Original Article

Breast
Differences in Chest Measurements between the Cis-
female and Trans-female Chest Exposed to Estrogen
and Its Implications for Breast Augmentation
Allison C. Nauta, MD*
Kyle M. Baltrusch, MD* Background: Gender confirming primary breast augmentation is becoming more
Aaron L. Heston, BS* common. The purpose of this study was to compare the demographic and anatomi-
Sasha K. Narayan, BS* cal differences in cis-female and trans-female populations.
Sven Gunther, MD, MAS† Methods: This was a retrospective analysis of trans-female patients and cis-female
Nick O. Esmonde, MD, MPH* patients undergoing primary breast augmentation at a single institution. Analysis
Kylie S. Blume, MA‡ included patient demographics and preoperative chest measurements including
Reid V. Mueller, MD* sternal notch to nipple distance (SSN), breast width (BW), nipple to inframam-
Juliana E. Hansen, MD* mary fold distance (N-IMF), and nipple to midline distance (N-M). Continuous
Jens Urs Berli, MD* variables were compared using independent t tests, and discrete variables were
compared using Pearson’s χ2 tests.
Results: Eighty-two trans-female and 188 cis-female patients undergoing primary
breast augmentation were included. Trans-female patients were older (40.37 versus
34.07), more likely to have psychological comorbidities (50% versus 12.23%), and
had a higher body mass index, 27.46 kg/m2 versus 22.88 kg/m2 (P = 1.91E-07), than
cis-female patients. Cis-female patients most commonly had an ectomorph body
habitus (52% versus 26%), whereas trans-female patients most commonly had an
endomorph body habitus (40% versus 7%). Pseudoptosis or ptosis was more com-
monly seen in cis-female patients (P = 0.0056). There were significant differences
in preoperative breast measurements including sternal notch to nipple distance,
BW, and N-M between groups, but not in N-IMF. The ratio of BW/N-IMF was sta-
tistically significant (P = 2.65E-07 on right), indicating that the similarity in N-IMF
distance did not adjust for the difference in BW.
Conclusions: The trans-female and cis-female populations seeking primary breast
augmentation have significant demographic and anatomical differences. This has
implications for surgical decision-making and planning to optimize outcomes for
trans-female patients. (Plast Reconstr Surg Glob Open 2019;7:e2167; doi: 10.1097/
GOX.0000000000002167; Published online 13 March 2019.)

INTRODUCTION tics.1 However, despite estrogen therapy, as many as 60%

Treatment of gender dysphoria through transition of patients fail to achieve adequate breast growth and
from the male to trans-feminine phenotype relies on an require implant-based augmentation to realize a more
adequate acquisition of female secondary sex characteris- feminine chest shape.2 Although augmentation in trans-
female patients shares obvious similarities with cis-gender
*Division of Plastic and Reconstructive Surgery, Oregon Health augmentation procedures, there are also significant differ-
& Science University, Portland, Ore.; †Division of Plastic and ences. The trans-female chest differs morphologically to
Reconstructive Surgery, Case Western Reserve University, University both cis-female and cis-male chests due to the exposure of
Hospitals Case Medical Center, Cleveland, Ohio; and ‡Division of testosterone during adolescence and exogenous estrogen
Plastic and Reconstructive Surgery, University of Minnesota School during gender transition. As trans breast augmentation
of Medicine, Minneapolis, Minn. procedures become more commonplace, it is important
Received for publication December 9, 2018; accepted January 4, to understand these differences and associated implica-
2019. tions for surgical planning.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, In this study, we hypothesized that there are signifi-
Inc. on behalf of The American Society of Plastic Surgeons. This cant differences in the preoperative breast measurements
is an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the Disclosures: The authors have no financial interest to de-
work provided it is properly cited. The work cannot be changed in clare in relation to the content of this article. This study was
any way or used commercially without permission from the journal. funded by a grant from Allergan pharmaceutical plc.
DOI: 10.1097/GOX.0000000000002167

www.PRSGlobalOpen.com 1
 PRS Global Open • 2019

Fig. 1. Illustration of all 3 body type classifications in transgender patients, compared with the most common cis-mesomorph body type.

