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    Dr. Sal Pacella: Welcome, everyone, this morning. We’re back on the air with Doctor Sam Jejurikar from Dallas, Texas. How are you doing?

    Dr. Sam Jejurikar: Good morning.

    Dr. Sal Pacella: Doctor Sam Rhee from Bergen, New Jersey. How’s it going? And, of course, I’m Doctor Pacella from San Diego, California. We are back with our podcast this morning and will have an exceptional topic today on internal bras. You may have noticed in the media that there’s a trend to go braless. This is a trend that makes women and men happy alike. So, this is…

    Dr. Sam Jejurikar: Maybe we should rewind that. And are we just starting all over from the beginning? Yeah.

    Dr. Sam Rhee: I’m going to get **** crazy.

    Dr. Sam Jejurikar: Yeah. You are.

    Dr. Sam Rhee: Alright. Start off.

    Dr. Sam Jejurikar: Okay.

    Dr. Sam Rhee: Alright. Keep going. Just go. Just start.

    Dr. Sal Pacella: Alright. So, I’ll just pick up from, yeah, the last comment.

    Dr. Sam Rhee: Yeah, the last comment.

    Dr. Sal Pacella: Okay. This morning we’re going to talk about a very interesting topic, internal bras. So, we use this structural support 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 prior to the breast procedure and say doctor Sam from New Jersey, I want to go braless.

    Dr. Sam Rhee: I would say at least three-quarters of my patients will say, all I want to do is be able to wear something and not have to wear a bra with that.

    Dr. Sam Jejurikar: Yeah. Totally agree with that, and usually, my response had been to people before internal bras were a thing. I used to say to them, that sounds great. I want your breast to look great without a bra and not put a bra back on because I can’t do anything about gravity. But this is an exciting topic because it can help a lot overcome what gravity can do.

    Dr. Sal Pacella: Alright, before we get into that, a few housekeeping items. So, going to hand it over to Doctor Rhee.

    Dr. Sam Rhee: Yup. This show is not a substitute for professional medical advice, diagnosis, or treatment. It shows for informational purposes only. Treatment and results may vary based on the circumstances, situation, and medical judgment after appropriate discussion. Always seek the advice of your surgeon or another 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.


    Internal Bras and Breast Augmentation Surgery

    Dr. Sam Jejurikar: Awesome. So, thanks for letting me lead the conversation today. So today, we’re going to talk about internal bras and breast augmentation surgery, and the premise is pretty simple with this. In general, when we have a breast implant, I know we can also use internal bras with native breast tissue as well, but the focus today is going to be predominantly on breast implants. When we have a breast implant, commonly, the decision being made is whether to put the implant in front of the muscle or behind the muscle in these anatomic diagrams, which you see here hoping you can see my mouse, but this is the pec muscle. This is the breast gland, and in this picture on the right, there 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 implant. So, it’s going from the chest wall usually to the under the surface of the PEC or if it’s a revision case where there’s already an implant sometimes to the capsule. We’re using that as a push-up bra sort of effect. We’re actually using a mesh material to hold the implant in a higher position. Much like a push-up bra, in addition to securing it so that the implant sits higher, we can also secure the mesh, as you can sort of see in this picture, along the side of the breast here to push the implant in. So, for women who say I want to have my implant sitting high and closer together, you can fashion the mesh or the bra, if you will, to hold the implant in a higher position. So, out of 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?

    Dr. Sal Pacella: I would say that in my practice where internal bras are the most beneficial in patients who have had revisional breast surgery or patients that, according to my physical exam, don’t really have 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 breast augmentation patient and you’re fit, and you’re young, and you have appropriate skin structure, then usually I haven’t found an internal bra to be very.

    Dr. Sam Rhee: Yeah, I would agree with that. I don’t use it as often in primary or first-time breast augmentation patients, but there is a subset of patients who have a lot of stretchiness or soft tissue laxity and skin laxity. They might be born with it. They might have developed it over time. Maybe they’re older, or they’ve had several children, and I’ll see it a lot in patients who’ve had a breast augmentation where the starting to bottom out is starting to get a lot of what we call pseudoptoses, where you can see the implant sinking below the breast and in those patients often times all use an internal bra.


