Mesh in a First-Time Breast Augmentation: Who Should Consider It

This is a fantastic question, and it's a specific one: when should you consider mesh in a primary breast augmentation? "Primary" means someone who has never had breast surgery before and is getting implants for the first time. This isn't a revision or a reconstruction, where scaffolding is often used to fix a problem that already exists.

So let me start with the honest answer, and then walk through the patients where I actually reach for it.

When I say "mesh" here, I mean a dissolvable surgical scaffold placed to add support inside the implant pocket. This is the same idea as an internal bra, not the permanent vaginal mesh from the lawsuit commercials.

The first group I consider is anyone where we're moving the inframammary crease, the fold underneath the breast. If your crease isn't in quite the right place and we need to set it somewhere new, there's a problem: a created crease is never as strong as a natural crease.

So I like a little extra reinforcement and a little extra strength in that area. Two examples where this comes up a lot:

• Tuberous breast deformity
• Trans women having breast augmentation

The next group is my massive weight loss patients. Their crease tends to be looser and not as tight, and I see more malposition problems in this population, meaning the implant doesn't stay where we put it. So I love adding support here.

The next group is patients who want very, very large implants that are disproportionate to their frame.

Those problems include a higher risk of capsular contracture and a higher risk of malposition. If you're going disproportionately large, mesh is worth considering. (I've written more about how implant size, tissue quality, and lifestyle drive sagging regardless of placement.)

This one is more of a patient choice, and it comes down to your activity level. If you do a lot of high-impact exercise, say you're a long-distance runner, you tend to see more inferior malposition, where the implant drops too low. That's especially true with saline implants. So this is another group where mesh is a reasonable thing to consider.

Finally, the newer implants on the market. Motiva implants are known to make a thinner capsule. The concern is that, especially with larger implants, that thinner capsule may stretch with time.

A little reinforcement at the bottom of the implant cavity can help prevent that.

Using a surgical scaffold this way is off-label. There are no surgical scaffolds that have been tested for on-label indications in the breast, but we do commonly use them. That's worth a real conversation with your surgeon before you decide.

My go-to is GalaFLEX. That's typically what I use, but different surgeons will use different products. If you want my full opinions, product by product, I've ranked the breast scaffolds I love and the ones I don't.

I love using mesh in these situations. I find it's nice to have that little bit of insurance policy. But I want to be really clear:

It's a nice to have, not a must.

Most patients having a first-time breast augmentation don't need mesh. But it can add useful support in a few groups:

• Patients whose crease is being moved (tuberous breasts, trans augmentations)
• Massive weight loss patients with loose creases
• Patients choosing very large, disproportionate implants
• High-impact athletes, especially with saline implants
• Motiva patients, particularly in larger sizes, because of the thinner capsule

It's off-label, surgeons have different preferences (mine is GalaFLEX), and plenty of patients in every one of these groups do perfectly well without it. Ask your surgeon whether you fall into one of these categories, and whether the extra support is worth it for you.