­ etween the cis- and trans-female populations, most no-

b grade, and if their breast showed signs of constricted lower
tably the ratio between breast width (BW) and nipple to pole or herniating areola. Patients who were thin and lean
inframammary fold distance (N-IMF) distance. Further- with low muscle content were classified as having an ec-
more, we postulate that the trans-female patients’ de- tomorph body habitus. On contrary, those patients with
mographics and comorbidities differ from the cosmetic underdeveloped muscles, elevated BMI, and likelihood of
patient population, particularly in regard to age, comor- storing fat were classified as having an endomorph body
bidities, and body mass index (BMI). We have noticed habitus. Finally, those patients with an average or mus-
that transgender augmentation patients in our clinic tend cular build were classified as having a mesomorph body
to fall into the “endomorph” body type, which is in sharp habitus. Breast ptosis was classified based on the modified
contrast to our cis gender patients, who tend to have a Regnault ptosis scale.3
more “mesomorph” build (Fig. 1). In this study, we at- Statistical comparisons were conducted using indepen-
tempted to validate these subjective observations and use dent t tests for continuous variables and Pearson’s χ2 test
this information to demonstrate how these differences in- for discrete variables. Demographics were analyzed using
fluence preoperative counseling, implant selection, and descriptive statistics, reporting means and frequencies. All
surgical planning, all of which are unique to the trans- analysis was conducted using Microsoft Excel (Microsoft
female population. Corporation, Redmond, Wash.). This study was approved
by the Institutional Review Board of Oregon Health & Sci-
METHODS ence University.
This is a retrospective analysis of prospectively collect-
ed data by a single surgeon who evaluated trans-female RESULTS
patients for augmentation mammaplasty between April
2016 and February 2018. For the control group, we in- Patient Demographics and Characteristics
cluded all cis-female patients seen by 2 senior surgeons The study population included 82 trans-female pa-
at the same institution between September 1998 and July tients and 188 cis-female patients seeking primary breast
2017. Inclusion criteria were the following: age between augmentation. The mean time trans-female patients were
18 and 80 years old, documentation of preoperative chest on estrogen was 54.3 months. Patient demographics and
measurements, and access to preoperative photos. Trans- characteristics including age at consultation, BMI (kilo-
gender patients were required to have a diagnosis of gen- gram per square meter), height (centimeter), and weight
der dysphoria and meet all World Professional Association (kilogram), as well as current and past smoking status and
for Transgender Health criteria for gender confirmation diagnosed psychological comorbidities of depression or
surgery (GCS). All transgender patients are required to anxiety were compared and can be seen in Table 1. Trans-
have been on exogenous estrogen for at least 1 year before female patients were more likely to seek primary breast
consultation. augmentation consultation at an older age compared
Demographic data, such as age at the time of consult, with cis-female patients, 40.37 versus 34.07 years of age,
BMI, smoking status, and other relevant social history respectively (P = 3.12E-05). Trans-female patients were
were analyzed between the 2 groups. Specific preopera-
tive measurements were recorded in metrics (centimeter/
millimeter), including N-IMF, nipple to midline distance Table 1. Body Habitus in Trans- and Cis-female Populations
(N-M), sternal notch to nipple distance (SNN), base BW , Trans
and areolar diameter. Cis Population Population
Two independent reviewers classified each partici- (n = 188) (n = 82) χ2 P
pant based on preoperative photographs (see Table 2 Ectomorph 98 52.13% 21 25.61%
and Fig. 1). Patients were classified as to their body habi- Mesomorph 77 40.96% 28 34.15% 6.20E-32
Endomorph 13 6.91% 33 40.24%
tus (ectomorph, mesomorph, endomorph), their ptosis

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Nauta et al. • Study of Chest Dimensions in Trans/Cis Females

