Acellular Dermal Matrices in Breast Reconstruction: CARE Trial 5-Year Outcomes Data for More Than 9500 Patients

Performance of Human and Porcine Derived Acellular Dermal Matrices in Prepectoral Breast Reconstruction: A Long-term Clinicaland Histologic Evaluation

BACKGROUND

Human acellular dermal matrices (ADMs) remain the most used matrices in prosthetic breast reconstruction. However, the availability and cost of ADMs limit their use in prepectoral reconstruction-which requires large amounts of ADM-and alternative matrices are therefore being explored.

OBJECTIVES

The aim of this study was to demonstrate the safety and efficacy of human-porcine ADM constructs via clinical outcomes and histologic evidence of graft integration.

METHODS

Consecutive patients undergoing tissue-expander/implant reconstructions with human-porcine ADM constructs were included. Biopsies of both ADMs were obtained at expander/implant exchange and evaluated for cellularization, vascularization, and inflammation. Postoperative complications were retrieved from patient records.

RESULTS

Fifty-nine patients met the inclusion criteria. Mean [standard deviation] follow-up was 6.7 [0.56] years; minimum follow-up was 5 years. Any complication rate was 8.6%, including skin necrosis (6.9%), seroma (1.7%), expander/implant exposure (1.7%), and return to the operating room (2.6%). A total of 138 ADM biopsy specimens were obtained from 38 patients at expander/implant exchange. Histologic analyses revealed lower fibroblast infiltration and vascularization and higher inflammatory response in porcine vs human ADM specimens, consistent with published results in nonhuman primates. Despite these differences, there were no cases of graft rejection, capsular contracture, or expander/implant loss.

CONCLUSIONS

Porcine ADM performs clinically in a similar manner to human ADM, albeit with minor differences in cellular ingrowth and vascularization, suggesting that it may be an alternative to human ADM in prepectoral breast reconstruction.

LEVEL OF EVIDENCE: 3

"Prepectoral tissue expanders without mesh as a bridge to delayed autologous breast reconstruction: Experience at a single academic center"

Acellular dermal matrix (ADM) is a useful adjunct in implant-based breast reconstruction. The benefits of using ADM with an expander as a temporary bridge to delayed autologous reconstruction are unknown. Placing prepectoral tissue expanders, without ADM, as a bridge to delayed autologous reconstruction could yield cost savings, shorten operating time and decrease complications. This investigation seeks to demonstrate the safety of placing prepectoral tissue expanders without ADM at the time of mastectomy as the first stage of autologous breast reconstruction. A retrospective, chart review was performed at our major academic institution between 2015 and 2020. Included were female patients, 18 years or older at the time of reconstruction, who underwent mastectomy with prepectoral tissue expander placement followed by autologous breast reconstruction at a delayed second stage. Excluded were patients of male gender, younger than 18, patients with lumpectomy only, subpectoral reconstruction, or immediate autologous reconstruction. Data on ADM, patient demographics, comorbidities, and cancer treatment were collected. There were 189 reconstructed breasts of which 56 (29.6 %) used ADM, 131 (69.3 %) did not use ADM, and 2 patients (1.1 %) of unknown ADM use. Expanders were in place for a mean time of 8.9±6.2 months. There was no statistically significant difference in complication rates between the ADM and no-ADM groups. Therefore, not wrapping prepectoral tissue expanders in ADM, at the time of mastectomy, has an equivalent rate of complications compared to ADM wrapping among patients who go on to have second stage autologous breast reconstruction.

A Long-term Evaluation of Acellular Dermal Matrix for Immediate Implant-based Breast Reconstruction following Risk-reducing Mastectomy

Background

Acellular dermal matrices (ADMs) are sometimes used in implant-based breast reconstructions (IBR), but long-term ADM-related evaluations are scarce. In this study, we evaluated early and late complications and patient-related outcomes (PROs) over an 8-year postoperative period in women who had undergone immediate IBR following risk-reducing mastectomy with bovine ADM (SurgiMend).

Methods

This prospective observational single-center analysis involved 34 women at high risk for breast carcinoma. Complications were prospectively recorded during the first year, followed by 4 years of postoperative retrospective chart reviews. Long-term evaluations were done using a questionnaire. Preoperative, 1 year, and 5- to 8-year postoperative PRO assessments were obtained based on results from the BREAST-Q questionnaire.

Results

In 56 breasts, complications after a mean of 12.4 months follow-up included implant loss (7.1%), implant change (1.8%), hematoma (7.1%), breast redness (41.1%), and seroma (8.9%). Most breasts (80.3%) were graded Baker I/II, which indicated a low capsular contracture incidence. After a mean of 6.9 years, the total implant explantation rate was 33.9%, and the revision surgery rate was 21.4%. Two cases of breast cancer were reported during the long-term evaluation. BREAST-Q results indicated significantly decreased satisfaction with outcome (P = 0.024). A positive trend regarding psychosocial well-being and declining trend regarding satisfaction with both breast physical- and sexual well-being parameters were reported.

