Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction

Does the use of Acellular Dermal Matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review

BACKGROUND

Breast cancer is the most common malignancy among women in the UK. Reconstruction - of which implant-based breast reconstruction (IBBR) is the most common - forms a core part of surgical management of breast cancer. More recently, pre-pectoral IBBR has become common as technology and operative techniques have evolved. Many surgeons use acellular dermal matrix (ADM) in reconstruction however there is little evidence in literature that this improves surgical outcomes. This review will assess available evidence for surgical outcomes for breast reconstructions using ADM versus non-use of ADM.

METHODS

A database search was performed of Ovid Medline, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (2012-2022). Studies were screened using inclusion and exclusion criteria. Risk of Bias was assessed using the Newcastle Ottawa scale and ROBIS tools. Analysis and meta-analysis were performed.

RESULTS

This review included 22 studies (3822 breast reconstructions). No significant difference between overall complications and failure rates between ADM and non-ADM use was demonstrated. Capsular contracture, wound dehiscence and implant rippling had significant differences however these results demonstrated high heterogeneity thus wider generalisation may be inaccurate. Patient quality of life scores were not recorded consistently or comparably between papers.

CONCLUSIONS

This review suggests a lack of significant differences in most complications between ADM use and non-use for pre-pectoral IBBR. If no increase in complications exists between groups, this has significant implications for surgical and legislative decision-making. There is, however, inadequate evidence available on the topic and further research is required.

Treatment of Capsular Contracture in Previously Irradiated Breasts Implants and Expanders with the Use of Porcine Acellular Dermal Matrices: Outcomes and Complications

Background: Radiation therapy is a crucial component of breast cancer treatment. However, it is well known to increase the risk of unsatisfactory cosmetic outcomes and higher complication rates. The aim of this study is to provide further insight into the use of acellular dermal matrices (ADMs) for the prevention of capsular contracture. Materials and Methods: This single-center, retrospective study analyzed irradiated patients who underwent post-mastectomy, ADM-assisted implant reconstructions. Of the 60 patients included, 26 underwent expander-to-implant substitution after radiotherapy (Group A), while 34 required implant replacement due to capsular contracture following radiotherapy (Group B). The primary objective was to evaluate the effectiveness of ADMs in reducing reconstructive failures, complications, and capsular contracture after breast irradiation. Results: We recorded a total of 15 complications and four implant losses. Reconstructive failures were attributed to implant exposure in two cases, full-thickness skin necrosis in one case, and severe Baker grade IV contracture in one case. Both Group A and Group B showed a significant decrease in postoperative Baker grades. US follow-up was used to demonstrate ADM integration with host tissues over time. Conclusions: Based on our findings, the use of ADM in selected cases appears to be a viable option for treating and preventing capsular contracture in irradiated breasts. This approach is associated with relatively low complication rates, a low rate of reconstructive failure, and satisfactory cosmetic outcomes and can be applied both in breast reconstructed with implants and with expanders.

Subareolar Sealant Reduces Minor Complications and Surgery for Necrosis in Prosthetic Reconstruction after Nipple-sparing Mastectomy

Nipple-sparing mastectomy (NSM) is aesthetically superior to skin-sparing only mastectomy or reconstructed nipples. However, nipple-sparing mastectomy partially preserves nipple ducts, which are remaining communications between the environment and breast pocket that can potentially allow bacteria transfer and compromise the prosthesis. Previous methods to create a subareolar "barrier" to reduce through-duct bacteria penetration involve subpectoral implant placement, adjunct meshes or acellular dermal matrix, and external nipple adhesives. To further protect the implant from nipple-derived contamination, we propose subareolar sealant (SAS). SAS involves the application of a synthetic sealant on the nipple undersurface before implant placement. In our study, we analyzed 77 breasts that received prepectoral prosthetic breast reconstruction. SAS was used in 70 of 77 breasts. All breasts received adjunctive acellular dermal matrix. Comparing SAS versus no-SAS, we found that no-SAS was associated with 10.4-fold more infections (P = 0.032) and 17.3-fold more re-hospitalizations (P = 0.017). No-SAS also resulted in more "at least one major complication" (P < 0.001), capsular contracture (P < 0.001), and necrosis requiring surgery (P < 0.001). Due to the small no-SAS sample size, goodness-of-fit (Quasi-likelihood independence model) criteria was applied, and a post hoc power analysis was calculated. Erythema, all minor complications, dehiscence, and necrosis requiring surgery remained significant (all P < 0.0001). This innovative technique markedly reduces overall minor complications and necrosis requiring surgery. A larger no-SAS sample size is required to adequately determine whether SAS reduces infection and hospitalization rates. Nonetheless, SAS reduces complications and is cost effective compared with other adjunct materials.

Acellular Dermal Matrix-Assisted, Prosthesis-Based Breast Reconstruction: A Comparison of SurgiMend PRS, AlloDerm, and DermACELL

BACKGROUND

Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in ADM derivatives, few studies directly compare their outcomes in the setting of iPBR. We sought to conduct a large head-to-head study comparing 3 ADMs used across our institution.

METHODS

A multicenter retrospective review of patients undergoing iPBR with SurgiMend PRS (fetal bovine-derived; Integra Lifesciences, Princeton, NJ), AlloDerm (human-derived; LifeCell Corp, Bridgewater, NJ), or DermACELL (human-derived; Stryker Corp, Kalamazoo, MI) between January 2014 to July 2022 was performed. Primary outcomes included rates of unplanned explantation and total reconstructive failure. Secondary outcomes included 90-day postoperative complications and long-term rates of capsular contracture development.

RESULTS

A total of 738 patients (1228 breasts) underwent iPBR during the study period; 405 patients received DermACELL (54.9%), 231 received AlloDerm (31.3%), and 102 received SurgiMend PRS (13.8%). Rates of short-term complications, total reconstruction failure, reoperation within 90 days, capsular contracture, and unplanned explantation were comparable. These findings remained true upon multivariate analysis accounting for baseline differences between cohorts, whereby ADM type was not an independent predictor of any outcome of interest. Conversely, factors such as body mass index, diabetes mellitus, smoking history, neoadjuvant and adjuvant chemotherapy, adjuvant radiation, skin-sparing mastectomy, Wise pattern and periareolar incisions, use of tissue expanders, and a subpectoral plane of insertion were significant predictors of postoperative complications.

CONCLUSION

Low rates of complications support the equivalency of fetal bovine and human-derived ADMs in iPBR. Patient characteristics and operative approach are likely more predictive of postoperative outcomes than ADM derivative alone.

Acellular dermal matrix in breast augmentation surgery: A systematic review

Background

The use of acellular dermal matrix (ADM) in breast reconstruction was described for the first time in 2000s. Recently, ADMs have been used not only in reconstructive surgery but also in cosmetic breast surgery for both primary and revision indications. Therefore, the matrices represent an important support to recent surgical techniques for breast augmentation in treatment or prevention of complications. Conversely, ADMs can affect operative times, costs, and additional complications related to their placement. A review of the literature was carried out to evaluate the efficacy, safety, and indication for the use of these matrices in cosmetic breast surgery.