Table 2. Patient Demographics and Characteristics

Cis Population (n = 188) Trans Population (n = 82)
Mean SD Mean SD P
Age at consultation 34.07 8.77 40.37 11.76 3.12E-05
BMI 22.88 5.50 27.46 6.39 1.91E-07
Height (cm) 165.60 10.43 173.20 21.25 3.93E-03
Weight (kg) 62.99 17.73 84.29 20.82 6.53E-13
Yes % Yes % χ2 P
Psychological comorbidities 23 12.23 41 50.00 1.69E-25
Current smoker (cis n = 151) 18 11.92 11 13.41 0.70
Smoking history (cis n = 142) 33 23.24 44 53.66 2.84E-11

Table 3. Additional Characteristics of the Trans-female Cis-female patients seeking primary breast augmen-
Population (n = 82) tation were more likely to be classified as having an ecto-
morph (52% versus 26%) or a mesomorph body habitus
Average SD (41% versus 34%). On the contrary, trans-female pa-
Duration of social transition (mo) 84.90 77.83
Duration of estrogen (mo) 54.20 56.01 tients were more likely to be classified as having an en-
Yes % domorph body habitus compared with cis-females (40%
Tattoos 19 23.17 versus 7%).
Constricted lower pole 22 26.83
Herniating areola 17 20.73 Trans-female characteristics regarding duration of
social transition and exogenous estrogen are shown in
Table 3. The trans-female population in this study on
Table 4. Breast Ptosis on Physical Examination average socially transitioned 84.9 months before consul-
tation with a range of 12–348 months. These patients
Trans had been on hormone therapy for on average of 54.20
Cis Population Population
(n = 188) (n = 82) χ2 P months before consultation with a range of 12–360
months.
No ptosis 123 65.43% 68 82.93%
Grade 1 24 12.77% 6 7.32% As previously noted, trans-female patients seeking
Grade 2 16 8.51% 6 7.32% 0.0056 primary breast augmentation do so due to failure to
Grade 3 5 2.66% 2 2.44% develop natural feminine breast shape despite estro-
Pseudo 20 10.64% 0 0%
gen therapy. Trans-female patients tend to have inter-
rupted breast development with a constricted lower pole
and without return of contour between the areola and
also more likely to be taller (P = 3.93E-03), weigh more the surrounding breast. In this study, 26.83% of trans-
(P = 6.53E-13), and had a statistically significantly higher BMI female patients demonstrated a constricted lower pole
than cis-female patients, 27.46 kg/m2 versus 22.88 kg/m2 and 20.73% demonstrated herniating areola on physical
(P = 1.91E-07) at the time of consultation. examination.
There were no significant difference in current smok- Patient population differences in breast ptosis can be
ing status between trans-female and cis-female patients, seen in Table 4.
11.92% versus 13.41% (P = 0.70). However, trans-female Trans-female patients were more likely to have no
patients were much more likely to have a history of smok- breast ptosis on physical examination than cis-female pa-
ing compared with cis-female patients, 51.95% versus tients, 82.93% versus 65.43%, respectively. Likely due to
22.82% (P = 2.124E-08). Trans-female patients were sta- breast changes after breastfeeding, cis-female patients
tistically more likely to have a diagnosis of depression or were much more likely to present with pseudoptosis
anxiety than cis-female patients, 50.0% versus 12.23% (20.2% versus 0.0%) or grade I–III breast ptosis compared
(P = 1.69E-25). with trans-female patients (P = 0.0056).

Table 5. Preoperative Breast Measurements of Cis- and Trans-female Patients

Cis Population Trans Population (n = 82)
Mean SD Mean SD P
SSN right (cm) (cis n = 187) 20.79 2.33 22.14 2.92 1.88E-03
SSN left (cm) (cis n = 187) 20.9 2.43 22.27 2.79 6.93E-04
BW right (cm) (cis n = 128) 11.42 1.45 15.18 2.33 1.67E-18
BW left (cm) (cis n = 128) 11.36 1.49 14.98 2.33 5.82E-18
N-IMF right (cm) (cis n = 111) 7.04 2.07 6.59 1.73 0.22
N-IMF left (cm) (cis n = 111) 7.1 2 6.57 1.63 0.08
N-M right (cm) (cis n = 94) 8.94 1.06 11.74 1.94 1.84E-14
N-M left (cm) (cis n = 94) 8.93 0.99 11.91 1.72 2.80E-30
N-IMF/BW right (cis n = 52) 0.63 0.23 0.43 0.09 2.65E-07
N-IMF/BW left (cis n = 50) 0.63 0.21 0.44 0.09 1.21E-07

