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Cabalag MS, Rostek M, Miller GS, Chae MP, Quinn T, Rozen WM, Hunter-Smith DJ. Alloplastic adjuncts in breast reconstruction. Gland Surg 2016; 5:158-73. [PMID: 27047784 DOI: 10.3978/j.issn.2227-684x.2015.06.02] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There has been an increasing role of acellular dermal matrices (ADMs) and synthetic meshes in both single- and two-stage implant/expander breast reconstruction. Numerous alloplastic adjuncts exist, and these vary in material type, processing, storage, surgical preparation, level of sterility, available sizes and cost. However, there is little published data on most, posing a significant challenge to the reconstructive surgeon trying to compare and select the most suitable product. The aims of this systematic review were to identify, summarize and evaluate the outcomes of studies describing the use of alloplastic adjuncts for post-mastectomy breast reconstruction. The secondary aims were to determine their cost-effectiveness and analyze outcomes in patients who also underwent radiotherapy. METHODS Using the PRSIMA 2009 statement, a systematic review was conducted to find articles reporting on the outcomes on the use of alloplastic adjuncts in post-mastectomy breast reconstruction. Multiple databases were searched independently by three authors (Cabalag MS, Miller GS and Chae MP), including: Ovid MEDLINE (1950 to present), Embase (1980 to 2015), PubMed and Cochrane Database of Systematic Reviews. RESULTS Current published literature on available alloplastic adjuncts are predominantly centered on ADMs, both allogeneic and xenogeneic, with few outcome studies available for synthetic meshes. Outcomes on the 89 articles, which met the inclusion criteria, were summarized and analyzed. The reported outcomes on alloplastic adjunct-assisted breast reconstruction were varied, with most data available on the use of ADMs, particularly AlloDerm(®) (LifeCell, Branchburg, New Jersey, USA). The use of ADMs in single-stage direct-to-implant breast reconstruction resulted in lower complication rates (infection, seroma, implant loss and late revision), and was more cost effective when compared to non-ADM, two-stage reconstruction. The majority of studies demonstrated inferior outcomes in ADM assisted, two-stage expander-to-implant reconstruction compared to non-ADM use. Multiple studies suggest that the use of ADMs results in a reduction of capsular contracture rates. Additionally, the reported beneficial effects of ADM use in irradiated tissue were varied. CONCLUSIONS ADM assisted two-stage breast reconstruction was associated with inferior outcomes when compared to non-ADM use. However, alloplastic adjuncts may have a role in single stage, direct-to-implant breast reconstruction. Published evidence comparing the long-term outcomes between the different types of adjuncts is lacking, and further level one studies are required to identify the ideal product.
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Affiliation(s)
- Miguel S Cabalag
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia
| | - Marie Rostek
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia
| | - George S Miller
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia
| | - Michael P Chae
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia
| | - Tam Quinn
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia
| | - Warren M Rozen
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia
| | - David J Hunter-Smith
- 1 Department of Plastic and Reconstructive Surgery, Frankston Hospital, Peninsula Health, Frankston, Victoria 3199, Australia ; 2 Monash University Plastic and Reconstructive Surgery Unit (Peninsula Clinical School), Peninsula Health, Frankston, Victoria 3199, Australia ; 3 Department of Surgery, Townsville Hospital, School of Medicine and Dentistry, James Cook University Clinical School, Townsville, Queensland 4814, Australia
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Capsular Contracture in Implant-Based Breast Reconstruction: Examining the Role of Acellular Dermal Matrix Fenestrations. Plast Reconstr Surg 2015; 136:629-635. [PMID: 26090760 DOI: 10.1097/prs.0000000000001570] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acellular dermal matrices have been proposed to decrease the incidence of capsular contracture in implant-based breast reconstructions. The authors have modified acellular dermal matrices with fenestrations to facilitate greater lower pole expansion and improve contour. The effect of fenestrations on the ability of matrices to suppress capsule formation, however, has not been examined. METHODS A retrospective review of all fenestrated acellular dermal matrix-assisted, implant-based breast reconstructions performed by the two senior authors, with a minimum of 1-year follow-up after permanent implant placement, was completed. Patient demographics, details of extirpative and reconstructive procedures, and complications were examined. Capsular contractures were scored according to the Baker grading scale and compared to those reported in the literature. RESULTS Thirty patients (50 breasts) underwent fenestrated acellular dermal matrix-assisted reconstruction, with mean follow-up times of 3.3 and 2.6 years after expander placement and implant exchange, respectively. Seven patients (23 percent) had a body mass index greater than 30 kg/m, three (10 percent) were active smokers, and six breasts (12 percent) were irradiated. Complications included one infection (2 percent), six cases (12 percent) of incisional superficial skin necrosis, and one (2 percent) tissue expander extrusion. Zero breasts had clinically significant Baker grade III/IV capsular contracture. The average Baker grade was 1.1. CONCLUSIONS Fenestrated acellular dermal matrices decrease capsular contracture to rates similar to what is seen with nonfenestrated matrices. Further research is necessary to determine whether this observation is a result of decreased need for inferolateral acellular dermal matrix coverage to achieve these effects or modified physical interaction of acellular dermal matrices with surrounding soft tissues. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Voineskos SH, Frank SG, Cordeiro PG. Breast reconstruction following conservative mastectomies: predictors of complications and outcomes. Gland Surg 2015; 4:484-96. [PMID: 26645003 DOI: 10.3978/j.issn.2227-684x.2015.04.13] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Breast reconstruction can be performed using a variety of techniques, most commonly categorized into an alloplastic approach or an autologous tissue method. Both strategies have certain risk factors that influence reconstructive outcomes and complication rates. In alloplastic breast reconstruction, surgical outcomes and complication rates are negatively impacted by radiation, smoking, increased body mass index (BMI), hypertension, and prior breast conserving therapy. Surgical factors such as the type of implant material, undergoing immediate breast reconstruction, and the use of fat grafting can improve patient satisfaction and aesthetic outcomes. In autologous breast reconstruction, radiation, increased BMI, certain previous abdominal surgery, smoking, and delayed reconstruction are associated with higher complication rates. Though a pedicled transverse rectus abdominis myocutaneous (TRAM) flap is the most common type of flap used for autologous breast reconstruction, pedicled TRAMs are more likely to be associated with fat necrosis than a free TRAM or deep inferior epigastric perforator (DIEP) flap. Fat grafting can also be used to improve aesthetic outcomes in autologous reconstruction. This article focuses on factors, both patient and surgical, that are predictors of complications and outcomes in breast reconstruction.
