Thoughtful breast implant selection is the key to a natural, long-lasting result. The following case illustrates one of the potential problems associated with poor implant selection – when the implant diameter exceeds the pocket dimensions.


Lesa, a 36-year-old woman, presented for evaluation and treatment of a failed left saline breast implant. Her initial breast augmentation was performed eight years prior in California; the implants were placed in the subpectoral position, through a periareolar incision. Her augmentation increased her breast size from a 34 A-cup to a 34 D-cup. Four years after her breast augmentation, Lesa experienced a deflation of her left breast implant. Lesa returned to her original surgeon, who replaced her left breast implant, and performed a right capsulotomy for a capsular contracture that was also present.

Following that implant replacement and revision surgery Lesa had no problems for three years. Then, about one year ago, she began to develop a recurrent capsular contracture of the right breast. The left breast has remained soft without contracture.

Lesa then experienced another (for the second time) left breast implant deflation. She contacted her plastic surgeon in California, contemplated traveling back to California, but subsequently decided to seek care locally in Milwaukee. I saw her in consultation three weeks after her deflation occurred.


Lesa was 5’2″and weighed 140 pounds. On examination, her left breast was obviously smaller and lacked projection because of the failure. The width of each breast (breast base-width) was no larger than 12.5 cm on each side. The right breast demonstrated a grade III capsular contracture. Some folding of the breast implant shell inside the contracture was noted. In the lateral aspect of the right breast there was a palpable “knuckle” where the implant shell was folded on itself. The left breast implant could be felt within the breast as well, but was soft because of the volume loss associated with the deflation. The presence of capsular contracture could not be assessed on the left side because of the implant deflation.


I recommended replacing the left breast implant through the previous periareolar incision; if any capsular contracture were present it would be treated as well. Since the right breast implant was eight years old, I recommended replacing this implant as well; a right capsulectomy would be necessary so that a larger space could be restored for the right implant. Lesa agreed.

Thought Process

Lesa’s surgical records were not available. But I was able to learn that her initial augmentation was performed with McGhan style 68, moderate profile, smooth, round, saline-filled 450 cc breast implants (McGhan model 68–450); the implants were filled to a volume of 450 mL.

I reviewed Lesa’s current breast implant dimensions prior to making a final implant selection. A McGhan style 68 450 cc implant has a diameter of 13.7 cm and a projection of 4.6 cm. That was surprising to learn, given that Lesa’s breast measured only 12.5 cm wide. The diameter of her implant was 1.2 cm greater than the external width of her breast, and therefore even wider than the width of the internal implant pocket.

Typically, when performing an implant replacement for deflation, the surgeon selects an identical implant for the replacement. However, in Lesa’s case, it was evident that her current implants had a larger diameter than her breast width. I had serious concerns that the large diameter of her 68-450 implants where the reason why Lesa had experienced a previous breast implant failure, and then again experienced a second failure only a few years later. Lesa’s breast implant failure was likely due to fold flaw failure as a result of the large implant being folded inside a smaller pocket. Shell folding is responsible for “fold flaw failure” — failure that occurs as a result of a flaw (hole) that develops in the implant shell at a location where it is folded.

The best potential solution was to select a smaller diameter breast implant.  I recommended that the diameter of her breast implants be decreased to more closely match the base-width of her breast.  A smaller diameter implant would fit within the internal pocket dimension and reduce the risk for shell folding. But since Lesa wanted to maintain her 450 mL volume, only a limited change in the implant diameter could be made.

Implant Selection

I selected a moderate profile Natrelle style 68, smooth, round, 390 cc saline breast implant (Natrelle model 68-390; what used to be McGhan is now Natrelle).  A Natrelle style 68 390 cc breast implant has a diameter of 13.0 cm and a projection of 4.5 cm. The diameter of this implant was still slightly larger than the width of Lesa’s breast, but was a substantial enough decrease to more closely match the breast , and yet still be able to achieve a 450 mL final fill volume. And in fact, as the implant is over-filled the diameter is likely to decrease slightly more.


I was about to learn that I made a very good decision.

The failed left implant was removed through a periareolar approach, utilizing the previous incision. When the implant was removed, a deep crease was present within the anterior silicone shell (where the upper third of the implant had been folded within the subpectoral pocket). At the peripheral edge of the implant, where the crease was located, was a small hole – a hole that clearly resulted from fold flaw failure. The constant stress of the folded shell, at the implant edge, gradually weakened the integrity of the shell at that point resulting in failure.

The right implant was removed in a similar fashion, and also had a deep crease extending across the entire anterior surface of the implant shell. Subtotal capsulectomies were performed, and the right inframammary fold was adjusted with internal sutures, before the Natrelle 68-390 implants were placed and filled to a volume of 450 mL. This smaller diameter implant fit appropriately within the pocket and gave a natural shape to the breast.


The above photograph shows the saline breast implants with deep creases in the silicone elastomer shells. The arrows help to delineate the creases which were more significant than they appear in these photographs. Note that the location of the crease on the breast implant demonstrates that these implants were significantly over-sized for the pocket in which they were placed; about one-fourth to one-third of the implant was folded over. The needle points to the location of the hole in the left implant.


I have never seen a crease in silicone elastomer like this before. Silicone elastomer is a very resilient material and to actually put a visible crease (fold) into it demonstrates just how tightly the previous implant fit, and how poorly sized it was. Lesa’s second implant failure represents an excellent example of fold flaw failure – a hole in the shell resulting from stress at this fold; and I suspect her first implant failure resulted in the same manner. This reinforces the importance of proper dimensional planning and implant selection.