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Preoperative Breast Measurements

Breast measurements on physical examination include
SNN, BW, N-IMF, and N-M. Table 5 demonstrates the sig-
nificant differences between cis-female and trans-female
breast measurements. All measurements were significantly
larger in trans-female patients, with the exception of N-
IMF distance bilaterally. Looking at the BW/N-IMF ratio,
however, the N-IMF comes out as relatively shorter when
compared to the overall breast dimension.

DISCUSSION
The masculine and feminine chest have distinct fea-
tures that are commonly recognized: male chests are wid-
er, have minimal breast tissue with little to no expansion
of the skin envelope, smaller areolas, lateralized nipple–
areola complex with less projection, a wider sternum, and
greater pectoral muscle bulk.4–6 The cis-female chest un-
dergoes changes as a result of puberty, including breast
tissue growth and other morphometric changes that do
not resemble the cis-male chest. Although it is anecdotally
understood that the trans-female chest resembles neither
the cis female or cis male, the existing literature does not
address the morphometric changes that result from the
limited effects of exogenous estrogen. Furthermore, with
the expansion of GCS in the United States, providers who
may not routinely treat this patient population will be in-
volved in their care, and it is important to understand how
Fig. 2. Implant removed due to inadequate base width compared to demographic differences and population factors unique
replacement implant with 16.5 cm base width. to the trans community can impact the preoperative coun-

Fig. 3. Before and after photos of trans-female patient who presented for revision augmentation. The wider base width implant
shown below provides superior cleavage and lateral fullness.

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Nauta et al. • Study of Chest Dimensions in Trans/Cis Females

seling. This paper tried to scientifically address both of This makes sense in light of the absence of breastfeeding
those aspects. and the late onset of breast growth in these patients.
Trans-female patients had a significantly higher rate If the clinician considers that a typical trans patient is
of smoking history and psychiatric comorbidities, which likely to be a tall endomorph patient with elevated BMI
is well in line with the higher rates of mental health co- and larger BW on clinical examination, it may be prudent
morbidities and low socioeconomic status described in to select a larger implant that accommodates the trans-
the overall transgender population.7,8 The trans cohort verse chest dimensions. Selection of the appropriate im-
primarily came through the state Medicaid program (Or- plant under these circumstances will allow the surgeon to
egon Health Plan), whereas the cosmetic population was achieve feminine proportions with medial fullness and per-
predominately private pay. This exemplifies an essential haps more cleavage.9 Consider a patient with a base width
difference between those 2 populations. The transgender of 16.5 cm and an implant choice with a width of 16 cm.
population is disproportionately burdened with mental The available sizes for Allergan Natrelle Inspira would be:
comorbidities and traumatic experiences, as well as prior extra-full N/A; full N/A; moderate 685; low-plus 590; low
discrimination within the medical setting. 510. Those are large-sized implants and differ from the
Patients presenting for cosmetic cis-gender augmenta- average cis-female augmentation.10 In practice, the senior
tion represent certain subgroups of the cis-gender pop- author uses implants with a wide BW for a vast majority
ulation, which is reflected in a lower mean age and SD of patients. Figure 3 shows a patient who underwent aug-
when compared with the trans-female group (40.48 versus mentation with an implant that was too narrow for her
34.07). The same findings were true for BMI, height, and base width of 18.5 cm. We exchanged the approximately
body habitus. This is an interesting finding in that sur- 400 mL implant with a 755 mL moderate profile implant
geons will be presented with a more heterogenous patient with a base width of 16.5 cm. The patient desired projec-
population of a wide age group and body habitus range tion. Otherwise a low-profile implant with an even wider
and should be prepared to alter their approach accord- base width would have been advisable. This case nicely il-
ingly. For example, contrary to what one would expect, lustrates the more proportional appearance of the lateral
the increase in age did not correlate with increased ptosis. breast border in this wider chested individual.
Trans females were significantly less likely to have relevant Compromising on the BW will hinder the ability to cre-
ptosis that would necessitate a discussion of mastopexy. ate medial cleavage but—maybe more importantly—will

Fig. 4. Trans-female patient with ectomorph body type—395 mL Allergan Natrelle 410FM textured silicone shaped implants in a submus-
cular pocket. (Patient counseled on risk of breast implant–associated large cell lymphoma.)

