Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery

Prepectoral Two-Stage Implant-Based Breast Reconstruction with Poly-4-Hydroxybutyrate for Pocket Control without the Use of Acellular Dermal Matrix: A 4-Year Review

BACKGROUND

Absorbable mesh has been used to mitigate the potential drawbacks of acellular dermal matrix (ADM)-based breast reconstruction. Poly-4-hydroxybutyrate (P4HB) has been demonstrated to be a lower-cost, safe, and effective alternative to ADM in subpectoral breast reconstruction. In this study, the authors used P4HB for pocket control and implant support in immediate two-stage prepectoral breast reconstruction, examining nonintegration, capsular contracture, implant malposition, patient comorbidities, and risk factors.

METHODS

A retrospective review of a single surgeon's (K.M.) experience was performed over a 4-year span for patients who had undergone immediate two-stage prepectoral implant-based breast reconstruction with P4HB mesh. Complications (implant loss, rippling, capsular contracture, and malposition) and patient satisfaction were examined.

RESULTS

From 2018 to 2022, 105 patients underwent breast reconstruction using P4HB mesh on a total of 194 breasts. P4HB mesh integration was 97%. Sixteen breasts (8.2%) experienced minor complications, and 10.3% of devices required explantation, which was significantly higher in the irradiated group at 28.6% ( P < 0.01). Patients who were older, had a higher body mass index, were active smokers, or had an increased mastectomy specimen size were more likely to undergo explantation. The capsular contracture rate and overall lateral malposition rate were 1.0%. Visible rippling was present in 15.6% of breasts. There was no significant difference between smile mastopexy and inferolateral incision with regard to capsular contracture, lateral malposition, and rippling. Overall, patients demonstrated a high level of satisfaction. There were no significant predictors of capsular contracture, lateral malposition, or visible rippling.

CONCLUSIONS

The authors show the safety and efficacy of P4HB in two-stage prepectoral breast reconstruction. There appears to be equal, if not reduced, capsular contracture rates when compared with the published data on ADM. This represents a large cost reduction to both the patient and the health care system.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Histological Assessment Tool for Breast Implant Capsules Validated in 480 Patients with and Without Capsular Contracture

BACKGROUND

Understanding the impact of breast implants on the histological response in the surrounding fibrous capsule is important; however, consensus is lacking on how to analyze implant capsules histologically. We aimed to develop a standardized histological assessment tool to be used in research potentially improving diagnostic accuracy and treatment strategies for capsular contracture.

METHODS

Biopsies of breast implant capsules from 480 patients who had undergone breast augmentation or reconstruction were collected and stained with hematoxylin and eosin. Initially, biopsies from 100 patients were analyzed to select histological parameters demonstrating the highest relevance and reproducibility. Then, biopsies from the remaining 380 patients were used to determine intra- and interobserver agreements of two blinded observers and agreement with a pathologist. Finally, we tested the association between the parameters and capsular contracture.

RESULTS

The histological assessment tool included ten parameters assessing the inflammatory, fibrotic, and foreign-body reaction to breast implants, each graded on two-, three-, or four-point scales. Intra- and interobserver agreements were almost perfect (0.83 and 0.80), and agreement with the pathologist was substantial (0.67). Four parameters were significantly correlated with capsular contracture, namely chronic inflammation with lymphocyte infiltration (p < 0.01), thickness of the collagen layer (p < 0.0001), fiber organization (p < 0.01), and calcification (p < 0.001).

CONCLUSIONS

This is the first validated histological assessment tool for breast implant capsules. The validated tool not only advances our understanding of capsular contracture but also sets a new standard for histological evaluation in breast implant research and clinical diagnostics.

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 .

Systematic Review of Capsular Contracture Management following Breast Augmentation: An Update

BACKGROUND

Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture.

METHODS

A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate.

RESULTS

The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature.

CONCLUSIONS

Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based treatment guidelines. Although more evidence is required to assess the effects of capsulectomy, implant exchange, and plane change, these appear to be useful mechanisms for reducing recurrent capsular contracture. There is more evidence regarding the use of acellular dermal matrix, although this still requires long-term follow-up studies. New developments regarding textured implants limit the revision breast augmentation surgeon to smooth devices.

Extracellular Matrices as Bioactive Materials for In Situ Tissue Regeneration

Bioactive materials based on a nature-derived extracellular matrix (NECM) represent a category of biomedical devices with versatile therapeutic applications in the realms of tissue repair and engineering. With advancements in decellularization technique, the inherent bioactive molecules and the innate nano-structural and mechanical properties are preserved in three-dimensional scaffolds mainly composed of collagens. Techniques such as electrospinning, three-dimensional printing, and the intricate fabrication of hydrogels are developed to mimic the physical structures, biosignalling and mechanical cues of ECM. Until now, there has been no approach that can fully account for the multifaceted properties and diverse applications of NECM. In this review, we introduce the main proteins composing NECMs and explicate the importance of them when used as therapeutic devices in tissue repair. Nano-structural features of NECM and their applications regarding tissue repair are summarized. The origins, degradability, and mechanical property of and immune responses to NECM are also introduced. Furthermore, we review their applications, and clinical features thereof, in the repair of acute and chronic wounds, abdominal hernia, breast deformity, etc. Some typical marketed devices based on NECM, their indications, and clinical relevance are summarized.

