Abstract
Background:
Breast shape remains a persistent challenge following mastopexy, breast reduction, massive weight loss breast reshaping, revision surgery, and selected reconstructive procedures. The central pedicle preserves vascularized parenchyma, whereas poly-4-hydroxybutyrate (P4HB) scaffold reinforcement has been proposed as a soft-tissue support during postoperative remodeling. This study describes a single-surgeon experience combining these procedures.
Methods:
A retrospective review of an operative database was performed. Thirty patients undergoing breast reshaping using a central pedicle technique combined with P4HB scaffold reinforcement between June 2025 and April 2026 were included. Demographic variables, indication for surgery, mesh configuration, resection weights, and documented complications were analyzed.
Results:
The mean age was 42 years, and the mean body mass index was 24.8 kg/m2. This cohort included massive weight loss breast reshaping (18 patients, 60.0%), aesthetic mastopexy/reduction (7 patients, 23.3%), explant/revision procedures (2 patients, 6.7%), late breast reconstruction (2 patients, 6.7%), and immediate breast reconstruction (1 patient, 3.3%). No patients were smokers, had diabetes, had a history of breast irradiation, or had breast implants at the time of surgery. Follow-up ranged from 3 to 12 months. The most common scaffold configuration was the origami construct (70.0%). No intraoperative or postoperative complications were recorded. One patient experienced transient inferolateral mesh palpability that resolved spontaneously after 4 weeks.
Conclusions:
In this preliminary single-surgeon experience, central pedicle breast reshaping combined with P4HB scaffold reinforcement was feasible. No major complications were observed. Objective measurements of recurrent ptosis, lower-pole stretch, projection maintenance, and patient-reported outcomes were not collected, so no conclusions regarding durability or superiority can be drawn. Prospective studies with standardized outcome assessment are warranted.
Takeaways.
Question: Can combining a central pedicle with poly-4-hydroxybutyrate mesh support breast reshaping across aesthetic, massive weight loss, revision, and reconstructive procedures?
Findings: In this retrospective, consecutive, single-surgeon series of 30 patients, predominantly undergoing massive weight loss breast reshaping, no intraoperative complications occurred. One transient episode of mesh palpability was reported. No major complications, reoperations, or mesh removals were documented during the available follow-up.
Meaning: Combining central pedicle reshaping with poly-4-hydroxybutyrate mesh integrates vascularized breast tissue with temporary structural support, with favorable preliminary outcomes across several different indications. Larger studies with longer follow-up are needed to determine whether this approach reliably maintains breast shape and stability over time.
INTRODUCTION
Long-term maintenance of breast shape remains one of the most challenging aspects of breast surgery. Despite advances in mastopexy, reduction mammoplasty, and reconstructive techniques, recurrent ptosis, lower-pole elongation, loss of upper-pole fullness, and progressive soft-tissue descent continue to occur over time. These changes may be particularly evident in patients with compromised tissue quality, including those following massive weight loss (MWL), revision surgery, or significant skin laxity. Selection of the pedicle represents a critical component of breast reshaping procedures. The central pedicle technique preserves a substantial volume of vascularized breast parenchyma while maintaining reliable perfusion to the nipple–areola complex (NAC).1–5 Beyond its role in NAC transposition, the preserved central parenchyma can be mobilized and reshaped to contribute to breast contour, projection, and volume redistribution.6–8 More recently, absorbable scaffold materials have been introduced as an adjunct to breast surgery. Poly-4-hydroxybutyrate (P4HB) is a fully absorbable monofilament scaffold that has been used in both aesthetic and reconstructive breast procedures with the intention of providing temporary soft-tissue reinforcement during the healing and remodeling phases. Previous studies have reported favorable short- and intermediate-term safety profiles, although evidence regarding long-term aesthetic outcomes remains limited.9–19 The rationale for combining a central pedicle approach with P4HB reinforcement is based on their potentially complementary roles. The central pedicle preserves vascularized glandular tissue that can be reshaped to restore breast contour, whereas the absorbable scaffold may provide temporary support to the lower pole and breast envelope during postoperative remodeling. The purpose of this study is to describe the surgical technique and report a preliminary single-surgeon clinical experience using central pedicle breast reshaping combined with P4HB scaffold reinforcement across a range of aesthetic, MWL, revision, and reconstructive breast surgery indications.