Conclusions

The observed complication rates agree with previous findings concerning ADM-assisted IBR. A high demand for revision surgery exists, and PROs remain relatively stable over time.

To acellular dermal matrix or not to acellular dermal matrix?-outcomes of pre-pectoral prosthetic reconstruction after nipple-sparing mastectomy with and without acellular dermal matrix

Background

Acellular dermal matrix (ADM) has been the go-to biomaterial in post-mastectomy breast reconstruction, particularly in pre-pectoral reconstruction. ADM is thought to decrease capsular contracture, control the pocket, and increase soft tissue, but may yield more complications. This study evaluated whether ADM is even needed.

Methods

All patients undergoing immediate breast reconstruction with pre-pectoral tissue expander (TE) or direct-to-implant (DTI) after nipple-sparing mastectomy (NSM) by the senior author between April 2013 and January 2021, were included in this study. Cohorts were stratified into breasts with ADM or no-ADM. Complications within 30 days post-operatively were analyzed.

Results

A total of 115 pre-pectoral reconstructions were performed in 66 patients. ADM was applied to 75 breasts. TEs were used in 80 breasts and DTI in 35 breasts. Controlling for implant type, breasts with ADM exhibited more nipple necrosis (28.0% vs. 10.0%, P=0.02). Controlling for ADM status, DTI compared to TE was associated with less necrosis of the nipple (11.4% vs. 26.3%, P=0.04), implant loss (5.7% vs. 38.8%, P=0.004), and surgery for any complication (14.3% vs. 27.5%, P=0.04).

Conclusions

Outcomes of prosthetic reconstructions with ADM and no-ADM were similar. DTI reconstruction was associated with less complications, which was likely due to intraoperative bias and placement of TEs more often in breasts with perceived poorer vascularity.

Revision Breast Reconstruction With Biologic or Synthetic Mesh: An Analysis of Postoperative Capsular Contracture Rates

Background

Both biologic and synthetic mesh have been found to reduce the risk of capsular contracture, yet there is limited data assessing the use of these scaffold materials in revision breast reconstruction.

Objectives

This investigation sought to assess the ability of either biologic or synthetic mesh to prevent capsular contracture in the revision breast reconstruction population.

Methods

A retrospective chart review was conducted of implant-based revision reconstructions performed by the senior author between 2008 and 2023. Patient demographics and outcomes were assessed, including the incidence of Baker Grade III or IV capsular contractures. Results were compared between biologic and synthetic mesh groups using univariate and multivariate analysis.

Results

Ninety-five breasts underwent revision reconstruction with 90 (94.7%) for correction of malposition, 4 (4.2%) for size change, and 1 (1.1%) for revision after additional oncologic breast surgery. Of these breasts, 26 (27.4%) used biologic mesh and 69 (72.6%) used synthetic mesh. Capsular contracture occurred in 1 (3.8%) biologic mesh breast and 4 (5.8%) synthetic mesh breasts. There was no significant difference in the incidence of capsular contracture between the 2 groups (P = 1.000). None of the recorded demographics were risk factors for capsular contracture, including the use of biologic or synthetic mesh (P = .801).

Conclusions

Both biologic and synthetic mesh are successful at preventing capsular contracture in patients undergoing implant-based revision reconstruction. This adds to the growing evidence that both scaffold materials can be used in complex revision breast reconstruction to aid in preventing capsular contracture.

Level of Evidence 4

Technical Refinements and Outcomes Assessment in Prepectoral Pocket Conversion After Postmastectomy Radiotherapy

BACKGROUND

Several studies show how submuscular breast reconstruction is linked to animation deformity, shoulder dysfunction, and increased postoperative chest pain, when compared to prepectoral breast reconstruction. In solving all these life-impairing side effects, prepectoral implant pocket conversion has shown encouraging results.

OBJECTIVES

The aim of this study was to propose a refinement of the prepectoral implant pocket conversion applied to previously irradiated patients.

METHODS

We conducted a retrospective study on 42 patients who underwent previous nipple- or skin-sparing mastectomy and immediate submuscular reconstruction, followed by radiotherapy. We performed fat grafting sessions as regenerative pretreatment. Six months after the last fat graft, we performed the conversion, with prepectoral placement of micropolyurethane foam-coated implants. We investigated the preconversion and postconversion differences in upper limb range of motion, Upper Extremity Functional Index, and patient satisfaction with the breast and physical well-being of the chest.