Attenuating Chronic Fibrosis: Decreasing Foreign Body Response with Acellular Dermal Matrix

Surgical implants are increasingly used across multiple medical disciplines, with applications ranging from tissue reconstruction to improving compromised organ and limb function. Despite their significant potential for improving health and quality of life, biomaterial implant function is severely limited by the body's immune response to its presence: this is known as the foreign body response (FBR) and is characterized by chronic inflammation and fibrotic capsule formation. This response can result in life-threatening sequelae such as implant malfunction, superimposed infection, and associated vessel thrombosis, in addition to soft tissue disfigurement. Patients may require frequent medical visits, as well as repeated invasive procedures, increasing the burden on an already strained health care system. Currently, the FBR and the cells and molecular mechanisms that mediate it are poorly understood. With applications across a wide array of surgical specialties, acellular dermal matrix (ADM) has emerged as a potential solution to the fibrotic reaction seen with FBR. Although the mechanisms by which ADM decreases chronic fibrosis remain to be clearly characterized, animal studies across diverse surgical models point to its biomimetic properties that facilitate decreased periprosthetic inflammation and improved host cell incorporation. Impact Statement Foreign body response (FBR) is a significant limitation to the use of implantable biomaterials. Acellular dermal matrix (ADM) has been observed to decrease the fibrotic reaction seen with FBR, although its mechanistic details are poorly understood. This review is dedicated to summarizing the primary literature on the biology of FBR in the context of ADM use, using surgical models in breast reconstruction, abdominal and chest wall repair, and pelvic reconstruction. This article will provide readers with an overarching review of shared mechanisms for ADM across multiple surgical models and diverse anatomical applications.

Do we need acellular dermal matrix in prepectoral breast reconstruction? A systematic review and meta-analysis

Acellular dermal matrices (ADMs) are commonly used in prepectoral breast reconstruction. However, ADM is associated with high cost and potentially infection and seroma. Comparative studies on prepectoral reconstruction with and without ADM are limited to small, single-institution series. The purpose of this study was to perform a meta-analysis of prepectoral reconstruction with and without ADM. A systematic literature review was performed to identify studies comparing prepectoral reconstruction with and without ADM using PubMed, EMBASE, and Cochrane databases. Pooled rates of patient demographics and outcomes were analyzed. Meta-analytic effect size estimates were calculated for reconstructive complications in studies comparing reconstruction with and without ADM. In total, 515 reconstructions from four studies were included. Most cases were nipple-sparing mastectomies and utilized tissue-expander reconstructions. Meta-analysis demonstrated no significant difference in the rate of complications between cohorts with and without ADM. Short-term complications included reconstructive failure (1.2% in ADM cohort and 2.8% in no-ADM), seroma (1.2% and 8.3%, respectively), hematoma (1.2% and 2.1%), infection (4.7% and 4.2%), and mastectomy flap ischemia and/or necrosis (2.4% and 5.2%). Long-term complications included rippling (3.3% in ADM and 5.1% in no-ADM cohorts) and capsular contracture (6.8% and 3.4%, respectively). This meta-analysis demonstrated no difference in the rate of complications between cases with and without ADM. However, the outcomes data from no-ADM reconstruction mostly reflect robust mastectomy flaps. Surgeon discretion as informed by specific clinical scenarios should guide decisions regarding the use of ADM in prepectoral breast reconstruction.

How Porcine Acellular Dermal Matrix Influences the Development of the Breast Capsule 1 Year after Implantation: A Histopathological Analysis

Background

In prepectoral breast reconstruction (PPBR) the acellular dermal matrix (ADM)'s integration capacity into the tissue is known. The aim of this study was to analyze the effect of the ADM on development and composition of the peri-implant breast capsule in a dynamic setting of breast tissue expansion during two-stage prepectoral breast reconstruction.

Methods

This is a prospective single-center study in which 50 patients who underwent mastectomy and breast reconstruction with prepectoral tissue expander and Braxon ADM (group A) and submuscular tissue expander (group B) were enrolled. One-year post implantation hematoxylin & eosin (H&E) staining and immunohistochemistry analyses were done on capsule tissue samples.

