Systematic Review of the Impact of Acellular Dermal Matrix on Aesthetics and Patient Satisfaction in Tissue Expander-to-Implant Breast Reconstructions:

Review: Implant-Based Breast Reconstruction After Mastectomy for Breast Cancer: A Meta-analysis of Randomized Controlled Trials and Prospective Studies Comparing Use of Acellular Dermal Matrix (ADM) Versus Without ADM

BACKGROUND

Breast cancer is the world's most prevalent cancer, and many breast cancer patients undergo mastectomy as the choice of treatment, often with post-mastectomy breast reconstruction. Acellular dermal matrix (ADM) use has become a method to improve outcomes of reconstruction for these patients. We aimed to compare postoperative complications and patient-reported outcomes, which are still poorly characterized, between groups utilizing acellular dermal matrix during reconstruction and those without.

MATERIALS AND METHODS

We searched electronic databases from inception to 16 June 2022 for randomized controlled trials and prospective cohort studies comparing the outcomes of patients who have and have not received acellular dermal matrix in implant-based breast reconstruction. The results were quantitatively combined and analyzed using random-effects models.

RESULTS

A total of nine studies were included, representing 3161 breasts. There was no significant difference in postoperative outcomes, such as seroma formation (p = 0.51), hematomas (p = 0.20), infections (p = 0.21), wound dehiscence (p = 0.09), reoperations (p = 0.70), implant loss (p = 0.27), or skin necrosis (p = 0.21). Only two of the studies included evaluated patient-reported outcomes between the use and non-use of ADM in implant-based breast reconstruction using BREAST-Q questionnaire, as well as self-reported pain. There was no reported significant difference in BREAST-Q or pain scores.

CONCLUSIONS

This meta-analysis shows comparable short- and long-term outcomes between ADM and non-ADM breast reconstruction, suggesting that the use of ADM may not be necessary in all cases given their additional cost. However, there is a paucity of data for patient-reported outcomes, and further research is required to determine whether ADM use affects patient-reported outcomes.

Improvement in Biocompatibility and Biointegration of Human Acellular Dermal Matrix through Vacuum Plasma Surface Treatment

Efforts are ongoing to enhance the functionality of human acellular dermal matrices (hADMs), which are extensively utilized in reconstructive surgeries. Among these efforts, plasma treatments, particularly vacuum plasma treatments, have recently emerged in the medical field. This study aims to investigate the efficacy of a vacuum plasma treatment in enhancing the biocompatibility and biointegration of hADMs. Utilizing a plasma activator (ACTILINK reborn, Plasmapp Co., Ltd., Daejeon, Republic of Korea), hADMs were treated and evaluated through in vitro and in vivo analyses. Hydrophilicity changes were gauged by the blood absorption times, while SEM imaging was used to analyze physical surface deformation. Protein adsorption was measured with fluorescently labeled bovine serum albumin and fibronectin. For the in vivo study, mice were implanted with plasma-treated and untreated hADMs, and the post-implantation effects were analyzed through histological and immunofluorescence microscopy. The plasma-treated hADMs demonstrated a significantly enhanced hydrophilicity compared to the untreated samples. SEM imaging confirmed the maintenance of the microroughness after the treatment. The treated hADMs showed a significant reduction in fibronectin adsorption, a critical factor for cellular adhesion. In vivo, the plasma-treated hADMs exhibited reduced capsule formation and enhanced fibroblast infiltration, indicating improved biocompatibility and integration. These findings highlight the potential of a plasma treatment to enhance the performance of hADMs in clinical settings, offering a promising avenue for improving reconstructive surgery outcomes.

Complication Profiles of Smooth vs Textured Tissue Expanders in Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a type of non-Hodgkin lymphoma first linked with breast implants in 2011. The correlation between BIA-ALCL and textured devices has led to increased use of smooth devices. However, much of the data surrounding smooth and textured devices investigates breast implants specifically and not tissue expanders.

