Your Questions

Q: Dr. Eppley, I am interested in breast implant replacements. I currently have 400cc saline breast implants in and the plastic surgeon I went to suggested replacing them with 650cc smooth round silicone implants. Based on where I am now and where I want to be (I attached a bunch of ideal breast augmentation results) I do not think he and I are on the same page. I don’t think he understands what I mean when I say extreme breast augmentation. Can you look at all my pictures and tell me what you think. Your reputation as a plastic surgeon precedes you so your opinion would mean a lot to me. Thanks!

A: Thank you for sending all the photos of your breasts and that of your ideal result. Based on how your breasts look now with 400cc implants and their degree of sag and nipple position, none of those ideal results are achievable for your breasts. Your breasts have too much skin and sag to look that high up on the chest or to be that round…regardless of the size implant used. All that can be done is to make them bigger and somewhat more round but getting enough implant volume in place is the key. It is clear to me with these goals that 650cc is not going to adequate. more likely it is somewhere between 800ccs and 1000ccs to be able to fill out your breasts for a rounder fuller look. No silicone implant is made over 800ccs and its weight will make the breasts bigger but not as round as you would like. Only overfilled saline implants will create a more rounder effect as they naturally sit higher and rounder when overfilled. Most likely an 800cc saline implant filled to 960cc to 1000cc will be needed. It would also be important to use an areolar incision when placing such large breast implants to keep the incision at the top of the mound and away from the skin stretching effects as the base of the breast mound. Anytime one gets over 800ccs in implant volume that would fall into the classification of extreme breast augmentation or the use of very large breast implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in extremely large breast augmentation. How big of breast implants do you do? I currently have 1200cc saline implants, under the muscle. Recent surgery done late last year. I realize I’m not done healing and I can’t have a revision for some months down the road, but I would like to at least double in size. I’m shooting for the 4000cc range one day. I’ve heard some surgeons say these sizes are not possible. My first surgery I’m not happy with, I was hoping for more roundness and projection. Please let me know if this sounds like a surgery you think you are capable of. Thank you

A: When it comes to extremely large breast augmentation, it is not a question of capability but implant possibility. Extremely large breast implants require that they be saline and overfilled. The largest U.S. manufactured FDA-approved saline breast implant is 800cc of which the manufacturer recommends a maximum fill of roughly 1000ccs. But they can be safely filled to more than that as your case illustrates. How far beyond that one can safely go has never been studied and is not scientifically known.The physical characteristics of the implant when filling to saline volumes of 2000cc or more with base sizes of 800ccs involves issues of rupture potential and extreme hardness of the implants. When it comes to filling to 3000cc or 4000ccs that is not going to be possible with any FDA approved saline breast implant.

While larger base size saline breast implants exist outside of the U.S., the vast majority of plastic surgeons are not going to risk their medical license by illegally importing in non-FDA approved foreign medical devices.

It is clear in looking at your pictures that you have a lot of breast skin and it has the capability of even great volumes than 1200ccs. And as a general rule, you do have to increase your volume by at least 50% to see an appreciable size difference. But a greater overfill than that is probably not going to be tolerated by the implant shell without a significant risk of rupture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in extra large breast augmentation. (technically extra large breast implant replacement. Can we do a consultation via email since I live far away. I want 1000cc implants. I currently have 500cc on right breast and 400cc on left and clearly they are not even close to being as big as I asked for. The dr was more concerned about doing what he thought looked best and not accommodating what I wanted at all. It is humiliating as they look awful. This is not remotely the size I was looking to get.

A: The concept of extra large breast augmentation is controversial amongst plastic surgeons. There is a large group of plastic surgeons who choose breast implants based on their assessment of the breast tissues to support them over the long-term. With this concept they do not put sizes that are wider than the patient’s natural breast base diameter or the less measurable quality of the support of the overlying breast tissue/skin sleeve. For many patients this means that sizes less than 400ccs are placed. There is another group of plastic surgeons, arguably smaller, that provide any breast implant size that the patient wants including very large sizes. These implant sizes do irreversibly stretch out the breast tissues and are more prone to bottoming out over time (loss of support) but do meet the patient’s expectations.

