Gender-affirming breast augmentation can provide significant emotional and physical benefits to transgender patients. It is important to understand some anatomic differences between cis-gender and transgender females, which may impact the techniques and approaches for augmentation. Transgender females may have more muscle bulk and a lower natural nipple position, so the surgeon may need to consider whether to place the implant under or over the muscle. Because most transgender females do not have a large natural breast, there can be less tissue coverage to protect the implant, particularly if a large implant is desired. The nipple position may look a bit lower over the breast implant mound, or the fold under the breast may need to be lowered to allow the nipple to be more centralized. Breast lift techniques may also be considered in transgender patients, depending on the individual anatomy. Preoperative hormone therapy to rebalance estrogens and other female hormones vs. testosterone may be helpful in naturally augmenting the breast partway. This may allow for a smaller implant in some patients. Occasionally, the unique anatomy may call for a shaped (teardrop) implant, rather than a round style, to create a more natural slope of the breast.