Episode 53: Thursday October 06

"All I want to do is wear clothing and not have to wear a bra!" Many patients come in with this goal. However, with breast augmentation surgery, some patients may require more support than their bodies can provide. A technique called "Internal bra" or mesh support can help. New generation meshes can help to provide lift in patients who need it.

Who needs internal bras? What are they made of? How do they work? Dr. Sam Jejurikar @samjejurikar leads the discussion with Dr. Salvatore Pacella @sandiegoplasticsurgeon and Dr. Sam Rhee @bergencosmetic as they delve into the inner workings of the internal bra.

#podcast #plasticsurgery #cosmeticsurgery #boardcertified #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetic #aesthetics #mastopexy #breastlift #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery #breastreduction #transformation ⁠#nobreastimplants #boobjob #internalbra

S03 E53 INTERNAL BRA IN BREAST AUGMENTATION

[00:00:00] Dr. Salvatore Pacella: Welcome everyone. This morning we're back on the air with, um, Dr. Sam Jejurikar from Dallas,

[00:00:13] Dr. Sam Jejurikar: Texas. How you doing? Good morning,

[00:00:15] Dr. Salvatore Pacella: Dr. Sam Rhee from Bergen, New Jersey. How's it going? And of course, I'm Dr. Pacella from San Diego, um, San Diego, California. We are back with our podcast this morning, and we are gonna have a very special topic today on the topic of internal bras. So these are, these are structural support that we use during breast augmentation or breast surgery.

This is a trend you may have noticed on social media or out in the world on women going braless. And how many, Let me ask you guys, how many of your patients come in after, uh, prior to their breast procedure and say, you know, Dr. Dr. Sam from New Jersey, I want to go Braless.

[00:01:44] Dr. Sam Rhee: I would say at least three quarters of my patients will say, All I wanna do is be able to wear something and not have to wear a bra with that.

[00:01:52] Dr. Sam Jejurikar: Yeah, totally agree with that. And, um, usually my response had been to people before. Internal bras were a thing. I, I used to say to them, That sounds great. I want your breasts to look great without a bra. And I put a bra back on because can't do anything about gravity. But this is an exciting topic cuz it can help, help a lot, um, overcome what gravity can.

[00:02:12] Dr. Salvatore Pacella: All right, so before we get into that, um, a few little housekeeping items. Um, so we're gonna hand it over to, uh, Dr. Reid. Yep. This

[00:02:20] Dr. Sam Rhee: show is not a substitute for professional medical advice, diagnosis, or treatment. This shows for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion.

Always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in this show.

[00:02:44] Dr. Sam Jejurikar: Awesome. So thanks for letting me, uh, lead the, the conversation today.

So today we're gonna talk about internal bras in breast augmentation surgery. And the premise is pretty simple with this in general. Um, when we have a breast implant, and I know we can also use internal bras with native breast tissue as well, but the focus today is gonna be predominantly with breast implants.

When we have a breast implant, commonly the decision being made is, are we gonna put the implant in front of the muscle? Or behind the muscle. And in these anatomic diagrams, what you're seeing is here's, uh, hopefully you can see my, my mouse, but this is, this is the peck muscle. This is the breast gland.

And in this picture on the right here is a breast implant sitting behind the muscle. So what do we do with an internal bra? We basically add some support across the very bottom. Of the, uh, of the implant. So it's going from the chest wall usually to the under surface of the peck, or if it's a revision case where there's already an implant sometimes to the capsule.

But we're using that as a push up bra sort of effect. We're actually using a mesh material, um, to hold the implant in a higher position, much like a push up bra, in addition to securing it so that the implant's sitting higher. We can also secure the mesh, like you can sort of see in this picture along the side of the breast here.

To push the implant in. And so for women who say, I want to have my implant sitting high and closer together, you can, you can fashion the, um, the mesh, um, or the bra, if you will, to, to hold the implant in a higher position. So, um, outta curiosity, gentlemen, who do you think are sort of the candidates who are coming to you for cosmetic breast surgery who do well with an internal bra?

