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Background: While testicle implants have been available and used for decades their aesthetic effects have not always been good. I have seen and replaced many testicle implants placed for reconstruction and the reasons for replacement have always been the same. It is a classic triad of symptoms that includes implants that are too small, too firm and unnatural in feel and position. These aesthetic symptoms occur because there is a direct basis for comparison…the opposite normal testicle.

Saline and most silicone testicle implants I have removed do not feel like a normal testicle and are much firmer. I have seen a few silicone gel testicle implants that feel much better but such implants are not available in the U.S. and are unlikely to ever be in the foreseeable future. These material limitations are overcome by the use of soft durometer solid testicle implants which feel much more natural. Even very large solid custom testicle implants can feel natural with an innovative inner chamber design. Why surgeons continue to use these firmer testicle implants is likely an unawareness of implant options and lack of aesthetic appreciation of implant differences.

Of all the ‘problems’ with testicle implants that I see the one that is the most perplexing is the use of suture fixation. While the natural testicle is connected by a neurovascular cord for physiological purposes (retraction and protection) an implant doesn’t need this anatomic feature. It will become encapsulated anyway and its initial ‘free floating’  state will be controlled by this natural process. The end goal is a lower position in the scrotum not higher. Suturing an implant in place aggravates the natural tendency to be higher in the scrotum anyway from the typical groin or high scrotal incision used. (which I don’t use but for the reason of the original testicle removal may have been used)

Implant size is another common problem with testicle implant replacements. With standard sizes up to 5cms this should satisfy almost all testicle implant replacement needs. Bit if bigger is needed this is when the custom implant process is used. It its not complicated but most surgeons generally don’t think of it due to lack of awareness that such an option exists. 

Case Study: This male had a prior history of loss of his left testicle un an accident as a teenager. He had an implant replacement eventually done which felt too firm, was too high and too small for his aesthetic needs. He desired a new left testicle implant replacements and concomitant right testicle enhancement by a side by side technique. His natural right testicle had shrunk down due to testosterone supplementation.

Custom testicle implants were designed per his specifications at 6.7cms in size.

Under general anesthesia and through a low midline 3cm raphe incision, the left testicle implant capsule was identified and opened. In trying to push the implant out it was prevented from doing so by a ‘restriction’. It could be seen that this was a solid very firm silicone implant. 

The restriction turned out to be a prolene stitch holding in place. The suture was released and the implant removed which had an oblong shape with a ‘handle’ on its one end to be used for the suture fixation.

In comparing the removed implant vs its replacement the size, shape and feel differences could be appreciated.

The left implant pocket was expanded by capsulotomies and the new larger custom implant placed with complete soft tissue coverage/closure.

An implant pocket was developed on the right side maintaining a soft tissue septum between them. The natural testicle was exposed and pushed up towards the groin. In these larger custom implants it is always the second implant placement that seems daunting as the first implant placement takes up a lot of space inside the scrotum. But with effort the second implant always makes it in.

With midline incision closure in tighter scrotums the large implants are going to be driven upward towards the groin as the scrotum will need some time to relax.

Contemporary concepts in testicle implants and surgical placement allow for better aesthetic results in both replacement and enhancement situations. Their benefits are fully seen when these two implant concepts are combined in a single patient…an outcome that would not be possible without embracing the custom implant design process.

Key Points:

1) Many older testicle implants are too firm, too highly positioned in the scrotum and are fixed by a suture.

2) Contemporary testicle implants have been sizes, are softer and are positioned lower in the scrotum for a more natural appearance and feel.

3) Testicular implant replacement can be combined with opposite testicular implant enhancement for an overall better scrotal effect.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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