The dreaded double bubble complication [Adam Schaffner, MD, New York City]

Dr. Schaffner (00:00):
I'm Adam Schaffner. I'm a plastic surgeon. I'm located in New York City. We're on Fifth Avenue between 47th and 48th, two blocks south from Rockefeller Center.

Eva Sheie (00:11):
There's a new and pretty popular technique floating around the internet called the internal bra. Is that something that you do?

Dr. Schaffner (00:19):
Absolutely. So the internal bra that mesh that we were talking about that ADM, the acellular dermal matrix, you can use human tissue, which is AlloDerm. You can use animal tissue such as stratus. You can use a synthetic like P4HB known as GalaFLEX, which is popularly the internal bra. Yes.

Eva Sheie (00:43):
What are the benefits of the internal bra?

Dr. Schaffner (00:46):
So it does help provide internal support so that it minimizes the risk of descent of the implant, keeps it in the position where you desire it to be, as you're taking that internal bra and you're suturing it to the chest wall.

Eva Sheie (01:00):
Who should get an internal bra? Is there a specific kind of patient that does really well with this?

Dr. Schaffner (01:07):
So if there's a patient who is very thin, who's had a previous breast augmentation, had bottoming out or double bubble where the implant has descended lower or that the tissue is stretched between the nipple and the inframammary fold, it's descended laterally towards the armpit and sometimes it's the stretchiness of the tissue. Sometimes it is due to just a lack of support, but with the weight of the implant, those would be great cases or candidates for an internal bra. Also for someone who's had symmastia or uniboob afterwards, same concept there to minimize displacement of the implant across the midline.

Eva Sheie (01:48):
How often do you see a uniboob show up?

Dr. Schaffner (01:51):
So quite often.

Eva Sheie (01:53):
Oh no.

Dr. Schaffner (01:53):
Yes, unfortunately if a woman has had an implant that is sometimes too large for the base width of the breast, it puts pressure on the fibers of the muscle towards the center, or if it was placed above the muscle on the tissue and then basically gives way and it crosses the midline. Sometimes it's due to over dissection, in which case it's noticeable right after surgery.

Eva Sheie (02:18):
And so the internal bra can reverse the uniboob and get it back to normal?

Dr. Schaffner (02:23):
Correct. So you'd have to reestablish what's called the footprint of the breast in order to be able to see that, that's correct.

Eva Sheie (02:30):
Can you also put an internal bra in where no implants are used or is it something that is sort of like peanut butter and jelly? You have to have implants to get the internal bra.

Dr. Schaffner (02:41):
So the purpose of the internal bra is to go ahead and help support the breast. That can mean the breast tissue. It can mean a breast implant. So in a woman say who's had a breast reduction and a breast lift or just a breast lift and is concerned about the longevity of the lift, this help improve the longevity of that lift.

Eva Sheie (03:02):
Is the internal bra something you can do on a primary augmentation and not in a revision like just first time around?

Dr. Schaffner (03:10):
Yes, you can do it. It is not very common to use it that way, but yes you can.

Eva Sheie (03:14):
Who would you do that for?

Dr. Schaffner (03:16):
In someone who's had a, say, a massive weight loss patient, someone who has very thin tissues, where you're concerned about bottoming out, double bubble, but more so bottoming out, which is stretching of the tissue, the length of the tissue between the nipple and the inframammary fold. This would help to minimize that risk.

Eva Sheie (03:37):
You mentioned that the internal bra is usually made from GalaFLEX. Is that accurate?

Dr. Schaffner (03:42):
Well, no. The internal bra is a marketing term. GalaFLEX is a term that is used for a type of material by a specific company. The material generically is called P4HB and it's chemical composition, but an internal bra can be made from that synthetic material. It could also be a human derived material like AlloDerm or animal derived material like stratus.

Eva Sheie (04:06):
Do you have a preference?

Dr. Schaffner (04:07):
And there's other manufacturers out there as well. I think the preference really depends on the indication. AlloDerm tends to be a little bit more stretchy. So for someone who, let's say we're putting on a tissue expander, want to go ahead and do it for a breast reconstruction, we would use something like an AlloDerm for someone who we would want more of a firmer reconstruction support, then we would look for something like a P4HB.

Eva Sheie (04:35):
Can you see or feel this material after surgery? Is it something that's present if you try to touch it?

Dr. Schaffner (04:43):
The answer is yes. You can go ahead and feel the material in some people who are very thin. These materials though are not permanent materials. These materials dissolve over time. They incorporate into the tissue, and so as a result, you will not feel them permanently, but it can take many, many months for them to resorb.

Eva Sheie (05:04):
Is recovery different? Is it longer or more painful if you have this internal bra or is it about the same?

Dr. Schaffner (05:12):
It can be a little bit more uncomfortable, especially if it's sutured into the chest wall or sutured to the muscle, so you can have a little bit more recovery period associated with that.

Eva Sheie (05:20):
Do you find that your patients who have this say it's absolutely worth it?

Dr. Schaffner (05:26):
Yeah. Yeah, they're very happy. No question about it. There is what we tell 'em straight up. There's more of a recovery period, but yes, absolutely.

Eva Sheie (05:32):
This is relatively new, at least to the public. And maybe it's been around for a while, but do you think this is becoming the standard?

Dr. Schaffner (05:44):
I'm not going to say it's the standard of care. I will say that it is becoming more popular. I do agree with you more people are becoming more aware of it. Certainly there's a lot more discussion about it in chat forums and on the internet. With regard to knowledge among surgeons, certainly that's increasing. Indications are increasing, and so I think it does become a judgment call though between the patient and the doctor. Some doctors are not comfortable using this. Some patients are concerned about the risk of a foreign body within them. So it's not the standard of care, meaning it's not an absolute requirement or a departure from the standard of care not to use it.

Eva Sheie (06:26):
Does it add a lot of cost to include it?

Dr. Schaffner (06:28):
It is expensive. Yes, it does add cost.

Eva Sheie (06:32):
Is the cost more time? Is it just more product and it's an expensive product?

Dr. Schaffner (06:37):
All the above. So it is an expensive product and then it takes time to actually properly position and suture the product, and then that means you're paying for anesthesia time, facility time, surgeon time for that.

Eva Sheie (06:51):
Okay. Where can we find you on Instagram and what's your website address?

Dr. Schaffner (06:55):
So on Instagram, you can view us at Dr. Shafner, Dr. Adam Schaffner, D-R-A-D-A-M-S-C-H-A-F-F-N-E-R. And our website, you can either go to drschaffner.com, that's D-R-S-C-H-A-F-F-N-E-R.com or plasticsurgeoninnyc.com. That's P-L-A-S-T-I-C-S U-R-G-E-O-N-I-N-N-Y-C.com. Or you can call us at (212) 688-6600.

Eva Sheie (07:25):
Thank you for your wisdom.

Dr. Schaffner (07:27):
Thank you very much.

Eva Sheie (07:29):
On this podcast, we bring you directly to the doctors who are where before meets after. Links to our guest's website and contact info are in your show notes. Follow us on Instagram @wherebeforemeetsafter. If you're a board certified plastic surgeon and would like to be a guest or a sponsor of the show, go to wherebeforemeetsafter.com for more information. Where Before Meets After is a production of The Axis, the podcast agency for aesthetics, theaxis.io.