OBJECTIVES

We performed a systematic review and a meta-analysis to compare surgical outcomes for smooth tissue expanders (STEs) and textured tissue expanders (TTEs).

METHODS

A search was performed on PubMed, including articles from 2016 to 2023 (n = 419). Studies comparing TTEs and STEs and reported complications were included. A random-effects model was utilized for meta-analysis.

RESULTS

A total of 5 articles met inclusion criteria, representing 1709 patients in the STE cohort and 1716 patients in the TTE cohort. The mean duration of tissue expansion with STEs was 221.25 days, while TTEs had a mean time of tissue expansion of 220.43 days.Our meta-analysis found no differences in all surgical outcomes except for explantation risk. STE use was associated with increased odds of explantation by over 50% compared to TTE use (odds ratio = 1.53; 95% CI = 1.15 to 2.02; P = .003).

CONCLUSIONS

Overall, STEs and TTEs had similar complication profiles. However, STEs had 1.5 times higher odds of explantation. The incidence of BIA-ALCL is low, and only a single case of BIA-ALCL has been reported with TTEs. This indicates that TTEs are safe and may lower the risk of early complications requiring explantation. Further studies are warranted to further define the relationship between tissue expanders and BIA-ALCL.

LEVEL OF EVIDENCE: 4

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.

In Vivo Efficacy of an Injectable Human Acellular Dermal Matrix

BACKGROUND

Human acellular dermal matrix (hADM) has found applications in a variety of settings, particularly in breast surgery. The most common hADM is a sheet. Recently, an injectable hADM has been introduced; we compared the biocompatibility and long-term structural integrity of, an injectable hADM and a sheet-type hADM in mice.

METHODS

An injectable hADM (experimental group) and a sheet-type hADM (control group) were implanted into sub-panniculus pockets on the backs of 50 mice. The animals were sacrificed 2, 4, 8, 12, or 24 weeks later and the hADMs and surrounding tissues were recovered and stained for histopathological analyses. The microscopic endpoints included the thickness of the hADM and capsule around the hADM, and the extents of fibroblast proliferation and neovascularization.

RESULTS

No animal developed a complication or infection. The capsule was significantly thinner in the experimental than the control group. There were no significant differences between groups in the hADM thickness. Microscopically, the fibroblast density inside the hADM was significantly higher in the experimental group. The fibroblasts inside of the hADM lay significantly deeper in the experimental group. Similarly, the experimental group exhibited significantly deeper microvessels inside the hADM.

CONCLUSIONS

The injectable hADM had a thinner capsule thickness (more biocompatible), than the sheet-type hADM. It maintained its thickness as well as the sheet-type hADM and had a more fibroblast proliferation and neovascularization. This means the tissue incorporation and long-term structural integrity of the injectable hADM may be as good as or better than that of the sheet-type hADM.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Less is more? One-stage versus two-stage implant-based breast reconstruction: A systematic review and meta-analysis of comparative studies

BACKGROUND

Most breast reconstructions are implant-based and can be performed either in a one-stage, direct-to-implant or in a two-stage, expander-implant-based reconstruction. The objective of this systematic review is to compare the safety and patient satisfaction of the two reconstruction approaches.

METHODS

A literature search was conducted on 27 September 2022 using various databases. Studies comparing one-stage and two-stage implant reconstructions and reporting the following outcomes were included: patient satisfaction, aesthetics, complications, and/or costs. Reviews, case reports, or series with less than 20 patients and letters or comments were excluded. Comparisons were made between the one-stage reconstruction with and without acellular dermal matrix (ADM) and two-stage implant-based breast reconstruction groups. The data extracted from all articles were analysed using random-effects meta-analyses.

RESULTS

Of the 1381 records identified, a total of 33 articles were included, representing 21529 patients. There were no significant differences between the one-stage and two-stage groups, except for the costs. The one-stage operation without ADM had lower costs than the two-stage operation without ADM, although the use of an ADM substantially increased the price of the operation to more than a two-stage reconstruction.