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Affiliation(s)
- Sophocles H Voineskos
- 1 Division of Plastic and Reconstructive Surgery, Department of Surgery, 2 Surgical Outcomes Research Centre (SOURCE), McMaster University, Hamilton, Canada ; 3 Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Simon G Frank
- 1 Division of Plastic and Reconstructive Surgery, Department of Surgery, 2 Surgical Outcomes Research Centre (SOURCE), McMaster University, Hamilton, Canada ; 3 Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
| | - Peter G Cordeiro
- 1 Division of Plastic and Reconstructive Surgery, Department of Surgery, 2 Surgical Outcomes Research Centre (SOURCE), McMaster University, Hamilton, Canada ; 3 Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
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Lee KT, Mun GH. Updated Evidence of Acellular Dermal Matrix Use for Implant-Based Breast Reconstruction: A Meta-analysis. Ann Surg Oncol 2015; 23:600-10. [PMID: 26438439 DOI: 10.1245/s10434-015-4873-9] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although the use of acellular dermal matrix (ADM) has increased exponentially, debates regarding its safety are still ongoing. There have been several meta-analyses; however, potential learning curve effects of using ADM might affect their outcomes. The present meta-analysis reappraised the potential benefits and risks of ADM on the outcome of implant-based breast reconstruction using recent publications. METHODS Electronic databases were searched to identify relevant studies comparing the outcome of ADM use with traditional submuscular technique, which were published from 2011 to 2014. The relative risks of postoperative complications and mean difference of expander dynamics between the two groups were computed. RESULTS A total of 23 studies representing 6199 cases were analyzed. There was one randomized controlled study and three prospective cohort studies. The use of ADM significantly elevated the risks of infection, seroma, and mastectomy flap necrosis, but did not affect the risks of implant loss, unplanned reoperation, and total complications. The risks of capsular contracture and implant malposition were significantly reduced by the application of ADM. The ADM allows for significantly greater intraoperative expansion and reduced frequency of injection to complete expansion. CONCLUSIONS According to this meta-analysis, the increasing risks for serious complication and overall morbidity related to ADM use might not be remarkable, while its benefits for preventing late complications and improving expander dynamics might be appreciable. Although future well-controlled studies would be required, the implant-based breast reconstruction using ADM may be reliable and advantageous.
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Affiliation(s)
- Kyeong-Tae Lee
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Goo-Hyun Mun
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Discussion: Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal? Plast Reconstr Surg 2015; 136:654-656. [PMID: 26397243 DOI: 10.1097/prs.0000000000001625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Understanding the Etiology and Prevention of Capsular Contracture: Translating Science into Practice. Clin Plast Surg 2015; 42:427-36. [PMID: 26408434 DOI: 10.1016/j.cps.2015.06.007] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Capsular contracture remains a common and preventable complication of implanted breast prostheses. As our understanding of the pathophysiology continues to develop, it is prudent to reexamine existing beliefs in a contemporary context. This article presents a current summary of clinical and laboratory evidence, expressed as an interaction between potentiating and suppressing factors, and how this understanding can be applied to practice.
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Poppler L, Cohen J, Dolen UC, Schriefer AE, Tenenbaum MM, Deeken C, Chole RA, Myckatyn TM. Histologic, Molecular, and Clinical Evaluation of Explanted Breast Prostheses, Capsules, and Acellular Dermal Matrices for Bacteria. Aesthet Surg J 2015; 35:653-68. [PMID: 26229126 PMCID: PMC4649701 DOI: 10.1093/asj/sjv017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Subclinical infections, manifest as biofilms, are considered an important cause of capsular contracture. Acellular dermal matrices (ADMs) are frequently used in revision surgery to prevent recurrent capsular contractures. OBJECTIVE We sought to identify an association between capsular contracture and biofilm formation on breast prostheses, capsules, and ADMs in a tissue expander/implant (TE/I) exchange clinical paradigm. METHODS Biopsies of the prosthesis, capsule, and ADM from patients (N = 26) undergoing TE/I exchange for permanent breast implant were evaluated for subclinical infection. Capsular contracture was quantified with Baker Grade and intramammary pressure. Biofilm formation was evaluated with specialized cultures, rtPCR, bacterial taxonomy, live:dead staining, and scanning electron microscopy (SEM). Collagen distribution, capsular histology, and ADM remodeling were quantified following fluorescent and light microscopy. RESULTS Prosthetic devices were implanted from 91 to 1115 days. Intramammary pressure increased with Baker Grade. Of 26 patients evaluated, one patient had a positive culture and one patient demonstrated convincing evidence of biofilm morphology on SEM. Following PCR amplification 5 samples randomly selected for 16S rRNA gene sequencing demonstrated an abundance of suborder Micrococcineae, consistent with contamination. CONCLUSIONS Our data suggest that bacterial biofilms likely contribute to a proportion, but not all diagnosed capsular contractures. Biofilm formation does not appear to differ significantly between ADMs or capsules. While capsular contracture remains an incompletely understood but common problem in breast implant surgery, advances in imaging, diagnostic, and molecular techniques can now provide more sophisticated insights into the pathophysiology of capsular contracture. LEVEL OF EVIDENCE 4 Therapeutic.
