Episode 64: What is an Internal Bra?

In this week’s episode the Plastic Surgery Untold crew will discuss the internal bra; what is it? Are you a good candidate? Should you consider it and discuss this with your surgeon? Listen as we dive deep into the topic of internal bras. We discuss its multiple purposes along with the benefits, potential surgical risks and outcomes, as well as when the use of an internal bra is not appropriate. This episode is a can’t miss if you’re considering breast augmentation surgery. Enjoy!


Dr. Johnny Franco:  All right team. Welcome back to Plastic Surgery Untold, greatest podcast in the world. Appreciate you guys tuning in, listening. We got our celebrity cast here today we’re going to be talking about internal bra. Should I get one during my breast enhancement, what does internal bra really mean? But before we get to that good stuff and I appreciate you guys tuning in after Gilbert made the last episode, weird. (Chuckles) So if you don’t know what I’m talking about go back to the previous episode, if you do know what I’m talking about, thanks for enduring. Let’s go around the room, let’s start this time celebrity. What’s going on?


Travis Osborne:  Not much man. I’m finally back. I had an Achilles injury, so back and running again. Yesterday I…


Dr. Johnny Franco:  That’s a weird injury from a stationary bike, but that’s interesting. (Chuckles) 


Travis Osborne:  …it had me on the stationary bike for a hot minute. I did not like that. I was like watching the paint dry on the wall for weeks on weeks. So, four weeks off running and finally back now. I’m like two and a half weeks in so it felt good. I ran six miles yesterday and unfortunately had some work stuff early in the morning so got out the door at 11:30. It was 100 degrees. 


Dr. Johnny Franco:  Yeah.


Travis Osborne:  Ten out of ten, I do not recommend running six miles when it’s 100 degrees. So, I’m back.


Dr. Johnny Franco:  I feel like the challenge does good for you.


Travis Osborne:  Yeah, no, it was good. I like it too because it’s almost like a sauna. Like, it’s like a mentally — it just makes you kind of grit your teeth and fight through it. So, I guess I’m like a little bit sadistic. I don’t know. (Chuckles)


Dr. Johnny Franco:  G, what’s going on with you? You’re looking rather damper today. I like red on you. That’s your color dude.


Gilberto Berto Saenz III:  Thank you. I’ve gotten a lot of compliments on this jacket before. I appreciate, I appreciate that. 


Dr. Johnny Franco:  Okay.


Gilberto Berto Saenz III:  Thank you. 


Dr. Johnny Franco:  Well, what’s going on? 


Gilberto Berto Saenz III:  Well, as I alluded to in the last episode, I had been doing a lot of traveling and you’d limited me to just one of my travels…


Dr. Johnny Franco:  Yup, true.


Gilbert Saenz III:  …in my last introduction so maybe I’ll talk about another one today.


Dr. Johnny Franco:  It’s been our new phase in our podcasts, we’re trying to limit G-Berto’s time. (Chuckles) He doesn’t realize this is a phase-out method, (Chuckles) so don’t tell him if you’re listening.


Gilberto Berto Saenz III:  But no, in all honesty and all joking aside, like I said, April was a busy month for me, but I felt like it was a really great month. I learned a lot, I attended a couple of different courses, of which again, like I mentioned before, I’m really excited to bring back to Austin Plastic Surgeon. But one of the other ones I attended was in Fort Lauderdale with Dr. Shino Bay, and I did a lot of interesting stuff with biostimulatory injectables, which we’ll talk about in a future episode too, but really, really interesting stuff. 

It was very different from the other course that I took earlier in the month of April where that one was kind of geared more towards HA fillers which people are, are more commonly used to or know about. This one is more about using your body’s own collagen to stimulate, you know, some of the some of the improvements that we see in the skin. So really neat and hoping to talk about that a little bit more later on.


Dr. Johnny Franco:  Was this one life-changing as the other one was (Chuckles) or (voice overlap).


Gilberto Berto Saenz III:  It really was, you know, it really was.


Dr. Johnny Franco:  So, which was more life-changing not to put, you know, Dr. Shino Bay and Dr. Arthur Swift against each other. If you guys are listening, you’re both great, but Gilbert’s got to pick one.


Gilberto Berto Saenz III:  So, the thing is they’re life-changing in their own way.


Dr. Johnny Franco:  Do you think they’re subscribers? Did they mention anything about it?


Gilberto Berto Saenz III:  I certainly hope so.


Dr. Johnny Franco:  Okay.


Gilberto Berto Saenz III:  It’d be great if we could get them on.


Dr. Johnny Franco:  Yeah, maybe we’ll get…


Gilberto Berto Saenz III:  Yeah.


Dr. Johnny Franco:  …shoot them an invite. We’ll tag them see if they’re interested.


Gilberto Berto Saenz III:  Yeah. But no, it’s very interesting because they have different approaches to the way they use these products. Dr. Shino Bay is very focused on like regenerative medicine and using the body’s own collagen producing effects, where Dr. Arthur Swift uses a lot more of the HA fillers which help volumize the tissue. And there is some, maybe some, there’s argument that there’s probably some collagen formation from that as well because of the injury from the injections and such, but they’re just very, very different and it’s really interesting to see both perspectives. And again, hoping to bring all that back to Austin Plastic Surgeon.


Dr. Johnny Franco:  But here in Austin, right in the middle you’re combining the best of both worlds.


Gilberto Berto Saenz III: Yeah. And interestingly enough, one was on the west coast one was on the east coast and I’m just bringing it here to like…


Dr. Johnny Franco:  Third coast.


Gilberto Berto Saenz III:  Yeah.


Travis Osborne: To the third coast.


Gilbert Saenz III:  To the third coast.


Travis Osborne:  Oh yeah, love that.