DISCUSSION

Equal patient satisfaction, aesthetic outcomes, and complication rates with lower costs justify one-stage breast reconstruction in carefully selected patients. This review shows that there is no evidence-based superior surgical approach. Future research should focus on the costs of the ADM versus an additional stage and patient-reported outcomes.

Do Corporate Payments Influence Research Related to the Use of Acellular Dermal Matrices in Breast Surgery?

BACKGROUND

No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs.

METHODS

The PubMed database was used to identify articles that reported on the use of ADM in breast surgery in four leading plastic surgery journals from January of 2014 to December of 2019. Financial COIs for authors were determined using the open payments database.

RESULTS

Fifty-five articles were included. Twenty-four articles (43.6%) supported use of ADM, 12 (21.8%) did not promote ADM use, and 19 (34.5%) were neutral. Fifty-one studies (92.7%) had either a first or senior author with a COI, and authors with a COI more commonly reported positive outcomes ( P = 0.02). Studies with positive outcomes featured first authors who received significantly larger financial payments ($95,955 versus $15,642; P = 0.029) compared with studies with negative or neutral outcomes. Receiver operating characteristic curve demonstrated that studies with first authors receiving over $376.28 were more likely to report positive results. Eight senior authors and three first authors received greater than $500 from ADM producers yet did not report any financial disclosure.

CONCLUSIONS

Financial COI is associated with higher likelihood of studies reporting benefit of using ADM in breast surgery. There remains inconsistent reporting of COIs, and better oversight is needed to ensure unbiased publication on the use of ADM in breast surgery.

Rise of Acellular Dermal Matrix: Cost Consciousness, Industry Payment, and Publication Productivity

BACKGROUND

Despite high cost and lack of FDA approval for breast surgery, acellular dermal matrix (ADM) has become commonplace in reconstructive surgery and has been the focus of more than 500 plastic surgery publications since its wide adoption. We hypothesized that ADM-related academic output would correlate with public interest and industry funding.

STUDY DESIGN

All PubMed-indexed studies focusing on ADM in 11 plastic surgery journals were included (n = 535). Data on industry funding to the 17 most productive authors were extracted from the Open Payments Database. Google Trends in "breast surgery cost" and related terms were queried. Relationships among publication quantity, author industry funding, and public interest were analyzed by Pearson's correlation and linear regression.

RESULTS

The most published authors produced 8 qualifying publications on average (range 5 to 17), with 80% focused on breast surgery. These individuals grossed a total of $19 million industry dollars overall with $17 million (89%) in nonconsulting compensation from ADM-producing companies (NC-ADM). Individual total compensation and NC-ADM compensation, by quartile, were $194,000/$320,000/$1.25 million and $17,000/$210,000/$1.1 million, respectively. These variables showed strong correlation with individual publication rate with a linear regression coefficient of $110K in NC-ADM per publication (p < 0.01). Authors disclosed funding in a mean ± SD of 65 ± 26% of their work with strong correlation between disclosure and NC-ADM (p < 0.01). Google "breast surgery cost" search volume has grown rapidly in significant correlation with ADM publications (p = 0.02).

CONCLUSIONS

This study demonstrates significant correlation between ADM-related publication, industry funding, funding disclosure, and public interest. Education in the potential for such relationships and the importance of objectivity in plastic surgery warrants discussion.

Autologous Skin Grafts, versus Tissue-engineered Skin Constructs: A Systematic Review and Meta-analysis

For over 100 years, autologous skin grafts have remained the gold standard for the reconstruction of wounds but are limited in availability. Acellular tissue-engineered skin constructs (acellular TCs) and cellular tissue-engineered skin constructs (cellular TCs) may address these limitations. This systematic review and meta-analysis compare outcomes between them.

