Does acellular dermal matrix really improve aesthetic outcome in tissue expander/implant-based breast reconstruction?

Early Complications after Prepectoral Tissue Expander Placement in Breast Reconstruction with and without Acellular Dermal Matrix

BACKGROUND

Prepectoral breast reconstruction has become popularized with the concurrent use of acellular dermal matrix (ADM). The authors sought to compare 3-month postoperative complication rates and explantation rates for first-stage, tissue-expander-based, prepectoral breast reconstruction with and without the use of ADM.

METHODS

A single-institution retrospective chart review was performed to identify consecutive patients undergoing prepectoral tissue-expander-based breast reconstruction from August of 2020 to January of 2022. Chi-square tests were used to compare demographic categorical variables, and multiple variable regression models were used to identify variables associated with 3-month postoperative outcomes.

RESULTS

The authors enrolled 124 consecutive patients. Fifty-five patients (98 breasts) were included in the no-ADM cohort and 69 patients (98 breasts) were included in the ADM cohort. There were no statistically significant differences between the ADM and no-ADM cohorts with regard to 90-day postoperative outcomes. On multivariable analysis, there were no independent associations between seroma, hematoma, wound dehiscence, mastectomy skin flap necrosis, infection, unplanned return to the operating room, or explantation in the ADM and no-ADM groups after controlling for age, body mass index, history of diabetes, tobacco use, neoadjuvant chemotherapy, and postoperative radiotherapy.

CONCLUSIONS

The authors' results reveal no significant differences in odds of postoperative complications, unplanned return to the operating room, or explantation between the ADM and no-ADM cohorts. More studies are needed to evaluate the safety of prepectoral, tissue expander placement without ADM.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Patient-reported outcomes of mesh in minimally invasive (laparoscopic/robot-assisted) immediate subpectoral prosthesis breast reconstruction: a retrospective study

BACKGROUND

Although there is increasing interest in minimally invasive prosthesis breast reconstruction (PBR), whether meshes application in minimally invasive PBR can improve complications and cosmetic effects remains controversial. The author retrospectively analyzed postoperative complications and evaluated patient-reported quality-of-life outcomes in minimally invasive PBR with and without mesh.

METHODS

This study enrolled patients who underwent minimally invasive nipple-sparing mastectomy (NSM) followed by PBR. We used the TiLOOP bra for the mesh-assisted procedure. Patient demographics and postoperative complications data were compared between the procedures. Patient-reported outcomes were evaluated with the Breast-Q.

RESULTS

A total of 158 patients underwent 160 minimally invasive NSM-PBR (with mesh, n = 64; without, n = 94). Postoperative complications were comparable in the mesh-assisted (5 [7.7%]) and non-mesh-assisted (5 [5.3%]) groups (p = 0.533). The most common complication in non-mesh-assisted group was infection, with four (4.2%) cases. In mesh-assisted group, implant exposure occurred in two (3.1%) patients. Removal of prosthesis was uncommon, with two (3.1%) and three (3.2%) cases in the mesh-assisted and non-mesh groups, respectively (p = 0.977). The BREAST-Q questionnaire was completed by 52 (81.3%) patients in the mesh-assisted group and 68 (72.3%) in the non-mesh-assisted group. Comparing the non-mesh group, patients in mesh-assisted group had improved scores on the BREAST-Q Satisfaction with breast (66.0) (p < 0.05), Physical Well-being (80.0), and Sexual Well-being (56.0).

CONCLUSIONS

Mesh-assisted minimally invasive NSM-PBR has good aesthetic outcomes and high patient satisfaction. There were no significant differences in complication rates between the mesh-assisted and non-mesh-assisted groups.

Should Acellular Dermal Matrices Be Used for Implant-based Breast Reconstruction after Mastectomy? Clinical Recommendation Based on the GRADE Approach

Acellular dermal matrices (ADMs) entered the market in the early 2000s and their use has increased thereafter. Several retrospective cohort studies and single surgeon series reported benefits with the use of ADMs. However, robust evidence supporting these advantages is lacking. There is the need to define the role for ADMs in implant-based breast reconstruction (IBBR) after mastectomy.

Methods

A panel of world-renowned breast specialists was convened to evaluate evidence, express personal viewpoints, and establish recommendation for the use of ADMs for subpectoral one-/two-stage IBBR (compared with no ADM use) for adult women undergoing mastectomy for breast cancer treatment or risk reduction using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

Results

Based on the voting outcome, the following recommendation emerged as a consensus statement: the panel members suggest subpectoral one- or two-stage IBBR either with ADMs or without ADMs for adult women undergoing mastectomy for breast cancer treatment or risk reduction (with very low certainty of evidence).

Conclusions

The systematic review has revealed a very low certainty of evidence for most of the important outcomes in ADM-assisted IBBR and the absence of standard tools for evaluating clinical outcomes. Forty-five percent of panel members expressed a conditional recommendation either in favor of or against the use of ADMs in subpectoral one- or two-stages IBBR for adult women undergoing mastectomy for breast cancer treatment or risk reduction. Future subgroup analyses could help identify relevant clinical and pathological factors to select patients for whom one technique could be preferable to another.

The BREASTrial Stage III: Acellular Dermal Matrix Breast Reconstruction Outcomes from 3 Months to 2 Years Postoperatively

BACKGROUND

The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial (BREASTrial) is a blinded, randomized trial comparing the outcomes of tissue expander breast reconstruction using AlloDerm or DermaMatrix. In this final stage of the trial, outcomes 3 months to 2 years after definitive reconstruction are reported along with patient satisfaction data.

METHODS

A randomized trial was conducted to compare complication rates between groups of patients who underwent reconstruction with AlloDerm and DermaMatrix. Regression models were used to analyze the impact of matrix type, age, chemotherapy, radiation therapy, and reconstructive type on complication rates. Premastectomy and postmastectomy questionnaires were used to assess patient satisfaction and were also analyzed using regression models.

RESULTS

Of the 128 patients (199 breasts) who were randomized in the trial, 108 patients (167 breasts) were available for analysis in stage III. There was no difference in the overall complication rates between the AlloDerm and DermaMatrix groups (6% versus 13.2%; P = 0.3) or the severity of those complications ( P = 0.7). Obesity was a positive predictor for complications, regardless of reconstruction group ( P = 0.02). Patient satisfaction was positive overall and did not grossly vary between AlloDerm and DermaMatrix groups.

CONCLUSIONS

Findings from the BREASTrial conclude that AlloDerm and DermaMatrix exhibit similar histologic and clinical outcomes. Patient satisfaction is also similar between matrices. Obesity is a predictor of complications, and acellular dermal matrices should be used with caution in these patients. As the largest head-to-head trial comparing two acellular dermal matrices, the BREASTrial contributes to the fund of knowledge regarding acellular dermal matrix supplementation in breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Co-Graft of Acellular Dermal Matrix and Split Thickness Skin Graft—A New Reconstructive Surgical Method in the Treatment of Hidradenitis Suppurativa

Hidradenitis suppurativa is a chronic disease that significantly reduces patients’ quality of life. Patients are chronically treated with systemic therapies, which are often ineffective. Surgical treatment for severe cases of hidradenitis suppurativa is one option for affected patients. Surgical treatment has its limitations, and wound closure may be particularly problematic. This requires the use of reconstructive techniques. The methods of choice for wound closure are split-thickness skin grafts or local flaps reconstructions. However, each method has its limitations. This is a presentation of a new reconstructive surgical method in hidradenitis suppurativa surgery: the use of a co-graft of Acellular dermal matrix and split thickness skin graft as a novel method in wound closure after wide excisions, based on two cases. The results of this method are very promising: we achieved very fast wound closure with good aesthetic results regarding scar formation. In this paper, we used several examinations: laser speckle analysis, cutometer tests, and health-related quality of life (QoL) questionnaire to check the clinical impact of this method. Our initial results are very encouraging. ADM with STSG as a co-graft could be widely used in reconstructive surgery. This is a preliminary study, which should be continued in further, extended research.