METHODS
A retrospective review was performed of an operative database from a single surgeon’s practice. Thirty consecutive patients who underwent breast reshaping using a central pedicle technique combined with P4HB scaffold reinforcement between June 2025 and April 2026 were included. Institutional ethics approval was not required for this retrospective review of existing surgical notes, in accordance with institutional policy. Patients were eligible when both a central pedicle breast reshaping technique and P4HB scaffold reinforcement were documented in the operative record. Cases included aesthetic mastopexy/reduction, MWL breast reshaping, explant/revision procedures, late breast reconstruction, and immediate breast reconstruction. Collected variables included patient age, body mass index, smoking status, diabetes status, previous bariatric surgery, implant status, history of radiotherapy, surgical indication, mesh configuration, resection weights, follow-up duration, and documented postoperative events (Tables 1–3). The primary objective of this study was descriptive and technical. Outcomes assessed included procedural feasibility, mesh configuration use, resection weights, and documented complications. Because this retrospective series was not originally designed as an outcomes study, objective measurements of breast projection, lower-pole stretch, nipple position, recurrent ptosis, and patient-reported outcome measures such as BREAST-Q were not available for analysis. Mean follow-up was 6 months (range, 3–12 mo). Fifteen patients had follow-up of greater than 6 months, and 8 patients reached 12 months of follow-up.
Table 1.
Cohort Summary
| Variable | Value | Comment |
|---|---|---|
| Total cohort | 30 | Central pedicle + P4HB cases |
| Study design | Retrospective | Single-surgeon consecutive case series |
| Study period | June 2025–April 2026 | Based on operative log dates |
| 2025 cases | 13 (43.3%) | June–December 2025 |
| 2026 cases | 17 (56.7%) | February–April 2026 |
| MWL | 18 (60.0%) | Largest subgroup |
| Aesthetic | 7 (23.3%) | Primary/secondary central pedicle aesthetic mastopexy |
| Revision/explant | 2 (6.7%) | Central-based reshaping after explant/revision |
| Late reconstruction | 2 (6.7%) | Late reconstruction/symmetrization |
| Immediate reconstruction | 1 (3.3%) | Immediate oncoplastic reconstruction; radiotherapy planned |
| Most common mesh configuration | 15 × 20 Origami: 21 (70.0%) | Preferred internal bra adaptation |
| Mean total resection | 264.7 g | n = 30; median 220.7 g; range 18–683 g |
| Mean individual breast resection | 139.3 g | n = 57 breasts; median 112 g; range 10–416 g |
| Documented intraoperative complications | 0 | All cases documented as without intraoperative events |
| Documented postoperative events | 1 transient palpability | Inferolateral P4HB palpability for 4 wk; no major event documented |
Table 3.
Mesh Configuration Summary
| Configuration | Cases, n (%) |
|---|---|
| 15 × 20 Origami | 21 (70.0) |
| 3D | 6 (20.0) |
| Divided 15 × 20 | 3 (10) |
3D, 3-dimensional.
Table 2.