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Affiliation(s)
- Louis Poppler
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
| | - Justin Cohen
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
| | - Utku Can Dolen
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
| | - Andrew E Schriefer
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
| | - Marissa M Tenenbaum
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
| | - Corey Deeken
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
| | - Richard A Chole
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
| | - Terence M Myckatyn
- Drs Poppler and Dr Cohen are Residents, Dr Dolen is a Breast Fellow, Dr Tenenbaum is Residency Program Director and Assistant Professor, and Dr Myckatyn is Breast Fellowship Director and Associate Professor, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO. Mr. Schriefer is a Physicist, Genome Technology Access Center, Department of Genetics, Washington University School of Medicine, Saint Louis, MO. Dr Deeken is Director of Biomedical Engineering and Biomaterials Laboratory, Department of Surgery, Section of Minimally Invasive Surgery, Washington University School of Medicine, Saint Louis, MO. and Dr Chole is Lindburg Professor and Chairman, Department of Otolaryngology, and Director of the Biofilm Core Facility, Washington University School of Medicine, Saint Louis, MO
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Preventive Effect of Human Acellular Dermal Matrix on Post-thyroidectomy Scars and Adhesions. Dermatol Surg 2015; 41:812-20. [DOI: 10.1097/dss.0000000000000410] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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The impact of chemotherapy and radiation therapy on the remodeling of acellular dermal matrices in staged, prosthetic breast reconstruction. Plast Reconstr Surg 2015; 135:43e-57e. [PMID: 25539350 DOI: 10.1097/prs.0000000000000807] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND An acellular dermal matrix will typically incorporate, in time, with the overlying mastectomy skin flap. This remodeling process may be adversely impacted in patients who require chemotherapy and radiation, which influence neovascularization and cellular proliferation. METHODS Multiple biopsy specimens were procured from 86 women (n = 94 breasts) undergoing exchange of a tissue expander for a breast implant. These were divided by biopsy location: submuscular capsule (control) as well as superiorly, centrally, and inferiorly along the paramedian acellular dermis. Specimens were assessed for cellular infiltration, cell type, fibrous encapsulation, scaffold degradation, extracellular matrix deposition, neovascularization, mean composite remodeling score, and type I and III collagen. Patients were compared based on five oncologic treatment groups: no adjuvant therapy (untreated), neoadjuvant chemotherapy with or without radiation, and chemotherapy with or without radiation. RESULTS Biopsy specimens were procured 45 to 1805 days after implantation and demonstrated a significant reduction in type I collagen over time. Chemotherapy adversely impacted fibrous encapsulation (p = 0.03). Chemotherapy with or without radiation adversely impacted type I collagen (p = 0.02), cellular infiltration (p < 0.01), extracellular matrix deposition (p < 0.04), and neovascularization (p < 0.01). Radiation exacerbated the adverse impact of chemotherapy for several remodeling parameters. Neoadjuvant chemotherapy also caused a reduction in type I (p = 0.01) and III collagen (p = 0.05), extracellular matrix deposition (p = 0.03), and scaffold degradation (p = 0.02). CONCLUSION Chemotherapy and radiation therapy limit acellular dermal matrix remodeling. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Remodeling characteristics and collagen distribution in biological scaffold materials explanted from human subjects after abdominal soft tissue reconstruction: an analysis of scaffold remodeling characteristics by patient risk factors and surgical site classifications. Ann Surg 2015; 261:405-15. [PMID: 24374547 DOI: 10.1097/sla.0000000000000471] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The study purpose was to evaluate the associations between patient characteristics or surgical site classifications and the histologic remodeling scores of biologic meshes biopsied from abdominal soft tissue repair sites in the first attempt to generate a multivariable risk-prediction model of nonconstructive remodeling. BACKGROUND Host characteristics and surgical site assessments may predict remodeling degree for biologic meshes used to reinforce abdominal tissue repair sites. METHODS Biologic meshes were biopsied from the abdominal tissue repair sites of n = 40 patients during an abdominal reexploration, stained with hematoxylin and eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell types, cell infiltration, extracellular matrix deposition, scaffold degradation, fibrous encapsulation, and neovascularization) and a mean composite score. Biopsies were stained with Sirius Red and Fast Green and analyzed to determine the collagen I:III ratio. On the basis of univariate analyses between subject clinical characteristics or surgical site classification and the histologic remodeling scores, cohort variables were selected for multivariable regression models using P ≤ 0.200. RESULTS The model selection process for cell infiltration score yielded 2 variables: age at mesh implantation and mesh classification (C statistic = 0.989). For the mean composite score, the model selection process yielded 2 variables: age at mesh implantation and mesh classification (r = 0.449). CONCLUSIONS These preliminary results constitute the first steps in generating a risk-prediction model that predicts the patients and clinical circumstances most likely to experience nonconstructive remodeling of abdominal tissue repair sites with biologic mesh reinforcement.
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Kyle DJT, Oikonomou A, Hill E, Bayat A. Development and functional evaluation of biomimetic silicone surfaces with hierarchical micro/nano-topographical features demonstrates favourable in vitro foreign body response of breast-derived fibroblasts. Biomaterials 2015; 52:88-102. [PMID: 25818416 DOI: 10.1016/j.biomaterials.2015.02.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 01/25/2015] [Accepted: 02/01/2015] [Indexed: 12/19/2022]
Abstract
Reproducing extracellular matrix topographical cues, such as those present within acellular dermal matrix (ADM), in synthetic implant surfaces, may augment cellular responses, independent of surface chemistry. This could lead to enhanced implant integration and performance while reducing complications. In this work, the hierarchical micro and nanoscale features of ADM were accurately and reproducibly replicated in polydimethylsiloxane (PDMS), using an innovative maskless 3D grayscale fabrication process not previously reported. Human breast derived fibroblasts (n=5) were cultured on PDMS surfaces and compared to commercially available smooth and textured silicone implant surfaces, for up to one week. Cell attachment, proliferation and cytotoxicity, in addition to immunofluorescence staining, SEM imaging, qRT-PCR and cytokine array were performed. ADM PDMS surfaces promoted cell adhesion, proliferation and survival (p=<0.05), in addition to increased focal contact formation and spread fibroblast morphology when compared to commercially available implant surfaces. PCNA, vinculin and collagen 1 were up-regulated in fibroblasts on biomimetic surfaces while IL8, TNFα, TGFβ1 and HSP60 were down-regulated (p=<0.05). A reduced inflammatory cytokine response was also observed (p=<0.05). This study represents a novel approach to the development of functionalised biomimetic prosthetic implant surfaces which were demonstrated to significantly attenuate the acute in vitro foreign body reaction to silicone.