DermACELL Acellular Dermal Matrix in Oncologic Breast Reconstruction: A Cohort Study and Systematic Review

Acellular dermal matrices (ADMs) are commonly used in tissue expander and direct-to-implant reconstruction following mastectomy. Few studies have reported outcomes of DermACELL use or compared DermACELL with AlloDerm ADM. This study sought to compare outcomes of DermACELL and AlloDerm in oncologic breast reconstruction and to review the literature reporting outcomes of patients undergoing reconstruction using DermACELL.

Abnormal Ultrasonographic Findings of Acellular Dermal Matrix in Implant-Based Breast Reconstruction: Correlations with Histopathology

Background: Acellular dermal matrix (ADM) in implant-based breast reconstruction can show various ultrasound (US) findings. However, there are limited reports on the US features of the ADM. The aims of this study were to evaluate US findings of the ADM in implant-based breast reconstruction and correlate them with histopathological findings. Methods: Between January 2015 and August 2020, 250 women who underwent implant-based breast reconstruction with ADM and a breast US examination at 6 months to 1 year after reconstruction were retrospectively analyzed. Abnormal US findings were classified as type 1 (focal thickening with decreased echogenicity), 2 (diffusely hyperechoic), or 3 (bright echogenic spots). ADM biopsy was performed in 33 patients who underwent second stage or revisional surgeries. Results: In total, 176 consecutive women with 207 US findings were analyzed. The US findings were normal in 52.2% of the women. The percentages of type 1, 2, and 3 patients were 13.5%, 11.1%, and 23. 2%, respectively. These patients had microscopic findings that showed patchy areas with chronic inflammatory infiltrates, dense collagen bundles without degenerative or inflammatory changes, and empty spaces or degenerated foci unaccompanied by inflammation. Conclusion: Knowing the various ADM presentations on US can help avoid unnecessary invasive procedures.

Comparing Outcomes of Wise-Pattern, Two-Stage Breast Reduction-Reconstruction with and without Acellular Dermal Matrix

BACKGROUND

Aesthetic results in breast reconstruction for ptotic/obese breasts may be improved when using Wise-pattern closures compared with nipple-sparing mastectomies. In two-stage reconstruction, acellular dermal matrix is commonly used to support the prosthesis. This study tests the efficacy of an alternate technique that uses deepithelialized excess breast skin in lieu of acellular dermal matrix. To better understand whether acellular dermal matrix is necessary, the authors compared postoperative outcomes from reduction-reconstructions that used matrix to those that did not.

METHODS

The authors retrospectively reviewed the outcomes of patients who underwent staged breast reconstruction following Wise-pattern closures between September of 2016 and October of 2019. Two cohorts were created based on whether acellular dermal matrix was used. Charts were reviewed for incidence of postoperative complications.

RESULTS

A total of 164 breasts were reconstructed in 85 female patients. The acellular dermal matrix cohort consisted of 68 breasts, whereas the non-acellular dermal matrix cohort included 96 breasts. After the first stage, the incidence of one or more complications was similar between cohorts (acellular dermal matrix, 32.4 percent; nonmatrix, 35.4 percent; p = 0.684). Minor infection rates were significantly higher in reconstructions using acellular dermal matrix (16.2 percent versus 6.3 percent; p = 0.040). After the second stage, the complication incidence was also similar between cohorts (acellular dermal matrix, 16.2 percent; nonmatrix, 13.5 percent; p = 0.638). Final follow-up time was 445.2 days.

CONCLUSIONS

Overall complication rates following both stages of reconstruction were similar with and without acellular dermal matrix. When acellular dermal matrix was used, minor infection rates were higher following expander placement. In patients desiring a reduction-reconstruction, the authors find the deepithelialized dermal flap provides ample prosthesis support, without the need for acellular dermal matrix. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Titanium-coated polypropylene mesh as innovative bioactive material in conservatives mastectomies and pre-pectoral breast reconstruction

Breast reconstruction is rapidly evolving, thanks to the growing acceptance of synthetic meshes as innovative biomaterials. 276 patients undergoing mastectomy (total of 328 mastectomies) were analyzed in a retrospective observational study to evaluate the pre-pectoral immediate breast reconstruction (IBR) using an implant wrapped with Titanium-Coated Polypropylene Mesh (TCPM) vs. patients treated with tissue expander (TE), equally placed pre-pectorally (and wrapped with the same TCPM in 74.3% of the control group’ breasts). 163 patients, of the study group (SG), underwent mastectomy and pre-pectoral IBR with implant wrapped with TCPM, in a one-step surgery, called direct-to-implant technique (DTI), while 113 patients control group (CG) underwent mastectomy and TE. DTI technique has been performed in 192 breasts of the SG while TE procedure in 136 breasts of the CG. The BREAST-Q questionnaire has been provided before the treatment and 2 years later. Baker scale has been used to evaluate capsular contracture. Oncologic, surgical, and aesthetic outcomes along with BREAST-Q scores were analyzed. Additionally, a histologic evaluation was conducted in 11 capsules' samples randomly chosen (6 derived from SG patients and 5 derived from CG). Complications were recorded in 43 cases (29SG-14CG): 8 skin-nipple necrosis (5SG-3CG), 8 wound dehiscence (6SG-2CG), 3 hematomas (1SG-2CG), and 24 infections (8SG-16CG). Grade IV capsular contracture was detected in 9 breasts (1SG-8CG), whereas 254 breasts were grade I (110SG-144CG), 33 (10SG-23CG) grade II, and 32 (4SG-28CG) grade III. Implant wrinkling was detected in 18 cases (10SG-8CG) after 30 months. The local tumor recurrence rate was 5.8%. Three recurrences were on the nipple-areola complex (1.9%). SG patients showed significantly higher rates in the BREAST-Q overall Satisfaction with Outcome (74.1), overall Satisfaction with Breasts (69.1), Psychosocial Well-being (81.9), and Sexual Well-being (63.1), versus CG's patients (p < 0.05). Histological analysis showed a process of normal tissue repair with a complete mesh integration and normal healing. Conservative mastectomies with pre-pectoral IBR assisted by TCPM proved themselves oncologically safe, biologically integrated into native tissues, and highly accepted in terms of quality of life guaranteeing a more natural and aesthetic breast appearance.

Core tip

This retrospective observational study provided clinical and histological outcomes of the pre-pectoral IBR using an implant wrapped with TCPM vs. patients treated with TE, equally placed pre-pectorally. The efficacy of IBR using an implant wrapped with TCPM was confirmed by the cosmetic results obtained and by a rate of side effects comparable to TE. All the histological analyses performed confirmed the TCPM mesh complete integration with the physiological aspects of healing: The Collagen 1 and 3 expressions did not differ, between TCPM and NO TCPM samples to confirm a process of healing overlapping to perfect device incorporation and normal healing.