Results

The analysis conducted on H&E-stained samples showed a significant reduction of cellular density and a decrease of the cellular infiltration in capsules of ADM-covered expanders compared with naked expander capsules (P < 0.05). The immunohistochemical analyses showed that group A capsules presented significantly less M1 CD68+ macrophages (P < 0.05), lower alfa-SMA expression levels, and a lower number of myofibroblasts (P < 0.05) compared with group B capsules. Presence of lymphatic vessels was minimally detected in both groups.

Conclusions

The ADM presence around the prepectoral tissue expander influences the development of the peri-implant capsule, causing a significant reduction of the number of cells and inflammatory infiltrate, especially M1 macrophages and myofibroblasts. The ADM Braxon is therefore effective in creating a noninflamed capsule around the implant and in dynamic tissue conditions, and such an environment is maintained in time.

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.

Long-Term Ultrasonographic and Histologic Changes in Acellular Dermal Matrix in Implant-Based Breast Reconstructions

BACKGROUND

Acellular dermal matrix (ADM) is composed of extracellular matrix (ECM) and is widely used in implant-based breast reconstructions. However, long-term changes in the ADM around implants have not been established. This study aimed to investigate long-term changes in the ADM covering breast implants using serial ultrasound and histologic evaluations.

METHODS

The authors evaluated the ultrasound results of 145 patients who underwent implant-based breast reconstructions with ADM coverings. The ultrasound results obtained within 18 months of surgery and those obtained 5 years postoperatively were analyzed to determine the change in ADM thickness. For histologic analysis, the ADM was harvested from 30 patients who underwent secondary breast surgery. Histologic features of the ECM and cellular components within the ADM were compared at specific intervals from ADM implantation and the second operation (early ADM group, <18 months; late ADM group, >5 years postoperatively).

RESULTS

The ADM thickness on ultrasound examination was significantly decreased in the late ADM group compared with that in the early ADM group ( P < 0.001). Histologic analyses revealed that the late ADM group had less thickness with lower ECM levels versus the early ADM group. Increased infiltration of host cells, such as vascular endothelial cells, myofibroblasts, and immune cells, occurred in the late ADM group.

CONCLUSIONS

Implanted ADMs underwent gradual thinning over time, in addition to ECM reduction and infiltration of host cells. These findings are useful in understanding the natural course of ADMs currently used in implant-based breast reconstructions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Incubation with porcine urinary bladder matrix yields a late-stage wound transcriptome in endothelial cells and keratinocytes isolated from both diabetic and non-diabetic subjects

Proper wound closure requires the functional coordination of endothelial cells (ECs) and keratinocytes. In the late stages of wound healing, keratinocytes become activated and ECs promote the maturation of nascent blood vessels. In diabetes mellitus, decreased keratinocyte activation and impaired angiogenic action of ECs delay wound healing. Porcine urinary bladder matrix (UBM) improves the rate of wound healing, but the effect of exposure to UBM under diabetic conditions remains unclear. We hypothesized that keratinocytes and ECs isolated from both diabetic and non-diabetic donors would exhibit a similar transcriptome representative of the later stages of wound healing following incubation with UBM. Human keratinocytes and dermal ECs isolated from non-diabetic and diabetic donors were incubated with and without UBM particulate. RNA-Seq analysis was performed to identify changes in the transcriptome of these cells associated with exposure to UBM. While diabetic and non-diabetic cells exhibited different transcriptomes, these differences were minimized following incubation with UBM. ECs exposed to UBM exhibited changes in the expression of transcripts suggesting an increase in the endothelial-mesenchymal transition (EndoMT) associated with vessel maturation. Keratinocytes incubated with UBM demonstrated an increase in markers of activation. Comparison of the whole transcriptomes with public datasets suggested increased EndoMT and keratinocyte activation following UBM exposure. Both cell types exhibited loss of pro-inflammatory cytokines and adhesion molecules. These data suggest that application of UBM may accelerate healing by promoting a transition to the later stages of wound healing. This healing phenotype is achieved in cells isolated from both diabetic and non-diabetic donors.

Implant-Based Breast Reconstruction after Risk-Reducing Mastectomy in BRCA Mutation Carriers: A Single-Center Retrospective Study

Women with BRCA gene mutations have a higher lifetime risk of developing breast cancer. Furthermore, cancer is usually diagnosed at a younger age compared to the wild-type counterpart. Strategies for risk management include intensive surveillance or risk-reducing mastectomy. The latter provides a significant reduction of the risk of developing breast cancer, simultaneously ensuring a natural breast appearance due to the preservation of the skin envelope and the nipple-areola complex. Implant-based breast reconstruction is the most common technique after risk-reducing surgery and can be achieved with either a submuscular or a prepectoral approach, in one or multiple stages. This study analyzes the outcomes of the different reconstructive techniques through a retrospective review on 46 breasts of a consecutive, single-center case series. Data analysis was carried out with EpiInfo version 7.2. Results of this study show no significant differences in postoperative complications between two-stage tissue expander/implant reconstruction and direct-to-implant (DTI) reconstruction, with DTI having superior aesthetic outcomes, especially in the prepectoral subgroup. In our experience, the DTI prepectoral approach has proven to be a safe and less time-consuming alternative to the submuscular two-stage technique, providing a pleasant reconstructed breast and overcoming the drawbacks of subpectoral implant placement.