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Affiliation(s)
- Daniel J T Kyle
- Plastic and Reconstructive Surgery Research, Manchester Institute of Biotechnology, University of Manchester, Manchester, UK; School of Computer Science, Centre for Mesoscience and Nanotechnology, The University of Manchester, Manchester, UK
| | - Antonios Oikonomou
- School of Computer Science, Centre for Mesoscience and Nanotechnology, The University of Manchester, Manchester, UK
| | - Ernie Hill
- School of Computer Science, Centre for Mesoscience and Nanotechnology, The University of Manchester, Manchester, UK
| | - Ardeshir Bayat
- Plastic and Reconstructive Surgery Research, Manchester Institute of Biotechnology, University of Manchester, Manchester, UK.
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The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial (BREASTrial). Plast Reconstr Surg 2015; 135:20e-28e. [DOI: 10.1097/prs.0000000000000809] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leong M, Basu CB, Hicks MJ. Further evidence that human acellular dermal matrix decreases inflammatory markers of capsule formation in implant-based breast reconstruction. Aesthet Surg J 2015; 35:40-7. [PMID: 25568233 DOI: 10.1093/asj/sju014] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Human acellular dermal matrix (HADM; previously termed "acellular cadaveric dermis") may limit inflammatory changes believed to play a role in capsular contracture, a common complication of implant-based breast reconstruction. OBJECTIVES Differences between HADM and native breast capsule specimens were evaluated by immunohistochemical analysis of key inflammatory markers involved in capsule formation. METHODS Twenty consecutive patients underwent immediate, 2-stage, implant-based breast reconstruction with dual-plane HADM. During tissue expander-implant exchange, full-thickness biopsies of biointegrated HADM and native breast capsule (internal control) from the tissue-expander envelope were obtained. Immunohistochemical analysis was performed for endothelial cells (CD31), B cells (CD20), T cells (CD3), macrophages (CD68), collagen I and III, and myofibroblasts (α-smooth muscle actin). Observed levels of marker labeling were semiquantitatively scored from 0 (none) to 3 (severe) by a blinded histopathologist and were statistically analyzed with the Wilcoxon rank sum test. RESULTS A bilateral sample was obtained from 1 patient; all other samples were unilateral. Compared with capsule samples from native breast tissue, HADM samples had significantly lower levels of all inflammatory markers (P < .001). CONCLUSIONS These lower levels of inflammatory markers support previous evidence that HADM may inhibit inflammatory and profibrotic signaling characteristics of breast capsule development and decrease the risk of capsular contracture. Further investigation is needed to determine the mechanism by which HADM inhibits these inflammatory cells, whether HADM reduces the incidence of breast capsular contracture, and if so, the longevity of this effect.
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Affiliation(s)
- Mimi Leong
- Dr Leong is a plastic surgeon at Michael E. DeBakey VA Medical Center, and Clinical Assistant Professor of Surgery and Pediatrics, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas. Dr Basu is a plastic surgeon in private practice in Houston, Texas. Dr Hicks is a professor in the Department of Pathology, Baylor College of Medicine, Houston, Texas
| | - C Bob Basu
- Dr Leong is a plastic surgeon at Michael E. DeBakey VA Medical Center, and Clinical Assistant Professor of Surgery and Pediatrics, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas. Dr Basu is a plastic surgeon in private practice in Houston, Texas. Dr Hicks is a professor in the Department of Pathology, Baylor College of Medicine, Houston, Texas
| | - M John Hicks
- Dr Leong is a plastic surgeon at Michael E. DeBakey VA Medical Center, and Clinical Assistant Professor of Surgery and Pediatrics, Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas. Dr Basu is a plastic surgeon in private practice in Houston, Texas. Dr Hicks is a professor in the Department of Pathology, Baylor College of Medicine, Houston, Texas
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De Vita R, Buccheri EM, Pozzi M, Zoccali G. Direct to implant breast reconstruction by using SERI, preliminary report. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2014; 33:78. [PMID: 25422034 PMCID: PMC4268891 DOI: 10.1186/s13046-014-0078-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/12/2014] [Indexed: 12/02/2022]
Abstract
Background There has been a “rising tide” in mastectomy utilization that can be attributed to more skin-sparing mastectomies (SSMs) performed concurrently with immediate breast reconstruction. We report our experience of the first use of SERI® Surgical Scaffold (SERI®; Allergan, Inc.) in 21 cases of direct to implant (DTI) breast reconstruction after SSM. Methods Our retrospective experience, from April 2013 to May 2014, is based on 21 cases of direct to implant (DTI) breast reconstruction after SSM (9 monolateral 6 bilateral). All the patients were oncological with a preoperative cancer stage was into 0–2 stage. In order to assess the level of satisfaction with the aesthetical result, on 4–13 months post-operative patients were asked to complete a questionnaire that evaluated various parameters by means of a Visual Analogue Scale (V.A.S.). Results Over a 13-months period, a total of 15 patients underwent 21 immediate breast reconstructive procedures with Allergan Natrelle 410 style implants plus SERI® after SSMs. Definitive histological examination give evidence of 5 patients intraductal carcinoma, 6 patients multifocal carcinoma and 4 patients carcinoma in situ. 6 bilateral cases of direct to implant (DTI) breast reconstruction after SSM had a monolateral oncological treatment and on the other side a prophylactic treatment. At the end of the short follow up (minimum 6 months) all the patient were cancer free with an excellent outcome. Complication rate presents just one implant exposure followed by a revised surgery. At V.A.S. the mean patient satisfaction was 5,77 (good), 4,09 (fair) for sensitivity of the nipple areola complex, 6,33 (good) assessment of implant position, 6,28 (good) self esteem, 5,2 (good) attraction ability, 4,99 (fair) intimate life, 6,81 (good) overall feelings about breast reconstruction, 6,71 (good) simmetry. Conclusions The really encouraging results of our early experience will help surgeons introducing SERI® into their practice to select appropriate patients for direct-to-implant single-stage immediate breast reconstruction. A larger study cohort and longer follow-up times are required to identify additional predictors and indications.
