported in transwomen worldwide [12], so the incidence agreed to some extent, and no patient stated that she did not
here is certainly more in the per thousand range, whereas the agree. Even though this question alone certainly does not
risk of high-grade capsular contracture with possible defini- do justice to a multi-layered construct as quality of life, but
tive implant removal and breast firming surgery is at least together with the other values collected, it very clearly shows
in the single-digit percentage range and is thus significantly the high value that breast augmentation has for transwomen.
greater. However, since a surgical breast augmentation for Furthermore, it was shown here that older transwomen
transwomen is not a purely cosmetic procedure, all risks seem to be even more satisfied with the results. The reasons
should be carefully weighed. for this may be, that older patients have not spent a larger
This becomes even clearer with a look at the level of proportion of their lifetime in the desired sex and therefore
satisfaction. The median psychosocial well-being of the have an overly positive view of the effect of breast augmen-
patients studied here was 86 of 100 points. This observation tation. It is also possible, that with increasing physiologi-
is consistent with the results of Weigert et al. [9], who con- cal aging of the body, the demand for perfection becomes
ducted the only study using the BREAST-Q in transwoman lower and older patients are therefore less critical with the
and who found the patients' psychosocial well-being to be cosmetic result.
median 85 points 4 months after surgery. 95% of the patients stated, that they did not regret the
Another important aspect of breast surgery is sexual well- operation, only 3% would not undergo the operation again.
being, although many patients stated that this was also very This is possibly due to complications suffered and associated
significantly dependent on the genital surgical outcome, discomfort, as Cash et al. [32] were able to survey in a study
which leads to a certain outcome bias. Although a median of non-transgender women after surgical breast reconstruc-
score of 67 was given, 25% of patients declared a satisfaction tion and as also mentioned by the transwomen interviewed
score of 91 or more. by DeBlok et al. [32, 33].

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1522 Archives of Gynecology and Obstetrics (2022) 305:1517–1524

Limitations In combination with the low complication rates of the oper-

ation, a good risk–benefit ratio can be assumed. Further-
The response rate of 62% is slightly above the existing lit- more, with regard to the low rate of capsular contracture,
erature. Weigert et al. [9] had recruited only 35 patients for new approaches to further understand the etiology of this
their study from the outset, of whom only 60% answered the complication and to further reduce its incidence were shown.
questionnaire sent to them after just one year. Kanhai et al.
[4] were able to include 58.2% in their study and Miller et al.
[18] were only able to achieve a response rate of 35.3% for Author Contributions AKS: Protocol/project development, Data col-
lection and management, Data analysis, Manuscript writing/editing.
their questionnaire. AKB: Protocol/Project development. JH: Manuscript writing/editing.
Two patients stated that they did not wish to participate RK: Manuscript writing/editing. OH: Protocol/ project development,
in our study, and in a total of 57 patients the address or data collection, Manuscript writing/editing.
telephone number was no longer correct, which is not sur-
prising given a period of 13 years. It seems reasonable to Funding Open Access funding enabled and organized by Projekt
DEAL.
assume that some patients moved after successful GAS, to
live a completely new life in a different place in the desired
Declarations
gender role without being reminded of their old life. It also
seems conceivable that some patients did not complete the Conflict of interest The authors have no relevant financial or non-fi-
questionnaire in order be not reminded of their old life and nancial interests to disclose.
the transition steps [4] or possibly because they regretted
the surgery [34]. Ethics approval This study was performed in line with the principles
of the Declaration of Helsinki. Approval was granted by the Ethics
One patient of our collective committed suicide, which is Committee of University Duisburg-Essen.
also a possible reason for the lack of responses from other
patients, because, as shown in a cohort study from Sweden,
Open Access This article is licensed under a Creative Commons Attri-
the suicide rate among transgender persons is still signifi- bution 4.0 International License, which permits use, sharing, adapta-
cantly increased after GAS compared to data from the non- tion, distribution and reproduction in any medium or format, as long
selected general population [34]. This study was also able to as you give appropriate credit to the original author(s) and the source,
show, that the overall mortality of trans-people is increased, provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
so that deaths in the context of diseases are also a possible included in the article's Creative Commons licence, unless indicated
explanation for non-response. otherwise in a credit line to the material. If material is not included in
Nevertheless, it should be noted that of a total of 60 per- the article's Creative Commons licence and your intended use is not
sons, there is no statement about satisfaction with the breast permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
or long-term complications. copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/.
Another limitation is the use of the BREAST-Q question-
naire, which is a validated instrument, but validity and relia-
bility were only evaluated in genetic women. Although other
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