Dr. Johnny Franco: Wow! Well, thank you Gilbert. All those people followed you with you so the people trying to buy a house in Austin don’t thank you (Chuckles) for having everyone follow you here, but yeah, thank you. (Chuckles)


Dr. Johnny Franco:  Dr. Weinfeld (Chuckles).


Dr. Adam Weinfeld:  Yeah. I mean I think it’s worth mentioning that this is our first podcast session, subsequent to the ASAPS meeting that was in San Diego.


Dr. Johnny Franco:  Mm-hm.


Dr. Adam Weinfeld:  What is that roughly four weeks ago, something like that.


Dr. Johnny Franco:  Yeah, just about a month.


Dr. Adam Weinfeld:  Yeah, just about a month ago.


Dr. Johnny Franco:  And part of the reason that we had a little hiatus, we had House of Modern Beauty, thank you RealSelf for that. 


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  And then San Diego, which was a busy week for both of us.


Dr. Adam Weinfeld:  Yeah. 


Dr. Johnny Franco: You actually spend — because you do the rhinoplasty symposium and then the aesthetic meeting.


Dr. Adam Weinfeld:  Yeah. It’s almost a week away, yeah. I mean it’s but it’s good, I learned so much at those meetings, you know, some of the highlights of that was really starting to understand the evolving role of preservation rhinoplasty in terms of the options that we can offer patients. And then, you know, as we have talked about in our last podcast and what we’re talking about now, there are a lot of changes afoot as it comes to cosmetic breast augmentation. And so, I made sure that I went to as many of the sessions as I could that focused on that topic so that we can educate our patients and provide the best results to them.


Dr. Johnny Franco: I think it’s almost interesting because people were like, why does stuff change and I was like, as you know, I personally don’t want to be 20 years from now sitting here doing the exact same thing that I do now…


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco:  …with technology, with our understanding, even some of this basic is anatomy. I feel like we still continue to evolve our understanding and as we understand our understanding evolves, as newer products, techniques things come out, you know, we continue to evolve with it…


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco:  …and I feel like the day that I stopped trying to like learn and evolve is the day that I should stop practicing.


Dr. Adam Weinfeld:  Without a doubt. If you if you’re not changing, you’re moving backwards, because it’s, you know, there’s just it’s such a complex endeavor. You know, there’s just like an infinite number of things that we are actually doing for a patient in terms of planning for a procedure and executing a procedure that if we at present think that we understand that infinite array of things that we can do to make it the best procedure possible, we’re not trying and we need to always be trying to understand even the most minute detail so that we can give our patients what they need from us.


Dr. Johnny Franco:  New question. Talking about new stuff and I got a few nuggets I want to share with you guys, not quite ready maybe the next episode. But, so let’s jump into the good stuff here, talking about new techniques, new stuff that we’ve learned. You know, internal bra is a question when we’re talking about breast enhancement, secondary breast surgeries, breast revisions, whatever you want to talk about we can get into that in a minute.

Internal bra is definitely a new not a new term but a term that’s definitely becoming in vogue, and maybe we can discuss what internal bra is, who’s a candidate for it? You know, we’ve even started discussing something called a prophylactic internal bra, which I think is new, I think that is, you know, a little bit forward thinking because I think the goals that we have, you know, whether we’re talking about breast surgery or something else. 

And you mentioned in our last episode for those who listen that, you know, most people if you’re getting your first breast augmentation, you know, in your 20s, you have to at least strongly consider the fact that it’s likely that you’ll have another surgery, and I tell my patients that’s it’s likely, you know, these aren’t going to last you the next 90 years of your life, you no longer have to change these every 10 years, but unlikely that you’re not going to want to or need to do something at some point.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  But we are always trying to improve our techniques and everything that we do to minimize that risk to try and get you as much lifespan out of that breast enhancement as humanly possible.


Dr. Adam Weinfeld:  Agreed, yeah. And that’s where the internal bras, if you will, come into play because they can help control the placement of an implant and really perhaps increase the durability of their results. 

Should we step aside or backwards just for a second and talk about what are we even referring to when we’re talking about internal bra?


Dr. Johnny Franco:  Yeah, a hundred percent. I feel like internal bra was this term that, you know, and that kind of was a slang or social media term that kind of came up that truly refers to what we call is a — and this term may not be completely true anymore with the when we talk about prophylactic internal bra. But in general, it used to mean like a capsulorhaphy, where we go in and do something that’s going to tighten that pocket and hold the implant into a better position. 


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco:  Because I would say if you even went back four or five years ago, you know, 98, 99 percent of my “internal bras” and I’m using quotation marks here, where a capsulorrhaphy done by sutures where, you know, someone came in because their implant had either bottomed out, so kind of slid down or slid towards their armpit and were trying to get it into a better position.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco: And that’s where the term internal bra came from is because we’re tightening that pocket, readjusting the pocket internally…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …to hold that implant into a better spot.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  Because I think we all understand if you’re just dependent on the skin to hold the implant into a good spot, that’s a set up for problems and not giving you longevity.


Dr. Adam Weinfeld:  Yeah, exactly. So yeah, let’s just definition of terms, nomenclature, so you know you’ve got the skin and the breast tissue, so manipulations of that we’re not going to call internal bra, what we’re talking about is the deeper tissues often when we’re going back to make a revision, you know, doing something deeper than the breast tissue, deeper than the skin we’re going to call it internal bra, and we can break that up into two categories. We can do an internal bra with the body’s own tissue…


Dr. Johnny Franco: Mm-mm.