Methods

A literature review was conducted including manuscripts published up to April 2023 on breast augmentation using ADM. PubMed and MEDLINE were the databases used for research. The keywords used were "Breast augmentation" and "Acellular Dermal Matrix." Non-English language articles have been excluded.

Results

The initial search for "breast augmentation" yielded 7900 results, which were further reviewed for "Acellular Dermal Matrices" in breast augmentation, selecting 74 articles. Following further screening, 12 articles were included in the review. A total of 787 patients were treated with breast augmentation and ADM placement. The main indication was capsular contracture (60%).

Conclusions

The current evidence from the published scientific literature, albeit limited, suggests the indication for the use of ADM in revision surgery, to support the prosthetic pocket, to minimize the risk of capsular contracture and its recurrence.

Acellular Dermal Matrix Cover Improves Skin Growth during Tissue Expansion by Affecting Distribution of Mechanical Forces

BACKGROUND

Biological cover over tissue expander prostheses has been introduced to provide soft-tissue support for tissue expanders during breast reconstruction. However, its impact on mechanically induced skin growth remains unknown. This study investigates the hypothesis that covering the tissue expander with acellular dermal matrix (ADM) affects mechanotransduction without compromising the efficacy of tissue expansion.

METHODS

Tissue expansion, with and without use of ADM, was performed on a porcine model. The tissue expanders were inflated twice with 45 mL of saline, and the full-thickness skin biopsy specimens were harvested from expanded and control unexpanded skin 1 week and 8 weeks after the final inflation. Histologic evaluation, immunohistochemistry staining, and gene expression analysis were performed. Skin growth and total deformation were evaluated using isogeometric analysis.

RESULTS

The authors' results demonstrate that use of ADM as a biological cover during tissue expansion does not impede mechanotransduction that leads to skin growth and blood vessel formation. Isogeometric analysis revealed similar total deformation and growth of expanded skin with and without a biological cover, confirming that its use does not inhibit mechanically induced skin growth. In addition, the authors found that use of an ADM cover results in more uniform distribution of mechanical forces applied by the tissue expander.

CONCLUSIONS

These results suggest that ADM improves mechanically induced skin growth during tissue expansion by facilitating a more uniform distribution of mechanical forces applied by the tissue expander. Therefore, the use of a biological cover has potential to improve outcomes in tissue expansion-based reconstruction.

Bovine Acellular Dermal Matrix-Based Breast Reconstruction in Previously Irradiated Breasts: Complications and Outcomes From a Single-Center Experience

ABSTRACT

Radiation therapy is considered today an integral part of the management of breast cancer. However, radiotherapy significantly increases the incidence of total complications in breast reconstruction. Several procedures have been adopted to reduce complication rates in irradiated fields, including the use of acellular dermal matrices (ADMs). We conducted a retrospective analysis of our single-center experience with ADM-assisted implant-based reconstruction or revision surgeries for capsular contracture treatment in irradiated breasts. We divided our population into 4 groups based on prior surgical history: group A (previous quadrantectomy), group B (previous mastectomy and expander reconstruction), group C (previous mastectomy and implant reconstruction), and group D (prior quadrantectomy followed by mastectomy and implant reconstruction). At the European Oncology Institute in Milan, Italy, between June 2017 and April 2019, we identified 84 patients for a total of 86 irradiated breasts reconstructed with implant and ADM. We observed a total of 12 reconstructive failure, with the highest rate of failure in group B (16.6%) and in group D (15.38%). Overall, we recorded 22 total complications (24.4%): 12 major complications and 10 minor complications. The most common complication was infection, with 9 cases (10.4%), 6 of which were classified as severe and required implant removal. In group B, we observed the highest complication rate, both major and minor, with 7 of 42 patients (16.6%) experiencing each. Before reconstruction with ADM, the Baker grade ranged from 3 to 4, with a mean of 3.25. At the 2-year follow-up, the Baker grade ranged from 1 to 4, with a mean of 1.9. Surgeons were highly satisfied with the aesthetic result in 72.1% of cases, moderately in 8.1% and unsatisfied in 5.81%, and in 13.9%, the outcome was not assessable because of reconstructive failure. The worst aesthetic result was in group B. We observed significant reduction in capsular contracture in revision surgeries despite a moderately high rate of complications in previous quadrantectomy and radiotherapy. In our experience, breast reconstruction with implant and ADM is not the primary surgical indication in case of prior irradiation, but it can be considered as a valid alternative with reasonable safety profile, to be used in selected cases.

Prepectoral Versus Subpectoral Implant-Based Reconstruction: How Do We Choose?

Aspects of a patient's lifestyle, their state of health, breast size, and mastectomy skin flap quality are factors that influence the suggested plane of dissection in implant-based breast reconstruction. This article aims to review developments in prosthetic breast reconstruction and provide recommendations to help providers choose whether prepectoral or subpectoral reconstruction in the best approach for each of their patients.

The effect of intraoperative immersion solutions on acellular dermal matrix: Biofilm formation and mechanical property

BACKGROUND

Acellular dermal matrix (ADM) is generally used on implant-based breast operations; However, it can increase surgical site infection. Many immersion solutions are applied to ADM, however, the most effective solution is unknown. The purpose of this study is to determine the effect of different solutions on the biofilm formation and mechanical properties of ADM.

METHODS

Aseptic porcine-derived ADMs were immersed in 5 different solutions for 30 min; sterile normal saline, 10% povidone-iodine, 0.5% chlorhexidine, antibiotics (cefazolin, gentamicin, and vancomycin), and taurolidine. They are transferred to 10 ml suspension of methicillin-sensitive/resistant Staphylococcus aureus (MSSA/MRSA) or Staphylococcus epidermidis and an overnight culture was performed. After rinsing and sonication to obtain the biofilm on ADM, colony forming unit (CFU) was measured. In addition, the maximum load before ADM deformation and the elongation length of ADM at the start of the maximum load was determined.

RESULTS

Regardless of strains, povidone-iodine, chlorhexidine, and taurolidine group had lower CFUs than the saline group with statistical significance. Meanwhile, the antibiotics group did not show statistical difference from the saline group. Moreover, only taurolidine group showed higher tensile strength (MRSA, p = 0.0003; S. epidermidis, p = 0.0023) and elongation length (MSSA, p = 0.0015) than the saline group. The antibiotics and chlorhexidine group yielded lower tensile strength and elongation length than the povidone-iodine and taurolidine groups.

CONCLUSIONS

It was suggested that the 10% povidone-iodine or taurolidine solution is effective. In contrast, the antibiotics solution could be considered as an effective intraoperative solution.