Methods

A systematic review was conducted using PRISMA guidelines, querying MEDLINE, Embase, Web of Science, and Cochrane to assess graft incorporation, failure, and wound healing. Case reports/series, reviews, in vitro/in vivo work, non-English articles or articles without full text were excluded.

Results

Sixty-six articles encompassing 4076 patients were included. No significant differences were found between graft failure rates (P = 0.07) and mean difference of percent reepithelialization (p = 0.92) when split-thickness skin grafts were applied alone versus co-grafted with acellular TCs. Similar mean Vancouver Scar Scale was found for these two groups (p = 0.09). Twenty-one studies used at least one cellular TC. Weighted averages from pooled results did not reveal statistically significant differences in mean reepithelialization or failure rates for epidermal cellular TCs compared with split-thickness skin grafts (p = 0.55).

Conclusions

This systematic review is the first to illustrate comparable functional and wound healing outcomes between split-thickness skin grafts alone and those co-grafted with acellular TCs. The use of cellular TCs seems promising from preliminary findings. However, these results are limited in clinical applicability due to the heterogeneity of study data, and further level 1 evidence is required to determine the safety and efficacy of these constructs.

Red Breast Syndrome and Acellular Dermal Matrix

Increasingly popular for use in breast reconstruction, acellular dermal matrix (ADM) can provide support and protection to implants. However, use of ADM may be associated with infection and complications, including red breast syndrome (RBS). RBS is an inflammatory event that typically presents with cutaneous erythema over the domain where the ADM is surgically implanted. As ADM use increases, presumably, more cases of RBS will occur. Thus, techniques and tools to mitigate or manage RBS are needed to improve patient outcomes. Here, we describe a case where RBS was diagnosed and interestingly resolved after exchange for a different brand of dermal matrix. This surgical resolution maintained excellent reconstructive results with no recurrent erythema over a follow-up period of 7 months. Although we cannot rule out RBS due to other variables, RBS due to patient hypersensitivity to certain ADMs has been documented in the literature. In this instance, our results suggest that revision with an alternate ADM brand may serve as a potential solution.

Comparing the Outcomes and Complication Rates of Biologic vs Synthetic Meshes in Implant-Based Breast Reconstruction: A Systematic Review

OBJECTIVE

This systematic review evaluates all published studies comparing biologic and synthetic meshes in implant-based breast reconstruction (IBBR), to determine which category of mesh produces the most favorable outcomes.

SUMMARY BACKGROUND DATA

Breast cancer is the most common cancer in women globally. Implant-based breast reconstruction is currently the most popular method of postmastectomy reconstruction, and recently, the use of surgical mesh in IBBR has become commonplace. Although there is a long-standing belief among surgeons that biologic mesh is superior to synthetic mesh in terms of surgical complications and patient outcomes, few studies exist to support this claim.

METHODS

A systematic search of the EMBASE, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies comparing biologic and synthetic meshes within the same experimental framework were included. Study quality and bias were assessed using the validated Methodological Index for Non-Randomized Studies criteria.

RESULTS

After duplicate removal, 109 publications were reviewed, with 12 meeting the predetermined inclusion criteria. Outcomes included common surgical complications, histological analysis, interactions with oncologic therapies, quality of life measures, and esthetic outcomes. Across all 12 studies, synthetic meshes were rated as at least equivalent to biologic meshes for every reported outcome. On average, the studies in this review tended to have moderate Methodological Index for Non-Randomized Studies scores.

CONCLUSION

This systematic review offers the first comprehensive evaluation of all publications comparing biologic and synthetic meshes in IBBR. The consistent finding that synthetic meshes are at least equivalent to biologic meshes across a range of clinical outcomes offers a compelling argument in favor of prioritizing the use of synthetic meshes in IBBR.

Hybrid Microsurgical Breast Reconstruction:: HyFIL® & HyPAD™ Techniques

There are numerous indications for hybrid breast reconstruction, with the most common being patients who have inadequate donor site volume to achieve the desired breast volume. This article reviews all aspects of hybrid breast reconstruction, including preoperative and assessment, operative technique and considerations, and postoperative management.