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Affiliation(s)
- Roy De Vita
- Plastic Surgery Department, Regina Elena Cancer Institute of Rome, Rome, Italy.
| | | | - Marcello Pozzi
- Plastic Surgery Department, Regina Elena Cancer Institute of Rome, Rome, Italy.
| | - Giovanni Zoccali
- Plastic Surgery Department, Regina Elena Cancer Institute of Rome, Rome, Italy.
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Tissue Reinforcement in Implant-based Breast Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2014; 2:e192. [PMID: 25426375 PMCID: PMC4236353 DOI: 10.1097/gox.0000000000000140] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/29/2014] [Indexed: 11/26/2022]
Abstract
Background: Tissue reinforcement with allogeneic or xenogeneic acellular dermal matrices (ADMs) is increasingly used in single-stage (direct-to-implant) and 2-stage implant-based breast reconstruction following mastectomy. ADMs allow surgeons to control implant position and obviate the need for submuscular implant placement. Here, we review the benefits and risks of using ADMs in implant-based breast reconstruction based on available data. Methods: A comprehensive analysis of the literature with focus on recent publications was performed. Additional information regarding the proper use of ADMs was based on our institutional experience. Results: ADM use may improve definition of the lateral confines of the breast and lower pole projection. It may facilitate direct-to-implant procedures and improve aesthetic outcomes. The effect of ADMs on complication rates remains controversial. Known patient risk factors such as obesity, smoking, and radiotherapy should be considered during patient selection. For patients with healthy, well-vascularized skin envelopes, ADM-assisted direct-to- implant reconstruction is a safe and cost-effective alternative to 2-stage implant reconstruction, with low complication rates. ADMs may be used to treat capsular contracture, and limited available data further suggest the possibility that ADMs may reduce the risk of capsular contracture. Novel synthetic or biosynthetic tissue reinforcement devices with different physical and ease-of-use properties than ADMs are emerging options for reconstructive surgeons and patients who seek to avoid tissue products from human or mammalian cadavers. Conclusions: ADM-assisted implant-based breast reconstruction may improve aesthetic outcomes. However, appropriate patient selection, surgical technique, and postoperative management are critical for its success, including minimizing the risk of complications.
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Persichetti P, Segreto F, Pendolino AL, Del Buono R, Marangi GF. Breast implant capsule flaps and grafts: a review of the literature. Aesthetic Plast Surg 2014; 38:540-8. [PMID: 24764105 DOI: 10.1007/s00266-014-0308-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 03/18/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND A breast implant capsule forms as a physiological response to the foreign material. Over the past decades, authors started to consider the breast implant capsule as a new source of tissue, thus describing several capsular flaps and grafts. The aim of this article is to provide an overview of the applications and indications for the use of capsular tissue flaps and grafts in reconstructive and aesthetic surgery. METHODS A review of the literature on breast implant capsule grafts and flaps was conducted. The reported surgical techniques were described and compared for indications and complications. The studies were evaluated and compared for number of patients and follow-up. RESULTS The search yielded a total of 21 citations. Patient population was reported in 11 studies for capsular flaps and 2 articles for capsular grafts. Between 1997 and 2012, a total of 74 patients underwent surgery with the use of capsular tissue. Among these, 60 patients had a capsular flap (81 %) and 14 (19 %) had a capsular graft. Complications were experienced in 5 patients (6.7 %). CONCLUSIONS Capsular flaps and grafts are indicated mainly to address breast implant-related problems. The breast implant capsule represents a versatile and reliable source of tissue for both aesthetic and reconstructive surgery. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.
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Affiliation(s)
- Paolo Persichetti
- Department of Plastic, Reconstructive and Aesthetic Surgery, Campus Bio-Medico of Rome University, 00128, Rome, Italy
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Direct-to-Implant Single-Stage Immediate Breast Reconstruction with Acellular Dermal Matrix. Plast Reconstr Surg 2014; 133:738e-747e. [DOI: 10.1097/prs.0000000000000171] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Forsberg CG, Kelly DA, Wood BC, Mastrangelo SL, DeFranzo AJ, Thompson JT, David LR, Marks MW. Aesthetic Outcomes of Acellular Dermal Matrix in Tissue Expander/Implant-Based Breast Reconstruction. Ann Plast Surg 2014; 72:S116-20. [DOI: 10.1097/sap.0000000000000098] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Maxwell GP, Gabriel A. Non-cross-linked porcine acellular dermal matrix in revision breast surgery: long-term outcomes and safety with neopectoral pockets. Aesthet Surg J 2014; 34:551-9. [PMID: 24692599 DOI: 10.1177/1090820x14528207] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Revision breast surgery represents a significant problem among patients who have undergone augmentation mammaplasty. Current techniques do not adequately prevent recurrence, thus requiring novel approaches, including placement of Strattice (LifeCell, Branchburg, New Jersey), a non-cross-linked porcine acellular dermal matrix, to minimize recurrence. OBJECTIVE The authors review their experience and long-term outcomes with placement of Strattice in revision breast surgery patients who underwent previous augmentation mammaplasty. METHODS All patients in the authors' practice with a previous history of augmentation mammaplasty who underwent revision breast surgery with placement of Strattice between January 2007 and December 2011, and who had a minimum of 12 months of follow-up, were included in this retrospective study. A total of 106 patients met the study's inclusion criteria. RESULTS Average patient age was 42.3 years and average follow-up time was 3.1 years. Indications for revision surgery included capsular contracture (51.9%), implant malposition (38.7%), and ptosis (8.5%); approximately 40% had ≥1 previous attempts to correct the presenting complaint. Revision surgery included creation of neosubpectoral pockets with retention of previous noncalcified capsules in 81% of patients with subpectoral implants. Presenting complaints were successfully resolved in all patients. The overall complication rate was 0.9%. CONCLUSIONS Adding Strattice to traditional revision surgery procedures results in reliable, durable repair of the presenting complaint with minimal associated complications. Treatment with Strattice in conjunction with noncalcified capsules retained during site change also appears to be safe. The data support a role for Strattice in revision breast surgery for patients who have undergone previous augmentation mammaplasty.