Single Stitch Vicryl Mesh Wrap for Prepectoral Implant Breast Reconstruction

Acellular dermal matrices are commonly used in prepectoral breast reconstruction for implant coverage and support, but they are associated with significant costs. The authors describe a technique for prepectoral breast reconstruction in which the implant is completely wrapped in a knitted Vicryl mesh and then positioned on the chest, without the need for any tacking sutures. A retrospective review was performed on all consecutive prepectoral breast reconstructions, using this technique at a single institution. A separate cohort undergoing prepectoral reconstruction with a conventional acellular dermal matrix technique was also reviewed for comparison. Patient demographics, oncologic and reconstruction characteristics, outcomes, complications, and materials cost were analyzed. Twelve patients (23 breasts) underwent prepectoral reconstruction with Vicryl mesh, and 34 patients (55 breasts) underwent prepectoral reconstruction with acellular dermal matrices. Overall complication rates in the Vicryl group were low (two infections, one case of skin necrosis, one hematoma) and did not differ statistically from the acellular dermal matrix group. Operative time per breast was nearly twice as fast (35.7 versus 68.0 min, P < 0.01). Calculated materials cost savings was $8273 per breast. Prepectoral breast reconstruction with Vicryl mesh only is a safe technique that is much faster and significantly cheaper compared with conventional reconstructive techniques utilizing acellular dermal matrices.

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.

Postoperative Complications Following Prepectoral Versus Partial Subpectoral Implant-Based Breast Reconstruction Using ADM: A Systematic Review and Meta-analysis

BACKGROUND

There is a paucity of evidence comparing the safety of prepectoral and partial subpectoral implant-based breast reconstruction using acellular dermal matrices (ADM). We performed a meta-analysis to evaluate the postoperative complications of the two approaches.

METHODS

PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The rates of the complications were, respectively, pooled, and relative risk (RR) was estimated with 95% confidence intervals (CIs) to compare the incidence between the two cohorts.

RESULTS

Ten articles reporting on 2667 breast reconstructions were eligible. The hematoma rate was lower in the prepectoral group (RR  =  0.590, 95% CI 0.351-0.992). No significant difference was observed in terms of seroma (RR = 1.079, 95% CI 0.489-2.381), skin flap necrosis (RR = 0.936, 95% CI 0.587-1.493), infection (RR = 0.985, 95% CI 0.706-1.375), tissue expander/implant explantation (RR  =  0.741, 95% CI 0.506-1.085), wound dehiscence (RR = 1.272, 95% CI 0.605-2.673), capsular contracture (RR = 0.939, 95% CI 0.678-1.300) and rippling (RR = 2.485, 95% CI 0.986-6.261). The RR of animation deformity for the prepectoral group compared with the subpectoral group was 0.040 (95% CI, 0.002-0.853).

CONCLUSIONS

This systematic review suggested that with appropriate patient selection, prepectoral breast reconstruction could avoid animation deformity without incurring higher risk of early wound complications, capsular contracture or rippling than partial subpectoral breast reconstruction. Plastic surgeons should complete a comprehensive assessment of the patients before choosing appropriate surgical approaches in clinical practice.

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 .

Braxon®-assisted prepectoral breast reconstruction: A decade later

We are sitting on the cusp of the bioengineered breast era, in which implant-based breast reconstruction is seeing a growing trend and biotechnology research progressively empowers clinical practice. As never before, the choice of biomaterials has acquired great importance for achieving reconstructive outcomes, and the increase in the use of acellular dermal matrices (ADMs) in the field of senology tells us a story of profound upheaval and progress. With the advent of prepectoral breast reconstruction (PPBR), plenty of devices have been proposed to wrap the silicone prosthesis, either completely or partially. However, this has caused a great deal of confusion and dissent with regard to the adoption of feasible reconstructive strategies as well as the original scientific rationale underlying the prepectoral approach. Braxon^® is the very first device that made prepectoral implant positioning possible, wrapping around the prosthesis and exerting the proven ADM regenerative potential at the implant–tissue interface, taking advantage of the body's physiological healing mechanisms. To date, the Braxon^® method is among the most studied and practiced worldwide, and more than 50 publications confirm the superior performance of the device in the most varied clinical scenarios. However, a comprehensive record of the working of this pioneering device is still missing. Therefore, our aim with this review is to lay a structured knowledge of surgery with BRAXON^® and to provide a decision-making tool in the field of PPBR through a complete understanding on the very first device for prepectoral, one decade after its introduction.