What your initial breast augmentation result was less than you wanted, your plastic surgeon probably placed implants that he felt comfortable could be adequately supported by your breast tissues. He or she was looking out for some long-term issues that most patients are understandably not aware of.  This may have been too conservative for you but was a safe approach. The good news is that this is an improveable problem, albeit with another surgery, and larger implants can be placed. You also have the advantage of now knowing what implant size may be acceptable since you know what size change has occurred with the volume you now have in. It is now about volume ratios. If you want a breast size that is twice as big as you now have, you will need a 100% increase in the implant’s volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a large breast augmentation. I am  5′ 3”, 112lb, cup size 32 A. Would a 500cc breast implant be too big for me do you think? I know what look I want and I know there is some increased risk with bigger implants. I tried on sizers in the office with the Volumetric Sizing System and 500 did not look too big to me. But the number does sound big.

A: The concept of a large breast augmentation is somewhat of a subjective one. Everyone’s interpretation of what that means may be somewhat different. While the number of 500cc breast implants is a big number and on a small frame will certainly look big, the most important question is what you think about its size. If you have tried on sizers and feel that it it not too big, then it is not too big for the look that you want. The other thing that you have to look at is the base width of the implant and see how that compares to your natural breast base width. With a high profile breast implant you want to make sure that it does not exceed  your natural breast base with so the implants are not too far to the side. When the implants get too far to the side because of their base width, they will generally be considered too big.  If so, you should then consider dropping down to 450ccs or less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how large of breast implants can I get? I know that most women don’t want to look like they have had breast implants but I do. I want a very round and very full look to them. I have a good breast shape 34C with no sagging but they look very small. I don’t know what extreme breast augmentation means but I think that is what I mean. I have had several consultations and I have tried on various sizers. (Mentor sizing system) The plastic surgeons I saw said they would not put in more than 500cc but I like the 650ccs the best. Is this too much for me? if I like the look why won’t they do it?

A: The size of breast implants is, of course, a very personal choice and no one can tell you what you should like. That is up to you. But it is important to remember that it is a medical device and there are risks and potential complications with them. These potential adverse effects can become more apparent or likely when the implant ‘exceeds the tissues to support them.’  Thus size can make a difference in these risks. Exceeding the limits of breast tissue support can be simplistically thought of as violating the breast base diameter, the existing perimeter of your natural breast skin mound. This can be measured in centimeters as well as can the base width of an implant. (as implants get bigger so does it’s base width) If the implant base width stays within your natural breast base width, the implant will be well supported by the tissue attachments and have little risk of bottoming out (dropping) over time. When an implant’s width exceeds that of your natural breast base width, the tissue attachments are stretched and the risk of the implants dropping, going to the side excessively or otherwise losening their retention up on the chest wall will likely occur over time. This can be a difficult problem to fix later.

What your plastic surgeons are telling you, and some plastic surgeons absolutely will not violate this guideline, is that your size request is exceeding what is believed your breast tissues can support. This is likely what they mean by being ‘too big’. I tend not to be so rigid about this concept and will let patients choose the breast implant size they want. But I do advise them, like much of life, the choices we make today will always have future ramifications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am currently looking for doctors who have experience with and are willing to place larger saline implants (900-1600cc overfilled). Please let me know if you are experienced in working with larger sizes, what the largest sizes you’ve worked with are, what your technique entails and if you have any example photo.

A:  As you may know, the largest saline breast implant that is manufactured for U.S. use is an 800cc implant. If you follow the manufacturer’s recommended fill volumes, the maximum fill should be 960cc. That is a fill volume established by the manufacturer based on the long-term tolerances of the silicone shell. I have filled 800cc implants up to 1200cc. At that point they start to become very hard due to the pressure of saline and the stretch of the implant shell. I would not recommend going any bigger than that given the high risk of shell rupture. It is important that you understand that anything beyond a 960cc fill volume would also nullify any warranty from the manufacturer once you exceed their FDA-approved fill volume.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I currently have breast implants which are inflated to 1200 cc’s. On the Purlz website there are references to 2000 cc implants and I am wondering if that is something which you actually do, since I am looking for extra-large implants near 2000 cc’s. In the seven years since my last surgery my skin has stretched enough that I think 2000 cc’s might be able to be achieved. Please reply with any information that you might be able to provide. Also, I am wondering if the sizers on the Purlz website fit nicely over breasts with existing implants? Thanks for your help.

A: I believe that you are confused about the Purlz products. These are breast implant sizers, not implantable breast implants. The only three manufacturers of FDA-approved breast implants for human implantation are Mentor, Allergan and Sientra. Only Mentor and Allergan offer saline breast implants that can be overfilled at the plastic surgeon’s discretion. Purlz offers presurgical sizers to be inserted over one’s breasts in a bra to help with surgical decision making about breast implant size for eventual surgery. They can not be used to be implanted either alone or over one’s existing breast implants.