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Affiliation(s)
- G Patrick Maxwell
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, California
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The effect of radiation on acellular dermal matrix and capsule formation in breast reconstruction: clinical outcomes and histologic analysis. Plast Reconstr Surg 2014; 133:214-221. [PMID: 24469157 DOI: 10.1097/01.prs.0000437255.01199.42] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The authors compared clinical outcomes to determine whether acellular dermal matrix altered the capsular tissue architecture in irradiated and nonirradiated breasts following matrix-assisted expander reconstruction. METHODS Part I included all 27 patients who underwent bilateral tissue expander reconstruction with acellular dermal matrix between 2007 and 2012 and subsequent unilateral radiation therapy. Part II included a subset of patients with capsular biopsy specimens taken at the time of implant exchange for histologic analysis. Specimens included irradiated and nonirradiated acellular dermal matrix and irradiated and nonirradiated native capsule. Clinical outcomes were analyzed in relation to capsule architecture and acellular dermal matrix performance. RESULTS In part I, mean follow-up was 28 months. Grade III/IV contractures were identified in nine patients (all on the irradiated side), and 12 developed noncontracture complications (75 percent on the irradiated side). Nine patients were unable to continue with implant reconstruction and required salvage with autologous tissue. In part II, postirradiation biopsy specimens were taken of the peri-implant capsule in six patients at the time of secondary surgery. Elastin content and the total cellular infiltrate were significantly greater in the irradiated versus nonirradiated native capsules (p = 0.0015). Conversely, the irradiated matrix capsule was composed of similar amounts of cellular infiltrate and collagen as the nonirradiated matrix capsules and nonirradiated native capsules. Irradiated acellular dermal matrix showed the least amount of alpha-smooth actin staining but a similar number of blood vessels. CONCLUSION Acellular dermal matrix appears to limit the elastosis and chronic inflammation seen in irradiated implant reconstructions and is potentially beneficial in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Treatment of capsular contracture using complete implant coverage by acellular dermal matrix: a novel technique. Plast Reconstr Surg 2013; 132:519-529. [PMID: 23985627 DOI: 10.1097/prs.0b013e31829acc1e] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Capsular contracture is a frequent complication of breast reconstruction that affects 2.8 to 15.9 percent of patients. Use of acellular dermal matrix has been reported for treatment of contracture, with a recurrence rate of 6.3 percent, but this was limited to partial implant coverage only. The authors describe a novel surgical technique using acellular dermal matrix to completely cover the implant anteriorly to treat and prevent capsular contracture. METHODS Charts were reviewed to identify patients who had received implant insertion with complete acellular dermal matrix coverage performed by a single surgeon. Patient demographic information, history of irradiation or capsular contracture, prior treatment, and postoperative complications were recorded. RESULTS Eleven patients (16 breasts) were identified. Mean age and body mass index were 52.3 ± 6.9 years and 23.6 ± 4.4 kg/m, respectively. Four patients (five breasts) had a history of capsular contracture requiring previous capsulectomy and implant exchange. Ten cases were for correction of new-onset grade III (n = 2) or IV (n = 8) capsular contracture and one was to prevent future capsular contracture. Mean acellular dermal matrix size was 229.8 ± 46.5 cm (range, 144 to 256 cm). Average follow-up was 9.2 months (range, 2.4 to 18.8 months). One patient (one breast) developed an infection requiring implant removal. No patients experienced recurrent capsular contracture. CONCLUSIONS Capsular contracture may be treated successfully using complete acellular dermal matrix coverage. This technique may be a useful addition to therapies currently used to treat recalcitrant capsular contracture (early recurrence or refractory to standard therapy).
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Wu YC, Jao JC, Yang YT, Wang HS, Wu CH, Chen PC. Preliminary study of non-invasive shock wave treatment of capsular contracture after breast implant: animal model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2013; 2013:1108-11. [PMID: 24109886 DOI: 10.1109/embc.2013.6609699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The incidence rate of capsular contracture after breast implant is about 8% to 12%. Patients would feel extremely uncomfortable after scar formation. Administering oral medications (such as vitamin E and Zafirlukast tablets, etc.) or invasive breast capsulectomy surgery was commonly used for capsular contracture repair in clinical therapy. However, the therapeutic effect is still under investigation. Shock waves can be used to remove soft connective tissue in clinical applications. It has been widely used in orthopedics and rehabilitation. No related research paper about shock wave treatment of capsular contracture has been published yet. It might provide another choice for capsular contracture repair. In order to simulate breast implantation, two silica-gel bags filled with normal saline were implanted into New Zealand rabbit's thighs bilaterally as an animal model. Six weeks later, daily shock wave treatment on the right thigh was performed for six weeks after capsular contractures were formed, while the other thigh was used as a control. Then, magnetic resonance imaging (MRI) was used to compare the difference between treated and un-treated thighs. Afterwards, pathological sections were analyzed to confirm the findings. It has been demonstrated that shock wave treatments are capable of changing the structure and composition of capsular contractures. The structure of scar became myxoid changed or collagen deposition of scar decreased after shock wave treatment, hence, the formation of scars decreased. Increased myxoid and decreased collagen deposition has also been found.