And who in general do you think doesn't need an internal bra? I,

[00:04:29] Dr. Salvatore Pacella: I would say that, um, you know, in my practice where internal brass are the most beneficial are in patients who have had revisional breast surgery or patients that, according to my physical exam, don't really have, uh, tissue support in their breasts.

A lot of patients who have had massive weight loss kind of fit into this category. I think if you're a first time, uh, breast augmentation patient and you're fit and you're young, then you have, um, appropriate. Uh, structure, then usually I haven't found an internal broad to be very, uh, necessary.

[00:05:05] Dr. Sam Rhee: Yeah, I would agree with that.

I, um, don't use it as often in primary or first time breast augmentation patients, but there is, uh, a subset of patients who. Have a lot of stretchiness or soft tissue laxity, skin laxity. Uh, they might be born with it. They might, uh, have developed it over time. Maybe they're, um, older or, or, um, they've had several children.

And if, and I'll see it a lot in, um, patients who've had a breast augmentation where the, the implants starting to bottom out is starting to get a lot of what we call pseudo, where you can see the implant sinking below the breast. And in those patients oftentimes, I'll use an

[00:05:46] Dr. Sam Jejurikar: internal. Couldn't, couldn't have said it better than both of you guys together.

I, I completely agree with that. So, um, within internal bras, I think we've gone through, um, multiple iterations of it. Um, the first versions of internal bras that we would use and we're kind of our. Only choice in the beginning. Were what we call biologic meshes. These are called a cellular dermal matrices.

Sometimes a huli abbreviation, ADMs. But what they are is they're artificial skin substitutes in which the very top layer of the skin has been removed, which is called the epidermis, leaving you with the dermis, and all of the living cells have been removed. So it's basically a, a lattice work or, um, a support structure which incorporates very well into your body.

Um, and. Forms a very well vascularized or a tissue plan with blood vessels to it. Um, I don't use this as much in cosmetic, uh, breast procedures unless someone has a different condition called capsular contractor, which would make a great topic for a, for another podcast. Um, but, um, I do know of many surgeons, great surgeons who like using these a lot along with their breast implants.

After the biologics, kind of the next iteration we had were something. Permanent meshes. Um, there was one made out silk that was popular for a few years. The problem with the permanent meshes is that they are permanent. Um, we could see some late infections with some of these permanent meshes. Um, and we, um, actually could see patients sort of develop permanent discoloration or redness of the breast from some of them.

So the, the permanent meshes, I don't think are very popular in most surgeons hands for, for, uh, using as an internal bra. I think in the world of cosmetic breast surgery where you're using an implant, Potentially with or without a lift. The most popular choices these days are these semi-permanent meshes, which came on the market a few years ago.

The two big ones, um, or the two big categories are, uh, poly four hydroxybutyrate or P four h b. It says how most plastic surgeons refer to it goes by the trade name of GalaFLEX in case a surgeon presents it to you. And also, um, poly dione or PDO goes by the trade name of Duras, or they have. Profiles and I think, um, my compatriots and I all sort of tend to use the P four HB meshes a little bit more than the PDO meshes, mainly cuz the P four HB meshes stick around a little bit la longer for, uh, anywhere from, you know, six to 12 months postoperatively what we thinks that critical period of time where the body's healing.

When the P four H B mesh goes away, it's been shown that the capsule that your body leaves in its place, um, is anywhere from two to five times strong. Then we would normally expect a capsule to be from a tenile strength standpoint. So the bottom line is P four HV mesh goes away, but the tissue left behind still can serve like a bra.

PDO meshes go away a lot faster. Um, usually lose their tenile strength in about, uh, three months. Um, so in some cases that's a good thing because, um, the longer these mentions stick around, the longer patients are aware of it. But in some cases we think that's not such a good thing because we want support for a longer period of.

