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Table 1. Criteria for the ideal internal bra material dermal matrix (ADM) in revision breast surgery for correction
Criteria of implant rippling. This was later expanded to include a
No interference with mammography variety of implant-related problems, with the common
Biocompatible denominator being inadequate soft tissue support and/or
Bio-inductive: template for long-term host tissue replacement coverage. Histologic analysis demonstrated integration
[11]
Maintains strength until host tissue replacement and transformation into host tissue, with follow-up as long
Handling characteristics: easy to template and suture [12]
Easily stored and ready-to-use as 12 years. The ability of these materials to replace
Available in a range of sizes deficient or weakened tissue led to their widespread
Affordable adoption in breast reconstruction and revision breast
Natural feel surgery and became the standard for many years. Host
[13]
recreating a stable breast implant pocket, but are not always tissue response and long-term integration may be affected
capable of providing a comprehensive solution. by decellularization and sterilization methods which can
alter the architecture of the matrix. [14]
Recognition of the potential benefit of non-autologous
internal breast support was initially constrained by the ADM’s have proven valuable in the setting of revision
lack of suitable materials [Table 1]. Most of the products breast implant surgery, for both reconstructive and
[15-17]
were developed for hernia repair and general soft tissue cosmetic cases. In primary reconstruction, they may
support rather than for breast procedures specifically. These allow for more rapid tissue expansion and higher initial fill
materials can be classified as first generation (nonresorbable volumes, though prospective studies on this are limited
synthetics), second generation (acellular dermal matrix), and and inconsistent. Selection of an adequately sized piece is
[18]
third generation (slowly resorbable textiles) [Table 2]. The important. Direct-to-implant immediate reconstruction
with skin-sparing mastectomy relies on the use of ADM’s to
developing role of these products will be reviewed.
offload the weight of the implant from the skin envelope
FIRST GENERATION INTERNAL BRA and control pocket shape. [19]
MATERIALS Further experience with ADM’s revealed their resistance to
radiation, of particular benefit to reconstruction patients.
[20]
The use of polypropylene mesh with reduction mammoplasty Another observation was a much lower than expected
was reported in 1981, and more recently a three- incidence of capsular contracture in reconstruction
[5]
dimensional pre-shaped polyester mesh was developed. patients, leading to the use of ADM’s in revision
[6]
[21]
Because Wise pattern/inverted T patterns rely on the skin breast surgery for established capsular contracture. [22,23]
envelope to shape the breasts, by offloading the support and In this application, the material may afford protection
shaping of the breast from the skin to the mesh, the role of against recurrent contracture, possibly related to altered
short scar techniques expanded. Góes originally proposed inflammatory aspects of capsule formation. Importantly,
[7]
[24]
the use of resorbable mesh with periareolar mastopexy ADM’s serve to replace tissue support and implant
but noted longer lasting results with a mixed mesh (40% coverage after capsulectomy. This ability to provide instant,
polyester, 60% polyglactin). More recently, a titanium-coated predictable, and durable tissue thickness remains a primary
mesh (TiLOOP Bra) has been introduced in Europe. advantage of ADM’s. Porcine-derived ADM’s, designed to
®
[8]
Nevertheless, concerns about biofilms and a permanent offer a non-human source alternative, have found utility
foreign body in the subcutaneous layer of the breast have in this application. In general, porcine ADM’s have more
limited the adoption of this approach. For these same consistent thickness and less stretch than human-derived
[9]
reasons, non-resorbable meshes have had limited use in ADM’s.
revision breast surgery although they helped establish proof
of concept for the idea of an internal bra. The use of ADM’s has been mostly limited to the
periprosthetic layer for creation of a stable pocket for
SECOND GENERATION MATERIALS implants, as a pectoral extension for post-mastectomy
breast reconstruction and in revision aesthetic breast
[10]
Duncan first reported the use of human-derived acellular implant surgery. Use of an ADM internal bra in reduction
Table 2. Internal bra materials
First generation Second generation Third generation
Mixed mesh (polyester/polyglactin) Human ADM Silk fibroin mesh
Polypropylene mesh • Alloderm • SERI Scaffold
Polyester three-dimensional cone • Dermamatrix P4HB mesh
Titanium-coated polypropylene (TiLOOP • FlexHD • GalaFLEX
®
Bra) • AlloMax • Phasix
Porcine ADM Mixed
• Strattice • TIGR (Fast resorbing copolymer of lactide,
®
• Permacol glycolide and trimethylene carbonate;
slow-resorbing copolymer of lactide and
trimethylene carbonate

ADM: acellular dermal matrix
4 Plast Aesthet Res || Vol 3 || Issue 1 || Jan 15, 2016