RESULTS

We reported a resolution of animation deformity in 100% of cases. The range of motion and the Upper Extremity Functional Index scores were statistically improved after prepectoral implant pocket conversion. BREAST-Q scores for satisfaction with the breast and physical well-being of the chest were also improved.

CONCLUSIONS

The refined prepectoral implant pocket conversion is a reliable technique for solving animation deformity and improving quality of life in patients previously treated with submuscular reconstruction and radiotherapy.

LEVEL OF EVIDENCE: 3

Reinforcement of a Subcutaneous Pocket for Implantable Cardioverter Defibrillator Insertion Using Acellular Dermal Matrix: A Case Report

Pediatric patients who undergo implant insertion into the chest wall face a high risk of implant exposure to the external environment. Five months after an 8-year-old boy underwent implantable cardioverter-defibrillator (ICD) implantation in a subcutaneous pocket in the left anterolateral chest wall to manage long QT syndrome, ICD replacement became necessary owing to exposure risk from distal and lateral thinning of the ICD pocket. Pocket rupture and exposure would increase the risk of infection; therefore, we performed ICD removal and primary pocket closure. Two weeks later, a new suprafascial pocket was created, an acellular dermal matrix (ADM) was attached to the inner wall to prevent ICD protrusion, and a new ICD was inserted. One year postoperatively, the ADM was engrafted, and no complications were observed. A thin subcutaneous layer increases the risk of ICD implantation complications. Inner wall strengthening with an ADM can help prevent pocket rupture.

Tissue engineering strategies for breast reconstruction: a literature review of current advances and future directions

Background and Objective

Mastectomy is a primary treatment for breast cancer patients, and both autologous and implant-based reconstructive techniques have shown excellent results. In recent years, advancements in bioengineering have led to a proliferation of innovative approaches to breast reconstruction. This article comprehensively explores the promising perspectives offered by bioengineering and tissue engineering in the field of breast reconstruction.

Methods

A literature review was conducted between April and June 2023 on PubMed and Google Scholar Databases. All English and French articles related to bioengineering applied to the field of breast reconstruction were included. We used the Evidence-Based Veterinary Medicine Association (EBVM) Toolkit 14 checklist for narrative reviews as a quality assurance measure and the Scale for the Assessment of Narrative Review Articles (SANRA) tool to self-assess our methodology.

Key Content and Findings

Over 130 references related to breast bioengineering were included. The analysis revealed four key applications: enhancing the quality of the skin envelope, improving the viability of fat grafting, creating breast shape and volume via bio-printing, and optimizing nipple reconstruction through engineering techniques. The primary identified approaches revolved around establishing structural support and enhancing cellular viability. Structural techniques predominantly involved the implementation of 3D printed, decellularized, or biocompatible material scaffolds. Meanwhile, promoting cellular content trophicity primarily focused on harnessing the regenerative potential of adipose-derived stem cells (ADSCs) and increasing the tissue's survivability and cell trophicity.

Conclusions

Tissue and bioengineering hold immense promise in the field of breast reconstruction, offering a diverse array of approaches. By combining existing techniques with novel advancements, they have the potential to significantly enhance the therapeutic options available to plastic and reconstructive surgeons.

National Trends in Acellular Dermal Matrix Utilization in Immediate Breast Reconstruction

BACKGROUND

Implant-based reconstruction is the most common method of immediate breast reconstruction in the United States, with acellular dermal matrices (ADMs) playing a significant role in implant support and coverage. This study evaluated recent national trends in ADM use in immediate breast reconstruction and assessed patient characteristics and 30-day complication rates.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing immediate breast reconstruction from 2015 to 2020. Primary outcomes were major surgical and medical complications, as well as ADM use per year. Subset analysis was performed to compare patients undergoing immediate breast reconstruction with ADM in 2015 versus 2020.

RESULTS

In 39,800 immediate breast reconstructions, ADMs were used in 55.5% of cases ( n = 22,087). ADM usage increased annually from 2015 through 2020. Direct-to-implant reconstruction was significantly associated with ADM use ( P < 0.001). Compared with the no-ADM cohort, there was a significantly increased rate of return to the operating room for any reason ( P < 0.001). When comparing the 2015 and 2020 ADM cohorts, the 2020 ADM cohort had a significantly higher rate of superficial infections. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wounds in patients receiving ADM.

CONCLUSIONS

ADM use in immediate breast reconstruction increased significantly from 2015 to 2020, likely reflecting national trends in increasing direct-to-implant and prepectoral breast reconstruction. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wound infections in the ADM cohort. Patients with ADM had a slight increased incidence of return to the operating room.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.