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Poly-4-hydroxybutyrate (P4HB) mesh improves breast support and lower pole stability with minimal complications in aesthetic breast surgery, though current evidence is too heterogeneous and biased to establish definitive clinical guidelines. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

October 4, 2025Open Access

Poly-4-hydroxybutyrate mesh (GalaFlex®) in aesthetic breast surgery: A comprehensive systematic review

MPMarco PalmesanoUniversity of Rome Tor Vergata GSGabriele StortiUniversity of Rome Tor Vergata ALAndrea LisaUniversity of Rome Tor Vergata

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Abstract

Background: Mastopexy, with or without implants, is a common cosmetic breast surgery. Despite various techniques, long-term issues like pseudoptosis and recurrent ptosis remain challenging, especially in patients with poor skin quality or significant weight loss. While autologous methods provide stability, they often fall short in complex cases. Therefore, non-autologous reinforcement, such as acellular dermal matrices (ADMs) and synthetic meshes, are increasingly used. This systematic review critically evaluates the efficacy, safety, and outcomes of P4HB mesh in aesthetic breast surgery, focusing on postoperative complications and patient satisfaction. Methods: This study followed Cochrane Handbook principles and PRISMA guidelines, with the protocol registered on PROSPERO (ID: CRD42024506060). Analyzing 183 patients (366 breasts) across seven studies, high heterogeneity, the absence of a control group, and a significant risk of bias precluded the possibility of conducting a meta-analysis, resulting in a systematic review instead. Result: This review evaluated the use of P4HB scaffolds in various breast surgeries, including mastopexy, augmentation, and revision procedures. Findings demonstrated improvements in breast support and lower pole stability over time. Complications were minimal. However, the studies highlighted outcome variability and the need for standardized assessment tools to measure results. Conclusions: The P4HB mesh offers notable advantages, including high biocompatibility, long resorption time, and cost-effectiveness, making it a promising option for challenging cases in aesthetic breast surgery. It provides internal support for soft tissues and implants, especially where implant visibility is a concern. However, due to the variability in surgical procedures and the lack of robust evidence, solid conclusions about the optimal clinical use of P4HB meshes are still premature, necessitating further high-quality studies.

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