    The final version of internal bras: biologic meshes

    Dr. Sam Jejurikar: I couldn’t have said it better than both of you guys together. I completely agree with that. So, within internal bras, I think we’ve gone through multiple iterations of it. The first versions of internal bras that we would use and be kind of our only choice in the beginning were what we called biologic meshes. These are called acellular dermal matrices, sometimes a Heli 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 are called the epidermis, leaving you with a dermis and all of the living cells have been removed. So, it’s basically a latticework or a support structure that incorporates very well into your body and forms a very well-vascularized tissue with blood vessels to it.

    I don’t use this as much in cosmetic breast procedures unless someone has a different condition called capsular contractor, which would make a great topic for another podcast. But 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 have or something called permanent meshes. There was one made out of silk that was popular for a few years. The problem with permanent meshes is that they are permanent. We could see some late infections with some of these permanent meshes, and we actually could see patients sort of develop permanent discoloration or redness of the breast from some of them. So, the permanent meshes, I don’t think, are very popular in most surgeons’ hands for use as an internal bra anymore.

    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 the semi-permanent meshes that came on the market a few years ago go. The two big ones or two big categories are polyp4 hydroxybutyrates or P4HB. This is how most plastic surgeons refer to it. Goes by the trade name of Galiflex in case a surgeon presents it to you, and also polydioxanone or PDO goes by the trade name of Durazzo. They have different profiles, and I think my compatriots and I all sort of tend to use the P4HB meshes a little bit more than the PDO meshes. Mainly because the P4HB mesh sticks around a little bit longer for anywhere from 6 to 12 months postoperatively. What we think is that critical period of time when the body’s healing. When the P4HB mesh goes away, that’s been shown that the capsule that your body leaves in its place is anywhere from 2 to 5 times stronger than we would normally expect the capsule to be from a tensile strength standpoint. So, the bottom line is P4HB mesh goes away, but the tissue left behind still can serve like a bra.

    PDO mesh goes away a lot faster. They usually lose their 10-cell strength in about three months. So, in some cases, that’s a good thing because 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 time. So, I’m going to go through some cases. I’m going to pick my fellow plastic surgeon’s mind sort of what they would do for this for these cases. So, in the first case, a young woman came to me a few years out from her breast augmentation. She’s in her 20s. She has saline implants that are in place. They’re about 325C, and she’s happy for the most part with 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, obviously? 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.


    What is capsulorrhaphy?

    Dr. Sal Pacella: Well, I think one of the traditional methods that plastic surgeons have used in the past to breeze a breasted gland on the chest wall is to do something called the capsulorrhaphy. Where simply put, what we do is we try to remove the implant and try to sew 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 is done with sutures. But what I’m going to caution you out there is that capsulorrhaphy are notoriously unreliable. I mean, the whole point of why we need capsulorrhaphy in the future or in surgery is because that tissue is weak. So, if you’re just sewing weak tissue to weak tissue, it’s probably going to happen again. So, I would, and she would fit this category for revision breast surgery. So, I would suggest using either a biological or a semi-permanent device.

    Dr. Sam Rhee: Yeah, I think in this case, especially since she wants to go larger with her implant, the risk of bottoming out more, and she has some bottoming. Even now, you can see that the lateral or on the side profile is pretty high. I remember seeing a patient similar to this where another surgeon actually tried the Orion procedure, which is one of those breast lifts where they’re only doing the inframammary fold excision, and it looked awful and it’s still bottomed out very quickly after she had that done. So, I think this is a much more useful tool for us nowadays in terms of patients who want to go bigger, who have a lot of soft tissue laxity, and who want to avoid putting large incisions on the breast itself.

    Dr. Sam Jejurikar: That’s like you guys were at the consultation with this patient when I saw her, because with particularly with saline implants, exactly what Doctor Pacella was saying. It’s a very unreliable capsule and indeed, what I found intraoperatively was a very flimsy capsule that would’ve, if I’d liked so, it together would provide almost no support. Sometimes there’s some reluctance for patients to proceed with these biological measures or these semi-permanent measures because there’s a cost that’s not insignificant involved with using; she asked specifically about this Orion procedure that Doctor 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 going to pull the areola down, and it doesn’t build any support, so the patient’s going to end up right in the same place.