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Further Evidence that Acellular Cadaveric Dermis (AlloDerm®) Decreases Inflammatory Markers of Capsule Formation in Implant-Based Breast Reconstruction. Plast Reconstr Surg 2013. [DOI: 10.1097/01.prs.0000436015.46253.b9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Analysis of Clinically Significant Seroma Formation in Breast Reconstruction Using Acellular Dermal Grafts. Ann Plast Surg 2013; 71:274-7. [DOI: 10.1097/sap.0b013e3182923dc9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Discussion: Treatment of capsular contracture using complete implant coverage by acellular dermal matrix: a novel technique. Plast Reconstr Surg 2013; 132:530-531. [PMID: 23985628 DOI: 10.1097/prs.0b013e318290f712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Dermal autografts as a substitute for acellular dermal matrices (ADM) in tissue expander breast reconstruction: a prospective comparative study. J Plast Reconstr Aesthet Surg 2013; 66:1534-42. [PMID: 23871569 DOI: 10.1016/j.bjps.2013.07.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/01/2013] [Accepted: 07/01/2013] [Indexed: 11/23/2022]
Abstract
The use of acellular dermal matrix (ADM) in tissue expander breast reconstruction has several advantages but increased complications have been reported. Dermal autografts may offer a safer and more cost-effective alternative. The purpose of this prospective study was to compare the outcomes of tissue expander breast reconstruction using dermal autografts with ADM-assisted reconstruction. Patients undergoing tissue expander breast reconstruction with either ADM or dermal autografts were enrolled. Autografts were harvested from the lower abdomen. At each follow-up visit, patients were surveyed on a seven-point scale for scar and overall satisfaction. Biopsies taken at the time of device exchange were evaluated histologically with CD34 staining to assess tissue integration and vessel ingrowth. Expansion parameters, complications, procedural costs, and operative times were compared. Forty-eight patients were enrolled (76 breasts). Twenty-seven patients received ADM, and twenty-one patients received dermal autograft. Wound healing complications were significantly higher in the ADM group (14.8% versus 4.8%, p-value = 0.03), as were major complications (18.5% versus 0%, p-value < 0.01). Histologic vessel counts in the autograft group averaged 21 vessels/mm(2), compared to 7 vessels/mm(2) in the ADM group (p-value < 0.01). There was no difference between the two groups in scar satisfaction or overall satisfaction. Patients receiving dermal autograft had a lower incidence of major complications and delayed wound healing than patients who received ADM. Despite harvest time, the overall cost of the ADM-assisted expander placement was higher. Dermal autograft-assisted breast reconstruction offers many of the benefits of ADM, but with a lower cost and improved safety profile.
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A Comparative Study of CG CryoDerm and AlloDerm in Direct-to-Implant Immediate Breast Reconstruction. Arch Plast Surg 2013; 40:374-9. [PMID: 23898434 PMCID: PMC3723998 DOI: 10.5999/aps.2013.40.4.374] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/26/2013] [Accepted: 05/12/2013] [Indexed: 11/18/2022] Open
Abstract
Background To date, various types of acellular dermal matrix (ADM) have been developed for clinical use. AlloDerm is the most familiar type of ADM to most surgeons in breast reconstruction. It is prepared by freeze-drying. CG CryoDerm is the first form of ADM that requires no drying process. Therefore, theoretically, it has a higher degree of preservation of the dermal structures than AlloDerm. We conducted this study to compare the clinical course and postoperative outcomes of patients who underwent direct-to-implant breast reconstructions using AlloDerm and those who did using CG CryoDerm. Methods We performed a retrospective analysis of the medical records in a consecutive series of 50 patients who underwent direct-to-implant breast reconstruction using AlloDerm (n=31) or CryoDerm (n=19). We then compared the clinical course and postoperative outcomes of the two groups based on the overall incidence of complications and the duration of drainage. Results The mean follow-up period was 16 months. There were no significant differences in the overall incidence of complications (seroma, infection, skin flap necrosis, capsular contracture, and implant loss) between the two groups. Nor was there any significant difference in the duration of drainage. Conclusions CG CryoDerm has the merits of short preparation time and easy handling during surgery. Our results indicate that CG CryoDerm might be an alternative allograft material to AlloDerm in direct-to-implant breast reconstruction.
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Israeli Ben-noon H, Farber N, Weissman O, Tessone A, Stavrou D, Shabtai M, Maor Y, Haik J, Winkler E. The effect of acellular dermal matrix on drain secretions after immediate prosthetic breast reconstruction. J Plast Surg Hand Surg 2013; 47:308-12. [DOI: 10.3109/2000656x.2013.766202] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Comparison study of two types of expander-based breast reconstruction: acellular dermal matrix-assisted versus total submuscular placement. Ann Plast Surg 2013; 70:10-5. [PMID: 21862915 DOI: 10.1097/sap.0b013e31822f6765] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent reported complications have called some authors to express concern regarding the increased popularity of acellular dermal matrix (ADM)-based breast reconstruction, and its role as an alternative to traditional total submuscular approaches. To address this issue, we compared tissue expansion properties, complication rates, and patient satisfaction for both operative techniques at the same institution. A retrospective review was completed on 75 patients and 100 tissue expander/implant-based breast reconstructions at a single academic institution from 2007 to 2010. Of these cases, 31 patients were reconstructed with ADM and 44 with a submuscular coverage technique. Total complications including seroma, hematoma, infection, skin necrosis, and explantation did not significantly differ between groups (n = 13 for ADM vs. 17 for submuscular, P = 0.814). Consistent with prior reports, ADM-based reconstructions were associated with significantly increased intraoperative fill volumes and lower total number of sessions to achieve final volume. Submuscular reconstructions required a significantly higher tissue expander fill volume. Eight patients in the submuscular group required surgical revision of the breast and inframammary fold, compared with 4 in the ADM group; however, this difference was not significant. Patient satisfaction was equivalent between the 2 groups; however, it was higher in patients with bilateral reconstruction and lower among those who had received adjuvant radiation therapy. Satisfaction with nipple reconstruction was inversely proportional to time elapsed from the procedure to survey conduction. This is the first study to perform a head-to-head comparison on the basis of patient satisfaction, the results of which may be useful in preoperative planning and counseling.