Dr. Adam Weinfeld:  …or now, what I what we are going to spend some time talking about is how do we employ external materials to help supplement the body’s own ability to hold that implant in place. So you’ve got capsulorhaphy, which is what you were talking about, bringing tissue together using sutures to hold it together. We’re going to call that, you know, sort of the body’s own tissue and then adding something to it in the form of bioabsorbable mesh, we’re going to call that something else. (Chuckles)


Dr. Johnny Franco: But I think this is important because you talked about even with the rhinoplasty and stuff. When we talk about doing stuff like, you know, preservation, we’re doing always trying to improve these methods that they’re less, you know, the recoveries are easier, the procedures are less destructive to the tissues that you have. And so, you know, in the past we’re limited with these internal bras because if you don’t have an implant then you haven’t created this capsule, so there’s not this material deep inside because every — performs a capsule which is some layer of scar tissue that forms around the implant. And, you know, this is, you know, almost like the porridge and the three bears right, so you want it to be just right where there’s some capsule around the implant that holds into a good position. If it’s too tight you get capture contracture where the implant feels really firm and can go move up. If it doesn’t form enough, then it can go off to the side, it can bottom out and this is where trying to do some of these internal bra techniques. We’re trying to take some of that variability out of the equation so we’re not just doing it and hoping for the best.


Dr. Adam Weinfeld:  Yeah. So why don’t we just take like a case example. So, let’s talk about that patient that we see occasionally where they’ve had a breast augmentation that served them very well for some time. They’re happy with the size of the implant, they don’t have a thick capsular contracture, but in time their tissues have weakened a little bit. The implant’s a little bit low, and it has kind of worked its way a little bit to the outside, and they want to have a sort of a secondary breast augmentation where — and let’s say that patient doesn’t necessarily have a lot of loose hanging extra skin, it’s really one that this sort of archetype patient is one where just the implant is low and to the outside and they just want that perky look that they had five ten years ago to be restored. So really, now we’re talking about sort of supporting the implant.

Now, before the meshes that we have available to us, like, you know, just walk us through really quick, what would you do with that patient?


Dr. Johnny Franco:  And I don’t want to misguide people because a little bit of movement of that implant is fine.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco: So, we’re not trying to say that the implant needs to be perfectly still because part of the benefit of the gels and these things is that you have some of that movement that keeps it soft so…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …a little movement to the side, a little movement down is okay. But we’re talking about once it gets beyond…


Dr. Adam Weinfeld:  Beyond that, yeah.


Dr. Johnny Franco:  …beyond that spot.


Dr. Adam Weinfeld:  Yeah, where it permanently kind of comes to sit with gravity low and to the outside.


Dr. Johnny Franco:  I would say my answer, you know, over the last five years has definitely evolved. If we went back, you know, when I got out of training and even when I was in Miami, I would have, one, if we’re going to go back, I always have a discussion with the patient about where are we with implant size. Because if you want to change the implant size this is a time to do it and for us to at least have that discussion.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  Two, you know, if you have an older saline implant and you’ve already had these issues, I will typically push them to use one of the new gummy bear-highly cohesive gel implants, because I do think that decreases their risk, that puts less stress on our repair and gives them the best chance for success.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  You know, and then from that this is where things have changed for me in the past, I would have done the suture repair where I suture that capsule together and try and line that up. The issue with that is it was a little hard to control so it definitely took more time in surgery. Two, I think there’s a little bit more variability. Three, it was solely dependent on the strength of that capsule to hold those sutures and not break and have a relapse. I think four, if I’m on four already, and sometimes the breast looked a little square or right angle it’s hard to give them a nice natural swoop. Most of that did in all fairness get better…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco: …over time, but, you know, for patients it can be concerning. You, you’re going through this big surgery and all you’re hearing from you and I is like be patient.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  And in the vast majority of people like it does round out and get to a good spot, but…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …it’s three or four months for it to get that nice shape.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  I’ve now evolved to doing something that Dr. — I first saw described by Dr. Calobrace and he may or may not be the one who invented it, but I give him credit for it is something that we call popcorn method or where you actually use heat to control and get that capsule to contract. I love this because I think you’re thickening that capsule, I think you have a smoother transition. It’s a lot easier to do so I do some variation of pocket adjustment to everybody now.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  And then I would say now most recently I’ve switched to — most of the time I’ll do the belt and suspenders while I’ll do the capsule with some of the thermal, the popcorn method and also use one of the meshes. And we can talk about, you know, why the meshes I’ve switched to reusing them because they’re not new but there are newer ones on the market.


Dr. Adam Weinfeld: Yup, yeah. So, let’s walk a patient through this, so, you know, envision your breast implant is lower than you want it to be, and it’s further to the outside and you’ve had a prior inframammary incision so where the breast meets the chest you’ve got an incision there, and you come to Dr. Franco or myself and you say, you know I’d just like it higher and more to the inside.

And again, this is different than motion, natural motion is as I think you’re very wise to point out totally normal, desirable and fact. So, what we would do is bring you to the operating room, discussing the techniques up to these meshes that we have available to us and then we’ll talk about what we do afterwards. 

But you make the incision, most likely where you had it before, take out the implant and then you use a little bit of thermal energy so you put the Bovie on a little bit of a higher setting and you go to the outer aspect of that breast envelope and to the lower aspect of it, and you just supply some of the heat which kind of shrinks it like a sweater in the dryer, and you shrink up some of that tissue, and as you said, stimulate some additional collagen. They may supplement that with some sutures although if you can avoid doing it that’s good or potentially better because you don’t get more of a square appearance perhaps or even puckering which you can kind of see through the skin. But if you need to add a little bit of sutures you can do that. So that’s kind of what we did up to, you know, relatively recently. 

