Total Muscle Coverage versus AlloDerm Human Dermal Matrix for Implant-Based Breast Reconstruction

The Usage of Mesh and Relevant Prognosis in Implant Breast Reconstruction Surgery: A Meta-analysis

BACKGROUND

Although mesh-based implant breast reconstruction surgery is emerging as the primary surgical procedure for breast reconstruction, mesh use remains controversial in implant breast reconstruction surgery, especially in terms of how to select the ideal mesh. Our aim is to elaborate relevant prognosis in the mesh-based implant breast reconstruction surgery.

METHODS

Relevant studies were identified from PubMed, Web of Science, EMBASE, and Cochrane library searches. Extracted data included study type, basic characteristics, mesh information, complications, etc. We analyzed the included cohort studies and randomized controlled trials that reported mesh-related implant breast reconstruction complications and breast quality scale scores.

RESULTS

A total of 32 studies including 7475 subjects were included. The results showed that the overall complication rate was 2.07 times higher in the biological mesh group than in the synthetic mesh group (risk ratio [RR]: 2.07, 95% CI 1.14-3.78). The risk of seroma was 4.50 times higher in the biological mesh group than in the synthetic mesh group (RR: 4.50, 95% CI 2.27-8.95). In terms of comparing breast quality scale scores, the mesh group had scores that were 1.49 (95% CI 0.19-2.78) higher than the non-mesh group for "physical well-being" and 2.05 (95% CI 0.08-4.02) higher for "sexual well-being."

CONCLUSIONS

Our study found that the risk of total complications was higher with biological mesh than with synthetic mesh in implant breast reconstruction surgery. Based on short-term cost, healthcare burden, and healthcare benefits, synthetic meshes are superior to biological meshes.

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 .

Serratus Anterior Fascia for Immediate Implant-Based Breast Reconstruction: A Case Series of 65 Patients With Breast Cancer

OBJECTIVE

After immediate implant-based breast reconstruction (IIBR) after mastectomy, implant exposure or capsular contracture can occur. This study aimed to evaluate IIBR using serratus anterior fascia in patients with breast cancer.

METHODS

This retrospective case series study enrolled patients with breast cancer underwent IIBR using the serratus anterior fascia after mastectomy in the Department of Breast Surgery of Fujian Cancer Hospital between January 2021 and December 2022.

RESULTS

Sixty-five cases with breast cancer underwent IIBR using serratus anterior fascia were enrolled, with a median age of 39 years (range, 24-57 years) and body mass index of 21.32 kg/m 2 (range, 19-25 kg/m 2 ). The aesthetic outcomes of the reconstructed breasts showed good in 53 cases (81.6%), moderate in 11 cases (16.9%), and poor in 1 case (1.5%) due to offset position. Two cases showed poor wound healing, which improved after repeat suturing and 5 cases developed partial ischemic necrosis of the nipple, which scabbed and healed spontaneously.

CONCLUSIONS

Implant-based breast reconstruction using serratus anterior fascia may provide good aesthetic outcomes with few complications.

The Effect of Early Cultures and Dual-port Expanders on Two-stage, Prepectoral Breast Reconstruction: The 25/25 Study

Background

Two-stage tissue expander to implant surgery remains the predominant technique for breast reconstruction. Unfortunately, there is a high incidence of reconstruction failure which portends a financial and emotional burden. Most failures are related to postmastectomy skin flap necrosis and infection. Recently, a dual-port tissue expander was introduced to the market, and the authors hypothesize that early cultures from the peri-implant fluid will guide antibiotic treatment and decrease reconstruction failure.

Methods

This is a cohort study of 50 consecutive patients treated for breast cancer or genetic susceptibility via a two-stage, prepectoral technique. The first 25 patients (46 breasts) were treated with a variety of tissue expanders, and the subsequent 25 patients (47 breasts) received a dual-port expander. Routine cultures from the drain port were taken from the dual-port group at the second postoperative visit, and cultures were taken in the control group only when signs of infection were present. All other procedures and interventions were similar.

Results

Fifty patients, totaling 93 breasts, completed the study with a mean follow-up of 145 days. There were no statistically significant demographic or pathologic differences between groups. Fifteen tissue expanders were explanted in the control group and five in the dual-port cohort (32.6% versus 10.6%, P = 0.012). All bacteria in the control group failures were either methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis, whereas failures in the dual-port group varied.

Conclusion

Treatment of routine, early cultures from a dual-port expander led to a statistically significant decrease in tissue expander explantation.