Case-level Dataset
| Case | Age, y | BMI, kg/m2 | Year | Date | Subgroup | Mesh | R/L Resection, g | Total, g |
|---|---|---|---|---|---|---|---|---|
| 30 | 35 | 23.2 | 2026 | 29 April | Late reconstruction | P4HB 3D | 18/NA | 18 |
| 29 | 31 | 24.5 | 2026 | 28 April | MWL | 15 × 20 Origami | 227/252 | 479 |
| 28 | 50 | 24.6 | 2026 | 28 April | MWL | 15 × 20 Origami | 100/110 | 210 |
| 27 | 36 | 24.7 | 2026 | 27 April | MWL | 15 × 20 Origami | 179/416 | 595 |
| 26 | 49 | 24.9 | 2026 | 27 April | MWL | 15 × 20 Origami | 180/215 | 395 |
| 25 | 29 | 25.3 | 2026 | 24 April | MWL | 15 × 20 Origami | 253/276 | 529 |
| 24 | 36 | 25.4 | 2026 | 13 April | MWL | P4HB 3D | 108/174 | 282 |
| 23 | 56 | 25.8 | 2026 | 7 April | Immediate reconstruction | P4HB 3D | 210/NA | 210 |
| 22 | 47 | 25.5 | 2026 | 25 March | Explant/revision | Divided 15 × 20 | 112/86 | 198 |
| 21 | 47 | 28 | 2026 | 23 March | MWL | 15 × 20 Origami | 129.9/134.5 | 264.4 |
| 20 | 37 | 25 | 2026 | 16 March | MWL | 15 × 20 Origami | 265.8/239.1 | 504.9 |
| 19 | 53 | 25.2 | 2026 | 5 March | Late reconstruction | P4HB 3D | 352/NA | 352 |
| 18 | 39 | 27 | 2026 | 2 March | Aesthetic | 15 × 20 Origami | 53.8/55 | 108.8 |
| 17 | 51 | 23.4 | 2026 | 9 February | MWL | P4HB 3D | 92/174 | 266 |
| 16 | 46 | 26.5 | 2026 | 6 February | Explant/revision | 15 × 20 Origami | 10/16 | 26 |
| 15 | 55 | 24 | 2026 | 6 February | Aesthetic | Divided 15 × 20 | 340/343 | 683 |
| 14 | 39 | 25 | 2026 | 2 February | Aesthetic | 15 × 20 Origami | 52/155 | 207 |
| 13 | 32 | 24 | 2025 | 2 December | MWL | 15 × 20 Origami | 125/106.3 | 231.3 |
| 12 | 45 | 24.1 | 2025 | 1 December | MWL | 15 × 20 Origami | 93.8/68.5 | 162.3 |
| 11 | 53 | 24.2 | 2025 | 29 October | MWL | 15 × 20 Origami | 11.7/61.5 | 73.2 |
| 10 | 52 | 27 | 2025 | 13 October | MWL | P4HB 3D | 34.9/41.9 | 76.8 |
| 9 | 32 | 24.6 | 2025 | 3 October | MWL | 15 × 20 Origami | 33/29 | 62 |
| 8 | 31 | 25.1 | 2025 | 26 August | MWL | 15 × 20 Origami | 284/286 | 570 |
| 7 | 28 | 25.2 | 2025 | 26 August | MWL | 15 × 20 Origami | 126/136 | 262 |
| 6 | 57 | 22.5 | 2025 | 11 August | MWL | 15 × 20 Origami | 22.1/135.5 | 157.6 |
| 5 | 28 | 25.6 | 2025 | 5 August | Aesthetic | 15 × 20 Origami | 27.4/45.3 | 72.7 |
| 4 | 58 | 24.4 | 2025 | 29 July | Aesthetic | 15 × 20 Origami | 240/260 | 500 |
| 3 | 26 | 23.8 | 2025 | 8 July | Aesthetic | 15 × 20 Origami | 42.9/80.7 | 123.6 |
| 2 | 60 | 24 | 2025 | 7 July | MWL | 15 × 20 Origami | 42/14 | 56 |
| 1 | 24 | 24.3 | 2025 | 25 June | Aesthetic | 15 × 20 Origami | 103/163 | 266 |
3D, 3-dimensional; BMI, body mass index.
SURGICAL TECHNIQUE
The procedure begins with standard preoperative markings in the standing position. A central pedicle is designed to preserve a broad segment of vascularized breast parenchyma attached to the NAC and posterior breast tissues. Following de-epithelialization and tissue resection as indicated, the preserved central glandular unit is mobilized and reshaped to restore breast contour and projection (Fig. 1). P4HB scaffold reinforcement is then tailored according to patient anatomy and operative goals. The most commonly used configuration in this series was a 15 × 20 cm sheet configured as an origami construct. (See Video 1 [online], which displays the origami cutting technique for a 15 × 20 cm P4HB scaffold.) Alternative 3-dimensional and divided configurations were used in selected revision and reconstructive cases. The scaffold was secured to stable fixation points within the breast support framework while avoiding excessive tension on the pedicle and NAC (Fig. 2). Scaffold fixation was performed using interrupted 3-0 polydioxanone sutures placed at predefined fixation points according to the selected scaffold configuration (Fig. 3). (See Video 2 [online], which displays the central pedicle breast reshaping with P4HB scaffold reinforcement, including preoperative marking, de-epithelialization, pedicle design, parenchymal reshaping, scaffold tailoring and fixation, skin closure, and the final construct.)