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.

Engineered nanovesicles from stromal vascular fraction promote angiogenesis and adipogenesis inside decellularized adipose tissue through encapsulating growth factors

Acellular matrix is a commonly used biomaterial in the field of biomedical engineering and revascularization is the key process to affect the effect of acellular matrix on tissue regeneration. The application of bioactive factors related to angiogenesis has been popular in the regulation of revascularization, but the immune system clearance, uncontrollable systemic reactions, and other factors make this method face challenges. Recent reports showed that engineered cells into nanovesicles can reorganize cell membranes and encapsulate cellular active factors, extending the in vitro preservation of cytokines. However, the problems of exogenous biological contamination and tumorigenicity restricted the clinical transformation and wide application of this method. Here, we for the first time engineer stromal vascular fraction (SVF) which is extracted from fat into nanovesicles (SVF-EVs) for angiogenesis in the acellular matrix. SVF-EVs not only promote the migration of vascular endothelial cells in vitro, but also facilitate the lipogenic differentiation of mesenchymal stem cells. In vivo, SVF-EVs enhanced the retention of decellularized adipose tissue after transplanting to the subcutaneous area of nude mice. Immunofluorescence staining further showed that SVF-EVs promoted the formation of vascular networks with large lumen diameter in the grafted acellular matrix, accompanied by adipocyte regeneration peripherally. These findings reveal that SVF-EVs can be a viable method for accelerating revascularization in acellular matrix, and this process of squeezing tissue into nanovesicles shows the potential for rapid clinical transformation.

Safety of Incision Placement with Nipple-sparing Mastectomy and Immediate Prepectoral Breast Reconstruction

In nipple-sparing mastectomy, adequate perfusion to the nipple-areolar complex (NAC) during reconstruction is paramount to avoiding unwanted outcomes. Previous studies have suggested that periareolar incisions may result in higher rates of NAC complications. However, studies to date have not specifically investigated this in prepectoral reconstruction. The purpose of this study is to evaluate the impact of incision location on NAC complications in patients undergoing prepectoral breast reconstruction.

Methods

We performed a retrospective review of all patients who underwent immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy between 2015 and 2018 at a single institution. We identified two types of incisions utilized: superior periareolar or inframammary fold (IMF). Patient demographics, comorbidities, and surgical details were compared between incision types, as were NAC complications.

Results

A total of 181 consecutive prepectoral breast reconstructions were included for analysis. A superior periareolar incision was used in 113 reconstructions (62%), and an IMF incision was used in 68 reconstructions (38%). There were 33 (18%) total NAC complications in our series. The periareolar incision group had a higher rate of any NAC complication (25% versus 7.4%; P < 0.01), as well as a higher rate of nipple necrosis requiring debridement (9.7% versus 1.5%; P = 0.03).

Conclusions

In patients undergoing immediate two-stage prepectoral breast reconstruction following nipple-sparing mastectomy, periareolar incisions are associated with an increased risk of NAC complications compared with IMF incisions. For patients who are candidates for either an IMF or periareolar incision, a periareolar incision should be avoided.

Acellular Dermal Matrix Mimicking a New Retroareolar Mass After Central Pillar Neonipple Reconstruction

