The problem with very large breast implants is the possibility of irreversible stretching changes to your breast and chest soft tissues which can be challenging to correct. Some plastic surgeons are still willing to "overdo" it with patients as they may care less about the long term consequences of their procedure on their patients. Regarding sizing decisions, it is most important that you have a clear and understandable discussion with your plastic surgeon well before your surgery, preferably at the time of a lengthy initial consultation and then a second preop visit.

Published on Jul 11, 2012

Very rarely is an implant needed that is greater than 800 cc. Consequently, most plastic surgeons have little experience using such large implants, or the extreme nature of the outcome is incompatible with their sense of proportion or esthetics. Another consideration is whether the patient's chest wall will allow for an implant of such large dimensions.

Published on Jul 11, 2012

I assume that by XL you mean extra large, am I correct? Personally, I don't place really large implants unless the individual's body can safely accommodate them. The larger the implant on the smaller the body, the more fake they look. Plastic surgeons like to achieve a natural look rather than a "plastic look." While I don't think that the individual performing them are necessarily warriors, I cannot speak to their intent.

When I operate on an individual, their breasts, their face, their tummy is my billboard. I would rather have a billboard that routinely shows natural results rather than fake. This is my personal perspective.

Published on Jul 11, 2012

XL implants are very heavy and cause the breasts to sag over time. The implants put pressure on the breast tissue, which leads to thinning and rippling. The largest implant sold by the three American companies has a recommended fill volume of 850 cc max. The implant won't pop until it surpasses 1,500 cc's, but the company recommends 850 max. Long-term XL implants will cause you problems.

Published on Jul 11, 2012

My specialty is XL breast implants, so I may not be an impartial plastic surgeon on this matter. It definitely takes more know-how and experience to deal not only with the surgery but also with complications that may arise. The incidence of infections, capsular contracture, asymmmetry and other problems is greater but still relatively small. So, most plastic surgeons don't really want to deal with this.

Published on Jul 11, 2012

Of course XL implants can cause huge problems & therefore be relatively unsafe, compared to smaller implants.

Published on Jul 11, 2012

I'm assuming that when you say XL you refer to large volume implants like 600 or 700 or even 800cc's? I'd say that they aren't commonly performed because the bulk of the market may not be requesting those sizes in certain regions or cities in the country. There is also evidence that shows greater complications and threats to patient satisfaction with larger and larger implants. We also know that a larger implant will put more stress on skin and shape over time and that results with very large implants do not have the longevity of a moderate-sized implant. With greatly stressed or stretched skin from a very large implant, the need for revision is eminent and those revisions can be much more difficult to do. All these factors are likely motivating surgeons as they discuss implant choices with patients. Hope this helps. Best wishes.

Published on Jul 11, 2012

First let’s talk numbers. I perform about 500 total augmentations and augmentation revisions each year. Around 200 of those I classify as XL- which I define as 600cc and up. The remaining 300 are under 600cc.

I don’t think there is anyone in the U.S. who does more XL augmentations than I do, but if you look at the numbers most of my patients are not XL patients- most are under 600cc.
I think lots of plastic surgeons don’t have experience with XL augmentations, and therefore they wisely steer clear of them, because there are lots of nuances to the procedure that are different when compared to non-XL augmentations. Knowing how much volume will fit, knowing how much volume it will take to reach a certain goal, proper support, etc., only come with experience.
Secondly, many plastic surgeons express the opinion that XL augmentations always develop complications. However, I believe that with experience the risk and rate of complications is comparable to non-XL augmentations. Capsular contracture, deflation, bottoming out, synmastia, etc all seem to occur at the same rates. For instance an 800cc implant is no more likely to encapsulate than a 200cc implant. If a plastic surgeon does not perform XL augmentations, then how can they accurately comment on the complication rates?
Thirdly, many plastic surgeons find XL augmentations to be aesthetically offensive. In my opinion, I should not be subjecting you to my own personal tastes. Part of specializing in breast augmentation surgery is being able to properly communicate with you to determine exactly what your goals are- whether it be 300cc or 800cc, without interjecting my own opinion. That is not to say I would do anything asked for by anyone, because I will not perform an unsafe procedure, but if you are a good candidate for 800cc, and you want 800cc, then I fully support your decision, and I will perform it safely for you.
So while I don’t consider myself a warrior, I do consider myself a breast augmentation specialist and an advocate for choice. I have an extensive revision experience, which I believe makes me a better first time surgeon. If I can diagnose and correct problems, I believe that I can better avoid those problems to begin with in my first time patients.

