Restoring Breast Volume in High BMI Patients

A Single-Center Review of Breast Reconstruction Using Hyperinflated Saline Implants

Milind D Kachare, MD; Swapnil D Kachare, MD, MBA; Bradley J Vivace, MD; Omar Elfanagely, MD; Brooke Barrow, MEng; Adam O'Toole, MD; Alyssa M Simpson, MD; Rachel Safeek, MPH; Joshua H Choo, MD; Terry M McCurry, MD; Bradon J Wilhelmi, MD


ePlasty. 2022;22(e30) 

In This Article

Abstract and Introduction


Background: Breast reconstruction in the obese patient is often fraught with poor patient satisfaction due to inadequate volume restoration. The off-label hyperinflation of saline implants is a direct yet controversial solution to this problem, with limited studies in the literature. This study sought to determine the safety and efficacy of this technique for breast reconstruction.

Methods: A retrospective chart review was performed to identify all patients with a body mass index (BMI) greater than or equal to 30 kg/m2 who underwent breast reconstruction between the years 2013 to 2020 with saline implants filled beyond the manufacturer's maximum recommended volume.

Results: The 21 patients identified had an average age of 49 years. The mean BMI was 39.5 kg/m2. A total of 42 implants were placed; 34 were 800 mL, 4 were 750 mL, and 4 were 700 mL. The average overfill volume was 302 mL (138%). Mean follow-up was 65.0 months. Of these, 1 (4.8%) patient with a history of chest wall radiotherapy underwent reoperation for unilateral implant exposure 27 days after the index procedure, no patient sustained spontaneous leak or rupture, and 1 patient had unilateral deflation following emergent central line and pacemaker placement 2 years after the implant was placed for an unrelated cardiovascular event.

Conclusions: Hyperinflation of saline implants beyond the maximum recommended volume may be considered for volume replacement in obese patients undergoing implant-based breast reconstruction. This practice is well tolerated, has a complication rate comparable to using implants filled to the recommended volume, and has the potential to restore lost breast volume in the obese patient post mastectomy.


Our society is in the midst of an obesity epidemic, with over 93 million adults affected.[1] With an increasing percentage of obese patients, there is a concurrent rise in the number of breast cancer diagnoses. In 2021, an estimated 281,550 female patients will be diagnosed with breast cancer in the United States alone.[2] This is in part due to the increased risk of breast cancer seen in patients with higher body mass index (BMI).[3] Mastectomy remains a popular treatment and is the standard of care in certain circumstances.[4] The reconstructive options following mastectomy continue to evolve; yet despite advancement in surgical techniques, restoration of breast volume in the obese patient remains a significant challenge to plastic surgeons.[5]

Obese patients experience lower rates of satisfaction with reconstructive cosmesis.[6] The replacement of the sizable amount of native breast tissue extirpated with mastectomy represents a formidable challenge given the largest available implant has a volume of 800 mL with a recommended maximum fill value of 960 mL in the United States.[7] Due to this constraint on implant size, methods to restore volume include autologous reconstruction with or without implant placement; however, this can expose the patient to increased operative time and increased incisions, both of which are inherently riskier in obese patients.[8]

A more elegant solution for attempting restoration of native breast volume in obese patients is to hyperinflate saline implants beyond the manufacturer's recommended value. Greenwald et al studied the mechanical properties of saline implants and concluded no significant differences existed in strength, elasticity, and toughness of the implant shell in overfilled implants as compared with those filled to the recommended maximum volume.[9] Similarly, Hallock studied the mechanical properties of tissue expanders and found overexpansion to 15 times the stated maximum volume was safe without risk of implant failure.[10] In the setting of breast augmentation, overfilling beyond the recommended maximum fill volume has been associated with increased implant longevity and higher patient satisfaction.[11,12]

The proven efficacy of overfilled implants regarding patient satisfaction and mechanical properties has been well documented. Prior studies have demonstrated this benefit in cosmetic patients. There is a paucity of literature, however, evaluating the use of hyperinflated saline implants in the setting of implant-based breast reconstruction. This study sought to determine the outcomes of hyperinflating saline implants in obese patients following mastectomy for the treatment of breast cancer and hypothesizes that this method is safe and effective.