Something that has popped up (in concert with increasing social media exposure in plastic surgery) is the use of terms that are neither technical nor descriptive, but are designed for maximum impact in a hashtag environment.

The “internal bra” is not new, but is is perhaps one of the most common of these terms amongst surgeons who are chasing the cosmetic breast surgery market. The interesting thing about “internal bra” is that not only do patients have no idea what it really means, but a lot of surgeons have no idea what it means either.

There is no definition of an “internal bra”. Like much of the lingo in plastic surgery, there is often a determined attempt to preserve a façade of mystery, to perpetuate the illusion that plastic surgeons have magic fingers and a little bit of surgical pixie dust, or to allow certain surgeons to pretend that they have a marketable advantage over their competition.

So let’s see if we can clear things up.

Firstly, me just say clearly and without any hint of confusion that “internal bra” is not the creation of any one surgeon, and it’s certainly not the creation of any of our instafamous colleagues (hashtags in bio or not).

The “internal bra” is a concept that I suspect hundreds of surgeons have independently arrived at in their practices over the years in response to some of the challenges we face in breast surgery. More importantly, because there is no definition of “internal bra” there is also no single accepted “technique” of creating said internal bra. Everyone does it differently. We’ll talk a bit about that.

The first logical question to ask is: what is meant by an internal bra?

So, the basic idea of the internal bra (and hence the name) is to mimic the function of an underwire (sort of) – that is, to create a firm support mechanism at the level of the breast crease. The purpose of that support mechanism, like an underwire, is to create a stable “fixed point” as a foundation for the breast to sit on. If there is a firmly fixed crease position,then the breast can be built upwards from that point with a greater degree of control. Without that firm fixation of the inframammary crease, the breast is at risk lacking good lower pole definition (something we see a lot in breast reconstruction, as well as breast augmentation) or the breast may be susceptible to forces which can create distortion in the breast shape (a very common issue I see after explant procedures done elsewhere).

I think it is more accurate to describe an internal bra as a reconstruction (or formation) of the breast crease. I think that is easier for people to understand when I explain what I am going to do during surgery. When I say during a consultation that I am going to reset the position of the breast crease, whether I am discussing implant revision, explant procedures, lifts or reductions, people get it. When I say "internal bra", I have to explain myself.

A simple rule that I follow is that if I have to explain a bit of terminology, I need to change the terminology to something that doesn't require explanation. So for me, despite this article being about the "internal bra" concept, what my patients will hear me say during a consultation is that I will reset/correct/fix/adjust the position of the breast crease. That is how we ensure that our patients understand clearly what their surgery involves, and that is how we manage expectations properly.

When does the internal bra get used?

The internal bra concept is most commonly (and I guess, originally) something that is applied to breast implant surgery (that is, breast augmentation). In those cases, the internal bra acts as a lower restraint to the implant – basically it creates a sling which will then support the weight of the breast implant better that just relying on intrinsic tissue supports alone.

I actually think the internal bra concept is a far more useful idea when it comes to procedures like breast reduction and mastopexy (although it is far less commonly applied in these contexts), and it can be a game-changer when used correctly for the explant procedures that I perform.

For me, the internal bra concept is something I have played around with a lot over the years. I have had to figure out the best way to use certain patterns of stitching to create the breast shapes I want in certain situations. I suspect I am not alone in this. Like I said above, the internal bra is poorly defined, and even less well described at a technical level. You sure don’t find videos or descriptions of how this stuff is done in text books. So, naturally, you make it up.

Techniques

One of the interesting consequences of doing explant surgery and lots of revision procedures is the ability to find out what other surgeons are doing (and where it’s gone wrong). Which means I have seen quite a lot of attempts at what I assume was meant to be an internal bra, but which has just ended up being a hot mess that I need to fix at the time of explant. The problem is that executing an internal bra accurately and with the right shape requires patience, quite a bit of checking, and sometimes repositioning individual sutures. Doing it quickly or lazily is worse than not doing it at all.