Currently, the largest FDA-approved saline breast implant sizes are 800cc which are recommended from the manufacturers to have a maximal fill of 960cc. They can be inflated to more than that and around 1200cc , as you have, is around the maximum fill after which they get unnaturally very firm. Outside the U.S. larger saline breast implant sizes exist and are used but those devices are illegal to import into this country for use. The breast implant manufacturers are working on bringing larger breast implant sizes to the market but I could not tell you when that may be in the future.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting fairly large breast implants. I am only 5′ 2” and 107lbs. I’m currently a 32A. I have been told that I would need multiple surgeries to get my desired size of 650cc. One plastic surgeon I consulted with suggested that I start with a 400cc implant and then have a second implant later to get to my size. My breast width is about 13cm. What is the largest implant (style and cc)that I can get based on my breast width?

A: There are some issues that you may be aware of when you place large implants in women with small breasts, primarily which is the stretching out of tissue support. This can cause some long-term problems such as tissue thinning, bottoming out and an increased risk of the need for revisional surgery. But I will assume you know these so I will answer your specific question.

Depending upon whether you are choosing a saline or silicone gel implant, there are different size consideration either of which would be a high profile style implant. I only use Mentor breast implants so I can only speak of those sizes. A 560cc high profile saline implant has a base width of 13.4 cms which can be maximally filled to 650cc. At maximal fill this will narrow its base to 13.1cm. For silicone Memory gel implants, a 650cc implant has a base width of 14.4cm.

As can be seen by these numbers, I do not know why you can not reach your desired breast implant size in a single breast augmentation surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting breast implants. I am fairly small framed, some call me petite, at ‘m 5’0” and 102lbs. I’m currently a 32A cup size. I have had one consultation and tried on sizers and it seems like 550cc implants seem to be the best fit for me for the size I am after. I have been told that this is a large implant for my type of body but this is the look I really want. My goal is a 34 DD. With implants of this size would it be possible for me to get a teardrop breast shape despites the large implant size on my small chest? Two other questions, will my areola stay the same size and what is the best implant and incision to use?

A: There is no doubt that you are interested in a very large implant for your frame. While it is every women’s right to choice any size implant they want, there are many plastic surgeons who will not accommodate an implant size that they feel may lead to loss of breast tissue support in the long run. That being said, whether it is a saline vs a silicone implant, you need a high profile implant to accommodate that volume with the most narrow implant base diameter so it does not end up too far to the side getting in the way of the swing of your arm. I would lean towards a saline high profile implant because it can be placed through a small armpit incision and gives the most projection with the narrowest implant width. As the skin expands to accommodate the breast implant underneath, your areolar size will get bigger.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dear Dr. Eppley, I would like to replace my existing saline implants which are now 10 years old with new ones. The original size was 800cc shells filled to 960cc which I was told was the maximum fill at that time. My annual mammogram is coming up and I worry about my decade old implants failing under the pressure (yes I know it is a remote possibility, but I still am concerned). In doing a replacement, I want much larger implants. It would have to be done with either custom made implants or largely overfilling the largest saline breast implants that are made. In doing a replacement I would want a lot more volume than 960cc with as much as a 200% fill to give me more upper pole fullness and more projection. In effect a “mastopexyless” breast lift (had one masto, don’t want to do it again). There are several surgeons in US who are doing very large fills of 800cc saline shells at a patient request. Fills of 1400cc to as high as 2000cc are documented in various internet implant breast forums.

A:  While available at one time, custom breast implanrs are no longer made by any US manufacturer. Neither breast implant manufacturer will custom make any implant size at this time. The largest off-the-shelf saline implant are still 800cc of which the manufacturer recommended maximum fill is 960cc. (which you obviously know) The 800cc imlants only come in moderate plus projection. (Mentor) What any plastic surgeon is willing to fill to beyond the recommended fill is between the surgeon and the patient. Beyond the manufacturer’s recommended maximum fill, the patient risks losing the lifetime implant replacement warranty from the manufacturer. Nobody knows for sure how much overinflation affects the potential for deflation or rupture, although it may be fair to say that it has a negative influence. As the implant becomes highly overinflated it also becomes quite hard and unnatural feeling. These are all issues that a patient needs to consider when requesting and/or receiving high volume overfills.

I have heard rumors that the manufacturers have requested from the FDA approval to manudfacture and sell larger breast implant sizes than that which is currently available. (I can not verify that this is true) So larger implants with a base size over 1000ccs may be available in the future.

Dr. Barry Eppley

Indianapolis, Indiana