•

This retrospective observational study, reports the results of pre-pectoral immediate breast reconstruction (IBR) using a prosthesis wrapped with Titanium-Coated Polypropylene Mesh (TCPM) vs. patients treated with tissue expander (TE) equally placed pre-pectorally (and wrapped with the same TCPM in 74% of the control group), with the aim to reduce the risk of reconstruction failure after conservative mastectomy.

•

The primary end-points of the study were the clinical outcomes. These outcomes were: the incidence of perioperative and postoperative complications (safety profile), quality of life (QoL) at 2 years after surgery, measured as the change between the pre- and post-op BREAST-Q scores, the aesthetic outcomes, and the capsular contracture grade. Two methods for the clinical analysis of the results have been used: Surgical-Team and patient self-evaluation. The Surgical-team evaluation was an objective evaluation based on clinical assessment, using a scale of six degrees (excellent, good, discreet, enough, poor, inadequate). The subjective patient-based self-evaluation applied the same six degrees. Moreover, secondary end-point of the study, was a histopathological capsule assessment to evaluate the integration of the TCPM in the mastectomy flap as a bioactive material.

•

Histological, and bio-molecular evaluation of TCPM samples were analyzed. In particular, Hematoxylin-eosin staining of post-operative biopsies of wrapping tissue TCPM mesh was performed focusing on the collagen presence and fibroblasts amount and specifically, on the complete healing and TCPM incorporation without side effects. Additionally, the immunofluorescence using specific markers CD 45 and Collagen 1, and immunohistochemistry using CD 45 on paraffin samples were performed. The endpoint was to evaluate the grade of inflammation represented by the number of lymphocytes in the treated site, and the eventual different collagen type expression (Collagen 1 and Collagen 3) in tissues underwent and not to radiotherapy and during the use of TCPM.

•

Analyzing the side effects with the use of t-test, the complication rate between SG and CG did not showed statistically significant differences (p=0,8472), although it was slightly higher in the SG. Despite the study group was bigger than the control group (+42%) the side effects' number did not statistically differ, confirming the safety and reliability of the TCPM procedure during DTI. Overall Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being scores were all significantly increased after sub-cutaneous pre-pectoral DTI immediate reconstruction with TCPM mesh (p < 0.05) compared to CG. Mean satisfaction with the overall aesthetic result was high after breast reconstruction (8.72) in patients who underwent DTI pre-pectoral immediate reconstruction (SG) after 2 years from surgery.

•

The histological analysis of fragments of implant's wrapping tissue incorporating TCPM mesh displayed complete incorporation of the mesh with physiological aspects of healing. The immunochemistry concluded the Collagen 1, and 3 expressions did not differ, with statistical significance, between TCPM and NO TCPM samples, showing a process of physiological healing overlapping to perfect device incorporation, confirming that TCPM was a bioactive material. Conservative mastectomies with pre-pectoral IBR assisted by TCPM are resulted oncologically safe preserving breast appearance.

"To Pre or Not to Pre": Introduction of a Prepectoral Breast Reconstruction Assessment Score to Help Surgeons Solving the Decision-Making Dilemma. Retrospective Results of a Multicenter Experience

BACKGROUND

Implant-based reconstruction is the most performed breast reconstruction, and both subpectoral and prepectoral approaches can lead to excellent results. Choosing the best procedure requires a thorough understanding of every single technique, and proper patient selection is critical to achieve surgical success, in particular when dealing with prepectoral breast reconstruction.

METHODS

Between January of 2014 and December of 2018, patients undergoing mastectomy and eligible for immediate prepectoral breast reconstruction with tissue expander or definitive implant, were selected. The Prepectoral Breast Reconstruction Assessment score was applied to evaluate patient-related preoperative and intraoperative risk factors that could influence the success of prepectoral breast reconstruction. All patients were scored retrospectively, and the results obtained through this assessment tool were compared to the records of the surgical procedures actually performed.

RESULTS

Three hundred fifty-two patients were included; 112 of them underwent direct-to-implant immediate reconstruction, and 240 underwent the two-stage procedure with temporary tissue expander. According to the Prepectoral Breast Reconstruction Assessment score, direct-to-implant reconstruction should have been performed 6.2 percent times less, leading to an increase of 1.4 percent in two-stage reconstruction and 4.8 percent in submuscular implant placement.

CONCLUSIONS

To date, there is no validated system to guide surgeons in identifying the ideal patient for subcutaneous or retropectoral breast reconstruction and eventually whether she is a good candidate for direct-to-implant or two-stage reconstruction. The authors processed a simple risk-assessment score to objectively evaluate the patient's risk factors, to standardize the decision-making process, and to identify the safest and most reliable breast reconstructive procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The relationship of human acellular dermal matrix thickness on complication rate and patient-reported outcomes in implant-based immediate breast reconstruction

Background

As it can be said that prosthetic breast reconstruction has been increased by the use of acellular dermal matrices (ADMs), ADMs are widely used in implant reconstruction. A large variety types of ADMs are now produced, but there is a paucity of data comparing the ADM products directly. We evaluated the effects of ADM thickness on complication rates and patient satisfaction after dual-plane subpectoral ADM-assisted implant breast reconstruction.

Methods

A retrospective study of patients who underwent immediate implant breast reconstruction using ADM was performed. We compared clinical course and postoperative outcomes for two ADM groups with different thicknesses [thin ADMs, 0.6-1.5 mm (group 1) vs. thick ADMs, 1.5-3.0 mm (group 2)] based on the incidence of complications and the duration of drainage. Patient satisfaction was also evaluated using the Breast Questionnaire (BREAST-Q), 6 months after surgery.

Results

A total of 51 patients were included in the study (group 1, n=21; group 2, n=30). Patient demographics were similar between the two groups, and no difference in postoperative complication rate (P>0.05) and Jackson-Pratt (JP) drainage durations (P>0.05). On regression analysis, ADM thickness was not an independent factor for any complication subtype. There were also no significant differences in BREAST-Q results, across all metrics, between the study groups.

Conclusions

In dual plane subpectoral implant placement breast reconstruction with an inferior ADM-sling, the thickness of ADM was not a factor in determining postoperative complications and patient satisfaction. Therefore, it is possible to select the thickness according to the surgeon's preference.

Comparisons of Therapeutic and Aesthetic Effects of One-Stage Implant-Based Breast Reconstruction with and without Biological Matrix

Background

Biological matrix can provide coverage of compromised muscle and augment the subpectoral pocket in the one-stage reconstruction. However, few studies compared one stage implant-based breast reconstruction with and without biological matrix. The primary endpoint of our study was to assess the patient-reported outcomes (PROs) based on BREAST-Q version 2.0 and analyze complications between SIS matrix-assisted implant-based breast reconstruction (IBBR) and no-matrix-assisted IBBR.

Methods

This retrospective single-center study was conducted from May 2015 to April 2019, and we analyzed 155 patients who underwent one-stage IBBR with at least 1 year of follow-up. Seventy-nine patients underwent one-stage IBBR with SIS matrix group and 76 patients underwent one-stage IBBR without SIS matrix group were evaluated of PROs with BREAST-Q version 2.0 (from 3 different domains) and compared with complications. Complications occurred in patients were divided into major complications and minor complications.