ABSTRACT

Acellular dermal matrix (ADM) is an increasingly popular alloplastic cadaveric dermis used to enhance postmastectomy reconstruction. Acellular dermal matrix can be used as a nipple-shaped cylinder in central pillar nipple reconstruction to help maintain long-term projection. We report a unique presentation of ADM mimicking a retroareolar mass after central pillar neonipple reconstruction. A 49-year-old woman with a history of invasive ductal carcinoma underwent delayed nipple reconstruction after lumpectomy and oncoplastic closure using an inframammary V-Y advancement flap.The nipple reconstruction was performed using pretattoo and articulated tab flaps. A rolled tube of acellular dermal matrix was placed in the central aspect of the neonipple reconstruction for projection. At 4 months postoperative, a screening mammogram and ultrasound noted a new retroareolar mass classified as BIRADS 4 necessitating a breast biopsy. Biopsy revealed portions of fibrous connective tissue consistent with partially incorporated acellular dermal matrix allograft. There was no evidence of malignancy. To mitigate the risk of future radiographic or clinical misinterpretation of ADM in nipple reconstruction, the placement of radiopaque markers such as microclips on the ADM implant could be a useful adjunct. Radiologists and surgeons should include ADM artifact in their differential diagnosis of radiologic imaging when evaluating a new mass in the proximity of prior ADM placement in neonipple reconstruction of the breast.

Clinical applications of acellular dermal matrices: A review

INTRODUCTION

The extracellular matrix (ECM) plays an integral role in wound healing. It provides both structure and growth factors that allow for the organised cell proliferation. Large or complex tissue defects may compromise host ECM, creating an environment that is unfavourable for the recovery of anatomical function and appearance. Acellular dermal matrices (ADMs) have been developed from a variety of sources, including human (HADM), porcine (PADM) and bovine (BADM), with multiple different processing protocols. The objective of this report is to provide an overview of current literature assessing the clinical utility of ADMs across a broad spectrum of applications.

METHODS

PubMed, MEDLINE, EMBASE, Scopus, Cochrane and Web of Science were searched using keywords 'acellular dermal matrix', 'acellular dermal matrices' and brand names for commercially available ADMs. Our search was limited to English language articles published from 1999 to 2020 and focused on clinical data.

RESULTS

A total of 2443 records underwent screening. After removing non-clinical studies and correspondence, 222 were assessed for eligibility. Of these, 170 were included in our synthesis of the literature. While the earliest ADMs were used in severe burn injuries, usage has expanded to a number of surgical subspecialties and procedures, including orthopaedic surgery (e.g. tendon and ligament reconstructions), otolaryngology, oral surgery (e.g. treating gingival recession), abdominal wall surgery (e.g. hernia repair), plastic surgery (e.g. breast reconstruction and penile augmentation), and chronic wounds (e.g. diabetic ulcers).

CONCLUSION

Our understanding of ADM's clinical utility continues to evolve. More research is needed to determine which ADM has the best outcomes for each clinical scenario.

LAY SUMMARY

Large or complex wounds present unique reconstructive and healing challenges. In normal healing, the extracellular matrix (ECM) provides both structural and growth factors that allow tissue to regenerate in an organised fashion to close the wound. In difficult or large soft-tissue defects, however, the ECM is often compromised. Acellular dermal matrix (ADM) products have been developed to mimic the benefits of host ECM, allowing for improved outcomes in a variety of clinical scenarios. This review summarises the current clinical evidence regarding commercially available ADMs in a wide variety of clinical contexts.

Review of Outcomes in Prepectoral Prosthetic Breast Reconstruction with and without Surgical Mesh Assistance

BACKGROUND

In the past decade, surgeons have increasingly advocated for a return to prepectoral breast reconstruction with claims that surgical mesh (including acellular dermal matrix) can reduce complication rates. However, numerous surgical and implant advancements have occurred in the decades since the initial prepectoral studies, and it is unclear whether mesh is solely responsible for the touted benefits.

METHODS

The authors conducted a systematic review of all English language articles reporting original data for prepectoral implant-based breast reconstruction. Articles presenting duplicate data were excluded. Complications were recorded and calculated on a per-breast basis and separated as mesh-assisted, no-mesh prior to 2006, and no-mesh after 2006 (date of first silicone gel-filled breast implant approval). Capsular contracture comparisons were adjusted for duration of follow-up.