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 PRS Global Open • 2019

provide adequate lateral fullness. On the other end of the similar to a mildly tuberous breast, which is perhaps con-
spectrum is the ectomorph body type where ideally a tex- sistent with arrested development between Tanner stages
tured implant would assist in providing the most natural 2 and 4.11 Surgically, the constricted lower pole must be
chest shape. In the setting of uncertainty around breast addressed with radial scoring. Areolar herniation in most
implant–associated anaplastic large cell lymphoma, it is cases was mild, and an inframammary incision is still a vi-
the senior author’s practice to reserve textured implants able option.
for patients who independently ask for this implant, are Another interesting finding was that that in our trans
of the ectomorph type and have enough health literacy to data, the average NAC width was 3.43 cm with an SD of 0.89.
understand the severe risks associated with these implants. While we did not directly compare this measurement to the
These implants are not routinely offered unless there is a cis-female NAC, the number can be compared with the Beer
specific request. Figure 4 shows a patient of ectomorph et al.5 paper citing an ideal male NAC width of 2.69. The rel-
type with textured implants. Figure 5 shows a mesomorph evance of this finding is that some trans-female patients are
body type and Figure 6 shows an endomorph body type. candidates for a periareolar approach due to significant are-
The N-IMF distance was not statistically significant be- olar enlargement after treatment with exogenous estrogen.
tween 2 groups. However, if we look at the ratio of BW/N- In the senior author’s practice, the above data assist in
IMF, then we do find a ratio that is statistically significant deciding on an implant. Knowing the differences between
and confirming that the N-IMF distance is shorter in the populations allows for better communication with the pa-
trans-female population (P = 2.65E-07 on right). This tient and guidance in decision-making on 4 aspects of the
translated into a clinical need to substantially lower the breast augmentation consult: choice of implant, placement
inframammary fold in most trans-female patients if an im- plane, incision site, and size. Estrogen starts to encour-
plant of appropriate base width is chosen. This has also age breast growth and body fat redistribution within 3–6
been the practical experience of the senior author on this months, with full effects in 2–3 years and 2–5 years, respec-
manuscript. Although comparative data were not available tively.12 It is, therefore, warranted to at least wait a year af-
for the cis-female control group, we did find a constricted ter beginning estrogen before performing augmentation.
lower pole in over a fourth of the trans-female popula- Further increase in volume may occur after augmentation.
tion and in over a fifth of a herniating areola. These ob- Although there are no commonly agreed on breast cancer
servations suggest that the trans breast is phenotypically screening guidelines for trans females, University of Califor-

Fig. 5. Mesomorph body type—445 mL SSM Allergan Natrelle silicone round implants in a subglandular pocket (written permission given
by patient to publish despite identifiers).

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Nauta et al. • Study of Chest Dimensions in Trans/Cis Females

Fig. 6. Endomorph body type—685 mL SSM Allergan Natrelle silicone round implants in a subglandular pocket.