Published on Jul 11, 2012

I assume by XL implants you mean implants greater than 800cc- the largest silicone gel implant currently available in the US. Implants larger than this are available out side the US and custom implants care available at a very high cost as well- but the primary reason is as stated above- they are not available here. The amount of skin and tissue required to cover these implants and still look good is significant- more than a lot of women have. Essentially all women who have chosen to get these implants have had to slowly expand their tissues with several implant surgeries to be able to even accommodate these devices. It is important to also remember that once the tissue is stretched out to that extent, nipple sensation loss is almost a guarantee and any hope of downsizing in the future to a more natural look without a lift is not possible.

I would not say systemic health per se is at significant risk with these devices, but the risk of postoperative complications such as infection, implant extrusion, skin and nipple loss, and implant malpositions is significant- a lot higher than a more standard size augmentation and more than a lot of surgeons want to deal with.

I think the majority of people who go into this field really like restoring and enhancing a persons body to make them look and feel better about themselves- but I think that when we delve into the realm of extremely large breast augmentation many doctors feel that we are leaving the realm of rejuvenation/enhancement and entering the field of extreme body modification not unlike radical piercings, tongue bifurcating, or subcutaneous horn placement that some doctors may view go against the Hippocratic Oath of "First doing no harm".

Published on Jul 11, 2012

I am not sure what size "XL" means in your case. For the purposes of this discussion I will assume you mean implants in the 700-800 cc range or custom implant sizes larger then this. The main concern with larger implants is the problems that they will typical cause with your breasts over the long haul. These larger implants, for lack of a better way to desribe it, are usually crammed into a space that really cannot accomodate them. This creates pressure on the breast tissue above the implant as well as the rib cage below implant. Essentially this crushes and thins the overlying breast tissue and can actually hollow out the rib cage beneath the implant. As the breast tissue thins out the implant as well as any folding in the implant shell become more obvious and problematic. The weight of these implants can also cause problems by stretching out the breast skin. This can lead to severe bottoming out (very droopy breast). When these issue occur they are difficult if not impossible to fix, can be very risky to attempt to fix, cost a lot of money to try and fix and often produce less then ideal aesthetic results. There is nothing wrong with large implants but you need to understand some of the issues they can create down the road that may not be fixable. I think the negativity attached to large implants has more to do with trying to keep you out of trouble then anything else.

Published on Jul 11, 2012

The reason most surgeons like myself don't like them is because their cosmetic result is poor, and they are prone to higher rates of complications: double bubble, capsular contracture, excessive tissue stretch and thinning, and malposition. Further, they don't age well. You may look good in the beginning, but time is not kind to those with over sized or XL HP implants. Yes, the surgeons that espouse their virtue are warriors of a sort. They either don't care, or they aren't paying enough attention to the outcome of their patients.

Published on Jul 11, 2012

XL implants do have risks / potential complications associated with them but in my practice, as long as the patient understands what they are undertaking and how future events may change things for them (as they get older, they may no longer want the XL Implants and therefore reduction in size +/- breast lifting may be necessary) I do my best to achieve their goals.
Experience does affect the results of XL breast implants.

Published on Jul 11, 2012

Thank you for asking. The concern with larger breast implants is regarding the patient's body being able to handle the size. Larger implants put additional stress on the breast tissues if the breast envelope cannot sufficiently handle it. The larger the implant, the more aware the patient and PS need to be about this. Seeing a board certied plastic surgeon can help determine if a patient's anatomy and tissues are reasonable for a larger implant. Hope that helps.

Published on Jul 11, 2012

Extra Large is not an easily quantified size- a 400 cc implant on someone 5 feet and 90 lbs is extra large for that person. The risks of complications (early and late) requiring implant removal goes up as the size of the implant increases, and once they are removed you are almost certainly going to be left with stretched-out skin that will require a breast lift to fix. Putting them in is not particularly difficult for the surgeon- they really would have your best long-term interests at heart if they discourage you from choosing an over-sized implant.

Published on Jul 11, 2012

The size choice of implants is up to the patient. However a surgeon may recommend a patient not go too large based on your body's charactetistics and previous surgery experience. This is what some women want from the surgery. It is usually not a problem, within reason. There should be some consideration regarding your body frame, and different aspect of your breasts prior to surgery that may include the amount of muscular and glandular tissue you have and the laxity of your skin. Please discuss all of these issues with your surgeon as you consider your decision.

Published on Jul 11, 2012