Fabrication and characterization of bilayer scaffolds made of decellularized dermis/nanofibrous collagen for healing of full-thickness wounds

Skin tissue engineering has progressed from simple wound dressings to biocompatible materials with desired physico-chemical properties that can deliver regenerative biomolecules. This study describes using a novel biomimetic hybrid scaffold of decellularized dermis/collagen fibers that can continuously deliver stromal cell-derived factor-1 alpha (SDF-1α) for skin regeneration. In diabetic rat models, the idea that sustained SDF-1α infusion could increase the recruitment of CXCR4-positive cells at the injury site and improve wound regeneration was investigated. The morphology of the scaffold, its biocompatibility, and the kinetics of SDF-1 release were all assessed. SDF-1α was successfully incorporated into collagen nanofibers, resulting in a 200-h continuous release profile. The microscopic observations exhibited that cells are attached and proliferated on proposed scaffolds. As evaluated by in vivo study and histological examination, fabricated scaffold with SDF-1α release capacity exhibited a remarkably more robust ability to accelerate wound regeneration than the control group. Besides, the SDF-1α-loaded scaffold demonstrated functional effects on the proliferation and recruitment of CD31 and CXCR4-positive cells in the wound bed. Additionally, no adverse effects such as hyperplasia or scarring were found during the treatment period. It may be concluded that the fabricated hybrid scaffold based on natural polymer opens up a new option for topical administration of bioactive molecules. We believe the SDF-1α-loaded hybrid scaffold has promise for skin tissue engineering.

Modern Approaches to Implant-Based Breast Reconstruction

The modern approach to implant-based breast reconstruction encompasses an evolution in surgical techniques, patient selection, implant technology, and use of support materials. Successful outcomes are defined by teamwork throughout the ablative and reconstructive processes as well as appropriate and evidence-based utilization of modern material technologies. Patient education, focus on patient-reported outcomes, and informed and shared decision-making are the key to all steps of these procedures.

From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction

BACKGROUND

Increasing amounts of acellular dermal matrix are being used with the adoption of prepectoral breast reconstruction. Postoperative infection remains a challenge in breast reconstruction, and the contribution of acellular dermal matrix type, processing, and sterility assurance level to risk of complications in prepectoral reconstruction is not well studied.

METHODS

The authors performed a retrospective review of patients who underwent immediate prepectoral breast reconstruction from February of 2017 to July of 2020. Because of an increase in the rate of infection, the drain protocol was changed and acellular dermal matrix type was switched from AlloDerm (sterility assurance level, 10-3) to DermACELL (sterility assurance level, 10-6) in January of 2019. Demographic and surgical variables were collected, in addition to details regarding development and management of infection.

RESULTS

Despite higher rates of direct-to-implant reconstruction and bilateral procedures and increased implant volumes, the rate of infection was significantly lower in patients who received DermACELL instead of AlloDerm [two of 38 (5.3 percent) versus 11 of 41 (26.8 percent); p = 0.014]. Drain duration was slightly longer in the DermACELL group, consistent with the change in drain protocol. Baseline demographic and clinical characteristics remained similar between the two groups.

CONCLUSIONS

With increased reliance on large amounts of acellular dermal matrix for prepectoral breast reconstruction, it directly follows that the properties of acellular dermal matrix with respect to incorporation, sterility, and implant support are that much more important to consider. There have been few studies comparing different types of acellular dermal matrix in prepectoral breast reconstruction, and further research is required to determine the contribution of acellular dermal matrix type and processing techniques to development of postoperative infection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Acellular Dermal Matrix-Associated Contracture: A Clinical and Histologic Analysis of Patients Undergoing Prosthetic Breast Reconstruction

BACKGROUND

Capsular contracture is a well-recognized complication following prosthetic breast reconstruction. It has been the authors' observation that some patients undergoing breast reconstruction experience contracture specifically of the acellular dermal matrix placed at the time of their tissue expander insertion. The goal of the authors' study was to identify clinical and histologic findings associated with the development of acellular dermal matrix-associated contracture.

METHODS

The authors performed a retrospective cohort study of all patients undergoing bilateral implant-based breast reconstruction performed by the senior author (M.S.A.). Patients were excluded if they had radiation therapy to the breast. Patients with suspected acellular dermal matrix-associated contracture were identified by clinical photographs and review of operative notes. Histologic analysis was performed on specimens taken from two patients with acellular dermal matrix contracture.

RESULTS

The authors included a total of 46 patients (92 breasts), of which 19 breasts had suspected acellular dermal matrix-associated contracture. Acellular dermal matrix contracture was less common in direct-to-implant reconstruction (4.2 percent versus 26.5 percent; p = 0.020) and more common in breasts that had seromas (0 percent versus 15.8 percent; p = 0.001) or complications requiring early expander replacement. Contracted acellular dermal matrix had less vascularity and a lower collagen I-to-collagen III ratio, and was twice as thick as noncontracted acellular dermal matrix.

CONCLUSIONS

The authors have described a distinct phenomenon of acellular dermal matrix-associated contracture that occurs in a small subset of breasts where acellular dermal matrix is used. This merits further investigation. Future work will be required to better characterize the clinical factors that make acellular dermal matrix-associated contracture more likely to occur.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Evaluation of Dual-port versus Single-port Tissue Expanders in Postmastectomy Breast Reconstruction

Background

Immediate tissue expander placement in postmastectomy breast reconstruction can be complicated by seroma or infection, requiring further imaging studies or interventions. This study compares dual-port tissue expanders, with both an aspiration and expansion port, with single-port expanders in terms of postoperative complications and further interventions.