So I'm gonna go through some cases. I'm gonna pick my, uh, Uh, fellow plastic surgeon's mind, sort of what they would do for this, for these cases. So first case, young woman who came to me a few years out from her breast augmentation. She's in her twenties. She has saline implants that are in place. They're about 325 ccs, and she's happy for the most part, what the way her implants are, but she really wished that they were sitting higher.

In addition, she wants more volume. So what would you guys tell this patient? Is there any, um, you know, obvious. Based on the topic we have today, it's probably pretty obvious that I use an internal bra, but I'm curious if you would jump straight to an internal bra or if you would try other things.

[00:09:34] Dr. Salvatore Pacella: Well, I think, um, you know, one of the, uh, one of the traditional methods that plastic surgeons have used in the past to raise a breast implant on the chest wall is to do, do something called a Capy. Where, uh, simply put, what we do is we try to, we. Remove the implant. We try to sow the capsule shut at the bottom portion of things with the intention of shoring up the tissue a bit.

So much like a tailor internal tailoring. And this is done with sutures, but what I'm gonna, I'm gonna caution you out there is that capor fees are notoriously unreliable. I mean, the whole point of why we need a capsular fee in the future, or. In the, in the surgery is because, um, that tissue is weak. So if you're just sewing weak tissue to weak tissue, it, it's probably gonna happen again.

So I would, and she would fit the, the category revision breast surgery. So I would suggest using either a biologic, uh, or a, or a semi-permanent device. Yeah,

[00:10:36] Dr. Sam Rhee: I think in this case, especially since she wants to go larger with her implant, the risk of bottoming. More and she has some bottoming. Even now you could see on the lateral or on the side profile is pretty high.

Um, I remember, uh, seeing a patient similar to this where an, uh, another surgeon actually tried Aion procedure, which is one of those. Uh, breast lists where they're only doing the infirmary fold excision, and it looked awful and it still bottomed out very quickly after she had that done. So, uh, I think this is a much more useful tool for us nowadays in terms of patients who wanna go bigger, who have a lot of soft tissue laxity, and you want to avoid putting large incisions on the

[00:11:20] Dr. Salvatore Pacella: breast.

[00:11:23] Dr. Sam Jejurikar: That's, uh, it's like you guys were at the consultation with this patient when I saw her because, um, with particular with saline implants, um, you know exactly what Dr. Pacella was saying. Um, It's, um, it's a very unreliable capsule. And indeed what I found intraoperatively was a very flimsy capsule, which would've, if I'd sun it together, would've provide an almost no support.

Sometimes there's some reluctance for patients to proceed with these biologic meshes or these semi-permanent meshes because there's a cost that's not insignificant involved with using them. She asked specifically about this Ryan procedure that Dr. Rhee was talking about, if we could just remove some skin from the bottom.

But I think any viewer can see that if you take out skin from the bottom to sort of shorten this length, it's gonna pull the ariola down. Um, and it doesn't build any support. So the patient's gonna end up right in the same place. So, um, I actually have did this case several years ago, and I, I have three year follow up on this patient.

I used, uh, P four HB mesh on her, um, which I secured one edge to the inframammory fold, so the fold at the very bottom of the breast. Um, I also sewed the other. To kind of a combination of the, of the capsule, but really the peck muscle that was there. I used one sheet in each side, and you can see from the side view when we do this, the implants stay in a higher position.

And I think this is significant cuz this is a patient who, um, has greater volume, so more weight in her breast. Um, and now using, uh, using a mesh material will actually hold the implant up higher and give her a rounder look on the top. Um, That's

[00:13:00] Dr. Salvatore Pacella: a, that's a great result and I think you really nailed it particularly, uh, at the level of the cleavage on the inner portion of the chest.

That looks fantastic. Um, one question for you. Um, so do you find that saline implants have a higher tendency to bottom out than traditional silicone implants?