nia, San Francisco has recommended that screening should Estrogen therapy is an imperfect solution for chest femi-
not start before the age of 50 years and after the patient at nization for some, and these are the patients who present to
least have been on exogenous hormones for 5–10 years.12 the plastic surgeon. However, there are patients in which es-
Limitations of this study include that the measure- trogen either produces a fully developed chest or an under-
ments in the cis-female population were performed by developed chest that is cosmetically pleasing or adequate
different surgeons, and there may be variability in the from the patient’s perspective. The patient satisfied with
measurement method. There was also significant varia- hormone therapy does not present to the plastic surgeon,
tion in which preoperative measurements were taken for and therefore these numbers are difficult to quantify. It is
cis-patients, preventing the full cohort to be compared also important to note that breast implants are currently
with the trans cohort for each preoperative measurement. not Food and Drug Administration approved for male gen-
The trans-female population in this study has a statistically der reassignment surgery and are currently used off-label.
higher variability in SD that is greater than the relative in- This is because the core studies involved in approval did not
crease of the respective measurement’s magnitude. This is include “male assigned at birth” patients.
not surprising as the trans-female population experience
is not homogeneous. In addition to genetic variability in-
herent to any population (cis-female patients included), CONCLUSIONS:
the trans-female population has unique hormonal factors Although surgical similarities exist between the opera-
at play. There are a vast number of medical and surgical tive choices and technique for cis-female and trans-female
options for females in transition, and each patient pres- breast augmentation, marked differences also exist. Sur-
ents at a different stage in the process. All are on estrogen geons see a wider age, BMI, and body habitus range in this
therapy, but from variable ages of initiation, formulations, population. Chest measurements reveal a statistically low-
doses, and lengths of time. As noted previously, estrogen er N-IMF/BW ratio when compared with the cis-female
begins to promote breast growth and body fat redistribu- cohort, necessitating not only larger implant selection
tion within 3–6 months, but its full effects are not seen for but also frequent need to lower the inframammary fold.
several years.12 These circumstances produce a complexity Plastic surgeons treating these patients should be familiar
in the patient population that is unparalleled by the cis- with these differences and understand the needs specific
gender group. to this patient population.

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5. Beer GM, Budi S, Seifert B, et al. Configuration and localiza-

Jens Urs Berli, MD
Division of Plastic and Reconstructive Surgery tion of the nipple-areola complex in men. Plast Reconstr Surg.
Assistant Professor 2001;108:1947–1952; discussion 1953.
Associate Residency Program Director 6. Hage JJ, van Kesteren PJ. Chest-wall contouring in female-to-
Gender Surgery Fellowship Director male transsexuals: basic considerations and review of the litera-
Oregon Health & Science University ture. Plast Reconstr Surg. 1995;96:386–391.
3181 SW Sam Jackson Park Road, MAC 3168C 7. James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S.
Portland, OR 97239 Transgender Survey. National Center for Transgender Equality;
E-mail: [email protected] 2016.
8. Winter S, Diamond M, Green J, et al. Transgender people: health
REFERENCES at the margins of society. Lancet. 2016;388:390–400.
1. Berli JU, Knudson G, Fraser L, et al. What surgeons need to 9. Liu YJ, Thomson JG. Ideal anthropomorphic values of the fe-
know about gender confirmation surgery when providing care male breast: correlation of pluralistic aesthetic evaluations with
for transgender individuals: a review. JAMA Surg. 2017;152: objective measurements. Ann Plast Surg. 2011;67:7–11.
394–400.
10. Young VL, Nemecek JR, Nemecek DA. The efficacy of breast aug-
2. Kanhai RC, Hage JJ, Karim RB, et al. Exceptional presenting con-
mentation: breast size increase, patient satisfaction, and psycho-
ditions and outcome of augmentation mammaplasty in male-to-
female transsexuals. Ann Plast Surg. 1999;43:476–483. logical effects. Plast Reconstr Surg. 1994;94:958–969.
3. Regnault P. Breast ptosis. Definition and treatment. Clin Plast 11. Templeman C, Hertweck SP. Breast disorders in the pediatric and
Surg. 1976;3:193–203. adolescent patient. Obstet Gynecol Clin North Am. 2000;27:19–34.
4. Agarwal CA, Wall VT, Mehta ST, et al. Creation of an aesthetic 12. Deutsch MB, Radix A, Wesp L. Breast cancer screening, manage-
male nipple areolar complex in female-to-male transgender ment, and a review of case study literature in transgender popu-
chest reconstruction. Aesthetic Plast Surg. 2017;41:1305–1310. lations. Semin Reprod Med. 2017;35:434–441.