    So, I actually did this case several years ago, and I have three-year follow-ups on this patient. I used P4HB mesh on her, which I secured one-edged the inframammary fold, so the fold was at the very bottom of the breast. I also sewed the other edge to kind of a combination of the capsule but really the pec muscle that was there. I used one sheet on each side. You can see from the side view when we do this; the implants stay in a higher position. I think this is significant because this is a patient who has greater volume, so more weight in her breast, and now using a mesh material will actually hold the implant up higher and give her a rounder look on the top.

    Dr. Sal Pacella: That’s a great result, and I think you really nailed it, particularly at the level of the cleavage on the inner portion of the chest. It looks fantastic. One question for you. So, do you find that saline implants have a higher tendency to bottom out the traditional silicone implants?

    Dr. Sam Jejurikar: I believe that’s true. Yes, I really do. For an equivalent weight, I think that the capsule that we tend to see intraoperatively 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 by the body is less, I have tended to see that there is more of a tendency for the lower pull to stretch out. Have you noticed the same thing?


    Silicone implants Perks

    Dr. Sam Jejurikar: Yeah, I mean, I’ve never heard it really articulated or written down somewhere, but the way I sort of think about it with patients, and I use this explanation is to imagine you had a water balloon at your child’s birthday party. And every time you sort of flex that water balloon, it sorts 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 higher release tension on the bottom portion of the breast, and it just causes a lot more expansion at the bottom portion. I just don’t see that with silicone. I think the product of silicone is much stronger, and it tends to absorb a lot of that muscle flexion, so.

    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 Galiflex or any of the other meshes that they normally show routinely. So, that’s very nice.

    Dr. Sam Jejurikar: Yeah, it’s a three-year follow-up, and it’s actually I did that surgery five years ago more, and so I haven’t even seen it in the last three years. So, I assume no news is good news. So, here’s the next case. She was a very nice woman who had had 300CC implants put in place before she had had children and had a couple of kids. The breast in her mind had dropped lower. The implants had dropped lower. Her goals were obviously to have her breasts sitting higher and also to go a little bit smaller. So how would you approach either one of you guys? How would you approach this case?

    Dr. Sal Pacella: So, I think you can clearly see on the lateral picture she’s lost a tremendous amount of tissue support. So, I see in my practice that a lot of patients that come in, they sort of want to be smaller and’ve kind of explained it to them if you have a pocket of a breast this big and I don’t with a smaller implant that’s this big. That’s actually going to look a lot worse because it’s not going to fill in everything up top, and it’s going to give the appearance that everything’s dropped down further. So, not only would I suggest tissue support for her, but I would also suggest doing a Mastopexy or breast lift to try to wrap that skin around in an effort to get a better nipple position.

    Dr. Sam Rhee: Yeah, I mean.

    Dr. Sam Jejurikar: I would breast lift these patients.

    Dr. Sam Rhee: I would like to. I would say if you’re going to put a smaller implant, as Sal said, less volume, more sagging. 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, you’re a magician, Sam, because, in my hands, this would have been a straight Mastopexy with or without tissue support.

    Dr. Sam Jejurikar: So, I’m definitely not a magician, you’d be happy to know, and I 100% agree with you guys in terms of needing a Mastopexy. Again, Dr. Pacella is complete; it’s like he listened to the consultation and was there. If you think about it, the implants that we put in are always some variations of a circle. The 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, there’s a narrower diameter to the implant. You’re going to create a pocket with a smaller implant that’s sitting much higher on the chest unless patients want their areolas to be pointing down to the ground; it’s not going to look good without a lift.

    So, here’s this patient about six months out. I converted her to, I think, 240CC implants. When you look at her, the implants are sitting higher, but they’re substantially smaller. There’s Mastopexy that’s done, and again, you can see that it’s just an overall much smaller look that’s sitting higher. I think I used; in this case, I used a PDO mesh. I actually used a mesh that went away a little bit faster. My concern when I used the PDO mesh was that if I used a P4HB mesh, given how thin and athletic this patient was that the palpability along the lower pole would create some issues for her. A lot of times, patients complain between that 6- and 12-month mark but how that mesh feels when it’s dissolving.

    In hindsight, being 2020 in this case now, I probably use a P4HB mesh because I think there’s been a little bit of stretching of the lower pole that’s happened, and I think we probably could have gotten the implants of the city even a little bit higher, but overall, I think it accomplished what she wanted.


