This 25 year-old M to F transgender patient has been living as a female for several years, has been on hormone therapy for nearly 2 years, and came to Minneapolis Plastic Surgery for breasts that were more proportionate with her chest and overall size. Estrogens had caused some breast enlargement, but this was now stable and insufficient for the patient’s desired goal of a full C-cup. Because of tight skin and muscle, and high infra-mammary creases, two-stage augmentation with tissue expander placement at one operation, outpatient expansion over several months, and placement of final silicone breast implants at a second operation was recommended. In this type of anatomy, this approach often avoids multiple re-operations for inadequate size, malposition, or firm, unnatural-appearing breasts that can occur when single-stage augmentation is attempted. Two planned operations are less costly than multiple unanticipated operations and re-operations. Post-op photographs are 4 months after her second stage procedure.