Acellular Dermal Matrix in Plastic and Reconstructive Surgery

Despite significant advances in medical research, plastic surgeons still face a shortage of suitable patient tissues, and soft tissue reconstruction is no exception. In recent years, there has been a rapid boom in the use of acellular dermal matrix (ADM) in reconstructive and aesthetic surgery. ADM is incorporated into the surrounding tissue and gradually replaced by the host's collagen, thus promoting and supporting the healing process and reducing the formation of scar tissue. The main goal of this article is to provide a brief review of the current literature assessing the clinical applications of ADM across a broad spectrum of applications in plastic and reconstructive surgery.

Catch-22: Acellular Dermal Matrix and U.S. Food and Drug Administration Premarket Approval-How Can We Construct Studies?

SUMMARY

As a biologic product derived from human tissue, acellular dermal matrices did not require premarket approval for their initial use as a soft-tissue support product. Since their first use in breast surgery, acellular dermal matrices have allowed for numerous advances in breast reconstruction. They quickly gained popularity in breast surgery and are used frequently in various applications. During an investigation into potential factors leading to breast implant-associated anaplastic large-cell lymphoma, the U.S. Food and Drug Administration made an official statement that acellular dermal matrices were not approved for use in breast reconstruction and that using them in breast surgery was considered off-label. This special topic article details the history of acellular dermal matrices in breast surgery and describes the ongoing evolution of the relationship between the U.S. Food and Drug Administration and acellular dermal matrices.

Pre-Pectoral One-Stage Breast Reconstruction with Anterior Coverage Using Superior Anterior Biological Acellular Dermal Matrix (ADM) and Inferior Anterior Dermal Sling Support

The use of acellular dermal matrix (ADM) implants has enhanced breast reconstruction. ADM is a biotechnologically designed human tissue of bovine or porcine origin in which tissue processing removes cellular antigens. In this case report, we describe the use of ADM in one-stage prepectoral breast reconstruction. Skin-reduction breast reconstruction with a prepectoral implant was performed. We created a combined dermal pocket using the inferior dermal flap, sutured with a patch of acellular dermal matrix to continue its extension until the upper pole, to cover the implant. This technique offers single-stage immediate reconstruction, with a decreased requirement for ADM and increased use of vascularized tissue and implant support. Additionally, in the pre-pectoral space, decreased pain postoperatively and less anatomic disruption is offered.

Risk of major postoperative complications in breast reconstructive surgery with and without an acellular dermal matrix; Development of a prognostic prediction model

Introduction

Acellular dermal matrices (ADM) have been suggested to allow for different approaches and reduce the risk of postoperative complications in implant-based breast surgery. Surgeons seem to embrace ADMs around the world, although a lack of consistent evidence regarding the factors that increase the risk of major postoperative complications remains.

Purpose

To develop and internally validate a model to predict the risk of a major postoperative complication in breast reconstructive surgery with and without an ADM.

Methodology

The DBIR is an opt-out registry that holds characteristics of all breast implant surgeries in the Netherlands since 2015. Using a literature-driven preselection of predictors, multivariable mixed-effects logistic regression modelling was used to develop the prediction model.

Results

A total of 2939 breasts were eligible, of which 11% underwent an ADM-assisted procedure (single-stage or two-stage). However, 31% underwent a two-stage procedure (with or without the use of ADM). Of all breasts, 10.2% developed a major postoperative complication. Age (OR 1.01), delayed timing (OR 0.71), and two-stage technique (OR 4.46) were associated with the outcome.

Conclusion

The data suggest that ADM use was not associated with a major postoperative complication, while two-stage reconstructions were strongly associated with an increased risk of major complications. Despite these findings, ADMs are not as popular in the Netherlands as in the USA. The predictive capabilities of the developed model are mediocre to poor, but because of the above findings, we believe that the role of the two-stage technique as a golden standard should be put up for debate.

Mastopexy: with or without Acellular Dermal Matrix?

In the years after unilateral breast reconstruction, the reconstructed breast resists ptosis more than natural breast tissue in the native contralateral breast. As acellular dermal matrix (ADM) becomes fully incorporated into the recipient's anatomy, thus reinforcing the inferior pole of the uplifted breast, we combined our mastopexy cases with ADM in an attempt to reduce the rate of recurrent ptosis.

Method

This was a prospective randomized analysis of a cohort of 24 patients, divided into two groups (A and B); all underwent primary unilateral mastopexy to correct grade III breast ptosis. Our patients had previously undergone contralateral skin sparing mastectomy with immediate breast reconstruction, for invasive breast cancer or ductal carcinoma in situ that originally was symmetrical to their native breast. The symmetrization mastopexy in half of our patients was carried out with the addition of an ADM sling to the inferior pole of the breast, to act as an internal, subcutaneous supportive "bra" (A). The other half of patients received a standard symmetrization mastopexy, without the addition of an ADM support (B). Patients were followed up for 36 months.

Results

The difference between control arm and study groups revealed a statistical difference (P < 0.05), when comparing the follow-up period. From the sixth postoperative month onward, the measurements for group A revealed a statistically significant difference (P < 0.05) when compared with group B.

Conclusion

The additional ADM sling acts as an added layer of support, thus delaying reoccurrence of ptosis following mastopexy.

In Vivo Comparison of Three Human Acellular Dermal Matrices for Breast Reconstruction

BACKGROUND/AIM

Acellular dermal matrices (ADMs) have become popular in implant-based breast reconstruction. The aim of this study was to compare three commonly used ADM products in vivo in an animal model.

MATERIALS AND METHODS

The nucleic acid content (residual double-stranded DNA) and the levels of the remaining growth factors after decellularization were measured for each ADM. Cytocompatibility with ADMs was documented using NIH 3T3 mouse fibroblast cells. In vivo, the implanted ADMs were histologically evaluated at 1, 2, 3, and 6 months (n=5) using male 8-week-old Sprague-Dawley rats.

RESULTS

Fibroblasts grew in the SureDerm HD and DermACELL with no cytotoxicity. In a rat model, SureDerm HD and DermACELL incorporated more readily into the surrounding host tissue, as measured by rapid cell influx and collagen deposition, and showed more delayed tissue remodeling with decreased matrix metalloproteinases levels compared to AlloDerm.

CONCLUSION

SureDerm HD and DermACELL can be used as biological materials for breast reconstruction.