[00:13:19] Dr. Sam Jejurikar: I believe that that's true. Yes, I really do for an equivalent weight. Um, I think that the capsule that we tend to see intraoperatively, um, is much flimsier in nature than what we might see with a silicone implant.

So for a given weight, if the amount of support being formed around the implant, um, by the body is less, I have tended to see that there is more of a tendency for the lower pole to stretch out. Have you noticed the same thing?

[00:13:46] Dr. Salvatore Pacella: Uh, yeah, I mean, I I, I've never heard it really, uh, articulated or written down somewhere, but, you know, I, the way I sort of think about it with patients and, and I use this explanation is, you know, imagine you had a, a water balloon at your child's birthday party, you know, in your.

Every time you sort of flex that water balloon, it sort of acts as a little mini expander to the lower portion of the breast. So particularly with the Submuscular implant, if you're flexing that muscle back and forth, there's a, there's a higher release tension on the bottom portion of the breast, and it just causes a lot more expansion at the, at the bottom portion.

And I, I just don't see that with, with silicone. I think the, the product of silicone is much stronger and harder. It tends to absorb a lot of that muscle. Muscle flexion. So

[00:14:34] Dr. Sam Rhee: I love that case because it's a three year follow up and I don't get to see a whole lot of three year posts for, um, you know, GalaFLEX or any of the other meshes that they, they normally show, uh, routinely.

So that's, that's very

[00:14:45] Dr. Sam Jejurikar: nice. Yeah. Yeah. It's a three year follow up and it's actually, uh, I haven't, I did that surgery five years ago, more than, uh, and so I haven't even seen her in the last two years, So I assume No news is good news. Um, so here's the next case. Very nice woman who had had, uh, 300 cc implants put in place, um, before she had had children, had a couple of kids.

Uh, the breasts in her mind had dropped lower, the implants had dropped lower. Her goals were obviously to have her breasts sitting higher, um, and also to go a little bit smaller. So how would you approach either one of you guys, how would you approach this case?

[00:15:29] Dr. Salvatore Pacella: So I think you, you know, you can clearly see on the lateral picture, you know, she's, she's lost a tremendous amount of, uh, tissue support. And so I, I see in my practice that a lot of patients that come in, they, they sort of want to be smaller. And, you know, I'm kind of explaining to them, you know, if you have a pocket of a breast this big and I go with a smaller implant that's this big, that that's actually gonna look a lot worse because of the, uh, you know, it's not gonna fill in everything up top and it's gonna give the appearance that everything's dropped down further.

So not only would I suggest tissue support for her, I would also suggest doing a Master Pepsi or breast lift to, to try to wrap that skin around. Uh, in an effort to get a better nipple position. Yeah, I mean,

[00:16:23] Dr. Sam Jejurikar: on these patient,

[00:16:24] Dr. Sam Rhee: I, I would too. I would, uh, say if you're gonna put a smaller implant in, as Sal said, less volume, more sagging, uh, if you did a straight, We haven't seen these pictures, so if you did a straight internal bra and got her to look good.

Magician, Sam, because I, in my hands, this would've been a straight Master Pepsi with or without tissue support.

[00:16:48] Dr. Sam Jejurikar: So, um, I'm definitely not a magician. You'll be happy to know, and I hundred percent agree with you guys in terms of needing a Master Pepsi. Um, Again, Dr. Pacella, um, complete. It's like he listened to the consultation, um, and he was there.

If you think about it, the implants that we put in are always some variation of a circle. This patient wants to go smaller. This isn't always true, but in general, the smaller the implant, the smaller that circle is. And if somebody wants their implants to be sitting higher on their chest wall and they're going smaller, so there's a narrow di, a narrower diameter to the implant, you're gonna create a pocket.