So now what we might do and we’re going to talk about these materials is now what we might do is supplement that so whether it be the thermal capsulorrhaphy, the sort of sweater shrinking technique and then plus or minus the sutures, we’re going to add a bioabsorbable mesh there that helps supplement that and really kind of what was the —  what the body is going to do is going to respond to that mesh and it’s going to create its own collagen that kind of welds everything together over the whole length of that tissue that we have. 

So, from, you know, just below the armpit all the way down swinging down around that gutter of the envelope that we just created to the inner part of the breast. And that mesh is going to be replaced and supplemented by the body’s own collagen creating this really new natural capsule that is really the dimensions of which were designed by Dr. Franco and myself and other surgeon to help support for a longer period of time that implant.


Dr. Johnny Franco: And I love this because, and this is what sometimes can be confusing because all of those can individually can be considered internal bra, right?


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco: So, you know, putting the mesh it could be considered internal bra, re-changing some of that pocket could be considered the internal bra. In the old days we would even sometimes take part of that capsular, flip it over, re-suture it, re-line it.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  You know, if we don’t have to be so destructive on the internal portion we would rather not, that’s where some of these have come apart.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  I’ll tell you for me, the reason that it switched recently is that I feel like the types of mesh available has changed a lot…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  … and that’s why I’m much more aggressive about offering them.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  You know, and not to go soft but the big reasons that they’re more on my armamentarium if you would of things to help patients is the cost has gotten much more reasonable for patients. I mean it wasn’t too long ago that, you know, some of these specialty meshes were $ 3,000.00 a piece.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  You know, so if you’re doing both breasts, you could usually spend $6,000.00 on just the mesh and nothing else.


Dr. Adam Weinfeld:  Yeah, and just to kind of clarify verify, when you’re referring to those older materials available are you referring to some of the animal and human derived collagen sheets?


Dr. Johnny Franco:  Some of the dermal matrices…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …for sure. I don’t know how you felt but in my hands they were a little bit harder to use as well.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  Sometimes suturing them into place was a little bit harder.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  Sometimes getting them to adhere to the soft tissues…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …is a little bit tougher.


Dr. Adam Weinfeld:  Oh yeah, yeah. 


Dr. Johnny Franco:  I don’t love using drains around an implant…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …and some of those if you didn’t use drains you were at a higher risk of some other problems so…


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco:  …and I’m just trying to give people an idea of why we’ve transitioned it’s not just that…


Dr. Adam Weinfeld: Well, it really is a game changer, it’s real a real game changer because, you know, one, the expense of those whether it be the AlloDerm or the Strattice, which came from – AlloDerm from human, Strattice from pig porcine collagen sheets. 

You know, those actually, they did help reinforce that new gutter that you created that really helped keep the implant where it was but you had to suture those in in many different locations with the idea that you might not get kind of collagen to collagen, sheet to sheet healing the way you want it, whereas these meshes really just their mere presence really stimulates some collagen production.

I mean also because they’re a mesh and they’re woven as opposed to a more sleek smooth piece of collagen just their coefficient of static friction is higher and they kind of velcro themselves down a little bit. I know we’ve talked about this offline so many times, but you really just put them — it’s kind of like set it and forget it a little bit. I know you put one suture, I put one or two sutures to really just hold it in place really, you know, kind of where like the top bottom if you will just so it’s not shifting or to hold it in place as I put the implant in, but I feel so much more comfortable that it’s going to stay where I need it to stay.


Dr. Johnny Franco:  And this is that and those are all the reasons that I’ve slowly started being more and more aggressive about offering them to patients, because, you know, there’s risk for everything we’ve talked about this on our other podcast and, you know, I’d hate in the past, one, ask you to pay a ton more money for something and then have a problem, you know. 

And so that’s why I think we were always super selective because if somebody’s listening is like well why didn’t you just offer this to me all the time and it’s like well, I didn’t want to create a problem for you, I didn’t want you to spend a bunch of money that on something that may or may not help you…


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco:  …and I feel like you talk about it all the time, kind of cost and rewards what do you get for that.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  I feel like as that cost goes down, you know…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …there’s not as much pressure that like what this is going to do because we’re getting you into a good spot.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  I think the complication rates are much, much lower cause pretty rare because of that woven, you know, type messed up seromas, some of these fluid collections that we’re worried about with the old ones. I, knock on wood, I have not seen that with these.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  And by design I think it’d be hard.


Dr. Adam Weinfeld:  Well, and these materials, you know, because they’re, you know, essentially man-made, they can be terminally sterilized, meaning that, you know, you open that package and you have every bit of confidence that there’s no bacteria, whereas unfortunately as good as the those the porcine pig and human-derived collagen sheets are, they, well, I shouldn’t say this, but some of the preparations are not actually terminally sterilized so they’re like the bacterial kind of super, super, super, super, super, super, super, super low is not nothing, and that’s an important thing to note. 

So that’s, I feel so much more comfortable with these meshes as you have really already hammered home, price, but also, we have more confidence that they’re not going to bring along a whole host of complication baggage.


Dr. Johnny Franco:  And the other thing that people worry about because they, if anybody who stayed up late sees these infomercials about meshes and like all the bad problems that’s (Chuckles)


Dr. Adam Weinfeld:  Really important to point out.


Dr. Johnny Franco:  These are very different, and you already alluded to it, is that these actually stimulate this collagen, thicken up this capsule wall, hold that implant in place and the idea is we’re just trying to hold that implant in place for the first few months, and the exact amount of time I think is still a little bit of debatable, but most of these newer meshes after nine months to a year and a half the body slowly absorbs them so there’s nothing left permanently that that’s going to cause some of these long-term problems…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  …so I think that’s a game changer.


Dr. Adam Weinfeld:  That’s a game changer, yeah.