Basically, the internal bra is most commonly intended to be a line of stitches which follow the lower curve of the breast. These stitches grab a supportive layer of tissue called the “superficial fascial system” (which is a connective tissue layer that runs up through the abdomen then splits to envelop the breast tissue) and attempt to fix that tissue to something rigid – in most cases, the “chest wall” (which is just a general way of referring to the deeper tissues like the pec major muscle, the “deep fascia” and/or the ribs).

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There are a variety of ways this can be achieved. Some surgeons use dissolving stitches, some use permanent stitches. Some surgeons run a continuous line of stitching (like a hem stitch), some place a series of individual “interrupted” stitches. Some will stitch all the way down the side of the breast and then along underneath the breast, some will just support the underside of the breast. Some will fix the stitches to the rib, others to muscle or deep fascia.

All of these approaches can create different outcomes, and different problems if done poorly.

What about mesh?

Yes indeed.

The other form of internal bra (and one which is increasingly coming to attention) is formed by the placement of a "mesh" of some description to create that sling construct. Rather than relying on natural tissue and sutures, the various meshes on the market are designed to create a layer of support that far more literally holds the breast in place.

There are two common meshes on the market, which are variably used.

The first is a dissolving mesh called P4HB (the brand name is Galaflex). Have a read of this article for more information about Galaflex.

The other is a permanent mesh called Ti-Loop.

Now, whilst our American friends are shoving this gear in left, right and centre, it is far less common in Australia. However, as more women are learning about internal bra online, the idea of using these meshes is becoming more prevalent.

I guess the major point I want to make here is this: mesh is not necessarily better than using sutures. They are two techniques with similar goals. They need to be used differently, as the indications for their use differ.

The other point is this:

For any women who "wants" an internal bra, or thinks that their surgeon has promised one, be very (very) clear with your surgeon about what you think that means. If you think that means mesh, but your surgeon doesn't, and if you aren't explicit about that, then the operation you get may be different to what you thought.

Outcomes and consequences

I tell all my patients that one of the main expected consequences of the internal bra is a sense of tightness during recovery. Most ladies will feel a band-like tightness under the bust, which is most noticeable when they take a deep breath in the first few weeks. It’s good to know that this is normal, but it is also important that we manage that discomfort to ensure that patients can take deep breaths properly after surgery. So, the internal bra is one of the main reasons for needing pain relief for a week or two after any breast operation.

The intention of the internal bra, for me, is to ensure that not only do we have a solid foundation to support the breast in a new position,but it also ensures that scars sit, as intended, right in the breast crease. The absence of an internal bra will result in scars that tend to sit on the underside of the breast (in the case of reductions and lifts) or below the crease, on the ribs (in the case of explants). Have a look at the following image - it's a good example of how important the internal bra concept is in explant procedures.

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It is also worth mentioning that in my implant revision work, I have found that attempts at an internal bra by other surgeons can be a major source of chronic pain and discomfort for ladies, and undoing that can be tricky. When I hear about surgeons who use a permanent “barbed” stitch in particular, I often wince a little. Barbed stitches don't need to be knotted or tied off, but in my experience they can be a recipe for disaster when used for an internal bra. Permanent stitches can result in ongoing foreign body responses, and may be a source of nerve irritation when used down the side of the breast in particular. Barbed stitches are an issue because if the placement of each bite of the stitch is not absolutely perfect, or if it is pulled just a little too tight, this can result in puckering and poor contours, a chronic feeling of tightness, and in some cases, chronic mastalgia (or breast pain). Having seen plenty of problems, I have adapted my own technique over the years to minimise the risks. The other major issue I see with the internal bra is when sutures either grab too superficially or are fixed at an incorrect level to the rib. Both of these things create puckered scars which often sit too high and can distort the lower part of the breast.

So the internal bra is a really important concept in breast surgery. I hate the name (it sounds like something cooked up in a marketing company, but whatever), and when done incorrectly it can be a source of serious problems.

There’s nothing magical about an internal bra. It can work well, or it can be a disaster in unskilled hands. No one can really claim to have created the technique - it’s just a bunch of stitches at the end of the day which forms part of the wound closure in many breast operations. But it’s a good thing to understand if you’re contemplating surgery.

Questions? Contact us, or request an appointment. Be well.

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