INTRODUCTION: Gender-affirmation surgery is essential in the management of gender dysphoria. For male-to-female transgender women (transwomen), feminization of the chest is a component in this process. There is minimal literature describing effective and safe techniques for breast augmentation in transwomen. Here we describe our operative techniques and considerations. METHODS: A retrospective review of a single surgeon experience was performed for transwomen who underwent primary breast augmentation between October 1, 2014, and February 1, 2017. Surgical outcomes and complications were analyzed. RESULTS: Thirty-four patients with an average age of 34.4 years were included in this series (range 19-59 years). Surgical approach was through an inframammary incision with a submuscular pocket and either silicone smooth round (24%) or textured anatomic implants (76%). Six patients experienced postoperative complications (17.6%). Two patients underwent reoperation for implant extrusion (5.9%). Higher BMI and longer preoperative hormonal therapy duration were significantly associated with complications ( = 0.008;  = 0.039, respectively). Feedback from the respondents was overall positive. Most of patients (92.7%) reported being happier and feeling more satisfied with their chest than before their operation. All respondents (100%) reported improvement in their gender dysphoria and would undergo the operation again. Patient dissatisfaction was significantly associated with longer time on preoperative hormones ( = 0.008) and had a trend toward association with higher implant volume ( = 0.083). CONCLUSIONS: Breast augmentation in transwomen is safe and typically leads to high patient satisfaction with improvement of gender dysphoria. Larger, longer term studies are needed to appropriately delineate complication risks and contributing factors.