Dr. Johnny Franco:  And most people don’t even realize some of these new meshes are actually made of the same material that we used for the sutures in the past to close that, but in a much more tight woven and basically a thousand of these sutures put together. So if you could imagine if we put a thousand sutures and lined your whole pocket that’s what we’ve done, but somebody’s done it for us so we wouldn’t have to sit there for six hours.


Dr. Adam Weinfeld:  Yeah. (Chuckles)


Dr. Adam Weinfeld:  That’s a good way to think of it, and I’m so glad that you pointed that out, is that these materials are not experimental in the sense that these are sutures we’ve been using for tens and tens and tens and tens of years. (Chuckles) 

It’s just that they — the way they’ve been prepared, the shapes, the sizes that they are, the material that’s created out of them is entirely new. And when we say new, we don’t mean like new, new yesterday, I mean they’ve obviously they’ve been trialled in patients for many years, but it’s, you know, such a refreshing thing that we have these to offer our patients.


Dr. Johnny Franco:  It’s funny because anesthesia can jump in on this, but one of our social media people asks me like, “Hey can you do a TikTok on what’s who’s a good patient for these new meshes,” and I stopped and I was like, I don’t know, because I feel like, you know, if we come back to this TikTok six months from now some of these indications may have changed and I think they’re going to get broader and broader and broader to the number of people that we offer some of these too.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  You know, and because I think you and I are the same when something’s new we don’t want to necessarily just offer it to everybody because it’s the newest thing on the market, you know, we like to see that this is helping people, I like to be able to tell you that you’re getting something for the money you’re spending for this.


Dr. Adam Weinfeld:  Yeah. You know, I think this — you brought up something and so we’re really fortunate to have Travis and Gilbert here who are like super knowledgeable about, you know, medicine, very well-trained medicine, about, you know, plastic surgery also from different perspectives, but to some degree are naive to what we’re talking about a little bit. So, I think it’s great to have like, you know, sort of an expert but not an absolute expert to kind of ask us some questions. 

So, based on what we’ve already talked about like what kind of questions does that stimulate for you guys? Because I know your question will be thoughtful and it’s going to help our patients understand why we might be suggesting these materials for them.


Travis Osborne:  Yeah, so I mean I luckily get to see you guys use a lot of these different meshes, and I mean from all the way from Strattice, five six years ago to, you know, some of the newer stuff that you guys are using today. 

So out of those, I mean when you’re doing these pocket revisions and without doing a mastopexy or a breast lift or anything with the skin, what is the level of lift and support that you guys can achieve with these meshes versus just a simple, you know, suture and trying to close down that pocket if you will?


Dr. Johnny Franco:  I mean I would say for me the difference on the table or immediately post-op is actually unperceivable. For me, these measures are more about longevity and trying to help people.


Travis Osborne: That makes sense.


Dr. Johnny Franco:  And so this is where the, you know, going back to the evolution of who’s a good candidate, like for me in my mind someone who’s had massive weight loss I feel like we should at least talk about this because I feel like they’re at higher risk. I feel like people who are using larger implants we should at least have this discussion about this. I think depending on their anatomy if you’re very kind of barrel chested where that implant looks like it might be more prone, I think that’s an indication. 

Talking about how these keep changing, somebody, when we were in San Diego, gave a talk about, you know, maybe even people who have tuberous breasts might be a good patient because you’re opening up that fold and now, you’re trying to you’re asking this implant to sit on something that you’ve just opened up…


Travis Osborne:  Yeah.


Dr. Johnny Franco:  …you know, and so I thought that was very insightful and very thoughtful and something that at least made me think about it.


Dr. Adam Weinfeld:  Yeah, yeah, I cuz I, the minute you asked that question I was kind of thinking what you just said, so let’s reiterate that for the patients, like the on table result likely we can achieve the same thing, but the result that we created on the table is not the result that patients end up having three and six months down the line in some cases. And so we never leave the operating room without thinking that it’s perfect or that it’s going to be perfect. 

But what these meshes are likely allowing us to do is to have the confidence leaving the operating room that what we designed in the operating room, what we’re trying to execute in the operating room is what they’re going to get at six months and six years, you know, 16 years, maybe not 60 years but, you know, I mean it’s going to give us an enduring result. 

Can we promise that that’s going to be the case? No, we can’t, but it makes me feel a lot more comfortable that, you know, if a patient is spending X amount of money on the procedure if they spend X plus a tiny fraction of X, that that’s going to make that sum that they paid for the procedure, a real value, you know. So and that’s where when it used to be, you know, three or four thousand dollars like I don’t know, but, you know, it because nothing’s promised, nothing’s guaranteed in terms of how this mesh is going to be performed. 

But when we’re talking about these meshes costing, you know, fractions-ish of those original cost, then I think it’s a worthwhile insurance policy, not the way that an insurance policy guarantees things, but it creates a much higher likelihood that what we intend to create in the operating room, what we left the operating room with, with a great plan, with great execution is what they’re going to get down the line, and that’s what we want for our patients, you know, we want them to get great value for their money.


Dr. Johnny Franco:  And I feel like this is where we are at this time point in plastic surgery history is trying to figure out a little bit better statistics of how much does this help, which mesh, because there’s a few different ones on, are best for each patient and who’s at higher risk.

And so, you know, the two that I use most commonly are one called GalaFLEX, which, you know, lasts about a year and a half or so, and then there’s a newer one called DuraSorb, which is considered the softest mesh on the market, so I think there’s a role for both depending on the special situations.

And that’s kind of where we are now is figuring out which is best for each situation, who’s at highest risk so we — I would love to be able to give people more statistics and I think that’s what we’re gathering right now is like how much does this decrease your risk, you know, what percentage does this help.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  Because right now I think we feel like it helps…


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco:  …we can’t tell you a percentage.