Results

In the satisfaction domain, the mean score for satisfaction with breasts was 60.27 (17.71) in the SIS matrix group and 54.49 (14.76) in the no-matrix group, p=0.045. The multivariate logistic regression for postoperative complications in the whole series pointed out a statistical significance for age>40 years old (odds ratio 3.314, 95% CI 1.012–10.854, p=0.048) and patients with endocrine therapy (odds ratio 0.260, 95% CI 0.092–0.736, p=0.011).

Conclusion

Patients who underwent SIS matrix-assisted one-stage IBBR yield better results in PROs of satisfaction with breasts. Other domains and complications between the two groups had no significant difference.

A Randomized Controlled Trial Comparing Alloderm-RTU with DermACELL in Immediate Subpectoral Implant-Based Breast Reconstruction

Background: The effectiveness of different acellular dermal matrices (ADM) used for implant-based reconstruction immediately following mastectomy is an important clinical question. A prospective randomized clinical trial was performed to evaluate the superiority of DermACELL over Alloderm-RTU in reducing drain duration. Methods: Patients undergoing mastectomy with subpectoral immediate and permanent implant-based breast reconstruction were randomized to Alloderm-RTU or DermACELL. The primary outcome was seroma formation, measured by the duration of postoperative drain placement. Secondary outcomes included: post drain removal seroma aspiration, infection, redbreast syndrome, wound dehiscence, loss of the implant, and unplanned return to the operating room. Results: 62 patients were randomized for 81 mastectomies (41 Alloderm-RTU, 40 DermACELL). Baseline characteristics were similar. There was no statistically significant difference in mean drain duration (p = 0.16), with a trend towards longer duration in the Alloderm-RTU group (1.6 days; 95%CI, 0.7 to 3.9). The overall rate of minor and major complications were statistically similar between the two groups; although patients with Alloderm-RTU had 3 times as many infections requiring antibiotics (7.9% vs. 2.5%) with a risk difference of 5.4 (95%CI −4.5 to 15.2), and twice as many unplanned returns to the operating room (15.8% vs. 7.5%) with a risk difference of 8.3 (95% CI −5.9 to 22.5) as DermACELL. Conclusion: This is the first prospective randomized clinical trial comparing the two most commonly used human-derived ADMs. There was no statistically significant difference in drain duration, minor, or major complications between DermACELL over Alloderm-RTU in immediate subpectoral permanent implant-based breast reconstruction post-mastectomy.

Breast Implants for Mammaplasty: An Umbrella Review of Meta-analyses of Multiple Complications

BACKGROUND

The association of breast implants and complications after mammaplasty has been extensively researched. The aim of this study is to summarize all available results in meta-analysis investigating the association between implants and the incidence of various complications.

METHODS

An umbrella review for breast implants and associated complications was performed by searching related reviews from electronic databases including Pubmed, Ovid and CINAHL. We collected and reviewed evidence across meta-analyses of observational and interventional studies of implants and any health outcome. The quality of the reviews was assessed using the AMSTAR tool (A measurement tool to assess systematic reviews).

RESULTS

The research included 92 meta-analyses of 609 studies concerning various areas. Capsular contracture was the most investigated outcome. Radiotherapy, human acellular dermal matrix application, direct-to-implant reconstruction, smooth implant, silicone-filled implant and periareolar incision were significantly associated with higher rates of some of the complications.

CONCLUSIONS

This umbrella review provides surgeons with summarized evidence of the association between the complications and implant-related factors in mammaplasty surgery to help surgeons make informed choices in the future.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The modified serratus anterior fascia flap improves satisfaction and long-term results in immediate implant-based breast reconstruction: A retrospective study

After immediate implant-based breast reconstruction (IIBR) following skin-sparing mastectomy, postoperative complications such as implant exposure or badly defined mammary folds can occur. Acellular dermal matrix can provide good esthetic outcomes but remain expensive. This study evaluates a new technique of one-stage IIBR by using a modified serratus anterior fascia flap (MSFF group), providing lower implant coverage, as compared to the classical submuscular technique. In this retrospective study, we included all patients who underwent IIBR using either the MSFF technique or the classic technique between November 2012 and February 2015. We collected data regarding demographics, perioperative factors, postoperative complications, patient satisfaction (Breast-Q score), and esthetic outcomes. One hundred twenty-three patients who underwent IIBR, of which 61 breasts (59 patients) using the MSFF and 67 breasts (64 patients) the classical technique, were included. The size of the implants used were significantly higher in the MSFF group (p = 0.036). There were no statistically significant differences between the two groups with regard to the immediate complications rate. After a mean follow-up of 43.9 months, we observed more capsular contractures in the classic group (p < 0.001). In the classic group, patients required more revision surgeries (p = 0.008), more implant changes (p < 0.001), and higher volume of additional lipofilling (p < 0.001). According to the Breast Q scores, patients' satisfaction was better in the MSFF group regarding their breasts (p = 0.001) and the outcomes (p = 0.009). The MSFF is a simple, safe, effective, and inexpensive autologous technique for IIBR, which improves implant coverage with a vascularized flap and provides satisfying outcomes as compared to classic IIBR, with less complications.

Complications after Perforated versus Nonperforated Acellular Dermal Matrix Use in Direct-to-Implant Breast Reconstruction: A Propensity Score Analysis

Acellular dermal matrices (ADMs) were first incorporated into direct-to-implant (DTI) breast reconstruction by the senior author in 2001 and have since become foundational to implant-based reconstruction. ADM composition has evolved recently and now includes perforated types, which some speculate decrease the likelihood of seroma. The authors performed a retrospective review of perforated (P-ADM) and nonperforated (NP-ADM) ADM-assisted direct-to-implant breast reconstruction patients to evaluate differences in complication rates.

Submuscular and Pre-Pectoral ADM Assisted Immediate Breast Reconstruction: A Literature Review

Background and objectives: Breast cancer treatment has deeply changed in the last fifty years. Acellular dermal matrices (ADMs) were introduced for breast reconstruction, with encouraging results, but with conflicting reports too. The present paper aims to summarize the current data on breast reconstruction using acellular dermal matrices. Materials and Methods: We reviewed the literature regarding the use of ADM-assisted implant-based breast reconstruction. Results: The main techniques were analyzed and described. Conclusions: Several authors have recently reported positive results. Nevertheless, an increased complications' rate has been reported by other authors. Higher cost compared to not-ADM-assisted breast reconstruction is another concern.

Surgical Outcomes in Prepectoral Breast Reconstruction

Background:

Prepectoral breast reconstruction has reemerged as a popular option for prosthetic-based breast reconstruction. Recent published literature highlights good outcomes; however, techniques are evolving and options exist for different technologies. The aim of this study is to evaluate short-term complication rates of prepectoral reconstructions using Cortiva acellular dermal matrix.

Methods:

A multicenter retrospective study was conducted of all patients who underwent mastectomy with immediate direct-to-implant or 2-stage prepectoral breast reconstruction with Cortiva (RTI Surgical, Alachua, Fla.) between January 2016 and September 2018. The incidence of surgical complications was determined and studied against patient demographics and procedural details.

Results:

One-hundred eighteen patients met the inclusion criteria for a total of 183 individual breasts reconstructed with prepectoral implant. Average length of follow-up was 9.26 months (range, 1.0 month to 2.5 years). Thirty-two breasts (17.49%) experienced 1 or more complications. Prepectoral reconstruction was successful 89.07% of the time. Infection was the most common cause of both reoperation and implant failure, with 7.65% of all breasts requiring washout and 5.46% failing prosthetic reconstruction secondary to infection.