The new bioabsorbable sheet for the sling method in immediate breast reconstruction with expander-implant: a study protocol for interventional prospective study

The popularity of a sling method using biomaterial sheets for immediate breast reconstruction based on prosthesis has been increasing in western countries. However, acellular dermal matrix, which is representative of the biomaterial sheet, is not available and the sling method also has not been accepted in Japan. We focused on a new bioabsorbable sheet (NEOVEIL sheet) as a substitute for the sling method and report a prospective study protocol to assess the safety and effectiveness of this material. This was an ongoing, single center, open-label, single-arm study. Inclusion criteria and exclusion criteria are defined restrictively. If the surgeon determined that the perfusion of skin envelope after mastectomy is poor, the surgical procedure can be modified and that patient was excluded from the study. The primary outcome was the incidence of tissue expansion or implant explantation occurring within 1 month after surgery. The secondary outcomes are as follows: (1) aesthetic outcome using a rating scale; (2) symmetry of the nipple areolar complex position; (3) patient reported outcomes using BREAST-Q; (4) pain intensity using the Visual Analog Scale; (5) histology of the capsule around the tissue expander; (6) inflation volume at the first stage and overall inflation time of expansion; and (7) other adverse events regarding the surgery. This study will determine the safety and effectiveness of the sling method using a NEOVEIL sheet in Japanese women.

A comparison of patient-reported outcomes between Alloderm and Dermacell in immediate alloplastic breast reconstruction: A randomized control trial

BACKGROUND

Alloderm and Dermacell are the two leading human acellular dermal matrices (ADM) in immediate breast reconstruction (IBR). Despite differences in sterility, consistency, thickness and cost, there are no comparative trials to date to compare patient-reported outcome measures (PROM) between the two products. The purpose of this study was to determine if there was a difference in patient-reported outcomes (as measured by the BREAST-Q) between patients reconstructed with Alloderm and Dermacell.

METHODS

A single center, open-label, randomized control trial of patients undergoing IBR with an implant for breast cancer or breast cancer prophylaxis was performed. Patients were randomized to either Alloderm or Dermacell. Baseline demographic data were compared, and linear mixed models were used to identify associations with BREAST-Q over time.

RESULTS

Between June 2016 and October 2018, 62 patients were randomized into two groups, 31(50%) Alloderm and 31(50%) Dermacell. Of these, 23(74%) patients in the Alloderm group and 27(87%) patients of the Dermacell group filled out BREAST-Q questionnaires. Baseline BREAST-Q scores with respect to satisfaction with breasts, psychosocial well-being, sexual well-being, and physical well-being were similar between groups (p>0.05). At 3 months postoperatively, the Alloderm group had a statistically significant improvement with respect to satisfaction with breasts (67 vs 53, p = 0.03), satisfaction with overall results (85 vs 61, p = 0.003), satisfaction with the surgeon (89 vs 67, p = 0.01), and satisfaction with information provided (74 vs 59, p = 0.02). At 12 months postoperatively, there were no statistically significant differences in PROM between groups (p>0.05).

CONCLUSION

We report the first randomized controlled trial to date comparing patient-reported outcomes of the two most commonly used ADMs in IBR in Canada. Although a short-term analysis favors the use of Alloderm, there does not appear to be any difference in outcomes between the two products in the longer term.

Complication rates of acellular dermal matrix in immediate breast reconstruction with radiation: A single-institution retrospective comparison study

BACKGROUND

The use of acellular dermal matrix (ADM) in immediate breast reconstruction (IBR) continues to rise despite ongoing concerns with respect to increased complication rates. While the indications for radiation continue to broaden, it is essential to critically evaluate ADM's performance in its context. The purpose of this study was to review complication rates between patients reconstructed with and without ADM, who underwent IBR and radiation.

METHODS

A retrospective review was performed for patients undergoing IBR and radiation from 2010 to 2019. Postoperative outcomes were compared between patients with and without ADM.

RESULTS

Over a 9-year period, 130 patients underwent IBR and radiation (42% preoperatively and 59% postoperatively). For patients with preoperative radiation (36 ADM and 18 non-ADM), the average follow-up was 312 and 296 days, respectively. In this group, there was no difference in minor complications (25% ADM, 22% non-ADM, and p = 1.00) or major complications (31% ADM, 22% Non-ADM, and p = 0.52). For patients with postoperative radiation (53 ADM and 23 non-ADM), the average follow-up was 544 and 748 days, respectively. There was no difference in minor complications (21% ADM, 26% non-ADM, and p = 0.11) or major complications (21% ADM, 26% non-ADM, and p = 0.61). Multivariable logistic regression analyses showed no difference between ADM and non-ADM groups (OR 0.83, 95% CI 0.22-3.08, and p = 0.78).

CONCLUSION

Despite increasing literature supporting the use of ADM in breast reconstruction, postoperative outcomes following radiation remain poorly understood. In the present study, we report no difference in overall complication rates between breasts reconstructed with and without ADM in an irradiated field. Nevertheless, the complication rate remains high, and future studies will be required to determine whether ADM-associated complications in an irradiated field outweigh the purported benefits.

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.

Exploration of Robotic Direct to Implant Breast Reconstruction

Breast reconstruction has undergone significant innovation over the past 50 years. Both the development of nipple sparing mastectomy and the use of acellular dermal matrices have facilitated the concept of direct to implant (DTI) reconstruction. The next step in this evolution is further limiting the length of incisions as well as placing access in a more remote location. A robot-assisted surgical approach for DTI reconstruction (R-DTI) with an acellular dermal matrix scaffold is feasible and addresses limitations with open approaches and ergonomics. The authors performed a cadaveric exploration to demonstrate proof of concept and feasibility for an R-DTI following a robot-assisted nipple sparing mastectomy. Tremor stabilization, direct visualization, endo-wristed robotic instrumentation, and exposure were noted as key benefits over existing open DTI reconstruction techniques. Additionally, the ability to have a more remote access to entry at the perimeter of the breast eliminated incisional tension which can jeopardize reconstructive results. Further exploration and procedure refinements are warranted.

Simple prosthesis versus prosthesis plus titanium-coated polypropylene mesh for implant-based immediate breast reconstruction after total mastectomy for breast cancer

Background

Our study compares the cosmetic effects, postoperative complications, and quality of life of immediate breast reconstruction with simple prosthesis or prosthesis plus titanium-coated polypropylene mesh (TCPM) after total mastectomy for breast cancer.

Methods

In total, 69 patients who underwent total mastectomy, sentinel lymph node biopsy, and immediate prosthetic breast reconstruction from January 2015 to December 2018 in our hospital were selected, and their cosmetic effects, complications, and quality of life after reconstruction were recorded immediately after surgery and 6 months after surgery.

Results

Of these 69 patients, 29 were in the simple prosthesis group and 40 in the prosthesis + TCPM group. The incidence of surgical complications was 17.2% in the simple prosthesis group (5/29; including 4 cases of capsular contracture and 1 case of infection) 15.0% in the prosthesis + TCPM group (6/40; 1 case of flap necrosis, 2 cases of poor wound healing, 2 cases of hematomas, and 1 case of inadequate blood supply to nipple). The complications were successfully managed after symptomatic treatment in both groups. No prosthesis loss was noted. The incidence of postoperative complications showed there to be no significant differences between these two groups (P=0.06, χ²=0.80). The satisfaction rate of patients on cosmetic effects was 95.0% (38/40) in the prosthesis + TCPM group, significantly higher than that in the simple prosthesis group (75.90%, 22/29) (P=0.05, χ²=3.87). The quality of life in the simple prosthesis group at 2 weeks and six months after the operation was significantly lower than that in the prosthesis + TCPM group. The incidence rate of arm pain and fatigue at 2 weeks after operation was significantly higher than that in the prosthesis + TCPM group (P=0.04, χ²=4.42). The satisfaction of family life and sexual interest 6 months after the operation was also significantly lower in the simple prosthesis group than in the prosthesis + TCPM group (P=0.03, χ²=4.95).