Dr. Adam Weinfeld:  Yeah, yeah. I think that’s really fair, that’s extremely fair really important. And I think really we are at a phase where we can’t say with certainty that one’s better than the other, I think that we can say that we have some intuitions about that that if let’s say we need — we feel like, and it is a little bit of a feeling until we have 100 of the data that if we feel that a patient would benefit from a little bit, maybe not stronger but longer term strength of their support, we might lean towards the GalaFLEX, whereas if it’s a patient that we want just a little bit more confidence that our tissues are going to heal together and stay together the way that we want, we might lean towards the DuraSorb. 

None of those are absolute rights or wrongs, and none of that is a hundred percent science based at this point, but that’s how a lot of plastic surgery is, you know, and you just have to have a thoughtful surgeon who really explains sort of what their decision making is and how it might influence, you know, your decision making as a patient and understand that in all likelihood what we believe is going on actually is what’s going to go on.


Dr. Johnny Franco:  And I feel like there’s the two extremes for this, right? So, there’s the extreme where I would strongly recommend it and maybe even go to the point of telling you doing surgery without it is not worthwhile.

And Gilbert, our quote of the day expert can correct me if I’m wrong if I’m misquoting, but I think it was Albert Einstein that said, you know, “Repeating the same activity over and over again expecting a different outcome is the definition of insanity.”

And so like, when somebody comes to me and has had two or three breast surgeries of trying to do some type of internal bra to just go in and try and do the same suture method or same, you know, thermal, you know, popcorn method to the thing without employing one of these new meshes or doing something different, to me just doesn’t make sense, especially, you know, in a tight-knit community like Austin where I’m like, hey the person that did your last surgery was a very good surgeon so for me to go back and do the exact same procedure and expect that this is just going to turn out better, I feel like is unlikely, and so I think those are people I feel really strongly that we have these new tools in our box.


Dr. Adam Weinfeld:  Yeah, yeah. I mean for — it’s such a subtle thing but it makes me feel so much more comfortable heading into these kind of surgeries that I’m doing everything I can do, you know, and I don’t feel uncomfortable about offering this to a patient because I think with those lower costs, lower potential for complications that now I’m really educating my patients about all of the possible options, whereas in the past I did feel a little uncomfortable bringing up Strattice or AlloDerm because it was so expensive, and I think in some ways it was a little bit conceptually flawed because you couldn’t be certain that you would have that smooth collagen sheet healed to a smooth capsule whereas again the very nature of these materials and how we believe that they’re behaving is kind of conceptually different from that in a way that I feel a lot more comfortable with and offering my patients, that and the price.


Dr. Johnny Franco:  Can we talk a little bit about, you know, kind of where we’re at and where we’re evolving to, because I think we can both pretty strongly agree someone who’s had a revision and needs another thing I think we feel pretty comfortable recommending something like this. I think someone that’s looking for extra support, you know, I think some of our massive weight loss people who we have — some reason to have a concern for their soft tissue we recommend them. 

I think evolving even more, I’ve even started bringing up to some of my patients this prophylactic internal bra so any of my patients that are going with larger implants, I try to at least have this conversation because…


Travis Osborne:  And is that even for a primary aug?


Dr. Johnny Franco: …even for a primary aug, and this is because that has been well shown in the literature the larger the implant you go the higher the risk of needing a secondary surgery becomes, because of the weight of the implant, because of the size, because of the stretch of the tissue.

So, what can we do to decrease that? I think some of the people like we talked about that, you know, have a full other stuff so on some of my primary breast augs we’ve talked about this for sure, and then maybe I can get your thoughts on that. And then the second part of that is, you know, what role do some of these soft tissues support like GalaFLEX, DuraSorb, these internal-bra meshes bioabsorbable meshes have been breast reductions or mastopexy without an implant…


Dr. Adam Weinfeld: Yeah.


Dr. Johnny Franco:  …which would be a little bit different but something more on the horizon that people have played with, again, I think these materials give us a little bit more options.


Dr. Adam Weinfeld:  Yeah, so for the last minute or two just for, you know, our future patients and the audience out there, we’re talking about the preventative use of one of these materials.

Now, it’s really important to kind of qualify that with the fact that — so we’re not talking about a revisionary procedure we’re talking about trying to anticipate the kind of things that can happen with a primary breast augmentation or you brought up mastopexy so breast lift or even a breast reduction.

So, what we’re trying to do and we can’t guarantee that it does, but we’re trying to prevent some of the known challenges that occurs, so let’s talk about the breast augmentation where you brought up the idea of a bigger implant or maybe a surgical plan that involves lowering the fold right? 

So tuberous breast is a good example of that or just, you know, a high, high fold but maybe not tuberous breasts where — so the inframammary fold, again, where the breast meets the chest internally there is a thick accumulation of collagen there that really serves as a barrier for the implant to — or a potential barrier at least for the implant to kind of sink lower within the body.

But there are some procedures in order to achieve the aesthetic goals that the patient and the surgeon has decided are important to the patient, you actually have to sort of incise through that lift up, that thick collagen attachment to the underlying structure so you have to lower the fold or disrupt the fold.

Well, that can create a problem because you no longer have that natural barrier for the implant sinking lower in the body and you can get it out. And that’s where the role of one of these meshes really is going to demonstrate a lot of utility, because you can lower that fold and then you can put the mesh to line that new gutter, that new junction of the breast tissue or the chest tissue and the deeper chest wall. And you can line it with that to hold that implant in place while your body replaces that mesh with its own collagen and really in some ways replicate or reconstruct that collagen netting that your body used to have there as the inframammary fold. So that’s a good example of how these might play a preventative role instead of sort of treating a problem in a secondary breast surgery.


