Internal bra or second skin for revisional breast implant lifts

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The augmentation-mastopexy is undoubtedly an exchange: acceptance of scars for a better breast shape.  
Regrettably, recurrence of the original "droopiness" frustrates both the patient and surgeon.  There are 
several factors which may contribute: a) skin hyperextensibility; b) chest wall anomalies; c) excessively wide, heavy smooth walled saline>silicone implant; d) prior subglandular plane.  Skin elasticity can be "lost" because of weight gain/loss, multiple pregnancies as well as loading by a wide standard profile saline implant in the subglandular plane.  Pectus carinatum or pigeon chest is characterized by a prominent breast bone (sternum), which tend to provide a steep "pitch" for any implant to drop "down and out".  Standard smooth walled profile implants are mobile and tend to exert a "water hammer" effect, ultimately dropping down and out. Relative breast composition changes throughout life and the subglandular plane provides less resistance to gravitational forces.  

Recurrence of droopiness or pseudoptosis may be evident by a) "bottoming out" or the stretch deformity, whereby the distance between the nipple and fold increases, b) "lateralization" whereby the implant travels towards the armpits upon recumbency.  Repeating the mastopexy will not correct the condition because resecting skin doesn't change its intrinsic strength or "carrying capacity".  The internal bra or second skin procedure has included the following: a) incorporation of a "hammock" of ADM (acellular cadaveric dermal matrix), such as Strattice, which is sutured to the free edge of the pectoralis major muscle, the anterior axillary line and the chest wall; b) utilization of a narrower and smaller volume silicone and often textured implant to ensure greater stability; c) use of drains postop to ensure revascularization of the ADM; d) activity restriction, including wearing compression garment for 6-8 weeks postop.  

Patients' objections to acceptance of this procedure include: a) financial: the cost of the ADMs is pricey but certainly less than the cost of reoperating; b) short term safety: the risks of infection and seroma are present however low in my experience; c) long term safety: the durability of the reconstruction as well as the ability for mammograms to be performed is well documented; d) alternate therapies: suture capsulorrhaphy is a technique which can be employed to make the periprosthetic pocket "smaller", however relapses are frequent.  Serica is silk scaffolding, which is deployed in a similar fashion, however long term data on mammography are not yet available. So as the technologies emerge and outcomes support these we hope that the second skin or internal bra variation of revisional breast lifts, will become more commonplace and accepted.  
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Orange County Plastic Surgeon