Comparison of Cromolyn Sodium, Montelukast, and Zafirlukast Prophylaxis for Capsular Contracture

BACKGROUND

Capsular contracture is the most common complication following breast augmentation. Recently, prophylaxis studies aiming to inhibit the release of profibrotic substances to prevent capsular contracture have gained in importance. This study investigated the effects of cromolyn sodium, montelukast, and zafirlukast on capsular contracture in a rat model.

METHODS

Thirty female Wistar albino rats were randomly divided into five groups: control, sham, cromolyn sodium, montelukast, and zafirlukast. Intraperitoneal injections were administered daily to the sham (1 ml per day), cromolyn sodium (10 mg/kg per day), montelukast (10 mg/kg per day), and zafirlukast (1.25 mg/kg per day) groups 1 month before surgery. Miniature breast implants were then placed on the backs of the rats in each group. Injections were continued for the next 3 months. The rats were subsequently killed, and the capsules were harvested and assessed histopathologically. The histopathologic outcomes were acute inflammation status, inflammation severity, synovial metaplasia, foreign body reaction, mast cell count, and capsular thickness.

RESULTS

The cromolyn sodium, montelukast, and zafirlukast groups had less acute inflammation and lower mean inflammation severity scores, foreign body reaction occurrence, mast cell counts, and capsular thickness than the control and sham groups ( p < 0.05). These parameters were better in the cromolyn sodium group than in the montelukast and zafirlukast groups ( p < 0.05).

CONCLUSIONS

Cromolyn sodium appears to inhibit capsular contracture more efficiently than montelukast and zafirlukast. This report may be a pioneer study for the prophylactic use of cromolyn sodium in capsular contracture.

CLINICAL RELEVANCE STATEMENT

The prophylactic administration of cromolyn sodium appears to reduce capsular contracture more efficiently than that of montelukast and zafirlukast. This report might constitute a pioneer study for the prophylactic use of cromolyn sodium in capsular contracture.

Biological Cover Mitigates Disruption of the Dermal Structure in Mechanically Expanded Skin in a Porcine Model

Tissue expansion is an integral procedure of the vast majority of breast reconstruction and has a significant impact on the final clinical outcomes. Therefore, technological advances leading to a fewer number of unfavorable outcomes and a decrease in complication rates are imperative. In this study, using a porcine model, we investigated an effect of acellular dermal matrix (ADM) used as a tissue expander cover on the dermal changes induced by mechanical forces during tissue expansion. After 14 days of expansion, skin samples were collected from one animal, while the second animal underwent radiation, and tissue was collected 8 weeks later. Tissue expanded without the use of ADM and unexpanded skin served as the controls. Collected skin biopsies were used for histological and immunohistochemical evaluation, and for gene expression analysis. We revealed that the biological cover incorporation into host tissue is facilitated by macrophages without inducing a broad inflammatory response. The utilization of ADM mitigated disruption in the dermal structure, excessive collagen deposition, and capsule formation in non-irradiated expanded skin. The protective effect was not fully maintained in irradiated skin. These results demonstrate that tissue expansion might be improved by using the tissue expander cover.

Acellular Dermal Matrix Favorably Modulates the Healing Response after Surgery

SUMMARY

When first described for breast reconstruction, the presence of acellular dermal matrices (ADM) was associated with increased seroma formation and infection. However, clinical safety data has gradually improved with surgeon experience to an acceptable outcomes profile of ADM-assisted reconstruction when compared to submuscular implant coverage. In fact, ADM use potentially decreases capsular contracture rates and facilitates expansion for staged pre-pectoral breast reconstruction. Due to new regulatory requirements, the collection of unbiased, well-powered pre-market approval data summarizing long-term clinical outcomes will be essential over the coming years to understand the clinical performance of ADM usage in breast reconstruction.Currently, we can highlight the physiologic benefits of ADM use in breast reconstruction by evaluating the components of surgical wound healing that are favorably augmented by the implanted collagen substrate. ADM takes advantage of the wound healing cascade to incorporate into the patient's tissues - a process that requires a coordinated inflammatory infiltrate and angiogenesis. The presence of ADM augments and modulates the wound healing process to its advantage by simultaneously increasing the invasion of appropriate cellular constituents to facilitate expeditious healing and accelerate angiogenesis. Herein, we summarize the wound healing literature to demonstrate the mechanisms ADM use to biointegrate and the literature in which cellular constituents and soluble growth factors are upregulated in the presence of ADM. Lastly, we use our experimental observations of ADM incorporation to corroborate the literature.

Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy

BACKGROUND

Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT.

METHODS

We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted.

RESULTS

We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events.

CONCLUSIONS

Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.