Conclusions

Breast reconstruction with prosthesis combined with TCPM does not increase surgical complications and has a good cosmetic effect and high patient satisfaction. Thus, it is a safe and reconstruction method.

Prepectoral Two-Stage Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix: Do We See a Difference?

BACKGROUND

Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes.

METHODS

This is a single-surgeon retrospective review of patients who underwent staged prepectoral implant-based breast reconstruction following nipple-sparing mastectomy over two periods. Patients with well-perfused mastectomy skin flaps with a homogeneous thickness underwent reconstruction with acellular dermal matrix initially. On evolution of the practice, it was not used. Patient demographics, operative data, and complications were analyzed. Aesthetic outcome was measured by the BREAST-Q survey and the Aesthetic Item Scale. A cost analysis was also performed.

RESULTS

Forty patients were included (acellular dermal matrix group, n = 19; non-acellular dermal matrix group, n = 21). The nonmatrix group had one case (5 percent) of seroma and one case (5 percent) with hematoma; there were none in the acellular dermal matrix group. Average BREAST-Q and Aesthetic Item Scale scores were 82.3 versus 81.6 (p = 0.954) and 20.98 versus 20.43 (p = 0.640) for the matrix and nonmatrix groups, respectively. The direct cost savings for the authors' institution over 1 year if matrix was not used in all cases of implant-based breast reconstruction would be estimated at $3,105,960 to $6,211,920 for unilateral and bilateral cases, respectively, for Medicare reimbursement.

CONCLUSIONS

With adequate patient selection, acellular dermal matrix is not always required during two-stage prepectoral implant-based breast reconstruction for good aesthetic outcomes. The economic burden on patients and the health care system could be lessened with selective matrix use.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Acellular Dermal Matrix Performance Compared with Latissimus Dorsi Myocutaneous Flap in Expander-Based Breast Reconstruction

Latissimus dorsi myocutaneous flap (LDMF) with tissue expander provides excellent results in breast reconstruction. Acellular dermal matrix (ADM) has been used in expander-based reconstruction (EBR) with good results. This study assesses how ADM compares to LDMF in EBR.

Methods

The cohorts comprised 124 patients (218 breasts) who had EBR using ADM between 2006 and 2012, and 242 patients (266 breasts) who had EBR using LDMF between 1994 and 2012. Postoperative complications, reoperations, Breast-Q scores, and objectively assessed aesthetic outcomes were compared.

Results

Median age was 55 years for both ADM (range 23-84) and LDMF (range 26-88) groups. No statistically significant differences were noted between the groups in the rates of major postoperative complications (P > 0.3). Forty-nine of the 218 (22.5%) in the ADM group and 67 of 266 (25.2%) in the LDMF group had a total of 63 and 84 reoperations, respectively (P = 0.52), with no significant differences in the reoperations rate (P > 0.3). No significant differences were observed in the Breast-Q scores. Some categorical differences were noted in the aesthetic outcomes; however, the difference between the overall outcomes was not significant (P = 0.54).

Conclusion

Our study revealed no statistically significant differences in the complications or reoperation rates, patient satisfaction, or overall aesthetic outcomes when comparing the use of ADM to LDMF in EBR. In conclusion, this study supports the hypothesis that ADM performs as well as LDMF in EBR.

Reconstruction of the Acromioclavicular Ligament Complex Using Dermal Allograft: A Biomechanical Analysis

PURPOSE

To analyze the posterior translational and rotational stability of the acromioclavicular (AC) joint following reconstruction of the superior acromioclavicular ligament complex (ACLC) using dermal allograft.

METHODS

Six fresh-frozen cadaveric shoulders were used (mean age of 65.3 ± 6.9 years). The resistance force against posterior translation (10 mm) and torque against posterior rotation (20°) was measured. Specimens were first tested with both the intact ACLC and coracoclavicular ligaments. The ACLC and coracoclavicular ligaments were then transected so simulate a Type III/V AC joint dislocation. Each specimen then underwent 3 testing conditions, performed in the following order: (1) ACLC patch reconstruction alone, (2) ACLC patch with an anatomic coracoclavicular reconstruction (ACCR) using semitendinosus allograft, and (3) the transected ACLC with an ACCR only. Differences in posterior translational and rotational torque across testing conditions were analyzed with a one-way repeated analysis of variance analysis.

RESULTS

Mean resistance against posterior translation in the intact condition was 65.76 ± 23.8 N. No significant difference found between the intact condition compared with specimens with the ACLC-patch only (44.2 ± 11.3 N, P = .06). The ACCR technique, when tested alone, had significantly less posterior translational resistance compared with the intact condition (38.5 ± 8.94 N, P = .008). ACLC patch in combination with an ACCR was closest in restoring native posterior translation (57.1 ± 19.2 N, P = .75). For rotational resistance, only the addition of the ACLC patch with an ACCR (0.51 ± 0.07 N-m) demonstrated similar torque compared with the intact joint (0.89 ± 0.5 N-m, P = .06).

CONCLUSIONS

The ACLC-patch plus ACCR technique was able to closest restore the percent of normal posterior translational and rotational stability.

CLINICAL RELEVANCE

Recurrent posterior instability of the AC joint is a potential complication after coracoclavicular reconstruction surgery. In the in vitro setting, this study demonstrated increased AC joint stability with the addition of an ACLC reconstruction using dermal allograft.

Comparison of Preparation Techniques for Isolating Subacromial Bursa-Derived Cells as a Potential Augment for Rotator Cuff Repair

PURPOSE

To identify an effective, nonenzymatic method for maximizing the yield of subacromial bursa-derived nucleated cells for augmenting rotator cuff repair.

METHODS

Subacromial bursa (minimum 0.2 g) was collected prospectively over the supraspinatus from patients (n = 7) with at least one full-thickness tendon tear undergoing arthroscopic primary rotator cuff repair. Samples were processed and analyzed prospectively using 4 different methods: (1) mechanical digestion with scissors (chopping), (2) collagenase digestion, (3) mechanical digestion with a tissue homogenizer, and (4) whole tissue with minimal manipulation. Tissue from each method were plated and cultured in a low oxygen tension, humidified incubator for 7 days. Following incubation, cellularity was assessed with nucleated cell count using a Coulter Counter. Flow cytometry was performed on the non-enzymatic method that demonstrated the greatest cell count to confirm the presence of mesenchymal stem cells (MSCs). The Kruskal-Wallis H test and post hoc Dunn's test were used for statistical analysis.

