Custom testicle implants are, by definition, implants that are both larger in size and composed of ultrasoft solid silicone. Such implants are usually in the size range of 6.0 to 7.5cm in size which are beyond standard sizes only available up to 5.0cms. In placing these larger testicle implants there are multiple technical details to consider.
The first decision in custom testicle implants is whether they would be a solid side by side implant placement or an internally hollow wraparound implant approach. The solid side by side design is preferred in most cases as it has less postoperative risks which would be expected given a solid implant vs any form of containment implant. (tesicle displacement out of the implant)
The incision to place these implants is a midline raphe skin incision that is closer to the bottom third of the scrotum. This incisional location is preferred as it enables the pocket to be developed as low as possible. Even though the size and weight of the implant will cause the scrotal skin/sac to stretch, placing the implants in the lowest possible position is essential long term to ensure that it be where they will end up.
Only a small raphe scrotal skin incision is needed…usually no more than 3.5cms. This is all that is needed regardless of the size of the implant. The elastic deformation property of the implant material allows its passage through an incision that is smaller than the actual width of the implant. Its the same principle as to how breast implants are placed.
After making the incision the two developed pockets must be kept separate. A tissue layer must be maintained between the two created pockets. As the body will naturally make a layer of scar around the implant (capsule), it is important that the capsule formation is created around two separate implants rather than creating one conjoined capsule around both implants.
In implants of these sizes the first implant inserted will occupy the majority of the initial scrotal space. When the second implant is inserted it will be pushed up higher or lower. Regardless of which direction it goes there will be some initial implant asymmetry because of the tight space. While the implants will eventually relax and settle this asymmetry in position will likely remain.
Once the implants are inserted there is a need for a secure multilayer tissue closure. This should be at least three, and preferably, four layers including the skin. The final skin layer is a fine resorbable suture that is covered with a skin glue as a sealant/dressing. While a scrotal support is applied at the end of the surgery, the benefits of its longer term use is not significant.
The larger size of custom testicle implants does not mean they need a large scrotal incision to place. It does mean, however, that two separate pockets need to be created and a meticulous multilayer close needs to be done.
Dr. Barry Eppley
Indianapolis, Indiana