    The Effects of Waterfall Harmony

    Dr. Sal Pacella: It’s great. Question for you, Sam. So, inherently the entire breast has lost structure in a case like this. And one of the challenges I think, in using internal bras and doing a mastopexy around the case it’s how independently each of those areas may drop with gravity. So, what I mean by that is your Putting mesh in to support the implant, but when you’re doing the Mastopexy, you’re not really putting the mesh around the breast tissue, the breast, right? And so, what I found is, many times in my practice, I’ve developed what they call a Waterfall Harmony, and so, a year or so later, after the breast procedure. And that is for our viewers is, imagine the breast tissue, the front breast tissue, the nipple, and the bottom portion of breath drops, where the implant stays in exactly the same place. It creates this excess kind of look like what they call Snoopy’s nose, and so Snoopy’s nose comes off the front of the breast, and that is a massively challenging problem, in my opinion. So, how do you address that?

    Dr. Sam Jejurikar: I think that it is a very common thing to develop, a waterfall deformity like you’re describing. So again, the implant basically stays fixed because the mesh is in place, and the soft tissue relaxes around it. What I like to do if someone’s developing a waterfall deformity is I like to let them get it as significant as it’s going to be. So, I wait for 6 to 12 months postoperatively. I see them every few weeks and measure the distance from their nipple to the inframammary 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 because it’s not in primary implant-based 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, Doctor Pacella is talking about this lower aspect of the breast. We’d take out just a little bit of tissue from the bottom, sometimes even in the office, but usually, I find that that addresses the issue. It’s a common problem to develop, but I think a relatively easy, straightforward complication to fix once it’s stabilized, in my estimation.

    Dr. Sal Pacella: You know what? I, oh, go ahead, sorry.

    Dr. Sam Rhee: No, no, go ahead because I was going to talk about something a little bit different so go ahead.

    Dr. Sal Pacella: So, what I’ve tried to do is at the time of the original surgery. So, at the time of the Mastopexy, I really tried to account for that. So, I oftentimes have been a bit more aggressive with removing and sculpting the lower portion of the breast and making that lower pole very very taught with the intention, Hey, this is going to drop down over time. I want to set this up for success. What I’ve also tried to do in the past is place some internal sutures from the undersurface of the nipple to the pec muscle in order to try to keep the nipple in exactly that position. It’s quite honestly; it’s a lot of work at the time of the Mastopexy. I found it to be modestly helpful. 

    Dr. Sam Jejurikar: Exactly. I was going to say it’s a lot of, and I do stuff like that as well. I just haven’t been convinced that it overcomes the effects of gravity.

    Dr. Sam Rhee: Yeah. I 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’s so much work that you don’t even see on the outside that we’re constantly doing for Mastopexies on the inside.


    A Challenging Breast Implant Case

    Dr. Sam Jejurikar: Exactly. Here’s a case I found really challenging. I’ve done this case about a year, year and a half ago. A woman had had a breast augmentation with silicone implants done by another surgeon in town. She had a couple of complaints postoperatively. The implants that were put into place were actually 385CC implants. She thought she looked asymmetric when she came to my office. Curious about what you guys see when you look at these pictures and how you’d handle it.

    Dr. Sal Pacella: Alright, Doctor Rhee, go ahead. I’ve been gone first.

    Dr. Sam Rhee: Oh, I don’t mind. So, the first thing I would do is examine her and ask if she was asymmetric, to begin with, or if this was some degree of capsular contracture or other change that occurred over time. If she was asymmetric from the get-go, right after the implant placement, then she has different size breasts that did not change once he put the same size implant on each side. 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 that is causing the asymmetry. She definitely looks asymmetric to me right now that the left side looks smaller. It looks elevated. So, that would be the first thing I would ask about that.

    Dr. Sam Jejurikar: So yeah, and to answer those questions real quick to make Dr. Pacella’s job easier, I realized threw 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 implants on both sides.

    Dr. Sal Pacella: Right. Not having known that, I would have thought on the right side. Possibly this could be an overzealous pocket to section by her original surgeon. Many times, when I see that one side might bottom out preferentially to the opposite side. But yeah, I mean.

    Dr. Sam Jejurikar: Well, that’s true as well. I and so you know, one of the things that we typically think about life is that usually there’s one explanation for problems. But in this case, I think there were actually two problems. One on her right side, left on the screen, right on her body, there is an elongation of this areola 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 was definitely, and I don’t know if it’s overzealous dissection or just bad anatomy, but this stretched out. In addition, the breast was very different sizes.