RESULTS

Following incubation, mean nucleated cell counts (cells/mL) were (1) 102,681 ± 73,249 for chopping, (2) 76,190 ± 66,275 for collagenase, (3) 31,686 ± 29,234 for homogenization, and (4) 11,162 ± 4016 for whole tissue. There was no significant difference between chopping and collagenase (P = .45) or between homogenization and collagenase (P = .52). Both chopping (P = .003) and collagenase (P = .03) produced significantly more cells when compared with whole tissue. Flow cytometry confirmed the presence of MSC markers on samples processed by chopping.

CONCLUSIONS

Mechanical isolation of subacromial bursa-derived cells using a chopping technique demonstrated similar nucleated cell count compared with collagenase, along with the confirmed presence of MSCs.

CLINICAL RELEVANCE

This study demonstrated a nonenzymatic, mechanical method for isolating subacromial bursa-derived cells to potentially augment rotator cuff repair. Further clinical studies are required to assess its possible advent in the tendon-bone healing process.

Evidence for the Use of Acellular Dermal Matrix in Implant-Based Breast Reconstruction

Acellular dermal matrices (ADMs) are tissue grafts that have been specially processed to remove all cellular components. These machined biological scaffolds have become popular in a variety of surgical settings due to their rapid incorporation into living tissue. As ADMs are highly malleable and cause minimal inflammation, they have come to serve as a useful tool in implant-based breast reconstruction procedures. The major benefits of using an ADM in this setting include superior initial breast contouring, decreased risk of capsular contracture after implant insertion, and consistent sustained positioning of the reconstructed breast. Despite these advantages, these tissue grafts are foreign to the host, and postoperative complications following ADM insertion, including infection and seroma, have been well documented. When considering using ADMs in this setting, it is important to first consider patient-specific factors that could preclude their use, such as low body mass index, small breasts, or a history of radiation exposure to the breast tissue. ADM grafts are also expensive, which may present another barrier to their use. Review of the literature ultimately suggests a continued role for ADMs in implant-based breast reconstruction, and continued research in this field is warranted.

The use of acellular dermal matrix in breast reconstruction: evolution of techniques over 2 decades

Acellular dermal matrices (ADMs) are biotechnologically derived tissues that have become a cornerstone of implant-based breast reconstruction over the last 2 decades. Their use in both dual-plane and prepectoral approaches have provided greater soft tissue coverage and implant support with good cosmetic outcomes and low rates of complication. This review describes the evolution of notable ADM-assisted surgical techniques that have advanced the field and broadened implant-based reconstructive options.

Biological materials in breast cancer reconstructive surgery

Currently, reconstructive-plastic surgery is becoming the standard for surgical and combined treatment of breast cancer (BC) patients.

With a one-stage reconstruction of the breast, the use of biological implants that can replace muscle autografts and, consequently, reduce trauma, blood loss and operation time, and also to avoid defects in the donor zones is becoming topical. From 2014 to 2017, 151 reconstructive operations on 121 patients with BC (average age 41.5 years) using synthetic and biological materials were carried out in P.Herzen Moscow Oncology Research Institute. 0 stage of BC TisN0M0 was diagnosed in 11 (9.1%) patients, I stage – in 52 (42.9%), IIA – in 41 (33.9%), IIB – in 9 (7.4%), IIIA – in 4 (3.3%), IIIB – in 2 (1.7%), IIIC – in 2 (1.7%). To strengthen the lower slope, a biological implant – Permacol acellular dermal matrix, was used in 34 cases. Cosmetic result was rated as excellent in 20 (58.9%) cases, good in 11 (32.3%), unsatisfactory in 3 (8,8%). Biological materials are an important addition to various options for breast reconstruction. The criterion for selecting the material for strengthening the lower slope of the breast with subcutaneous or cutaneous mastectomy for cancer with a one-stage reconstruction using a silicone endoprosthesis is the pinch-test value.

Outcomes After Elevation of Serratus Anterior Fascia During Prosthetic Breast Reconstruction

BACKGROUND

Achieving optimal inferolateral coverage is critical to successful prosthetic breast reconstruction. Serratus anterior fascia (SF) elevation, a promising alternative to muscle flaps and acellular dermis (ADM), has not been rigorously studied. This study evaluates complication rates after mastectomy and immediate tissue expander (TE) coverage using SF, relative to other existing methods of reconstruction.

METHODS

Retrospective review of consecutive patients undergoing mastectomy with immediate TE reconstruction over 10 years at 1 institution was performed. Patients with serratus muscle (SM) or SF elevation were analyzed. ADM reconstructions were used for comparative analysis only. Relevant demographic and clinical data were recorded. Complications were categorized by type and end outcome, including nonoperative (no further surgery), operative (surgery except explantation), and explantation.

RESULTS

The SM and SF elevation was performed in 375 (487 breasts) and 177 (255 breasts) patients, respectively. Mean follow-up was 43.8 months. The SM and SF patients were demographically similar, but SF had higher intraoperative fill volumes (P < 0.0001) and required fewer postoperative expansions (P < 0.0001). There were no differences in complications between SM and SF patients. Regression analysis, adjusted for several variables, revealed that SF was not an independent risk factor for complications. The ADM- and SF-assisted reconstruction also showed no differences in outcomes.

CONCLUSIONS

Our review demonstrates that SF elevation is a safe, feasible alternative for achieving inferolateral coverage during prosthetic breast reconstruction. Furthermore, this technique allows for greater fill volumes and less expansions than SM. As a readily available alternative to muscle flaps and ADM, SF elevation should be considered integral to any prosthetic breast reconstruction algorithm.

Early assessment of post-surgical outcomes with pre-pectoral breast reconstruction: A literature review and meta-analysis

BACKGROUND

Pre-pectoral breast reconstruction is an emerging surgical approach. This study provides an early assessment of outcomes with the technique.

METHODS

A comprehensive literature review was performed through searches of PubMed^® /MEDLINE^® to identify studies on pre-pectoral reconstruction. Patient characteristics and outcomes were extracted from studies and pooled. Linear relationships between complication rates and patient characteristics with pre-pectoral reconstruction were analyzed. A meta-analysis compared complication rates between pre-pectoral and dual-plane reconstruction.

RESULTS

Fourteen studies (406 women/654 breasts) were included. The most common complications with pre-pectoral reconstruction were flap necrosis (7.8%), seroma (6.7%), capsular contracture (5.8%), and explantation (4.6%). No hyperanimation was reported. Significant correlation between previous radiation and flap necrosis, post-operative chemotherapy and infection, hypertension and flap necrosis, diabetes and dehiscence, and smoking and explantation were found. A meta-analysis of four studies comparing pre-pectoral (135 women/219 breasts) and dual-plane (230/408) reconstruction found no significant difference for likelihood of infection (odds ratio, 0.46; 95% confidence interval, 0.16-1.30), explantation (0.83; 0.29-2.38), necrosis (1.61; 0.77-3.36), seroma (1.88; 0.71-5.02), dehiscence (1.84; 0.68-4.95), or capsular contracture (0.14; 0.02-1.14).

