XL(EXTRA LARGE)Saline Breast Implants

Have an outside silicone shell and are filled with saline, which normally is in our bodies, at surgery. You can think of them as a balloon that is then inflated. The shells come pre-sterilized from the manufacturer and packaged that way. They come in various progressive sizes at about 50cc increments. About every 120-150cc increases the cup size by one cup size. Also, the weight of the saline or implants is about the same as breast tissue. So, if you add a 1000cc saline, or for that matter, a silicone implant, you are increasing the cup sizes by about 6 to 8 cup sizes and the weight is about 1000grams or 2 pounds! 

           The largest saline shell that is available in the US and overseas is 800cc. This shell is then placed through various incisions- the armpit, the belly button, in the crease under the breast, a cut partially around the areola and even through a tummy tuck incision. Each of these incisions can cause a decrease or even absence of breast nipple sensation but in a very small minority of patients. It does not matter which incision is used for the nerve is tiny and can be injured temporarily or permanently not because of where the incision is placed but how the opening inside the breast is made. The armpit(unless endoscopic equipment is used), the belly button and to a less extent the tummy tuck approaches are relatively blind so you do not see exactly where you are opening the space and it may cause problems like differences in positioning of the implants which may cause them to look different one from the other(breast asymmetry), single breast(synmastia) where the space between one implant and other is gone as well as increased bleeding for you do not control the bleeding directly but just by pressure on the outside of breast or compression from the breast implants themselves. 

   Saline breast implants are placed either under the muscle(sub-pectoral-between the ribs and the pectoralis muscle) or subcutaneous(between and underneath the breast tissue and the pectoralis muscle). The saline breast implants are usually placed in the sub-pectoral space to camouflage the implants(so can't see edges and ripples). Also, I can place an internal bra to attempt to decrease the XL implants from sagging but the foreign material has about a 10% chance of infection which may require the removal of it and the overfilled XL saline implant.

    The manufacturers of all these saline shell implants and there are four available in the United States presently, Allergan, Ideal, Mentor, and Sientra, recommend that their saline implant shells are overfilled with saline by only 10%. So, for a 800cc breast saline shell, by only 80cc! However,  studies have been shown that shells act like a balloon and can usually accommodate much more than that and I do overfill these shells. If the patient wishes to be less than 1400cc then this is a reasonable way to go. Otherwise, the tissue expander is the answer.  The sterile normal saline is placed into the shells, after the air is sucted out, through sterile tubing provided by the manufacturer. For larger volumes, I utilize a pump to fill these implants. After filling through the valve which is self-sealing, there is an attached cap that is inserted to provide more safety from leakage. 

 There are several negatives  with saline implants. The main one is that they may deflate or lose volume. Also, as I mentioned above, ripples may be seen through the skin as well as you may be able to feel the edges of the breast implants. Unfortunately, the pectoralis muscle does not cover the entire breast implant, especially on the sides and below the nipple so these are the areas that you may feel and see the breast implants.  Saline implants can be placed in the subcutaneous space but then the seeing and feeling of the saline implants is more pronounced because they have less covering! The more breast tissue that one has, the more that it will hide the breast implant and the less you will see or feel it. Also, with XL sizes, you may lose the shape of the breast. They may not be tear drop anymore! Also, the fullness which patients desire may not occur for because of the narrow base or diameter of the 800cc saline over filled shell, the projection is forward and is not throughout the breast but at bottom and may not give the patient the "fake look". 

 The IDEAL implant is still saline but has more than one compartment. Interesting for I had similar design many years ago and had these manufactured but failed to patent them. Limitation for XL patient is again the maximum shell size of 800cc. 

    I have been using different synthetic material or INTERNAL BRA to increase the thickness of the area below the nipple where the breast implant is covered only by the subcutaneous tissue and not the pectoralis muscle. This material has been shown, but not conclusively, to also decrease firmness or capsular contracture though usually with an XL size, and definitely with overfilled saline, firmness is common. Patients who go to XL size of breast implants, need to be concerned about possible erosion of the breast implant through the skin, especially under the areola because that is where the implant rubs against the skin and it is the most pressure. 

    I would also like to caution patients to go to a reputable plastic surgeon certified by the American Board of Plastic Surgery that has a lot of experience with XL breast sizes and patients for these are challenging cases. Also, I have found that when I replace the overfilled saline implants, many times I find that the volume that was told the patient had placed is not correct and is sometimes much less!!