    So, let’s just jump ahead. She is seen about six months out in this picture. What I ended up doing was on her right side. I used; she had a 385CC implant. I actually ended up using her same implant because it’s 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 the lower pole to the right position because she actually had a pretty robust capsule. I probably put in forty of those stitches all the way across. Then I laid my P4HB mesh all the way across the bottom of it without actually even suturing it in. So, I laid it on there over the capsule sutures to try to give sort of a better curve to give her this fullness she wants on the top. On the other side, I find that if I only use a P4HB mesh on one side and not the other. The breast looked very different from one another. So, I did the same thing even though I didn’t think she had a bottom down on that side.

    I ended up using trial sizers which for our viewers are temporary implants, end up going from a 385 to a 485 on her left side. So, she actually got a substantially bigger implant going up about 100 CCs on her left side. Again, right on the screen, and here she is postoperatively again, you see with the mesh the greater pulled fullness that she got.

    Dr. Sam Rhee: I think…

    Dr. Sam Jejurikar: That’s a great result. 

    Dr. Sam Rhee: Yeah, I was just about to say that it’s a great result. It’s really hard to recreate that inframammary fold once it’s blown through like that. And the fact that you took the time to put 40 sutures in and then laid the mesh on top of it, I think, set you up for success on that. The other thing is, I assume I mean the symmetry is fantastic. It’s so much closer, and I assume she wanted to maintain that right-sided volume, and you just match the left to it, which is very, very symmetric and sort of in concert with her body in terms of symmetry and proportion.

    Dr. Sal Pacella: And let me just clarify you did this all without excising any skin without doing a mastopexy.

    Dr. Sam Jejurikar: Correct.

    Dr. Sal Pacella: Yeah, and so for our viewers out there, I just want to reiterate how challenging this can be for the surgeon. Because I think a knee-jerk reaction is, well, clearly, you need to remove the skin, and you need to do a mastopexy. But in this instance, it was all about volume and not necessarily skin excess.

    Unclarified Speaker: Yeah, and on a slight 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 it interesting. I find that when I’m doing a revision plant case and I’m using mesh. I like putting in a bunch of capsular sutures or basically closing down the pocket using a combination of electrocautery, which is called popcorn capsulorraphy, first to sort of tighten up the capsule. Then put in a bunch of stitches to try to close it down, and then just lay the mesh down on top. And so, it’s a nice way to do it. I think it allows me to create greater symmetry than just sewing the mesh.

    I’m going to 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. She’d had a breast reduction followed by a subsequent breast reduction, and then at the time of her second breast reduction, she actually had wanted to have implants placed. So, she came to me with relatively poor tissue elasticity. I have found that in cases like this, I often times have the implants bottoming out afterward. So, to try to prevent her from being in a situation where she would need to have revision surgery after this implant placement. I just went ahead and put in P4HB mesh.

    So here she is, preoperative. Here 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 P4HB mesh to hold the implants in a higher position. And so, in this case, this isn’t a revision implant case, but it is a revision case. And someone who has poor skin elasticity, which, because she had just such a high possibility of ending up with post-op, went ahead and prophylactically used 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 only do it if there’s a problem?

    Dr. Sal Pacella: Oh, all the time; I think this is an absolutely perfect indication for an internal bra because this goes into the category of patients who have very poor tissue, and very poor structural support to their breasts. So, 100% I would suggest that.

    Dr. Sam Rhee: Yeah, that was a hard learning experience for me, too, is doing a mastopexy, having problems with it, and then learning that I need more support inside because some patients just completely lack good tissue integrity in terms of their support. So, absolutely.

    Dr. Sam Jejurikar: It’s good to see how aligned we are. We all seem to be on this topic. I think there are a lot of indications for using internal bras. If they were slightly less expensive, I think we’d have fewer reservations, and we probably would expand our indications even more. But as always, I learned from you guys and a great podcast. Looking forward to doing the next one.

    Dr. Sal Pacella: Alright, gents.

    Dr. Sam Rhee: Awesome.

    Dr. Sal Pacella: We’ll see you next time. Take care.

    Dr. Sam Rhee: Alright.



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