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Archive for the ‘testicular implants’ Category

OR Snapshots – Silicone Testicle Implant Replacement

Monday, November 20th, 2017

 

Testicle implants have been used for decades in various forms. It is the only known surgical method to replace the lost volume and shape occupied by a natural testicle. Originally they were composed of solid silicone but that material was removed from commercial availability as a result of the silicone breast implant issues in the early 1990s. They were subsequently replaced by saline-filled implants, a dubious choice for the scrotum, but was the only implant material available at the time.

Newer custom testicle implant devices are now available on an individual patient basis. They are much softer than that of saline implants and have no risk of implant deflation. Because they are done on a custom basis the size options are much greater and better size matches to the opposite side now exist.

In almost all cases of testicle implant replacement that I am asked to performed, due to size and feel issues with the indwelling implant, a saline testicle implant is encountered. But in a most recent case of a twenty-five year old implant replacement, an old silicone implant was encountered. It was smaller than the opposite side and was very highly positioned. It also had a mesh patch on one of its ends presumably to encourage tissue adherence/fixation…wbich it clearly had done with an adverse aesthetic effect. (highly positioned and a feeling of intermittent tugging) Its custom replacement was 25% larger, made of a much softer solid silicone material and a new pocket was made much lower in the scrotal sac.

Their is a long history in testicle implants of wanting to fix the implant into position. This is a curious implant technique as it can be the cause of a high implant position and some level of chronic discomfort. This harkens back to the early of breast implants when various methods were used to fix the implant to the chest well. Like a breast implant, a testicle implant should be allowed to float freely and let it seek its own natural low position in the scrotal sac.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Extra Large Custom Testicle Implants in Penile-Scrotal Disproportion

Saturday, September 23rd, 2017

 

Background: Testicle implants are an accepted and low risk device that can effectively create the appearance of a testicle in the scrotal sac. Available in saline-filled and solid silicone styles, their effectiveness is judged by having an adequate size and feeling soft and slightly compressible. Because of larger sizes and a softer feel to the implant, the solid silicone device would be judged to be superior in the scrotal location.

IIn testicular restoration one the most important criteria is size of the implant. While solid silicone implants are available in five different sizes, up to 5cms in linear length or 5.5vm in arched length, there are men where even larger implants are needed. Such implants can be made on a custom basis to dimensions that are only limited by the stretch of the scrotal skin.

The need for extra large testicle implants is most commonly needed in aesthetic penile-scrotal disproportion. This can be created by penile enhancement procedures where the length and girth of the penis becomes bigger and disproportionate to the natural underlying scrotum. While there are no established measurements or numbers to determine the aesthetic proportionate relationship between penile and scrotal size, patient perception of it becomes the determining factor. 

Case Study: This middle-age male had a history of  having both penile enhancement (fat injections and a pump) and saline testicle implants. He was bothered by the relatively small size of his testicle compared to that of his penis. To meet his aesthetic implant replacement size, custom testicle implants were made with a linear dimension of 6 cms ands and arced length of 6.5 cms.

Under general anesthesia a median raphe incision was used to access both sides of the scrotum. A thick layer of  tissue was maintained in the middle. The saline implant pockets were opened and the devices were removed including their fixation sutures. The capsule was released in many linear lines and the scrotal pockets stretched and expanded.  The old saline implants were compared to the new implants. The new custom silicone testicle implants were then inserted and a three layer closure done. A semi-circumferential ring of skin was removed from the base of the penis to get rid of a ‘turkey neck’. (loose skin)

The need for custom silicone testicle implants is indicated when standard sizes are inadequate. Penile enhancements can create penile scrotal disproportions where such larger implants may be needed.

Highlights:

  1. Large testicle implants are only available in silicone and must be custom made.
  2. The scrotal tissue pocket can be released by capsulotomies and skin stretching to accommodate much larger implants.
  3. Custom testicle implants may be needed when their is significant aesthetic penile-scrotal disproportion.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Silicone Testicle Implant Replacement

Monday, September 11th, 2017

 

Background: Testicle implants are available in saline filled and solid silicone types. The solid type of implant would generally be considered superior as it can never fail or deflate over the patient’s lifetime. But despite this advantage, it still has to be the right implant size, shape and feel for an optimal aesthetiuc outcome. In addition the pocket and location of the implant should be as close as possible to the opposite side. (even though natural testicles do not hang symmetrically)

While silicone implants do exist for testicle implants, they are not all the same and are produced by different manufacturers. Beyond the size limitations of some scrotal implants, the softness of them is also a very important feature. The lowest possible durometer or silicone elastomer cross-linking should be done to ensure they have the greatest compressibility while still being a cohesive structure.