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Analysis of Acellular Dermal Matrix Integration and Revascularization following Tissue Expander Breast Reconstruction in a Clinically Relevant Large-Animal Model. Plast Reconstr Surg 2013; 131:741e-751e. [DOI: 10.1097/prs.0b013e3182865c6d] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Comparison of in vivo adipogenic capabilities of two different extracellular matrix microparticle scaffolds. Plast Reconstr Surg 2013; 131:174e-187e. [PMID: 23358012 DOI: 10.1097/prs.0b013e3182789bb2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The extracellular matrix is an essential microenvironment for cell survival activity. The adipose tissue extract microparticle scaffolds from human adipose tissue and small intestine submucosa microparticle scaffolds from porcine jejunum were prepared. Their effects on the adipogenic capabilities of human adipose-derived stem cells were compared in vivo. METHODS A combination of physical and chemical methods was used to decellularize human fat and porcine jejunum. Expression of CD molecules on the adipose-derived stem cell surface was determined by flow cytometry. The stem cells were then cultured with the scaffold materials in vitro. The cell-scaffold complexes were implanted subcutaneously into nude mice, and samples were collected 4 and 8 weeks later. The adipogenic differentiation capabilities of adipose-derived stem cells were studied by histologic methods and real-time polymerase chain reaction. RESULTS The authors observed high expression of CD90 and CD44; no expression of CD34, CD45, CD31, or CD106; and weak positive expression of CD49d on the extracted cells, which indicates that the cells were adipose-derived stem cells. The main constituent of the decellularized adipose tissue extract and small intestine submucosa microparticles was collagenous fiber, and the cells proliferated faster on the adipose tissue extract than on small intestine submucosa. Formation of adipocytes in the adipose tissue extract group was closer to that of normal human fat tissue compared with that of the small intestine submucosa group. CONCLUSIONS Extracellular matrix microparticle scaffolds could promote proliferation, adhesion, and adipogenic differentiation of adipose-derived stem cells. The role of the adipose tissue extract microparticle scaffold in promoting adipogenesis was stronger and more suitable as a vector in fatty tissue engineering.
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Maxwell GP, Gabriel A. Efficacy of acellular dermal matrices in revisionary aesthetic breast surgery: a 6-year experience. Aesthet Surg J 2013; 33:389-99. [PMID: 23439064 DOI: 10.1177/1090820x13478967] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Augmentation mammaplasty and augmentation mastopexy are associated with a substantial primary and secondary revision rate. Capsular contracture (CC), implant malposition, ptosis, asymmetry, and rippling are the main reasons for revisionary surgery in these patients. Traditional corrective techniques have not been completely reliable in preventing or treating these complications. Recently, acellular dermal matrices (ADM) have been used to assist with revisionary surgery with promising results. OBJECTIVE The authors review their 6-year experience using ADM for revisionary surgery in aesthetic patients and evaluate long-term outcomes with this approach. METHODS Patients who underwent revisionary breast augmentation or augmentation mastopexy with ADM in conjunction with standard techniques over a 6-year period between October 2005 and December 2011 were retrospectively reviewed. Only patients with at least 1 year of follow-up were included in the analysis. RESULTS A total of 197 revisions were performed (197 patients). Reasons for revision included CC (61.8%), implant malposition (31.2%), rippling (4.8%), ptosis (4.8%), implant exposure (1.6%), and breast wound (0.5%). The mean ± SD follow-up period was 3.1 ± 1.1 years (range, 0.1-6.1 years). The complication rate was 4.8%, including Baker grade III/IV CC (1.6%), infection (1.6%), implant malposition (0.5%), hematoma (0.5%), and seroma (0.5%). Most (98%) revisions were successful, with no recurrence of the presenting complaint. CONCLUSIONS The use of ADM in conjunction with standard techniques for the reinforcement of weak tissue in revision augmentation and augmentation mastopexy patients appears to be effective.
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Affiliation(s)
- G Patrick Maxwell
- Department of Plastic Surgery, Loma Linda University Medical Center, Loma Linda, California 92354, USA
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Is the shear wave sonographic elastography correlated with pain after breast augmentation with silicone implants an indication of inflammatory activity? A preliminary report. Wideochir Inne Tech Maloinwazyjne 2012; 6:217-25. [PMID: 23255983 PMCID: PMC3516953 DOI: 10.5114/wiitm.2011.26255] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 07/19/2011] [Accepted: 07/25/2011] [Indexed: 12/03/2022] Open
Abstract
Introduction Formation of a capsule is a natural inflammatory response to a foreign body such as a breast implant. Breast capsular contracture is the most severe complication of implant surgery. Aim To evaluate breast tissues and the periprosthetic reaction with sonoelastography. Material and methods Nineteen patients aged 20-41 underwent breast augmentation with silicone-filled implants. Their 38 breasts were evaluated before surgery, and 7 and 14 days after surgery. Whole breast stiffness was measured by applanation tonometry. Patients underwent shear wave elastography and Young's moduli of breast tissues and the periprosthetic capsule were estimated. During surgery patients underwent standard anaesthesia and were released home 2 days later after removal of drainage. Each day, patients completed the pain visual analogue scale questionnaire separately for left and right breasts. Results Applanation tonometry did not correlate with any parameter. In shear wave elastography we observed statistically significant changes in elasticity of all breast tissues with the highest values on day 7 after surgery and decreasing on day 14. The correlations between pain and capsule elasticity in lower quadrants measured were significant between days 4 and 10, whereas correlations of pain with applanation tonometry were insignificant. Glandular tissue elasticity in lower quadrants did not correlate with pain, whereas in upper quadrants there was a significant correlation on days 6-10. Fatty tissue, muscle and thoracic fascia elasticity did not correlate with breast pain. Breast implant volume correlated with pain only shortly after surgery, but did not correlate with any sonoelastographic parameters. Conclusions Breast pain correlates strongly with periprosthetic stiffness in elastography 4 to 10 days after breast augmentation, suggesting the possible role of an inflammatory reaction.
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Use of Dermal Matrix to Prevent Capsular Contracture in Aesthetic Breast Surgery. Plast Reconstr Surg 2012; 130:126S-136S. [DOI: 10.1097/prs.0b013e3182605d18] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Utility of Acellular Dermis–Assisted Breast Reconstruction in the Setting of Radiation. Plast Reconstr Surg 2012; 130:750-758. [DOI: 10.1097/prs.0b013e318262f009] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The adjunctive use of acellular dermal matrices in breast surgery is expanding. The purpose of this article is to provide an overview of the various applications of acellular dermal matrices in breast surgery, the benefits and complications associated with their use, and best practices to optimize outcomes using a human acellular dermal matrix (AlloDerm [LifeCell Corp., Branchburg, NJ]) as an example.
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