CONCLUSIONS

Complication rates are comparable following pre-pectoral and dual-plane reconstruction, indicating the pre-pectoral technique may be a feasible option for appropriate patients.

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.

Two-Stage Tissue-Expander Breast Reconstruction: A Focus on the Surgical Technique

OBJECTIVE

Breast cancer, the most common malignancy in women, comprises 18% of all female cancers. Mastectomy is an essential intervention to save lives, but it can destroy one's body image, causing both physical and psychological trauma. Reconstruction is an important step in restoring patient quality of life after the mutilating treatment.

MATERIAL AND METHODS

Tissue expanders and implants are now commonly used in breast reconstruction. Autologous reconstruction allows a better aesthetic result; however, many patients prefer implant reconstruction due to the shorter operation time and lack of donor site morbidity. Moreover, this reconstruction strategy is safe and can be performed in patients with multiple health problems. Tissue-expander reconstruction is conventionally performed as a two-stage procedure starting immediately after mammary gland removal.

RESULTS

Mastectomy is a destructive but essential intervention for women with breast cancer. Tissue expansion breast reconstruction is a safe, reliable, and efficacious procedure with considerable psychological benefits since it provides a healthy body image.

CONCLUSION

This article focuses on this surgical technique and how to achieve the best reconstruction possible.

Soft Tissue Adjuncts in Revisionary Aesthetic Breast Surgery

Reconstructive breast surgery is challenging and continually evolving. In the past decade, numerous soft tissue adjuncts, such as acellular dermal matrices (ADMs), have revolutionized breast reconstruction serving as a tool to improve results and minimize the need for revision. The use of ADMs has been widely discussed in primary and secondary breast reconstruction after mastectomy. They have been shown to be an effective and safe option to correct complications; however, there is a relative paucity of literature on their use in revisional surgery after aesthetic breast procedures. The authors queried PubMed for existing literature regarding the use of ADMs in secondary breast surgery. Five case series from an initial search of 278 articles met the inclusion criteria. An overall infection rate of 2% and a complication rate of implant malposition was 0.8% with the use of ADMs. Although the literature is sparse regarding their use in this setting, early reports indicate that they are both safe and efficacious with a reasonable rate of complications.

One-Stage Immediate Breast Reconstruction: A Concise Review

BACKGROUND

One-stage direct-to-implant immediate breast reconstruction (IBR) is performed simultaneously with breast cancer resection. We explored indications, techniques, and outcomes of IBR to determine its feasibility, safety, and effectiveness.

MATERIAL AND METHODS

We reviewed the available literature on one-stage direct-to-implant IBR, with or without acellular dermal matrix (ADM), synthetic mesh, or autologous fat grafting. We analyzed the indications, preoperative work-up, surgical technique, postoperative care, outcomes, and complications.

RESULTS

IBR is indicated for small-to-medium nonptotic breasts and contraindicated in patients who require or have undergone radiotherapy, due to unacceptably high complications rates. Only patients with thick, well-vascularized mastectomy flaps are IBR candidates. Expandable implants should be used for ptotic breasts, while anatomical shaped implants should be used to reconstruct small-to-medium nonptotic breasts. ADMs can be used to cover the implant during IBR and avoid muscle elevation, thereby minimizing postoperative pain. Flap necrosis, reoperation, and implant loss are more common with IBR than conventional two-staged reconstruction, but IBR has advantages such as lack of secondary surgery, faster recovery, and better quality of life.

CONCLUSIONS

IBR has good outcomes and patient-satisfaction rates. With ADM use, a shift from conventional reconstruction to IBR has occurred. Drawbacks of IBR can be overcome by careful patient selection.

A Meta-analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications

BACKGROUND

The use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications.

METHODS

A literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated.

RESULTS

A majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014).

CONCLUSION

This study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.

Tissue expansion for breast reconstruction: Methods and techniques

OBJECTIVE

In this work, the authors review recent data on the different methods and techniques of TE/implant-based reconstruction to determine the complication profiles and the advantages and disadvantages of the different techniques. This information will be valuable for surgeons performing breast reconstructions.

MATERIALS AND METHODS

A thorough literature review was conducted by the authors concerning the current strategy of tissue expander (TE)/implant-based breast reconstruction following breast cancer surgery.

RESULTS

Loss of the breast can strongly affect a woman's personal and social life while breast reconstruction reduces the sense of mutilation felt by women after a mastectomy, and provides psychosocial as well as aesthetic benefits. TE/implant-based reconstruction is the most common breast reconstructive strategy, constituting almost 65% of all breast reconstructions in the US. Although numerous studies have been published on various aspects of alloplastic breast reconstructions, most studies are single-center observations. No evidence-based guidelines are available as yet. Conventional TE/implant-based reconstruction can be performed as a two-stage procedure either in the immediate or delayed setting. Moreover, the adjunctive use of acellular dermal matrix further broadened the alloplastic breast reconstruction indication and also enhanced aesthetic outcomes.

CONCLUSIONS

TE/implant-based reconstruction has proved to be a safe, cost-effective, and reliable technique that can be performed in women with various comorbidities. Short operative time, fast recovery, and absence of donor site morbidity are other advantages over autologous breast reconstruction.

Refinements in the Techniques of 2-Stage Breast Reconstruction

BACKGROUND

Two-stage breast reconstruction with tissue expanders is one of the most common plastic surgery procedures. Acellular dermal matrix (ADM) has become popular for its ability to improve expansion parameters and aesthetics, albeit with a higher complication profile. We present data that support redefining 2-stage reconstruction to include tissue expanders regardless of final reconstructive modality to act as a bridge. Furthermore, we show that cooperation with the ablative surgeon and technical refinements support ADM omission from the first stage of reconstruction.

METHODS

We retrospectively reviewed charts from the senior author's (D.A.J.) private practice over a 10-year follow-up period. Inclusion criteria included all women over 18 years who underwent mastectomy and had a tissue expander placed immediately or in a delayed fashion and successfully completed tissue expansion and are finished with the second stage of reconstruction or awaiting second stage of reconstruction. Demographic data, tissue expander filling data, final reconstruction, aesthetic outcome, and complications were tabulated.

RESULTS

A total of 118 women (165 breasts) met inclusion criteria. There were no statistically significant differences in initial fill volume (P = 0.094), number of visits until final expansion (P = 0.677), or final fill volume (P = 0.985) between the ADM and non-ADM cohorts. In addition, non-ADM patients had superior aesthetic scores with respect to defects other than scarring (P = 0.015), projection (P = 0.013), and inframammary fold quality (P = 0.009). Fifteen percent of women decided to change desired final reconstruction modality during the tissue expansion phase.