Case Study: This 50 year-old male had a history of testicular cancer with a solid silicone implant placed after testicle removal and radiation therapy. While the implant was clearly better than no replacement at all, its size was inadequate. Also its smaller size and higher position inside the scrotum allowed it to fall back between the legs…an uncomfortable and annoying issue that constantly required repositioning.

Under general anesthesia, a midline scrotal incision was used as a scar was already in this location. The existing implant was removed and a capsulotomy performed to lower the implant pocket in the scrotum A permanent implant stores was also removed from the prior surgery. The new implant replacement’s size and shape could be seen compared to the removed implant. The softness of the new implant could be seen to be greater than the previous implant.

His immediate result at the end of the operation could be seen to have improved scrotal symmetry. It is presumed that the larger implant with a lower pocket will prevent posterior migration between the legs when erect.

Highlights:

  1. The best silicone testicle implant is one that has adequate size, shape and a very soft feel.
  2. Malpositioning of a testicle implant requires a capsulotomy and pocket adjustment.
  3. A midline scrotal incision is the best approach for repositioning the implant pocket.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Testicular Implant for Correction of Smaller Testicle and Scrotal Asymmetry

Monday, July 3rd, 2017

 

Background: Testicular reconstruction can be effectively done to replace a lost testicle and improve scrotal symmetry. Such scrotal implants can be either saline (fluid-filled) or made of a very soft solid silicone material.  I prefer to implant the solid silicone devices as they feel more natural and will never need to be replaced due to device failure.

The most logical use for testicular implants is to replace a lost testicle. Whether that loss has occurred from cancer, trauma, a medical condition or a congenital absence, the necessary space inside the scrotum can be created to place an implant. The scrotum is a suspended dual-chambered sac of skin and muscle so a separate space on the absent side can be created that keeps it anatomically separate from the opposite normal testicle via the scrotal septum.

Significant scrotal asymmetry can be caused even though one has two testicles. If one testicle is much smaller than the other one the sac will be very discrepant in size and shape. Adding an implant to the smaller testicle side can be done without removing the existing testicle. While the function of the smaller testicle is not known, it is prudent to keep it for whatever function it may serve.

Case Study: This 30 year-old male had a history of a right undescended testicle. Surgery was done as a child to bring it down into the scrotum which was successful. However the testicle always remained much smaller than the opposite side and was positioned high up in the scrotum. He desired as an adult better scrotal symmetry.

Under general anesthesia his existing mid-scrotal scar was used as access for a right testicular implant. The right testicle was identified and retracted superiorly. A submuscular pocket was made into the lower scrotal sac into which was placed a #4 size soft silicone testicular implant.

For the aesthetic correction of scrotal asymmetry due to a smaller testicle on one side, an implant can be placed into the same scrotal sac. One does not have to remove the existing testicle given its high scrotal position and its unknown contribution to male sexual health.

Highlights:

  1. Scrotal asymmetry can occur having both testicles with one being smaller than the other.
  2. A testicle implant can be added to the scrotum on the smaller side for improved symmetry without removing the smaller testicle.
  3. A solid soft silicone implant creates s more natural feeling testicle.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Silicone Testicle Implant Replacement

Monday, June 19th, 2017

 

Background: The only viable replacement for a lost testicle is that of an implant. Placing an implant in the scrotal sac has a very low risk of any significant complications such as infection or a hematoma. This because the anatomy of the scrotum is fairly straightforward and the testicular replacement must merely provide a static volumetric substitution for the space previously occupied or would have been occupied by the normal testicle.

The aesthetic demands of a testicular implant is what represents the most common postoperative problems with them. Size discrepancies (usually too small), an implant that feels too firm and lack of implant mobility are the most common complaints with testicular implants. These have all been associated primarily with saline-filled implants whose hydrodyamic properties are not necessarily an ideal substitute for a more naturally solid soft tissue structure.

What is unique about the aesthetics of the testicle is that how it feels and moves about between the upper inner thighs is equally, if not more important, than that of its appearance. (scrotal symmetry) The scrotal sac ends up being partially compressed between clothing and the skin which creates awareness of how it feels. While the scrotum is a suspensory soft tissue envelope, this is not how it is primarily perceived. (we spent a lot more time in clothes than out of them)

Case Report: This 35 year-old male had a history of a left saline testicle implant being placed for a congenital undescended testicle. The implant felt too firm and had a visibly smaller size compared to the opposite normal right side.