Dr. Johnny Franco:  And I think this is where one of the ones that we’re truly trying to define, like who’s at higher risk, who does this help the most, and so I think there’s some extreme cases where we get a really good feeling, but still trying to…


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco: …to define that, and so, you know, and I just because sometimes people see our podcasts, our Instagram, why did wasn’t this, you know, offered to me or my account for this? And like, you know, we really, we want to offer you what we think is best but we also don’t want to like offer you stuff you don’t need.


Dr. Adam Weinfeld:  Yeah. And our understanding of what best changes and really, you know, these conversations are coming off the heels of the meeting where we had a lot of — people had sort of early exposure to these meshes on study are really presenting their findings and now we’re able to offer it to our patients, you know, so they’ve just — a lot of them have kind of — not just come to market but they’ve come to market where, you know, other plastic surgeons who had their availability on study are now relaying their experiences, and because the cost is much lower than the alternatives and because the potential complications are also much lower, we have the confidence to offer them to our patients now, whereas honestly six months ago a year ago that was really not something that we could offer our patients, yeah.

So, patients who had surgery — they should in no way feel shortchanged by that, it’s just that this is one of those wonderful new tools that we can offer our patients.


Dr. Johnny Franco:  And involved in practice.


Dr. Adam Weinfeld:  Exactly, yeah. We’re not — we don’t want to walk backwards.


Travis Osborne:  This reminds me a lot about kind of that time over the past five, six, seven years in anesthesia where we’ve kind of shifted our mindset with nausea prophylaxis, right? Like, you know, five, six years ago, we’re trying to just throw everything that we can at these patients while doing kind of the same general anesthetic and hitting them with a bunch of medications that help with post-operative nausea and vomiting either during the case or afterwards. 

And we reserve, we had a couple medications like Emend, and some of these kind of novel anti-nausea medications that were price prohibitive at the time for everybody getting it. And now, we have ways to kind of identify who’s at higher risk for nausea and vomiting and these — the price of these drugs has kind of come down so now if we identify these candidates we can start to apply that to more patients.

So, I think it’s very similar to the meshes it’s like, you know, we’re constantly evolving our practice and seeing like what works, what’s coming to market? Okay that’s been on the market for a little while, the price is starting to come down, now we can offer this to a wider array of patients, now instead of doing this we can do in a total IV anesthetic if we know that this person’s had issues with three different providers and I know they’re all fantastic providers, now let’s — instead of trying the same thing six more times let’s change the game and do something that is a little bit different.


Dr. Adam Weinfeld:  You know, I just thought about this, you know, in many ways what we’re talking about sort of in a more macro fashion in breasts, really relates to some of the information that you learned from Shino Bay with regard to stimulating the body’s ability to create its own collagen.


Gilbert Saenz III:  Yeah.


Dr. Adam Weinfeld: Yeah. With that in mind do you have any questions for us, you’re always very thoughtful?


Gilbert Saenz III:  I do have a question and it might kind of backtrack a little bit to what we were talking about earlier, but — so in our last episode, we were talking about submuscular versus subfacial implants, and one of the things that you guys mentioned was how with a subfascial over the muscle but underneath the fascia implant placement, there may be some risk for some rippling in the upper pole of the of the breast, I believe that was the phrasing. Would mesh over that area help minimize the appearance of some of that rippling?


Dr. Johnny Franco:  I think this is a great question. I almost tell people, and when I grew up, you know, Cadillac was like the car, now maybe it’s like a G-Wagon or a Tesla truck or something, I don’t know. But like if somebody’s like I want everything possible to decrease my chance of, you know, rippling, you know, support, everything. No question you could do like one of these extra cohesive breast implants, you could do some of these mesh sling stuff, because I think, one, it’s going to thicken up that capsule which is going to give you some of what you were trying to achieve with the muscle, I think it’s going to hold that implant in a different place.

It’s a talk for another day, but I think it’s replaced some of the stuff that, you know, benefit from textured implants, you know, without some of the downsides of it, conversation for another day not to go down that rabbit’s hole.

But no question, I think it can help thicken and protect some of that from rippling, so I think there’s a combination of the highly cohesive gels and, you know, the mesh that would be, you know, is a really interesting and I think – for this.


Dr. Adam Weinfeld: You know, and one word really sums up my answer, and you kind of said this, but “may”, I mean I think the real answer to your question is that it may help with that. And so I think the way that that conversation for me would work out as — so we have and, you know, and really, audience, patients can go back and listen to our last podcast, but, you know, there’s now options to place the implant above the muscle and so, you know, part of the conversation — actually you and I had in our role play, was that above the muscle might lead to more rippling, right?

So, you know, the conversation would be, you know, I’ve got a patient who like, I really love the idea for all the reasons, all the pluses, really the idea of above the muscle breast augmentation, I’m a little concerned about the rippling so I’m going to make that decision, Dr. Weinfeld, to go above the muscle but is there anything else you might say or anything you could offer me to potentially mitigate or downgrade that potential for the rippling? 

And so, this is where I would say, you know, I can’t say that this absolutely – well, I can’t say that at all. But if we’re going to do, if you want me to do everything I can you made the commitment above the muscle but you may do — pull out all the tricks that I have in my bag, might I suggest that we use this mesh, you know the data, our understanding of these suggests that it may help. I can’t guarantee that it would, I would never do anything that I think is going to hurt or be a step backwards, but it may and if you’re interested in spending a little bit more money for something, I can’t 100 say it will definitely help, let’s do this.


Dr. Johnny Franco: And, and…


Travis Osborne:  It’s like the G-Wagon approach…


Dr. Johnny Franco:  Yeah, yeah.


Travis Osborne:  …that you’re talking about.