Fig. 1.
Intraoperative view of the central pedicle before P4HB placement. The image shows preservation of the central vascularized parenchymal unit.
Fig. 2.
Intraoperative view after P4HB placement. The image represents the relationship between the reshaped central pedicle and the P4HB scaffold.
Fig. 3.
P4HB origami/3-dimensional fixation. The image shows the schematic fixation targets and the internal-bra configuration.
Video 1. This narrated video demonstrates a reproducible origami cutting sequence for a 15 × 20 cm poly-4-hydroxybutyrate scaffold. The scaffold is folded to preserve symmetry, sequential cuts are made while maintaining the central bridge and fixation extensions, and the construct is unfolded to demonstrate its final configuration before placement as internal breast support.
Video 2. This narrated operative video demonstrates preoperative marking, de-epithelialization, central pedicle design and mobilization, parenchymal resection and reshaping, tailoring and fixation of a poly-4-hydroxybutyrate scaffold, redraping of the skin envelope, closure, and the final breast construct.
RESULTS
Thirty consecutive patients underwent central pedicle breast reshaping combined with P4HB scaffold reinforcement during the study period. Mean patient age was 42 years, and mean body mass index was 24.8 kg/m2. The majority of patients (18 of 30, 60.0%) had previously undergone bariatric surgery and presented for MWL breast reshaping. Seven (23.3%) patients underwent aesthetic mastopexy or breast reduction; 2 (6.7%) patients underwent explant/revision procedures; 2 (6.7%) patients underwent late reconstructive procedures; and 1 (3.3%) patient underwent immediate reconstruction (Fig. 4). No patients were active smokers or had diabetes mellitus. No patients had a history of breast irradiation. One patient in the immediate reconstruction subgroup underwent planned adjuvant radiotherapy following surgery. No patients had breast implants. Follow-up ranged from 3 to 12 months. The most frequently used scaffold configuration was the 15 × 20 cm origami construct, used in 21 (70.0%) patients. Three-dimensional scaffold configurations were used in 6 (20.0%) patients, whereas divided 15 × 20 cm constructs were used in 3 (10.0%) patients. Resection weight data were available for all patients. Mean total resection weight was 264.7 g (median 220.7 g; range 18–683 g). Among the 57 individual breast specimens available for analysis, mean specimen weight was 139.3 g (median 112 g; range 10–416 g). Representative preoperative and 6-month postoperative photographs of an MWL patient are shown in Figures 5 and 6. A representative aesthetic breast reduction result at 6 months is shown in Figure 7. No intraoperative complications were documented. Twenty-nine (96.7%) patients experienced an uneventful postoperative course based on the available medical records. One patient developed transient inferolateral mesh palpability that resolved spontaneously within 4 weeks without intervention. No cases of mesh removal, infection, seroma, hematoma, NAC necrosis, wound dehiscence requiring reoperation, implant-related complications, or reoperation were documented during the available follow-up period. The largest subgroup consisted of MWL patients, representing 60.0% of the cohort. This subgroup frequently demonstrated poor tissue quality and significant skin laxity, making it the most common indication for adjunctive scaffold reinforcement. Aesthetic mastopexy and breast reduction procedures represented 23.3% of cases and were generally characterized by lower resection weights and less severe soft-tissue compromise. Reconstructive procedures accounted for a small proportion of the cohort and included both immediate and delayed reconstructive applications. Given the limited number of patients in these categories, no subgroup-specific conclusions can be drawn. This consecutive series demonstrates that central pedicle breast reshaping combined with P4HB scaffold reinforcement can be performed across a range of breast surgery indications with a low rate of documented short-term complications. However, objective assessment of breast shape maintenance, lower-pole stretch, recurrent ptosis, patient satisfaction, and quality-of-life outcomes was not available and therefore cannot be evaluated in the present study.
Fig. 4.
Distribution of P4HB scaffold configurations used in the cohort.
Fig. 5.
Preoperative photographs of an MWL patient with grade III breast ptosis. A, Oblique view. B, Side view. C, Front view.
Fig. 6.
Six-month postoperative photographs after mastopexy using the central pedicle technique with P4HB scaffold support. A, Oblique view. B, Side view. C, Front view.
Fig. 7.
