What is P4HB?
P4HB is Poly-4-Hydroxybutyrate. It is a synthetic mesh that is fully resorbable, non immunogenic, biocompatible, porous, monofilament. It is made as a mesh to help with strength of the tissue. It has been shown to keep 50-70% of its strength at 12 weeks postop. It is thought to promote tissue healing to make stronger, more durable tissue. It is FDA approved for many clinical indications, including tendon and hernia repair.
Why use mesh in breast surgery?
To be fair, I do not use it often. But there are cases where breast plastic surgeons want to use mesh to help strengthen a repair. The FDA considers its use as a support in breast surgery as “off label” use, though again, the mesh is FDA approved for many other surgical indications and is safe.
- Breast implant migration. Did your implant migrate into your armpit? Bottom out? For many women with thin tissue, have had a mastectomy, or have larger heavy implants, you need “thicker” tissue, “stronger” tissue. This mesh can help with that.
- Maintain the lift in a breast lift or breast reduction. This mesh is used in breast lifts and breast reduction to help keep the breast from sagging in the future. It is mainly used by the ANCHOR lift (not the lollipop vertical lift I do). Why? The anchor breast lift or reduction is lifting by tightening the skin- there isn’t the same internal reshaping as I do in the vertical lift. Skin stretches, so the mesh tries to prevent that.
- Support for poor skin quality. Sometimes you know ahead of time someone is at high risk for having an issue with an implant based on the tissue quality. Is your skin thin? Have you had major weight loss? Do you have poor elasticity?
- Skin “thickener.” Visible wrinkles? ripples? An implant step off? Studies have shown the new tissue range in thickness to be 0.75-1.5mm, which is thicker than the scaffold thickness of 0.6mm.
Study: Systematic Review of P4HB in Modern Breast Surgery
This was published in the Aesthetic Surgery Journal November 2025. “Systematic Review of P4HB in Modern Breast Surgery.” (I love that they put “modern” into the title.) They were looking at this mesh use in reconstructive and aesthetic breast surgery. This study is a metanalysis of 16 studies and 1400 patients.
- Reviewed study uses showed at one year, when used, there was less recurrent ptosis (drooping) or pseudoptosis (bottoming out of the lower pole of the breast).
- Reviewed study showing less recurrent capsular contracture
- Reviewed study using mesh when moving implant from behind the muscle to in front of the muscle, “subglandular.”
- Improving the thickness of the tissue in the cleavage area in complex revision cases.
- Study comparing ADM to P4HB showed P4HB had earlier drain removal, but no difference in seroma. One study showed P4HB had a higher capsular contracture rate in dual plane use. One study compared biologic mesh (ADM) vs synthetic mesh (P4HB) and found the capsular contracture rate was not significantly different.
- ADM is 6x the cost of P4HB
- ADM is incorporated into the tissue. P4HB is hydrolyzed slowly over 18-24 months, giving it extended support of the area, which is thought to give it better strength.
- It has been used for nipple reconstruction successfully.
- P4HB lasts for about 2 years. Studies need to evaluate the long term effects
They conclude by discussing their issues with biologic ADM mesh: higher seroma rate and cost. The authors state that P4HB is safe, cost effective, and a good adjunct for a variety of indications.
Dr. Greenberg’s thoughts
I use P4HB mesh. The brand I use is called Galaflex. I have found it easy to use, supportive, and have had no issues with it. I started using it after a meeting where many breast surgeons I respect, who were well versed in both ADM and Galaflex, thought they had better long lasting results with the Galaflex, and the Galaflex was less expensive. That is a win-win.
Using mesh in breast reductions? When I talked to the rep, when I told them I do a vertical breast lift and reduction he said “You don’t need mesh.” See my blog on it. I do use mesh for breast lifts in some of my major weight loss patients as their tissue quality is so poor. They are at high risk for the skin stretching and bottoming out with the weight of the implant.
I do use it P4HB in some breast revision cases where the tissue is thin and the implant has migrated. I use it in thin patients who want bigger, heavier implants.
It is a discussion I have with my patients. There is an increased cost and risk of some issue (though knock on wood I have not had one yet), so it is a joint decision after a discussion of the pros and cons. It is a good tool in my toolbox.
Medical Citations & References
Systematic Review of Poly-4-Hydroxybutyrate: A Swiss Army Knife in Modern Breast Surgery , Aesthetic Journal Nov 2025.
Galaflex Mesh Website
The information provided on this website is for general informational purposes only and does not constitute medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider for any questions regarding your health or medical condition.