Dr. Johnny Franco:  And it may have other benefits besides just decreasing the rippling because it probably helps decrease the risk of the implant displacement, may have a decreased risk of capsular contracture, so this is some of the stuff where I think as we, you know, work through some of these are going to make it even more confident, more easy for us to recommend these things more often.


Dr. Adam Weinfeld:  Yeah.


Dr. Johnny Franco:  And then — mentions this, what helps more, the extra cohesive gel or the mesh, and I think that’s still TBD.


Dr. Adam Weinfeld:  Yeah, and maybe to kind of like dissect that out even a little bit more. You know, so Dr. Franco and I have at this point really been talking about mesh really to support the implant lower, and I think we can theoretically suggest to a patient that if we can prevent that implant from bottoming in and out even if it’s just a little bit centimeter or two, we’re keeping that implant up better supported against the breast tissue and that implant breast tissue interface if there’s a little bit a slight snug fit to that, then it really sort of forces the — it forces that interaction where the implant is shaping the breast but in some way the breast is shaping the implant. 

And one of the ways in which the — especially in a younger woman, the breast may shape the implant as kind of ironing out some of those ripples that the patient has. But now if your implant sinks down even a centimeter or two, that interface between them is not quite as snug, it’s not quite as a Hana glove fit, and then you’re going to see potentially some of those ripples as the breast does not shape the implant as much as it did in that relationship, so if you can keep that implant tucked up against that breast tissue better, less likely to have that.

Now, though, when you were asking, what I thought you were asking about and may — this is where the may comes in, is can you line the upper part of that implant with the mesh? And I think the answer is — and you I think this is what you and I were talking about, yes potentially, you know, yes that might help. 

That’s a little bit more theoretical, you know, what I talked about before is slightly more practical, pragmatic, you know, there’s a little bit more science behind that, but yes, I also think, and I think you were suggesting you think this too, that lining the upper part of that implant might also help decrease the rippling because it stimulates a little bit more controlled collagen production in the upper part of that interface that might help sort of camouflage and iron out some of those ripples, but may really is the important thing to say.


Dr. Johnny Franco:  I’d be surprised if we’re not having another follow-up podcast a year from now talking about some of our experiences and the stuff that we’ve tweaked.


Dr. Adam Weinfeld:  Yeah.


Gilbert Saenz III:  Maybe a study in the making?


Dr. Johnny Franco:  Yeah, I mean there’s definitely some ongoing stuff, I think we got some good things that we can look at ourselves as well so lots of horizons. 

Any last summary points you’d like to drop about internal bra and kind of the incorporation of mesh into some of these? I think we’ve kind of helped outlined a little bit, the internal bra is a broad, stropping statement and then there’s some segments underneath that.


Dr. Adam Weinfeld:  Yeah. I think two things, one is that — and you talked about this and I talked about this as well, we don’t want patients ever to have regret or feel like they got something less than the best, so really up to this point if these materials weren’t used in you, you were still getting the state of the art and what plastic surgeons and what Dr. Franco and I had to offer patients.

And then from this point forward you — I think you’re going to hear a lot more discussion from plastic surgeons and from Dr. Franco and myself about these meshes because to some degree they do offer an insurance policy, not one that’s guaranteed to prevent problems, but one that we have a really strong feeling is likely to create the kind of result that lasts you longer than we once had available to offer you with the things available to us.

And the reason that has happened is because the new materials are less expensive and less likely to cause problems and likely behave more the way we’re hoping them to behave.


Dr. Johnny Franco:  I love it, that was such a good summary. A little quote of the day?


Gilbert Saenz III:  I got one, I think…


Dr. Johnny Franco:  Okay.


Gilbert Saenz III:  …this is applicable.


Dr. Johnny Franco:  Yeah.


Gilbert Saenz III:  Milton Berle, a comedian said, “If opportunity doesn’t knock, build a door.” 


Dr. Johnny Franco: So, we’re building a door now?


Gilbert Saenz III:  Yeah.


Dr. Johnny Franco: Oh yeah, awesome.


Gilbert Saenz III:  So…


Dr. Adam Weinfeld:  That’s a good one. I love that.


Dr. Johnny Franco:  I feel like we’ve walked through the door. We’ve walked through the door right now.


Gilbert Saenz III:  Yeah. And, you know, it’s like we were talking about with these meshes, you know, we’re creating, you know, these opportunities for patients to, you know, achieve their desired goals and giving them the best outcomes possible or at least attempting to with these meshes.


Dr. Johnny Franco:  And I hope the purpose of our podcast here is to just educate people about options and so, you know, something, I know there’s a lot of people listening who don’t see Dr. Weinfeld or I and there’s — and that’s fine there’s a lot of really great plastic surgeons throughout the country, throughout the world and even, especially even here in Austin and so, you know, just something so that they can have that discussion, ask their surgeon about it and that way they have an educated decision that they can make together about what’s the best path forward for them.


Dr. Adam Weinfeld:  Yeah. Patients at large are happier even if they’re not our patients it’s just better for the field unless it’s better for us and for our patients.


Dr. Johnny Franco:  Last question for you guys, did you guys plan this because you both got a little red…


Travis Osborne: I saw that.


Dr. Johnny Franco:  …entourage with a little — you got a blue and red, you got a red and blue, I kind of like this. Our social media team is going to appreciate that.


Travis Osborne:  Yeah. (Chuckles)


Dr. Adam Weinfeld:  At a sort of metaphysical level, we definitely planned it.


Dr. Johnny Franco:  It shows the connection. Appreciate all of you guys listening to Plastic Surgery Untold, greatest podcast in the world as voted by us. You can listen to us anywhere you get your favorite podcast, iTunes, iHeart, Spotify, Pandora and then of course you can if you want to see these great outfits you can see us on YouTube. All right, we’ll see you guys bye.


Dr. Adam Weinfeld:  Bye.