Preoperative and 6-month postoperative photographs after aesthetic breast reduction using the central pedicle technique with P4HB scaffold support. A, Preoperative front view. B, Postoperative front view. C, Preoperative oblique view. D, Postoperative oblique view.
DISCUSSION
The primary contribution of this report is the description of a reproducible technical approach rather than the demonstration of superior clinical outcomes. Although the combination of a central pedicle and absorbable scaffold reinforcement may be conceptually appealing, the current study was not designed to establish causality, superiority, or long-term effectiveness. The central pedicle has been previously described as a reliable method for preserving vascularized breast parenchyma and maintaining blood supply to the NAC.1–5 In addition to its vascular reliability, preservation of a substantial central glandular unit allows reshaping of the breast mound and redistribution of parenchymal volume.6–8 This characteristic may be particularly useful in patients with poor tissue quality, where preservation of native breast tissue becomes an important component of surgical planning. The rationale for combining a central pedicle with P4HB reinforcement is based on the possibility that preservation of vascularized parenchyma and temporary scaffold support may address different components of breast reshaping.9–19 The central pedicle contributes tissue volume and contour, whereas the scaffold may provide temporary reinforcement during the healing and remodeling phases. Nevertheless, the present study was not designed to evaluate the biomechanical interaction between these components, and no objective measurements were collected to support such conclusions. An important observation from this series is the few documented short-term complications. No cases of infection, seroma, hematoma, mesh removal, NAC necrosis, or reoperation were identified during the available follow-up period. Although encouraging, these findings should be interpreted cautiously given the relatively small cohort size, retrospective design, and limited duration of follow-up. The reconstructive subgroup deserves particular caution in interpretation. Only 3 reconstructive patients were included, and only 1 patient underwent planned postoperative radiotherapy. Consequently, no conclusions can be drawn regarding scaffold performance in irradiated tissues or oncological reconstruction. One of the most important limitations of this study is the absence of objective outcome measurements. Parameters such as nipple position, lower-pole stretch, breast projection, recurrent ptosis, and upper-pole fullness were not prospectively evaluated. Similarly, patient-reported outcomes, including BREAST-Q assessments, were not available. As a result, the study cannot determine whether scaffold reinforcement improves long-term breast shape, durability, or patient satisfaction. Another limitation is the lack of a comparator group. The current design does not allow comparison between central pedicle breast reshaping performed with and without P4HB reinforcement. Consequently, no conclusions regarding superiority, cost-effectiveness, or reduction of recurrent ptosis can be made. This represents an important direction for future research. Future investigations should incorporate prospective data collection, standardized photographic analysis, objective breast measurements, patient-reported outcome instruments, and comparative cohorts. Such studies would provide a more rigorous evaluation of the role of absorbable scaffold reinforcement in central pedicle breast surgery. Despite these limitations, the present series contributes a practical description of a contemporary breast reshaping strategy and demonstrates its technical feasibility across multiple clinical indications.
CONCLUSIONS
Central pedicle breast reshaping combined with P4HB scaffold reinforcement was technically feasible across a range of aesthetic, MWL, revision, and selected reconstructive breast surgery indications in this consecutive single-surgeon series. The technique combines preservation of a vascularized central parenchymal unit with temporary absorbable scaffold reinforcement. Within the limitations of this retrospective study, no major mesh-related complications were observed during the available follow-up period. Because objective measurements of recurrent ptosis, lower-pole stretch, projection maintenance, and patient-reported outcomes were not collected, no conclusions regarding long-term durability, superiority, or prevention of tissue descent can be drawn. Prospective comparative studies with standardized outcome assessment are required to better define the role of P4HB scaffold reinforcement in breast reshaping surgery.
DISCLOSURES
The author received financial support from Becton, Dickinson and Company solely for the publication fee (APC) charged by the journal. No funding was provided for the conduct of the study, and Becton, Dickinson and Company had no involvement in the study design, data collection, analysis, interpretation, or manuscript preparation.
ACKNOWLEDGMENTS
During preparation of this article, the authors used ChatGPT (OpenAI) for English-language editing and to improve readability. The authors reviewed and edited all AI-assisted content and take full responsibility for the accuracy, integrity, and final content of the article.
Footnotes
Disclosure statements are at the end of this article, following the correspondence information.
Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
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