CONCLUSIONS

This reconstructive algorithm emphasizes surgical cooperation between the ablative and reconstructive surgeon, improved technique, and patient education. This focus translates into maintained tissue expansion, aesthetically pleasing results, and allows for the omission of ADM from reconstruction.

Delayed post mastectomy breast reconstructions with allogeneic acellular dermal matrix prepared by a new decellularizationmethod

Acellular dermal matrix (ADM) is a tissue graft of allogeneic origin from post-mortem tissue donors prepared by an innovative decellularization process. The newly developed non-toxic and low cost decellularization process of cadaver origin dermis included ADM in breast reconstruction procedures proved to help coverage of the lower-pole of breast expanders or implants. As the results have shown, it did help to eliminate autologous dermis donor site morbidity along with shortening the operation time by avoiding elevation of additional muscle or fascia during the operation. Main aims of this article include histology evaluation of allogeneic acellular dermal matrix prepared by a new decellularization method and presentation of clinical results of its use. A total of 22 patients underwent 26 ADM based breast reconstructions. The mean patient's follow up was 12.6 months. Average total size of ADM used for one breast was 273 cm². Post-operative complications occurred in 3 patients including one expander infection, one expander extrusion and one expander pocket disfiguration. Microscopic analysis of tissue samples has confirmed incorporation of the acellular dermal matrices into the surrounding connective tissue without any noticeable immune reaction. In a majority of the ADM samples we found pseudocapsullar formation on implant side of samples without acute or chronic inflammatory cells. The use of ADM prepared by new preparation method in expansive post mastectomy breast reconstruction was associated by a relatively low complication rate resulting in good outcomes.

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.

Predictors of Complications and Comparison of Outcomes Using SurgiMend Fetal Bovine and AlloDerm Human Cadaveric Acellular Dermal Matrices in Implant-Based Breast Reconstruction

BACKGROUND

Implant-based breast reconstruction with an acellular dermal matrix is one of the most common procedures performed by plastic surgeons. Although numerous matrices are available, there is little literature comparing them. This study compares the rates of complications between two commonly used products: AlloDerm (human cadaveric) and SurgiMend (fetal bovine) acellular dermal matrices.

METHODS

A retrospective review of a single center's 6-year experience was performed for consecutive, immediate breast reconstructions with acellular dermal matrix from 2009 to 2014. The authors compared demographics and surgical characteristics between patients receiving AlloDerm versus SurgiMend. Multivariate logistic regression was used to determine any association between type of matrix and surgical complications and to identify other clinical predictors for complications.

RESULTS

A total of 640 patients underwent 952 reconstructions using AlloDerm [578 breasts (61 percent)] or SurgiMend [374 breasts (39 percent)]. The average follow-up was 587 days. Multivariate analysis revealed that type of matrix was not an independent risk factor for the development of complications. However, smoking, age, radiotherapy, and initial tissue expander fill volume were associated with increased risk of postoperative complications.

CONCLUSIONS

Both AlloDerm and SurgiMend acellular dermal matrices demonstrate similar rates of major complications when used in immediate implant-based breast reconstruction. In contrast, preoperative radiation therapy, smoking, increasing age, and initial tissue expander fill volume are independent risk factors for postoperative complications. Reconstructive surgeons should take these findings into consideration when performing implant-based breast reconstruction with a dermal matrix.

Acellular Dermal Matrix-Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience

BACKGROUND

Use of acellular dermal matrix for implant-based breast reconstruction appears to be associated with a lower incidence of capsular contracture compared with standard reconstruction. The majority of acellular dermal matrix studies were, however, of short duration; thus, long-term incidence of capsular contracture with acellular dermal matrix use is unknown.

METHODS

Patients undergoing acellular dermal matrix-assisted breast reconstruction from December of 2001 to May of 2014 at two institutions were evaluated. Cumulative incidence of capsular contracture was determined by the performing surgeon. A retrospective chart review was performed on prospectively gathered data on patient-, breast-, surgery-, and implant-related characteristics that were analyzed as potential risk factors for the development of capsular contracture.

RESULTS

A total of 1584 breast reconstructions in 863 patients were performed. Mean follow-up of patients was 4.7 years; 45 percent of patients had greater than or equal to 5 years of follow-up. The cumulative incidence of capsular contracture was 0.8 percent. Smaller implant size (<400 ml) and postoperative radiotherapy were significantly associated with an increased risk of capsular contracture, but the incidence of capsular contracture was 1.9 percent in irradiated breasts. All capsular contractures developed within the first 2 years, with no new events with longer follow-up.

CONCLUSIONS

In this long-term study, the cumulative incidence of capsular contracture with acellular dermal matrix-assisted reconstruction remains low, even in irradiated breasts. Capsular contracture appears to be an early event, and longer follow-up does not appear to increase the incidence, suggesting that acellular dermal matrix may truly mitigate the development of capsular contracture as opposed to delaying its occurrence.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Subcutaneous Implant-based Breast Reconstruction with Acellular Dermal Matrix/Mesh: A Systematic Review

Background:

The availability of acellular dermal matrix (ADM) and synthetic mesh products has prompted plastic surgeons to revisit subcutaneous implant-based breast reconstruction. The literature is limited, however, with regards to evidence on patient selection, techniques, and outcomes.

Methods:

A systematic review of the Medline and Cochrane databases was performed for original studies reporting breast reconstruction with ADM or mesh, and subcutaneous implant placement. Studies were analyzed for level of evidence, inclusion/exclusion criteria for subcutaneous reconstruction, reconstruction characteristics, and outcomes.

Results:

Six studies (186 reconstructions) were identified for review. The majority of studies (66.7%) were level IV evidence case series. Eighty percent of studies had contraindications for subcutaneous reconstruction, most commonly preoperative radiation, high body mass index, and active smoking. Forty percent of studies commenting on patient selection assessed mastectomy flap perfusion for subcutaneous reconstruction. Forty-five percent of reconstructions were direct-to-implant, 33.3% 2-stage, and 21.5% single-stage adjustable implant, with ADM utilized in 60.2% of reconstructions versus mesh. Pooled complication rates included: major infection 1.2%, seroma 2.9%, hematoma 2.3%, full nipple-areola complex necrosis 1.1%, partial nipple-areola complex necrosis 4.5%, major flap necrosis 1.8%, wound healing complication 2.3%, explantation 4.1%, and grade III/IV capsular contracture 1.2%.

Conclusions:

Pooled short-term complication rates in subcutaneous alloplastic breast reconstruction with ADM or mesh are low in preliminary studies with selective patient populations, though techniques and outcomes are variable across studies. Larger comparative studies and better-defined selection criteria and outcomes reporting are needed to develop appropriate indications for performing subcutaneous implant-based reconstruction.