Conclusions:

Surgical outcomes for prepectoral breast reconstruction using 2-stage and direct-to-implant are similar and comparable to the literature for dual-plane reconstruction, with infection being the main cause of failure.

In Vitro Characterization of a Novel Human Acellular Dermal Matrix (BellaCell HD) for Breast Reconstruction

In the past, acellular dermal matrices (ADMs) have been used in implant-based breast reconstruction. Various factors affect the clinical performance of ADMs since there is a lack of systematic characterization of ADM tissues. This study used BellaCell HD and compared it to two commercially available ADMs—AlloDerm Ready to Use (RTU) and DermACELL—under in vitro settings. Every ADM was characterized to examine compatibility through cell cytotoxicity, proliferation, and physical features like tensile strength, stiffness, and the suture tensile strength. The BellaCell HD displayed complete decellularization in comparison with the other two ADMs. Several fibroblasts grew in the BellaCell HD with no cytotoxicity. The proliferation level of fibroblasts in the BellaCell HD was higher, compared to the AlloDerm RTU and DermACELL, after 7 and 14 days. The BellaCell HD had a load value of 444.94 N, 22.44 tensile strength, and 118.41% elongation ratio, and they were higher than in the other two ADMs. There was no significant discrepancy in the findings of stiffness evaluation and suture retention strength test. The study had some limitations because there were many other more factors useful in ADM’s testing. In the study, BellaCell HD showed complete decellularization, high biocompatibility, low cytotoxicity, high tensile strength, high elongation, and high suture retention strengths. These characteristics make BellaCell HD a suitable tissue for adequate and safe use in implant-based breast reconstruction in humans.

Clinical experience with Surgimend in breast reconstruction: an overview

In the field of breast reconstruction, products and techniques are continuing to evolve to ensure good clinical and quality outcomes. This article reviews the published literature regarding the use of fetal bovine-derived acellular dermal matrix (SurgiMend, SurgiMend PRS and SurgiMend PRS meshed), focusing on safety, clinical outcomes and surgical techniques.

Optimization of Prepectoral Breast Reconstruction

Introduction

Acellular dermal matrix (ADM) were introduced in the early 2000s and more recently permitted new protocols for breast reconstruction allowing a short operative time with improved outcomes until the new muscle-sparing breast reconstruction proposed in 2014 using the Braxon® ADM. The aim of this research is to propose a technique to improve the aesthetic outcome using Braxon ADM with prepectoral implants.

Materials and Methods

The enrolled patients were submitted to a nipple skin-sparing mastectomy leaving 1 additional centimeter of subcutis on the proximal part of the upper pole of the breast (see Surgical Technique). Aesthetic outcomes were compared to those obtained with traditional breast reconstruction with prosthesis and the Braxon ADM placed in the prepectoral space. Mean values of aesthetic outcomes were analyzed using the Student t test, and the κ test was used to analyze interobserver variability.

Results

The overall aesthetic score was improved of 29.6% of the patients; in particular the most improved score was that for contour (+98.01%). Statistical significance was found for contour, upper pole definition, and total score average (p < 0.05). The κ test showed interobserver variability with a good level of agreement on contour (κ = 0.832).

Conclusions

The proposed technique has allowed attainment of good results in terms of aesthetic outcomes. In a small sample we did not register any particular complications but we verified a better satisfaction on the evaluation of the aesthetic result (level of evidence: 3).

Direct-to-Implant Extracellular Matrix Hammock-based Breast Reconstruction; Prepectoral or Subpectoral?

BACKGROUND

Skin-sparing mastectomy followed by immediate implant-based breast reconstruction is a commonly used treatment for breast cancer. However, when placing the implant in a subpectoral pocket, a high incidence of breast animation deformity (BAD) has been reported. Besides the nuisance that BAD can cause, lifting of the pectoralis major muscle (PMM) can result in a more extended postoperative recovery period. When placing the implant solely prepectorally leaving the PMM undisturbed, the incidence and severity of BAD might be mitigated. However, new challenges may occur because of thinner skin cover.

METHODS/DESIGN

A prospective, multi-centre, randomised controlled trial will be carried out with the primary aim of assessing and comparing the incidence and degree of BAD in women having a direct-to-implant breast reconstruction with either a prepectorally or a subpectorally placed implant. The secondary outcomes are shoulder and arm function, quality of life, aesthetic evaluation, length of stay, complications, need for surgical corrections, and development of capsular contracture. A total of 70 included patients will be followed under admittance and at clinical check-ups 3 months and 1 year after surgery.

DISCUSSION

To our knowledge, this trial is the first randomised controlled trial evaluating and comparing subpectoral and prepectoral implant placement when performing direct-to-implant breast reconstruction following skin-sparing mastectomy. The results will hopefully provide us with a broader knowledge of the outcomes of immediate breast reconstruction, making better preoperative planning possible in the future by providing our patients with a more objective information.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03143335. Prospectively registered on 8 May 2017.

Reconstruction of Large Ptotic Breasts After Nipple-Sparing Mastectomy: A Modified Buttonhole Technique

As nipple-sparing mastectomies continue to gain popularity, the reconstruction of a large ptotic breast remains a challenge. The purpose of this article is to introduce the senior author's modifications of a novel technique previously described for addressing the redundant skin envelope in ptotic breasts during immediate reconstruction after nipple-sparing mastectomy. In this review, 15 patients (29 breasts) were reconstructed using our modified "buttonhole" technique. Postoperative complications included 1 case of nipple necrosis and 1 case of tissue expander loss secondary to infection. All patients eventually underwent full expansion and exchange to permanent implants. Ultimately, this surgical approach offers immediate reconstruction after nipple-sparing mastectomy while concurrently performing a safe and aesthetically pleasing mastopexy with acceptable risk to the nipple-areolar complex.

A simple clinical assessment of breast animation deformity following direct-to-implant breast reconstruction

BACKGROUND

A high incidence of breast animation deformity (BAD) has been reported following immediate breast reconstruction with subpectorally placed implants. The aim of this study was to assess and compare the incidence of BAD in women who underwent either subpectoral or prepectoral immediate breast reconstruction. Therefore, we developed a grading tool and tested its reproducibility in a clinical setting.

METHODS

Video recordings of 37 women who had undergone unilateral or bilateral immediate breast reconstruction were evaluated by two consultant plastic surgeons. The degree of BAD was assessed by our grading tool, named the Nipple, Surrounding Skin, Entire Breast (NSE) grading scale, which evaluates the degree of tissue distortion in three areas of the breast. Blinded assessments were performed twice by each observer.

RESULTS

Eighteen patients were reconstructed with subpectoral implant placement and 19 with prepectoral implant placement. Using the NSE grading scale, we found a significant difference in the degree of BAD between the groups, in favor of patients who underwent prepectoral immediate breast reconstruction (0.2 vs. 4, P=0.000). Inter- and intraobserver agreement was moderate (74%) to strong (88%).

CONCLUSIONS

The incidence and severity of BAD was significantly lower in women reconstructed with a prepectorally placed implant than in those who underwent subpectoral immediate breast reconstruction. All patients reconstructed using the subpectoral technique had some degree of BAD. The inter- and intraobserver agreements were high when using the NSE grading scale, suggesting it is an easy-to-use, reproducible scale for assessing BAD in women who undergo immediate breast reconstruction.