Complete Implant Wrapping with Porcine-Derived Acellular Dermal Matrix for the Treatment of Capsular Contracture in Breast Reconstruction: A Case-Control Study

Background

Capsular contracture (CC) represents one of the most common complications in breast reconstruction surgery, impairing final result and patients’ well-being. The role of acellular dermal matrixes (ADM) has been widely described for the treatment and prevention of contracture. The aim of the study was to evaluate the efficacy and safety of complete implant coverage with porcine-derived ADM in preventing CC limiting complications. In addition, patients’ reported outcomes were evaluated in order to define the role of ADM in improving sexual, physical and psychosocial well-being and satisfaction.

Methods

42 patients who underwent surgical treatment of 46 contracted reconstructed breasts from May 2018th to May 2019th were collected in the two groups (ADM group vs. Control group).

Results

The ADM group showed lower rate of CC recurrence and a higher rate of implant losses and minor complications. A significant difference was observed in red breast syndrome (27.3% in the ADM group vs. absent in control the group) and skin ulceration rates (18.2% in the ADM group vs. 4.18% in the control group). As for patients’ perceived outcomes, the ADM group showed a statistically significant higher postoperative Satisfaction of Breast Scale score compared to the control group. In addition, a significant difference was observed in the improvement of Physical Well-Being of the Chest Scale and the Satisfaction of Breast Scale after surgery, in favor to the ADM group.

Conclusion

Complete implant coverage with ADM may reduce the risk of CC recurrence in breast reconstruction. An accurate patient selection allows minimizing complications improving patient well-being and satisfaction.

Level of Evidence IV

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.

A Comparative Study of Breast Sensibility and Patient Satisfaction After Breast Reconstruction: Autologous, 2-Stage Implant-Based, and Prepectoral Direct-to-Implant Reconstruction

BACKGROUND

Currently, a variety of treatment modalities are implemented for breast reconstruction. However, clinical prognosis regarding sensory regeneration of the breast and patient-reported satisfaction remains underexamined. In this study, we aimed to compare breast sensibility after various reconstruction.

METHODS

We conducted a retrospective comparative study of all patients who underwent breast reconstruction between August 2016 and October 2019 at our institution. Acellular dermal matrixes were used to cover the implant inferolaterally in a dual-plane subpectoral approach and to wrap the implant in prepectoral direct to implant (DTI). The cutaneous tactile pressure threshold and patient satisfaction outcome were tested.

RESULTS

A total of 105 breasts were assessed, 30 breasts reconstructed with deep inferior epigastric perforator (DIEP) flap, 40 breasts reconstructed with 2-stage subpectoral implant, and 35 breasts reconstructed with prepectoral DTI. In the specific group-to-group analysis, DIEP and implant groups showed significant differences in sensory recovery, mainly in lateral areas of the reconstructed breast. In 2-stage reconstruction and DTI groups, there were no statistically significant differences. When comparing patient groups using only patients with follow-up lengths of more than 12 months, the difference was more clearly indicated (P = 0.049). Better sensory recovery predicted high satisfaction scores in patient-reported outcomes (P = 0.007).

CONCLUSIONS

We found that subpectoral implant reconstruction and DTI show no statistically significant differences in sensory recovery, and autologous DIEP flap reconstruction results in a better prognosis than prosthesis implant reconstruction. Furthermore, the clarity of the differences increased when the follow-up length was longer than 12 months. Better patient-reported satisfaction was associated with good breast sensibility.

A systematic review and meta-analysis on the prepectoral single-stage breast reconstruction

BACKGROUND

The use of acellular dermal matrices (ADMs) and mesh reopened the possibility for the prepectoral single-stage breast reconstruction (PBR). The complications of single-stage breast reconstruction after PRB are controversial. We conducted a systematic review and meta-analysis of the impact of implant plane on single-stage breast reconstruction. Our aim was to evaluate the different postoperative complications between patients receiving prepectoral breast reconstruction and subpectoral breast reconstruction (SBR) on single-stage breast reconstruction.

METHODS

A comprehensive research on databases including PubMed, Embase, and Cochrane libraries was performed to retrieve literature evaluating the effect of implant plane on single-stage breast reconstruction from 2010 to 2020. All included studies were evaluated the complications after single-stage breast reconstruction. Only studies comparing patients who underwent prepectoral reconstruction with a control group who underwent subpectoral reconstruction were included.

RESULTS

A total of 13 studies were included in the meta-analysis, with a total of 1724 patients. In general, compared with SBR group, the PBR significantly reduced the risk of total complications (including seroma, hematoma, necrosis, wound dehiscence, infection, capsular contraction, implant loss/remove, and rippling) after single-stage breast reconstruction (OR: 0.54, 95% CI: 0.44-0.67, p < 0.001). Compared with the SBR group, the PBR had remarkably decreased capsular contracture (OR: 0.40, 95% CI: 0.27-0.58, p < 0.001) and postoperative infection (OR: 0.58, 95% CI: 0.36-0.95, p = 0.03).