Under general anesthesia and using the existing high scrotal scar, the implant pocket was opened  and the indwelling implant removed. A capsulotomy was performed to expand and lower the implant pocket. A solid soft testicle implant measuring 5.0 x 4.0cms was chosen as the replacement which appeared about 30% bigger in overall volume. Better scrotal symmetry was achieved with its placement and closure.

Sizing testicle implants can be challenging but almost always the size needs to be bigger than what one would think. Many patients often end up between two sizes and it is important to ask the patient before surgery if they would prefer to be a ‘little too small’ or a ‘little too big’.

The feel of a testicle implant is often very relevant and may supersede that of a size discrepancy. It is hard to get around the material feature that a saline implant just doesn’t feel normal, it almost always feels too firm particularly if it has been filled to its minimal volume or has any amount of overfill at all. Low durometer solid silicone implants always feel more natural as they replicate the compressibility of a normal testicle better

Case Highlights:

  1. Replacement of saline testicle implant with a solid silicone one results in a soft more natural feel.
  2. To accommodate a larger implant in the scrotal sac, a release of the scar tissue (capsulotomy) is usually needed.
  3. Sizing of the new implant is best done by measurements taken from the existing implant during surgery and choosing a new implant with larger dimensions

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Long Term Silicone Testicular Implant Results

Saturday, April 1st, 2017

 

Background: The replacement of a congenitally absent or surgically removed testicle is done historically by a saline implant. Borrowing from saline breast implants, a small fluid-filled shell is used as the testicular replacement. This has been the standard device used as a testicle implant since the early 2000s. It is currently the only FDA approved device for such indications.

While it is a marvel of engineering to make such a diminutive device that can be filled with a few ccs of fluid, it is a conceptually flawed device. The natural testicle is not hard like a fluid filled device nor does it ever have the risk of spontaneous deflation. Its size options are also limited and trying to increase their size by greater fluid fill only makes the implant get even harder.

One unique phenomenon that can happen to testicular implants is that of capsular contracture. While well known in breast implants it can occur in any spherical device that is placed in the body. The surrounding scar layer can thicken and contract, making the implanted device feel firm and potentially distorted. As the only other spherical device placed in the body other than breast implants, this same postoperative problem can develop in testicle implants as well.

Case Study: This younger male had a saline testicle implant placed as reconstruction from a lost testicle from a varicocele. He had it in place for three years but never liked it because it felt too hard, did not move and was smaller than the other side. It also was positioned too high and caused noticeable scrotal asymmetry.

Under general anesthesia and through a high scrotal incision, his existing saline implant was removed. A capsulotomy was performed to extend the pocket back down into the  lower end of the scrotum to match the other side. A larger 5.5cm oval  ultrasoft silicone testicle implant was placed in to the new pocket. His immediate intraop result showed a much improved scrotal asymmetry.

One year results showed a soft implant feel and good scrotal symmetry. No recurrence of the capsular contracture occurred. He was very pleased with his results and had developed new self-confidence.

The ultimate success of a testicle implant is that is matches in size that of the opposite testicle and remains soft and easily moveable. Since it is non-functional its cosmetic characteristics are essential. Ultrasoft silicone implants have numerous advantages over saline, the least of which is that they can never fail or deflate.

Highlights:

  1. Saline testicle implants often feel hard and are too small.
  2. A small hard testicle implant can be prone to capsular contracture, increasing scrotal asymmetry.
  3. Silicone testicle implants offer soft long-term results for a more natural scrotal appearance and feel.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Silicone Testicular Implant Replacement

Saturday, July 23rd, 2016

 

Background: The most common device for replacement of a lost testicle is that of a saline implant. While this is the only FDA-approved implant for this purpose, it is actually not a good concept for a prosthetic device sitting in the scrotal sac. It most certainly does not feel natural (more firm than a natural testicle) and often is undersized for some men. In addition the concept of attaching it inside the scrotum using a fixation suture is prone to causing a tethering effect. Because it is a fluid-filled device a saline implant has a lifelong risk of failure by rupture of the containment shell. This will result in the need for future replacement surgeries.

A soft but solid silicone implant is far superior as a testicle implant. Very low durometer silicone that feels extremely soft (squishy) has far better material properties to reside inside the hanging and mobile scrotum. Because it is a solid implant it can also never deflate.