Evaluation of Prepectoral Implant Placement and Complete Coverage with TiLoop Bra Mesh for Breast Reconstruction: A Prospective Study on Long-Term and Patient-Reported BREAST-Q Outcomes

BACKGROUND

Breast reconstruction is rapidly evolving, because of the changing face of cancer surgery and the growing acceptance of acellular dermal matrices and synthetic meshes. Although some early reports showed encouraging results after prepectoral breast reconstruction, there is a paucity of data on long-term outcomes.

METHODS

Between January of 2012 and March of 2015, 179 patients undergoing mastectomy were enrolled at the authors' institution. Patients underwent mastectomy and immediate prepectoral breast reconstruction with the definitive implant entirely wrapped in a titanium-coated polypropylene mesh (TiLoop). The BREAST-Q questionnaire was administered before surgery and after 2 years. Capsular contracture was evaluated using the Baker scale. Oncologic, surgical, and aesthetic outcomes and changes in BREAST-Q score were analyzed over time.

RESULTS

Average follow-up was 38.5 months. A total of 250 mastectomies were performed. The locoregional recurrence rate was 2.1 percent. Complications requiring reoperation were recorded in six patients (2.4 percent) and implant removal was necessary in three cases (1.2 percent), followed by reconstruction with submuscular expanders. Grade IV capsular contracture was detected in five breasts (2 percent), whereas 212 breasts were evaluated as grade I (84.8 percent), 28 breasts as grade II (11.2 percent), and five breasts as grade III (2 percent). Patients reported significant high rates in the BREAST-Q overall Satisfaction with Outcome (73.8), overall Satisfaction with Breasts (72.5), Psychosocial Well-being (77.7), and Sexual Well-being (57.9), scoring a significant increase in these domains from the preoperative period to the postoperative period (p < 0.05).

CONCLUSION

The authors report encouraging results of a prepectoral direct-to-implant reconstruction technique using a synthetic mesh, supporting the evaluation of the muscle-sparing subcutaneous approach as a valid alternative to traditional submuscular reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Sientra AlloX2 Short-Term Case Study, Surgical Pearls, and Roundtable Discussion

BACKGROUND

The AlloX2 Breast Tissue Expander (Sientra, Santa Barbara, Calif.) is a unique device that contains a second port to allow for transdermal communication with the pocket around the implant. The injection dome of this expander contains two ports; one is used for traditional saline injection, and a new second port facilitates fluid drainage from the periprosthetic space through an integral drain. The AlloX2 allows for the treatment of seromas and diagnostic fluid sampling to identify bacteria and hone antibiotic treatment in the setting of periprosthetic infection. This device has a significant advantage over traditional expanders, given that seromas and infections are the most common complications in implant-based breast reconstruction, with or without the use of soft-tissue support matrix.

METHODS

This article provides short-term case studies and surgical pearls from 3 surgeons who utilize the AlloX2 in primary breast reconstruction patients. Three surgeons implanted 40 primary reconstruction patients with AlloX2. Follow-up was approximately 6 months, per the standard of care. All patients implanted with AlloX2 underwent immediate reconstruction, with the exception of 1 delayed reconstruction.

RESULTS

The most common complications the patients experienced were seromas. In most cases, the surgeons successfully used the second port to drain periprosthetic fluid.

CONCLUSIONS

The AlloX2 has been successful in treating seromas and should be considered a tool for noninvasive treatment of common complications of implant-based breast reconstruction. Three surgeons with varied backgrounds and techniques provide their surgical and postoperative management experiences and recommendations.

The use of meshes and matrices in breast reconstruction

Breast cancer is the most common cancer diagnosed in the UK ( Cancer Research UK, 2018 ). Breast reconstruction following mastectomy can be performed with prosthetic devices or autologous tissue. In the UK implant-based breast reconstruction following mastectomy is the most common type of breast reconstruction, estimated to account for 70% of the reconstructive caseload in the UK. Since 2001 there has been a considerable increase in the number of prosthetic reconstructions performed with the use of mesh or matrix to augment the reconstructive pocket. This article introduces the main types of mesh and matrix used in implant-based breast reconstruction, reconstructive techniques and reviews the benefits and complications associated with their use.

Long term effects of modern breast cancer surgery

Breast cancer surgery includes a wide array of surgical treatment options. Not only does it involve the oncologic excision of the breast cancer disease but it also involves the reconstruction of the breast. Surgical treatment options vary with regards to the size of the tumor relative to the size of the breast further complicated by the preferences of the patient and the ability of the available surgeon(s). The goal of this paper is to highlight major long-term effects, positive and negative, of modern breast cancer surgery.

The Evolution from Subcutaneous to Prepectoral Prosthetic Breast Reconstruction

Prosthetic breast reconstruction is the most common method of reconstruction offered to women following mastectomy. Prepectoral breast reconstruction has recently reemerged as an alternative technique to the partial and total muscle coverage methods. Though this technique has been demonstrated to be safe and effective in the recent published literature, many surgeons have been hesitant to adopt it out of fear of incurring the same complications associated with subcutaneous reconstructions of the past. However, recent advancements in plastic surgery including the use of acellular dermal matrices, autologous fat grafting, and improved breast implants and improved mastectomy techniques have enabled plastic surgeons to revisit the prepectoral space. In this review, the authors describe the evolution of prosthetic-based breast reconstruction from subcutaneous to prepectoral and review outcomes.

Efficacy of Partial- Versus Full-Sling Acellular Dermal Matrix Use in Implant-Based Breast Reconstruction: A Head-to-Head Comparison

BACKGROUND

Acellular dermal matrix (ADM), popularly used in tissue expander-based breast reconstruction, is applied either as a partial or full sling, but without any consensus regarding which method of application produces better outcomes. We aimed to compare the outcomes between two patient groups who underwent tissue expander-based breast reconstruction using these techniques.

METHODS

A retrospective review was conducted for consecutive patients who underwent immediate two-stage implant-based breast reconstruction using ADM between January 2013 and June 2016. They were categorized into two cohorts: cohort 1 included patients in whom ADM was applied using the partial-sling technique, insetting it obliquely after releasing the pectoralis major muscle from its costal origin, and cohort 2 included those who underwent a full-sling technique, insetting it transversely after releasing the muscle from its costal and lower sternal origin. Postoperative complications and aesthetic outcomes were compared between the two groups.

RESULTS

We analysed 329 cases (167 in cohort 1 and 162 in cohort 2) with similar baseline characteristics in both cohorts. Reconstruction failure occurred in 2.4% of overall patients. The rates of each and overall acute complications did not differ significantly between the cohorts. Cohort 2 showed significantly lower rates of tissue expander displacement and malposition following the first-stage operation and rippling following the second-stage operation, differences that retained the influences in multivariate analyses. Higher aesthetic scores were obtained in cohort 2.

CONCLUSION

Using the full-sling ADM might reduce unintended migration of prostheses and enable proper tissue expansion, resulting in better overall outcomes without increasing morbidities.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of Modifications to Tissue-Expander Breast Reconstruction, a Quality Improvement Assessment Within a Private Practice

BACKGROUND

As technology advances, surgical practice evolves over time. The author assesses a new approach to implant-based breast reconstruction and the impact of two changes implemented over several years.