CONCLUSION

The PBR is a safe single-stage breast reconstruction with fewer postoperative complications. It is an alternative surgical method for SBR.

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.

Histological Analyses of Capsular Contracture and Associated Risk Factors: A Systematic Review

BACKGROUND

Capsular contracture is a severe complication to breast surgery with implants. Previous studies suggest multiple risk factors are associated with capsular contracture, but the etiology is still unknown. We performed a literature review to investigate existing studies on histological analyses of breast implant capsules and how clinical risk factors impact the capsule morphology.

METHODS

The literature search was conducted in PubMed. Studies that performed histological analyses of breast implant capsules were included. Animal studies or studies with a study population of less than five patients were excluded.

RESULTS

Fifty-two studies were included. The histological analyses showed that the breast implant capsules were organized in multiple layers with an inner layer of synovial-like metaplasia which was reported to diminish in capsules with capsular contracture. The remaining layers of the capsule mostly consisted of collagen. The alignment of the collagen fibers differed between contracted and non-contracted capsules, and capsules with higher Baker grade were generally thickest and contained more tissue inflammation. Studies investigating capsules affected by radiotherapy found a more pronounced inflammatory response and the capsules were generally thicker and fibrotic compared with nonirradiated capsules.

CONCLUSIONS

The included studies offer valuable insights into the histological changes caused by capsular contracture and their relation to clinical risk factors. Further studies with larger sample sizes and more strict inclusion criteria are needed to further investigate implant capsules and the role of the synovial-like metaplasia for the development of capsular contracture.

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 https://www.springer.com/00266 .

Tissue Expansion after Non-Skin-Sparing Mastectomy: A Comparative Study of Expansion Courses of Prepectoral and Subpectoral Tissue Expander Placement with Acellular Dermal Matrix

Although skin- or nipple-sparing mastectomy has been popular in the treatment of breast cancer, the radical excision of breast tissue is unavoidable in certain circumstances. However, the ability of an acellular dermal matrix (ADM) to expand remains questionable, and this situation may further hinder tissue expansion. From October 2017 to January 2020, patients who underwent immediate breast reconstruction with tissue expander placement using ADM whose initial fill volume was less than 50 mL were retrospectively reviewed. The primary outcomes were the number of visits and number of days required to complete the expansion, and the secondary outcomes were the amount of postoperative expansions, expander fill ratio and expander volume. Between the prepectoral group (n = 26) and subpectoral group (n = 39), the mean number of days (81.46 days versus 88.64 days, p = 0.365) and mean number of visits (5.08 versus 5.69, p = 0.91) required to complete expansion exhibited no significant differences. Additionally, there were no significant differences in the mean amount of postoperative expansion (314.23 mL versus 315.38 mL, p = 0.950), the mean final volume (353.08 mL versus 339.62 mL, p = 0.481) or the mean final volume ratio (0.89 versus 0.86, p = 0.35) between the two groups. Therefore, we suggest that prepectoral tissue expander placement after conventional mastectomy can be a valid option.

Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management

Over 400,000 women in the United States alone will have breast implant surgery each year. Although capsular contracture represents the most common complication of breast implant surgery, surgeons continue to debate the precise etiology. General agreement exists concerning the inflammatory origin of capsular fibrosis, but the inciting events triggering the inflammatory cascade appear to be multifactorial, making it difficult to predict why one patient may develop capsular contracture while another will not. Accordingly, researchers have explored many different surgical, biomaterial, and medical therapies to address these multiple factors in an attempt to prevent and treat capsular contracture. In the current paper, we aim to inform the reader on the most up-to-date understanding of the pathophysiology, prevention, and treatment of capsular contracture.

Understanding the Evidence and Improving Outcomes with Implant-Based Prepectoral Breast Reconstruction

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of prepectoral breast reconstruction. 2. Have knowledge of primary immediate and delayed prepectoral breast reconstruction techniques and secondary procedures required. 3. Describe data on outcomes of prepectoral breast reconstruction.

SUMMARY

Once considered to have an unacceptable complication profile, prepectoral breast reconstruction is increasing in popularity because of decreased surgical invasiveness and postoperative pain and the absence of animation deformity. Short-term outcomes studies comparing prepectoral breast reconstruction to partially submuscular techniques demonstrate similarly acceptable rates of postoperative complications. Aesthetic outcomes demonstrate similar rates of capsular contracture but increased rippling and implant palpability of the upper pole. Postoperative functional data are limited but overall show decreased pain and more rapid return of function but equivalent satisfaction on the BREAST-Q. Long-term aesthetic data and rates of revision are lacking.

Do We Need Support in Prepectoral Breast Reconstruction? Comparing Outcomes with and without ADM

Background:

The majority of two-stage prepectoral breast reconstruction has been described utilizing acellular dermal matrix (ADM). Although reports of prepectoral breast reconstruction without ADM exist, there is a paucity of comparative studies.