Exchanging a hard saline implant with a larger silicone testicle implant requires management of the capsule. If the existing implant capsule is not released (capsulotomy) or in some areas removed (capsulectomy), the implant will remain positioned too high. While no two testicles are every at exactly the same level, significant horizontal positional asymmetries are aesthetically undesireable.

Case Study: This 35 year-old male had a history of a left testicular implant placed in his teenage years after a traumatic injury caused loss of the testicle due to torsion. The implant was replaced with a larger saline implant more recently but he was unhappy with the aesthetic result. It was positioned too high and felt tethered into this position. He presented for a silicone testicular implant replacement.

Testicular Implant Capsulotomy Dr Barry Eppley IndianapolisSilicone vs Salinje Testicular Implant Dr Barry Eppley IndianapolisUnder general anesthesia his existing high inguinal incision was reopened and the indwelling saline implant removed including the fixation sutures. A new silicone implant was chosen that was 1/3 bigger. With the implant removed the scrotal sac was inverted through the incision and the implant capsule released and partially removed. This allowed the pocket to be developed to the bottom of the scrotum. The new silicone implant was then inserted. The incision was closed in layers with no fixation suture used to the implant..

Remove and Replace Testicular Implant result Dr Barry Eppley IndianapolisTesticular Implant Replacement Surgery result Dr Barry Eppley IndianapolisSilicone is a superior testicular implant material because it is softer, comes in larger sizes and will never need to be replaced due to device failure. When replacing an unsatisfactory hard saline testicular implant, almost always a larger size is needed.

Highlights:

1) Saline testicle implants can feel too firm and may be of inadequate size for some men.

2) Replacing a high tethered saline testicle implant requires a scrotal sac capsulorraphy.

3) Silicone testicle implants offer a much softer feel and bigger sizes than saline implants.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Silicone Testicle Implant Surgery

Sunday, May 22nd, 2016

 

Background: While many body parts can be partially replaced or augmented, few can be completely replaced in their totality by a single prosthesis. Such is the case with the testes undoubtably due to its small size and location in the hollows of the scrotal sac. While a testicular implant will not resume the functions of the natural testicle, it can create the external appearance that a pair is present.

The physical and aesthetic requirements of a testicular implant are fairly simple. It should replicate in size and shape that of the opposite testicle. It should also feel soft and supple, not only to match the feel of the opposite testicle, but be easily compressible given its near continuous exposure to external forces.

Testicular Replacement Implant Dr Barry Eppley IndianapolisThe solid but very soft silicone material fulfills all requirements needed for a testicle implant. It is extremely compressible with a very low durometer silicone composition. It is available in sizes up to 5 x 4 cms which will work for most men. A custom testicle implant can be made for even larger sizes.

Case Study: This 55 year-old male lost his right testicle at fourteen years of age due to an unknown pathology. He had a long scar on his right scrotal sac that went its full vertical length. He had always felt inadequate and embarrassed his entire life with a missing testicle and was often referred to as ‘single shot’ throughout his life. He was completely unaware that a testicle implant even existed until very recently.

Right Scrotal ScarTesticular Implant intraoperative sizing Dr Barry Eppley IndianapolisUnder general anesthesia the upper portion of his scrotal scar was reopen and a pocket made into the right scrotal sac. The skin was very elastic and a pocket of adequate size was easily made. The largest size silicone testicle implant was used which matched well to his opposite left normal testicle. The scrotal sac was closed in layers and dissolveable sutures used for the skin.

Right Testicular Implant Reconstruction result Dr Barry Eppley IndianapolisHis immediate intraoperative result showed a good match between the implant and the normal testicle. They had a very similar feel externally.

The use of a silicone testicle implant provides a natural feeling and looking testicle that creates good scrotal sac symmetry. It is a procedure that has minimal discomfort afterward with a rapid recovery. One can return to all normal activities within a few weeks after the procedure.

Highlights:

1) Testicular implants can be done at any age no matter how long ago the natural testicle  was lost.

2) A soft silicone testicular implant provides the most natural feeling replacement prosthesis.

3) Recovery from testicular implant surgery is rapid with a return to all normal activities in a few weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Solid Silicone Testicular Implant Reconstruction

Saturday, May 14th, 2016

 

Background:  Lost of a testicle in a male can occur for a variety of reasons. Congenital absence, an undescended testicle, infection, traumatic injury, varicoeles and other pathologies can all cause an absent scrotal sac on one side. While a man can fully function in all capacities with one testicle, there is psychological benefit for some men to feel and be seen as ‘whole’.