With a smaller implant that's sitting much higher on the chest. Unless patients want their arolas to be pointing down to the ground, it's not gonna look good without a lift. So here's this patient about six months out, I converted her to um, I think 240 cc implants. Um, you know, um, When you, when you look at her, the implants are sitting higher, but they're substantially smaller.

Um, there's a Pepsi that's, that's done. And, and again, you can see that it's just an overall, a much smaller look that's sitting higher. I think. Um, um, I used, uh, in this case I used a PDO mesh. Um, I actually used, um, a mesh that went away a little bit faster. Um, My concern when I used the PDO mesh was that, um, if I used a P four H V mesh, given how thin and athletic this patient was, that the palpability along the lower pole would, would, um, create some issues for her.

A lot of times patients complain between that six and 12 month mark about how that mesh is feeling when it's dissolving. Uh, hindsight being 2020, in this case now I probably use a P four H B mesh because I think there's been a little bit of stretching of the lower pole that's happened. Um, and I think, um, we probably could have gotten, um, the implants that said even a little bit higher, but overall, I think it accomplished what you wanted.

That's great.

[00:18:46] Dr. Salvatore Pacella: Um, question for you, Samir. Um, so, you know, inherently the entire breast. Has lost structure in a, in a case like this. And one of the challenges I think in, in using internal bras and doing a master Pepsi around the case is how independently each of those areas may drop with gravity. So what I mean by that is the, you're putting mesh in to support the implant, but when you're doing a maax, you're not really putting the mesh around the.

Tissue, the breast pera. Right. And so what I found is, you know, many times in my practice I've developed what they call a waterfall deformity. Mm-hmm. . So a year or so later after, after the breast, uh, procedure. And what that is for our viewers is imagine the breast tissue, the front breast tissue, the the nipple and the bottom portion of the breast drops where the implant stays in exactly the same place, and it creates this excess kind.

Looks like they, they called Snoopy nose, you know? And so Snoopy's nose comes off the, the front of the breast, and that, that is a massively challenging problem, in my opinion. And, and so how do you address.

[00:20:04] Dr. Sam Jejurikar: I think that, um, it is a very common thing to develop, um, a waterfall deformity like you're describing.

So again, implant basically stays fixed because of the mesh being in place. The soft tissue relaxes around it. What I like to do if someone's developing a waterfall deformity is I like to let. Get it as significant as it's gonna be. So I wait for six to 12 months postoperatively. I see them every few weeks measure the distance from their nipple to the infr fold until they've gotten to the point where it's actually stabilized and it's no longer changing.

At that point, in my mind, it's usually a fairly easy thing to fix, um, because it's not a primary. Base issue. It's the skin that's superficial to it, the skin and the breast tissue. So at that point, I'll oftentimes just do a little wedge excision of skin off the bottom. So what Dr. Ella is talking about is this lower aspect of the breast.

We take out just a little bit of tissue from the bottom, sometimes even in the office. Then usually I find that that addresses the issue. It's, it's a common problem to develop, but I think a relatively easy, straightforward complication to fix once it's stabilized in my estimation.

[00:21:11] Dr. Salvatore Pacella: Um, and you know what I, Oh, go ahead.

Sorry.

[00:21:13] Dr. Sam Rhee: No, no, go ahead. Cause I was gonna ask about something a little bit different, so go ahead.

[00:21:17] Dr. Salvatore Pacella: Um, so, you know, what, what I've tried to do is, at the time of the, of the, uh, original surgery, so at the time of the mastopexy, I really try to, uh, account for that. So I, I oftentimes have been a bit more aggressive.

um, removing and sculpting the lower portion of the breast and making that lower pole. Very, very taught with the intention, Hey, this is gonna drop down over time. I wanna set this up for success. And what I've also tried to do in the past is place some internal sutures, um, from the under surface of the nipple to the peck muscle in order to try to keep a nipple in exactly that position.