METHODS

A series of tissue-expander reconstructions performed early in the author's experience were retrospectively compared with a similar number of cases prospectively performed. Demographics, perioperative characteristics, and postoperative outcomes were assessed.

RESULTS

Fifty-three patients (87 breasts) were analyzed, 29 treated earlier with one of the early acellular dermal matrices (ADMs) available and 24 current cases using a no-touch operative approach and pliable, perforated ADM. Demographics and perioperative characteristics between the cohorts were comparable. Mean age was 47.6 years, body mass index (BMI) of 25.8 and 18.9% had current or former nicotine use. Immediate reconstruction was performed in 75 (86.2%) breasts. Drains remained in situ 16 ± 8.9 days, with a significantly lower number of days required in latter patients. At a mean follow-up of 9.6 months, complications included early capsular thickening in 7 (13.2%) patients requiring capsulectomy at the second stage exchange surgery, prosthetic (expander) removal in 3 (3.4%) breasts, significant infection requiring intervention in 3 (5.7%) patients, seroma in 3 (5.7%) patients, 2 (3.8%) cases of wound dehiscence, and 1 (1.9%) case of flap necrosis and hematoma. Incomplete ADM incorporation was observed in 9 (10.3%) breasts. Three reconstructive failures occurred in the early cohort. Patients in the later cohort reported significantly improved BREAST-Q scores (P < 0.005) postoperatively with a high level of satisfaction.

CONCLUSIONS

Using a no-touch technique and an ADM designed with functional characteristics advantageous to breast reconstructive surgery appears to have improved patient outcomes.

A 3D Mammometric Comparison of Implant-Based Breast Reconstruction With and Without Acellular Dermal Matrix (ADM)

This retrospective study utilizes 3D imaging and mammometrics to compare implant-based breast reconstruction with and without the use of ADM. Previous studies have suggested improved aesthetic outcomes with the use of ADM, but none have been able to quantify this difference. Images were obtained at early and late time points following the expander-implant exchange procedure. Measurements included the point of maximum projection, the superior, inferior, medial and lateral volumetric distribution, and the distance from the point of maximum projection to the inframammary fold along the breast meridian. The patients' demographic information, implant size, and complication rate between the two cohorts were similar. In the early post-operative period, the patients with ADM demonstrated higher medial pole volume; however, this difference did not persist in the late post-operative period. Patients with ADM demonstrated a small but statistically significant greater point of maximum projection and length of lower pole curvature in comparison with the non-ADM cohort. In summary, the results of this study demonstrate improved mammometric measurements when ADM is used in implant-based breast reconstruction, supporting superior aesthetic outcomes in early and late post-operative time points.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Novel devices for implant-based breast reconstruction: is the use of meshes to support the lower pole justified in terms of benefits? A review of the evidence

The use of novel devices such as acellular dermal matrices (ADMs) to support the lower pole in implant-based breast reconstructions (IBBRs) has been described as one of the most important advances in breast reconstructive surgery following mastectomy. However, the majority of outcomes studies focus primarily on providing evidence for the rates of short-term complications associated with their use, as opposed to their reported benefits. Given the high costs associated with using ADMs, together with an increasing number of alternative, cheaper synthetic products entering the market, it is important to clarify whether their use is actually justified and whether the alternative products offer equivalent or superior outcomes. The purpose of this article is to present a comprehensive and updated review of the evidence for the benefits of using different products for lower pole support (LPS) in IBBR compared to reconstructions without. A secondary aim was to determine if there is any evidence to support the use of one product over another.

Benefits and risks with acellular dermal matrix (ADM) and mesh support in immediate breast reconstruction: a systematic review and meta-analysis

In modern implant-based immediate breast reconstruction, it has become common to use biological acellular dermal and synthetic matrices in combination with a tissue expander or an implant. The aim of this systematic review was to examine differences in recurrence of cancer, impact on oncological treatment, health related quality of life, complications and aesthetic outcome between matrix and no matrix in immediate breast reconstruction. Systematic searches, data extraction and assessment of methodological quality were performed according to predetermined criteria. Fifty-one studies were eligible and included in the review. The certainty of evidence for overall complication rate and implant loss is low (GRADE ⊕⊕□ □). The certainty of evidence for delay of adjuvant treatment, implant loss, infection, capsular contraction and aesthetic outcome is very low (GRADE ⊕□ □ □). No study reported data on recurrence of cancer or health related quality of life. In conclusion, there is a lack of high quality studies that compare the use of matrix with no matrix in immediate breast reconstruction. Specifically, there are no data on risk of recurrence of cancer, delay of adjuvant treatment and Health related quality of life (HRQoL). In addition, there is a risk of bias in many studies. It is often unclear what complications have been included and how they have been diagnosed, and how and when capsular contracture and aesthetic outcome have been evaluated. Controlled trials that further analyse the impact of radiotherapy, type of matrix and type of procedure (one or two stages) are necessary.

Evaluation of Complication Rates after Breast Surgery Using Acellular Dermal Matrix: Median Follow-Up of Three Years

INTRODUCTION

Acellular dermal matrices (ADMs) are now commonly used for breast reconstruction surgery. There are various products available: ADMs derived from human (HADM), porcine (PADM), or bovine (BADM) sources. Detailed long-term follow-up studies are necessary to detect differences in complication rates between these products.

MATERIAL AND METHODS

From 2010 to 2015, forty-one patients underwent 52 ADM-breast reconstructions in our clinic, including oncologic breast reconstructions and breast augmentation revisions (n = 52). 15x HADMs (Epiflex®/DIZG), 21x PADMs (Strattice®/LifeCell), and 16x BADMs (Tutomesh®/RTI Surgical) were implanted. Retrospective data collection with median follow-up of 36 months (range: 12-54 months) was performed.

RESULTS

Overall complication rate was 17% after ADM implantation (HADM: 7%; PADM: 14%; BADM: 31%). In a composite endpoint of complications and Red Breast Syndrome, a lower event probability was observed between BADMs, PADMs, and HADMs (44%, 19%, and 7%, resp.; p = 0.01 for the trend). Furthermore, capsular contracture occurred in 6%, more frequently as compared to the current literature.

CONCLUSIONS

When ADM-based reconstruction is indicated, the authors suggest primarily the use of HADMs and secondary the use of PADMs. It is shown that BADMs have the highest complication probability within our patient cohort; nevertheless, BADMs convey physical advantages in terms of flexibility and better aesthetic outcomes. The indication for the use of ADMs should be filled for each case individually.

Prospective unbiased experience with three acellular dermal matrices in breast reconstruction

BACKGROUND

The use of acellular dermal matrix (ADM) has become the standard of care in breast reconstruction. However, the majority of current studies are biased or combine large databases introducing inherent flaws. Here, we present a prospective single surgeon experience comparing three ADM.

METHODS

All expander based breast reconstructions between 2014 and 2015 using ADM were included.

RESULTS

Eighteen patients (32 breasts) underwent reconstruction using Flex Pliable, 15 patients (22 breasts) used Alloderm, and 14 patients (20 breasts) had Dermacell. There were no significant differences in patient demographics or comorbidities. All expanders were placed into a subpectoral position, and there were no direct to implant cases. Average intraoperative fill was comparable, (Flex: 225 cc, Alloderm: 180 cc, Dermacell: 130 cc). There were no differences in seroma, infection, or mastectomy skin flap necrosis rates. There were no cases of red breast, expander explanation or failed reconstruction in any cohort. Time to drain removal was significantly shorter in Flex and Dermacell patients compared to Alloderm (20 days vs 15 days vs 26 days, respectively; P = 0.01).

