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Table 3. Comparison of Internal bra materials
Advantages Disadvantages
First generation
Polypropylene mesh; Durable; Foreign body may be subject to biofilms/
Mixed mesh Affordable; infection/exposure;
Variety of sizes and shapes Possible interference with mammograms
Second generation
Human-derived ADM Potentially very long lasting; Expensive;
Elastic (facilitates tissue expansion); Potential for seromas;
Extensive clinical record Need for long-term drains;
Red breast syndrome;
Limited sizes

Porcine-derived ADM Potentially very long lasting; Same as human-derived
Inelastic;
1:1 correction for revision surgery;
Instant thickness
Third generation
SERI Scaffold, P4HB mesh More affordable than ADM’s; Limited clinical data for breast surgery
Variety of shapes and sizes;
Slowly resorbing with induction of replacement
by host tissue;
Open weave may facilitate fluid egress and
mesh integration

ADM: acellular dermal matrix
mammoplasty has been proposed, but the large pieces two proteins: fibroin, comprised of fibers with high tensile
[25]
required can make it expensive. In the case of reconstruction, strength, and sericin, a glue-like substance which coats the
the concept of an internal bra is logical as the breast mound fibroin strands but provokes an inflammatory response
is entirely comprised of the implant; in the case of a breast as an implant. Removal of the sericin component yields a
augmentation, the concept is more limited because it biocompatible material that can be woven or knitted into
supports the implant but not breast tissue unless placed in various configurations. Experimentally, implantation is
[32]
a more superficial layer. This would require placement in a quickly followed by fibroblast migration, adherence, and
subcutaneous layer, encompassing both implant and breast. proliferation. Early iterations of implantable fibroin-
[33]
ADM’s are not generally suitable for this application without based scaffolds included anterior cruciate ligament and
[34]
extensive meshing as with skin grafts. abdominal wall repair. Silk scaffolds seeded with specific
[35]
cell lines or growth factors is an active area of research in
Disadvantages of ADM’s include cost, concerns about tissue engineering. [36]
[26]
animal or cadaveric sourcing, the need for long-term suction
drains, and complications such as red breast syndrome SERI surgical scaffold is a knitted multifilament implantable
®
[27]
and seromas. [28,29] Placement of fenestrations may ameliorate material derived from the cocoons of the silkworm Bombyx
these issues to a degree. Another limitation is the inability mori. It is easily cut without unraveling and suitable for a
[30]
to form an adherent capsule on textured implants, which variety of applications in breast reconstruction, revision
may be desired in some cases to prevent rotation of form- breast surgery, and some cases primary aesthetic breast
stable implants. surgery such as augmentation-mastopexy. In an ovine
[37]
model of two-stage breast reconstruction, SERI scaffold
THIRD GENERATION demonstrated maintenance of burst strength greater than
host fascia through 12 months, with histologic evidence
As ADM’s helped to propel the concept of an internal bra, of scaffold resorption and replacement by new tissue.
[38]
the need for more versatile materials became evident. Slowly Interim one-year data from an ongoing clinical trial of two-
resorbing materials which induce formation of a strong stage breast reconstruction shows low complication rates
[39]
and durable host tissue layer would have the versatility and high patient satisfaction. Early results from a European
of permanent meshes and the biocompatiblility of ADM’s. trial with SERI in direct-to-implant reconstruction after skin-
SERI surgical scaffold (Allergan, Inc.), comprised of purified sparing mastectomy showed good aesthetic outcomes and
®
fibroin silk, and meshes based on poly-4-hydroxybutyrate acceptable complication profile.
[40]
(GalaFLEX , Tepha Medical Devices) are the leading products
®
in this category. Poly-4-hydroxybutyrate is a bio-derived polymer produced
by micro-organisms under specific conditions. P4HB is a
Silk-based scaffolds have been explored in various monofilament used as a suture or knitted into a mesh, and
reconstructive surgery applications because of their is somewhat stiffer than SERI scaffold. Clinical experience
®
potential to induce a host response characterized by site- with P4HB meshes is extensive but only recently has it been
[31]
specific tissue replacement. Raw silk consists primarily of applied to breast surgery. In a porcine model of abdominal
[41]
Plast Aesthet Res || Vol 3 || Issue 1 || Jan 15, 2016 5