Systematic Review of Poly-4-Hydroxybutyrate in Modern Breast Surgery

Several biologic and synthetic adjuncts have been employed to reduce ptosis and improve cosmesis in breast surgery. Poly-4-hydroxybutyrate (P4HB), a fully absorbable polymer, continues to increase in use. This study sought to identify uses of P4HB in both reconstructive and aesthetic breast surgery and synthesize the available data on its outcomes and efficacy. A literature search was performed from inception to May 2024 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses in PubMed (MEDLINE), EMBASE, and Cochrane databases. Two independent reviewers screened the studies for eligibility. Bibliographies and cited references from selected articles from Scopus (Elsevier) were also reviewed. The search identified 372 studies, with 16 articles included. All prospective and retrospective case series utilizing P4HB reported high rates of patient satisfaction and scaffold incorporation as well as low complication rates, including recurrent ptosis, implant malposition, and capsular contracture. One retrospective cohort study reported significantly higher rates of capsular contracture with the use of P4HB sling in dual-plane, 2-stage breast reconstruction. No other studies reported significantly higher rates of capsular contracture with P4HB and no other significant differences in complication rates were noted. Two animal studies exploring the use of P4HB in nipple reconstruction reported that P4HB promoted the growth of fibrovascular tissue with higher rates of nipple projection with respect to control. This study supports P4HB as a safe and efficacious adjunct in a variety of indications. Large-scale, randomized trials between P4HB and other types of soft tissue support are needed to further delineate the above trends. Level of Evidence: 3 (Therapeutic).