Methods:

Patients with immediate tissue expander placement from March 2019 to March 2020 were reviewed. Complications included seroma, infection, hematoma, necrosis, and malposition of the expander. Further intervention included aspiration, ultrasound imaging, interventional radiology (IR) drainage, or return to operating room.

Results:

In total, 128 dual-port expanders were compared with 125 single-port expanders. Patients with single-port expanders were younger (P = 0.022) and of lower BMI (P = 0.01). There were no significant differences in key complications between these groups. In multivariate analysis, single-port expanders had a 3.4× higher odds of postoperative ultrasound imaging when controlling for texture, placement, and age (P = 0.01). Mean time to IR drain placement in the dual-port group was approximately 30 days after placement in single port (51.1 versus 21.4 days, P = 0.013). Thirty-four percent of dual-port expanders had at least one aspiration in clinic performed by plastic surgery, versus 2% of single port that required ultrasound-guided aspiration (P < 0.001).

Conclusions:

There were no differences in key postoperative complications between the two expander cohorts. Dual-port expanders significantly reduced postoperative ultrasound imaging, and delayed IR drain placement. The added convenience of clinic aspirations likely reduced costs related to utilization of resources from other departments.

Improving plastic surgery resident education and quality of care with outcomes feedback using the surgery report card: An initial experience

BACKGROUND

The practice of tracking and analyzing surgical outcomes is essential to becoming better surgeons. However, this feedback system is largely absent in residency training programs. Thus, we developed a Surgery Report Card (SRC) for residents performing tissue expander (TE)-based breast reconstruction and report our initial experience with its implementation.

METHODS

We performed a systematic review and meta-analysis for TE-based breast reconstructions and compared outcomes to our retrospective cohort. The primary outcome was overall complications. The SRC compares patient and complication statistics for resident-led teams to the meta-analysis.

RESULTS

The meta-analysis included 12 studies, with 2093 patients (2982 breasts) that underwent TE-based reconstruction. The pooled complication rate was 26.9%; infection was most common (8.3%); failure rate was 5.9%. Our cohort included 144 patients (245 breasts) among 13 resident-led teams. Overall complication rate was 31.8%; infections were most frequent (17.6%) and failure rate was 7.3%. Our cohort had significantly higher BMIs (29.7 vs 25.4, p<0.0001) more diabetics (6.9% vs. 3.2%, p = 0.02), and more patients receiving adjuvant radiation therapy (41.4 vs 26.3%, p<0.0001). Every 3 months, residents receive a customized SRC of their cases, with the meta-analysis used as a benchmark. A survey demonstrated the SRC made residents reconsider surgical technique and more conscientious surgeons, and would like it implemented for other procedures during residency.

CONCLUSIONS

The implementation of our SRC for TE-based breast reconstruction establishes a baseline for surgical performance comparison for residents, demonstrates that residents can safely perform the procedure, and allows for critiquing of surgical techniques to improve patient care.

The Impact of Device Innovation on Clinical Outcomes in Expander-based Breast Reconstruction

Staged expander-based breast reconstruction represents the most common reconstructive modality in the United States. The introduction of a novel tissue expander with an integrated drain (Sientra AlloX2) holds promise to further improve clinical outcomes.

An overview of advanced biocompatible and biomimetic materials for creation of replacement structures in the musculoskeletal systems: focusing on cartilage tissue engineering

Tissue engineering, as an interdisciplinary approach, is seeking to create tissues with optimal performance for clinical applications. Various factors, including cells, biomaterials, cell or tissue culture conditions and signaling molecules such as growth factors, play a vital role in the engineering of tissues. In vivo microenvironment of cells imposes complex and specific stimuli on the cells, and has a direct effect on cellular behavior, including proliferation, differentiation and extracellular matrix (ECM) assembly. Therefore, to create appropriate tissues, the conditions of the natural environment around the cells should be well imitated. Therefore, researchers are trying to develop biomimetic scaffolds that can produce appropriate cellular responses. To achieve this, we need to know enough about biomimetic materials. Scaffolds made of biomaterials in musculoskeletal tissue engineering should also be multifunctional in order to be able to function better in mechanical properties, cell signaling and cell adhesion. Multiple combinations of different biomaterials are used to improve above-mentioned properties of various biomaterials and to better imitate the natural features of musculoskeletal tissue in the culture medium. These improvements ultimately lead to the creation of replacement structures in the musculoskeletal system, which are closer to natural tissues in terms of appearance and function. The present review article is focused on biocompatible and biomimetic materials, which are used in musculoskeletal tissue engineering, in particular, cartilage tissue engineering.