The creation of a normal paired scrotal sac can be done with a testicular implant. There are two types of such body implants currently available. An FDA-approved saline filled testicular implant an a solid silicone contoured caving block in the shape of a testicle. A solid silicone testicle implant is preferred in my hands because it is a permanent implant that will not fail or need to be replaced because of device failure. It can also withstand high levels of impact and compression without risk of rupture or implant deformation.

Case Study: This 35 year-old male lost his right testicle due to several years previously due to benign testicular tumor. He had an otherwise normal scrotal sac skin and had never received radiation for his tumor. Having only one testicle made him very self conscious and was a source of psychological concern.

Right Testicular Implant result Dr Barry Eppley IndianapolisTesticular Implant and Incision Dr Barry Eppley IndianapolisUnder general anesthesia, he had a size 4 testicular implant placed through a high scrotal incision of 3 cms. The soft compressible features of the implant made it possible to insert a 4.6 cm side implant through a much smaller incision than its width. The inserted implant had a fairly good size match to the opposite left testicle and a very similar feel as well.

Testicular Replacement Implant Dr Barry Eppley IndianapolisSolid silicone testicular implants come in a variety of sizes with the maximum dimensions of 5 x 4 cms. Such an implant size may seem large but it is surprising how often it is needed when men are intraoperatively sized.

Men who are missing a testicle should find reassurance that it can be replaced with an implant that feels very natural in sizes that can match the opposite testicle. The implant operation is short with a similarly limited recovery time as well.

Highlights:

1) Reconstruction of a lost or congenitally absent testicle can be safely performed by a silicone testicle implant.

2) The best testicular replacement is a soft solid silicone testicle implant which can never fail or need to be replaced.

3)  A silicone testicle implant can be placed through a small (3cm) skin incision placed high near the scrotal-groin crease junction.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Silicone Testicular Replacement

Sunday, January 24th, 2016

 

Background: Testicles are naturally paired structures residing in the scrotal sac. Loss of a testicle can occur for a variety of reasons which in an adult male is usually due to cancer or a traumatic injury. Scrotal sac asymmetry obviously occurs when only one testicle remains. Whether having only one testicle is a concern will vary for each man so affected.

Softer Silicone Testicle Implant Dr Barry Eppley IndianapolisFor those men bothered by scrotal sac asymmetry, testicular replacement surgery can provide a straightforward and low risk solution. There are two implant options for testicular replacements, saline-filled and solid silicone. There is little question that the ultra soft, low durometer silicone testicular implant offers the most natural feel. In addition, they offer no risk of mechanical failure over a patient’s lifetime. This is unlike saline testicular implants which have an increasing risk of spontaneous deflation the longer they have been implanted.

Testicles obviously are different in size for each man. Presumably a pair of testicles has the same size although size discrepancies in the same man are known to exist. It would also be anticipated that the larger the man, the bigger the testicles are. Thus, a range of silicone testicular sizes are needed to properly service the broadest range of male patients. Size ranges exist from 2.5 x 2cms to 5 x 4 cms. Sizes can be determined by preoperative measurements or the use of intraoperative sizers.

Case Study: This 40 year-old man had his right testicle removed several years previously due to cancer. He was having other surgical procedures and desired to have it replaced at the same time. He had not had radiation after his testicular cancer surgery.

Testicular Implant Sizing Dr Barry Eppley IndianapolisUnder general anesthesia a 4.5 x 3.5cm silicone testicular implant was placed into a created scrotal pocket. This was done through a high scrotal incision placed near the groin crease. The size of the implant was based on measurements and feel of the opposite testicle with a range of implants available at the time of the procedure.

Right Testicular Replacement result Dr Barry Eppley IndianapolisThe proper size of a testicular replacement is just as important as the implant having a similar feel to the opposite normal testicle. Preoperative measurements can be done before surgery to have the proper implant size available for surgery. The alternative strategy is to have a variety of testicular replacement sizes available and made the size judgment during surgery.

Highlights:

  1. Lost of a testicle in an adult male creates scrotal asymmetry and potential self-esteem issues.
  2. Soft silicone implants offer the most natural form of testicular replacement.

3. The sizing of testicle implants can be done by preoperative measurements or intraoperative sizing.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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