Quite honestly, it's a lot of work at the time of the Master Pepsi. Um, I found it to be modestly

[00:22:05] Dr. Sam Jejurikar: helpful. Exactly. I was gonna say, it's a lot of, And I do stuff like that as well. I just haven't been convinced that it, uh, overcomes the effects of gravity. Yeah. I

[00:22:15] Dr. Sam Rhee: think when we talked to him, he described a lot of different techniques to try to help with that type of issue.

And you're right, it just, it's so much work that you don't even. On the outside that we're constantly doing for Mastopexies on the inside.

[00:22:32] Dr. Sam Jejurikar: Exactly. Here's the case I found really challenging. I've done this case about a year, year and a half ago. A woman had had breast augmentation with silicone implants done by another surgeon in town.

She had a couple of complaints postoperatively. Um, the, the implants that were put into place were actually. 385 cc implants. Um, she thought she looked asymmetric when she came to my office. Curious what you guys see when you look at these pictures and how you'd handle it.

All right, Dr. Re, go ahead. I've

[00:23:05] Dr. Salvatore Pacella: been, I've been going first. Oh, I don't mind.

[00:23:08] Dr. Sam Rhee: So the first thing I would, uh, do is examine her and ask her was she asymmetric to begin with. Or is this some degree of capsular contracture or, or other change that occurred over time? Um, if she was asymmetric from the get go right after the implant, uh, placement, then she has different sized breasts that did not change once he put the same size implant on each side.

Uh, if it did change over time and if she has some symptoms of capsular contracture, that might suggest that there's something else going on here. Uh, causing the asymmetry. Uh, she definitely looks asymmetric to me right now. That left side looks smaller, it looks, uh, elevated. Um, so that would be the first thing I would ask about that.

[00:23:56] Dr. Sam Jejurikar: So, yeah, and to an, and to answer those questions real quick to make Dr. Patella's job easier. I realize just through through that at you, she said she was asymmetric going into the operation, asymmetric immediately after the operation as well. She wasn't quite clear why her surgeon had used the same size implants on both sides.

[00:24:13] Dr. Salvatore Pacella: Right. Um, not having known that I, you know, I, I would've thought on the right side, you know, possibly this could be an overzealous, uh, pocket dissection by her original surgeon. You know, many times when I see that one side might bottom, an bottom out preferentially to the opposite side. But yeah,

[00:24:33] Dr. Sam Jejurikar: I mean, Yeah, well, well, it, it, that's true as well.

And so, you know, one of the things that we typically, um, think about in life is that usually there's one explanation for, um, for problems. But in this case, I think there were actually two problems. One on her right side, um, left on the screen, but right on her body there is. An elongation of this, of this arriola to the lower portion of the pole, and her entire fold is actually sitting lower on this left side.

You can tell from the oblique. So there, there was definitely, um, an, uh, you know, I don't know if it was over zes dissection or just bad anatomy, but this stretched out. In addition, the breasts were very different sizes. So let's just jump ahead. Um, She's seen about six months out in this picture. What I ended up doing was on her right side, um, I used, I I, she had a 385 cc implant.

I actually ended up using her same implant because it was only a few months old. But what I did do was I did a substantial number of capsule sutures all the way across the bottom to restore, um, the lower pole to the right position, cuz she actually had a pretty robust. Capsule, I probably put in 40 of those stitches all the way across.

Then I laid my P four H B mesh all the way across the bottom of it without actually even suturing it in. Um, so I laid it on there over the capsule Ory sutures to try to give sort of a better curve to give her this fullness she wants on the top. On the other side, um, I find that if I only use a P four HP mesh on one side and not the other, the breasts look very different from one another.

So I, I do the same thing, even though I didn't think she had bottomed down on that side. I ended up using, um, uh, trial sizers, which for our, our viewers, our, um, temporary implants ended up going from a 3 85 to a 4 85 on her left side. Um, so she. Got a substantially bigger implant going up about a hundred ccs on that.