RESULTS

A total of 58 articles were included encompassing 3120 patients from 1966 to 2019. The majority of the included studies were retrospective case series. Reported complication outcomes were variable, with no significant difference between groups in hematoma, infection, or explantation rates. Capsular contracture rates were higher in historical no-mesh cohorts, whereas seroma rates were higher in contemporary no-mesh cohorts.

CONCLUSIONS

Limited data exist to understand the benefits of surgical mesh devices in prepectoral breast reconstruction. Level I studies with an appropriate control group are needed to better understand the specific role of mesh for these procedures. Existing data are inconclusive but suggest that prepectoral breast reconstruction can be safely performed without surgical mesh.

Implant Delivery Technique for Prepectoral Reconstruction after Endoscopic-assisted Nipple-sparing Mastectomy

Prepectoral breast reconstruction through a small axillary incision during endoscopic-assisted nipple-sparing mastectomy or robotic nipple-sparing mastectomy is difficult. Cases involving implants covered with an acellular dermal matrix (ADM) are particularly difficult. Therefore, a new delivery technique for ADM-covered implants is needed. The ADM pocket for complete coverage of the implant is made with double-crossed ADMs. The pocket end is open and sutured at the funnel entry. After insetting the ADM pocket at the mastectomy site through an axillary incision, the implant is delivered from a funnel to the ADM pocket by squeezing. Prepectoral breast reconstruction with the new delivery technique for implants covered with ADM pockets proved easy and safe. Our new implant delivery technique could be a good option for prepectoral breast reconstruction after minimal breast surgery.

Biological and synthetic mesh assisted breast reconstruction procedures: Joint guidelines from the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons

These guidelines have been produced with the involvement of the Association of Breast Surgery and the British Association of Plastic, Reconstructive and Aesthetic Surgeons. Recommendations have been derived after a review of published data regarding the use of acellular dermal matrix (ADM), biological and synthetic mesh in breast reconstruction. The guidelines represent a consensus opinion on the optimal management of patients having biological or synthetic mesh assisted breast reconstruction informed by peer-review publications. The Guidelines should be used to inform clinical decision making. Ultimately, members of the MDT remain responsible for the treatment of patients under their care.

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

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

Development of an evidence-based approach to the use of acellular dermal matrix in immediate expander-implant-based breast reconstruction

BACKGROUND

Although acellular dermal matrix (ADM) is widely used in expander-implant-based breast reconstructions, previous analyses have been unable to demonstrate improvements in patient-reported outcomes (PROs) with this approach over non-ADM procedures. This study aims to develop a more selective, evidence-based approach to the use of ADM in expander-implant-based breast reconstruction by identifying patient subgroups in which ADM improved clinical outcomes and PROs.

STUDY DESIGN

The Mastectomy Reconstruction Outcomes Consortium Study prospectively evaluated immediate expander-implant reconstructions at 11 centers from 2012 to 2015. Complications (any/overall and major), and PROs (satisfaction, physical, psychosocial, and sexual well-being) were assessed two years postoperatively using medical records and the BREAST-Q, respectively. Using mixed-models accounting for centers and with interaction terms, we analyzed for differential ADM effects across various clinical subgroups, including age, body mass index, radiation timing, and chemotherapy.

RESULTS

Expander-implant-based breast reconstruction was performed in 1451 patients, 738 with and 713 without ADM. Major complication risk was higher in ADM users vs. nonusers (22.9% vs. 16.4% and p = 0.04). Major complication risk with ADM increased with higher BMI (BMI=30, OR=1.70; BMI=35, OR=2.29, interaction p = 0.02). No significant ADM effects were observed for breast satisfaction, psychosocial, sexual, and physical well-being within any subgroups.

CONCLUSION

In immediate expander-implant-based breast reconstruction, ADM was associated with a greater risk of major complications, particularly in high-BMI patients. We were unable to identify patient subgroups where ADM was associated with significant improvements in PROs. Given these findings and the financial costs of ADM, a more critical approach to the use of ADM in expander-implant reconstruction may be warranted.