CONCLUSIONS

While there are differences between available ADM, successful outcomes can be achieved with proper patient selection, sound surgical technique, and diligent post-operative management.

Technique to Promote Symmetry in 2-Staged Bilateral Breast Reconstruction in the Setting of Unilateral Postmastectomy Radiation

BACKGROUND

Bilateral breast reconstruction in the setting of unilateral postmastectomy radiation therapy (PMRT) remains one of the most difficult reconstructive challenges due to significant radiation-induced asymmetry from capsular contracture and superior migration of the irradiated reconstructed breast. We describe a novel and straightforward intraoperative technique for creating compensatory asymmetry to maximize postradiation symmetry in immediate bilateral tissue expander (TE) and acellular dermal matrix (ADM) reconstruction requiring unilateral PMRT.

METHODS

A cohort of 25 bilateral TE/ADM breast reconstructions with planned unilateral PMRT was performed using this approach, and outcomes were reviewed. On the PMRT side, the ADM edge was inset to a lower inframammary fold (IMF) position resulting in a near "bottoming-out" effect. On the non-PMRT side, the ADM was inset using a triple point stitch onto the IMF in a higher chest wall location. The planned PMRT side TE was overexpanded and second-stage exchanges were performed 6+ months post-PMRT.

RESULTS

Post-PMRT results showed improved symmetry as the PMRT side migrated superiorly to match the contralateral non-irradiated side. Minimal pocket or IMF adjustments were required during second-stage procedures, with just 6 patients (24%) requiring minor lowering and 1 patient (4%) requiring elevation of the PMRT side IMF. Thus, most (72%) patients undergoing bilateral mastectomy and unilateral PMRT did not require any IMF modifications during the second-stage procedure.

CONCLUSIONS

A differential ADM inset and TE pocket creation for bilateral TE/ADM breast reconstructions with planned unilateral PMRT can minimize the typical adverse aesthetic effects of PMRT on reconstruction results and maximize symmetry.

The BREASTrial Stage II: ADM Breast Reconstruction Outcomes from Definitive Reconstruction to 3 Months Postoperative

Background:

The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a prospective randomized trial comparing outcomes of tissue expander breast reconstruction using either AlloDerm or DermaMatrix. The trial was divided into 3 outcome stages; this study reports stage II outcomes, which are those from the time of definitive reconstruction to 3 months postoperative.

Methods:

A randomized trial was conducted to compare complication rates between AlloDerm and DermaMatrix groups. The impact of matrix type, age, obesity, radiation therapy, chemotherapy, and reconstruction type on complications was analyzed with regression models.

Results:

Of the 128 patients (199 breasts) who were randomly assigned into the trial, 111 patients (173 breasts) were available for analysis in stage II. There was no difference in overall rates of complications (15.4% vs 18.3%, P = 0.8) or implant loss (2.2% vs 3.7%, P = 0.5) between the AlloDerm and DermaMatrix groups, respectively. Obesity was the only significant predictor of complications on regression analysis (odds ratio, 4.31, P = 0.007). Matrix type, age, radiation therapy, chemotherapy, or reconstruction type had no impact on the incidence/severity of complications.

Conclusions:

Acellular dermal matrix (ADM) will likely continue to have a role in breast reconstructive surgery; however, caution should be taken when using ADM because of relatively high complication rates, especially in obese patients. The particular ADM product should be selected based on individual surgeon preference, experience, and success rates. These data and forthcoming long-term outcomes from the Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial will enable surgeons to carefully weigh the risks and benefits of ADM use in breast reconstruction.

Two-stage implant-based breast reconstruction compared with immediate one-stage implant-based breast reconstruction augmented with an acellular dermal matrix: an open-label, phase 4, multicentre, randomised, controlled trial

BACKGROUND

The evidence justifying the use of acellular dermal matrices (ADMs) in implant-based breast reconstruction (IBBR) is limited. We did a prospective randomised trial to compare the safety of IBBR with an ADM immediately after mastectomy with that of two-stage IBBR.

METHODS

We did an open-label, randomised, controlled trial in eight hospitals in the Netherlands. Eligible women were older than 18 years with breast carcinoma or a gene mutation linked with breast cancer who intended to undergo skin-sparing mastectomy and immediate IBBR. Randomisation was done electronically, stratified per centre and in blocks of ten to achieve roughly balanced groups. Women were assigned to undergo one-stage IBBR with ADM (Strattice, LifeCell, Branchburg, NJ, USA) or two-stage IBBR. The primary endpoint was quality of life and safety was assessed by the occurrence of adverse outcomes. Analyses were done per protocol with logistic regression and generalised estimating equations. This study is registered at Nederlands Trial Register, number NTR5446.

FINDINGS

142 women were enrolled between April 14, 2013, and May 29, 2015, of whom 59 (91 breasts) in the one-stage IBBR with ADM group and 62 (92 breasts) in the two-stage IBBR group were included in analyses. One-stage IBBR with ADM was associated with significantly higher risk per breast of surgical complications (crude odds ratio 3·81, 95% CI 2·67-5·43, p<0·001), reoperation (3·38, 2·10-5·45, p<0·001), and removal of implant, ADM, or both (8·80, 8·24-9·40, p<0·001) than two-stage IBBR. Severe (grade 3) adverse events occurred in 26 (29%) of 91 breasts in the one-stage IBBR with ADM group and in five (5%) of 92 in the two-stage IBBR group. The frequency of mild to moderate adverse events was similar in the two groups.

INTERPRETATION

Immediate one-stage IBBR with ADM was associated with adverse events and should be considered very carefully. Understanding of selection of patients, risk factors, and surgical and postsurgical procedures needs to be improved.

FUNDING

Pink Ribbon, Nuts-Ohra, and LifeCell.

Complication Rates With Human Acellular Dermal Matrices: Retrospective Review of 211 Consecutive Breast Reconstructions

Background:

Human acellular dermal matrix (HADM) is commonly used to provide coverage and support for breast reconstruction. The primary purpose of this study was to evaluate the complication rates associated with breast reconstruction procedures when performed in conjunction with multiple types of HADM in a consecutive series.

Methods:

After receiving institutional review board approval, medical records from a single surgeon were retrospectively reviewed for 126 consecutive patients (170 breasts and 211 procedures) who received a breast reconstruction or revision with implantation of HADM between 2012 and 2014. Patient demographics, surgical technique, and the complication profile of 4 major types of HADM were evaluated by procedure. Complication data were primarily evaluated for infection, seroma formation, necrosis, and other complications requiring additional surgery.

Results:

The total complication rate was 19.4%. The complication rates were not statistically different between all 4 types of HADM: Alloderm (n = 143); Alloderm RTU (n = 19); FlexHD (n = 18); hMatrix (n = 32) (P > 0.05). Smokers and large-breasted women (≥500 g) had a significantly higher complication rate than the rest of the population (P < 0.01 and P < 0.03, respectively). The complication rates associated with all other patient cohorts analyzed (age, body mass index, comorbid conditions, cancer diagnosis, prepectoral technique) showed no influence on complication rates (P > 0.05).

Conclusions:

In characteristically similar cohorts, there was no statistically significant difference in complication rates based on type of HADM; however, certain risk factors and anatomy should be considered before HADM-assisted breast reconstruction.