On her left side again, right on the screen. And here she is postoperatively again, You see with the mesh, the greater pole fullness that she, that she got. I think that's, that's a great

[00:26:37] Dr. Sam Rhee: result. Yeah, I was just about to say that. It's a great result. It's really hard to recreate that inform fold once, once it's blown through like that.

And the fact that you took the time to put 40 sutures in and then laid the mish on top of it, I think set you up for success. The other thing is, is I assume, I mean the symmetry is fantastic. It's so much, so much closer, right? Uh, and I assume she wanted to maintain that right sided volume and you just match the left to it, which, uh, is very, very symmetric and sort of in concert with her body, uh, in terms of symmetry and, uh, proportion.

[00:27:16] Dr. Salvatore Pacella: Um, and let me just clarify here. You, you did this all without exci any skin without doing a master. Correct. Yeah. And so, so for our viewers up there, I just wanna reiterate how challenging this can be, uh, for the surgeon, because, you know, I think a knee jerk reaction is, well, clearly you need to remove skin and you need to do a Master Pepsi.

But in this. In this instance, it was all about volume and not necessarily skin excess.

[00:27:42] Dr. Sam Jejurikar: So, Yeah, and you know, in a, in a slight, um, just sort of technical point, which I don't even know how much our viewers will care about, but I think you guys will find interesting. I find that when I'm doing a revision implant case and I'm using mesh, I like.

Putting in a bunch of Capy sutures are basically closing down the, the pocket using a combination of electric cautery, which is called a popcorn Capy, first to sort of tighten up the capsule, then putting in a bunch of stitches to try to, to, to close it down, and then just laying the mesh down on top. Um, and so, um, you know, it's, it's a nice, it's a nice way to do it.

I think it allows me to create greater symmetry than just sewing the me mission. I'm gonna show one last quick case here. Just to illustrate one more difference. So this is a patient that had never had implants. She'd actually had two previous breast reductions in the past. Um, she'd had a breast reduction followed by a subsequent breast reduction.

And then, um, Um, at the time of her second breast reduction, she actually had wanted to have implants placed, so she came to me with, um, relatively poor tissue elasticity. Um, I have found that in cases like this, um, I, um, oftentimes have problems with the implants bottoming out afterwards. So to try to prevent her from being in a situation where she would need to, um, have a revision surgery.

After this implant placement, I just went ahead and put in P four HV mesh. So here she is preoperatively. He or she's seen about six months postoperatively. I did a large skin excision to try to get rid of the fullness across her sides. I put in some P four H B mesh to hold the implants in a higher position.

Um, and so in this case, this isn't a revision implant case, but it is a revision breast case and someone who has a poor skin elasticity who. Um, because she had just such a high possibility of, of ending up with boning out post-op, we went ahead and prophylactically used it to try to avoid problems. Would you guys ever consider using mesh in a case like this, or would you sort of take your chances to see what happened first and then, and then, uh, only do it if there's a problem.

Oh, all the

[00:29:43] Dr. Salvatore Pacella: time. I think this is a, this is an absolutely perfect indication for an internal bra because this, this goes into the, uh, the category of patients who have, uh, very poor tissue, very poor structural support to their, to their breast. So 100%

[00:29:59] Dr. Sam Jejurikar: I would suggest that.

[00:30:01] Dr. Sam Rhee: That was a hard learning experience for me too, is doing a massive Pepsi, having problems with it, and then, you know, learning that I need more support inside because some patients just completely lack, you know, good tissue integrity in terms of their support, so absolutely.

[00:30:20] Dr. Sam Jejurikar: Well, it's good to see how aligned we are. We all seem to be on this topic. I think there is, um, a lot of indications for using internal bras. If they were slightly less expensive, I think we'd have fewer reservations, um, and we probably would expand our indications even more. But, um, as always, I learned from you guys in a great podcast.

Looking forward to doing the next one. All right, Jeff, Awesome job. We'll see you next time. Take care

[00:30:45] Dr. Salvatore Pacella: All.