Methods:

A single-institution retrospective review was performed of consecutive patients undergoing immediate prepectoral two-stage breast reconstruction with tissue expanders from 2017 to 2019. Short-term reconstructive and aesthetic complications were compared between cases that utilized ADM for support and those that did not.

Results:

In total, 76 cases (51 patients) were identified, of which 35 cases utilized ADM and 41 did not. Risk factors and demographics were similar between the two cohorts with the exception of body mass index, which was higher in the ADM cohort (29.3 versus 25.4, P = 0.011). Average follow-up length was also longer in patients who received ADM (20.3 versus 12.3 months, P < 0.001). Intraoperative expander fill was higher in patients who did not receive ADM (296.8 cm³ versus 151.4 cm³, P < 0.001) though final implant size was comparable in both cohorts (P = 0.584). There was no significant difference in the rate of any complication between the ADM and no ADM cohorts (25.7% versus 17.1%, respectively P = 0.357), including major mastectomy flap necrosis (P = 0.245), major infection (P = 1.000), seroma (P = 0.620), expander explantation (P = 1.000), capsular contracture (P = 1.000), implant dystopia (P = 1.000), and rippling (P = 0.362).

Conclusions:

Immediate two-stage prepectoral breast reconstruction with tissue expanders has comparable rates of short-term complications with or without ADM support. Safety of prepectoral expander placement without ADM may warrant more selective ADM use in these cases.

Splitting the Difference: Using Synthetic and Biologic Mesh to Decrease Cost in Prepectoral Immediate Implant Breast Reconstruction

SUMMARY

Prepectoral breast reconstruction has minimized morbidity and dynamic deformities associated with submuscular implant-based breast reconstruction. However, reliance on implant coverage with acellular dermal matrix in immediate implant reconstruction remains limited by high material costs. The authors describe a technique in which anterior implant coverage in prepectoral reconstruction is split into acellular dermal matrix inferolaterally and synthetic, absorbable mesh superiorly. Use of acellular dermal matrix inferiorly provides coverage and reinforces the inframammary fold, whereas the absorbable mesh is trimmed and sutured to the acellular dermal matrix at the appropriate tension to support the implant and relieve pressure on mastectomy flaps. A retrospective review was performed on all consecutive prepectoral one-stage breast reconstructions using this technique at a single institution. Patient demographics, mastectomy and reconstruction characteristics, reconstructive outcomes, and cost of support materials were queried and analyzed. Eleven patients (21 breasts) underwent prepectoral immediate implant reconstruction with Vicryl and acellular dermal matrix anterior coverage. Average mastectomy weight was 775.8 g. Smooth, round cohesive implants were used in all cases and average implant size was 514.5 ml. Overall complication rates were low and included one minor infection (4.8 percent) and one case of minor mastectomy flap and partial nipple necrosis each (4.8 percent). Calculated cost savings of Vicryl and acellular dermal matrix anterior coverage was up to $3415 in unilateral and $6830 in bilateral cases. Prepectoral breast reconstruction using acellular dermal matrix inferiorly and Vicryl mesh superiorly is a safe technique that decreases material costs associated with support materials and allows the surgeon to precisely control the implant pocket and position.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options

Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.

Applying Principles of Breast Revision to Managing Aesthetic Patients with Textured Implants

SUMMARY

Textured breast implants have garnered increased attention recently because of their risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), an uncommon and treatable type of T-cell lymphoma. Treatment involves bilateral en bloc capsulectomy, which is curative in the majority of cases. At present, there is no defined management approach for aesthetic patients asymptomatic for BIA-ALCL requesting the removal of their textured implants, particularly as it relates to the management of the capsule. It is unclear if en bloc capsulectomy is necessary in these patients as it is in patients with BIA-ALCL. In the absence of clear guidance on the management of the capsule in asymptomatic patients, the basic principles of breast revision surgery can be applied to these patients.

Capsulectomy, Implant Exchange, and Placement of Acellular Dermal Matrix Is Effective in Treating Capsular Contracture in Breast Augmentation Patients

BACKGROUND

Capsular contracture is a common complication of breast augmentation surgery and many techniques to prevent and treat it have been suggested with inconsistent or variably effective results.

OBJECTIVES

The aim of this paper was to describe a protocol for treating established capsular contracture after breast augmentation with a low recurrence rate.

METHODS

From January 2009 to December 2012, 79 previous bilateral breast augmentation patients presented for treatment of established capsular contracture. There were 135 breasts with capsular contracture: 56 were bilateral and 23 were unilateral. Ten patients opted for no treatment; 2 patients opted for implant removal. Twenty-four were treated with the ICES (implant exchange, capsulectomy, and possible exchange of site) protocol and 43 were treated with the SPICES (Strattice placement in the reconstructive position, implant exchange, capsulectomy, and possible exchange of site) protocol.

RESULTS

The 24 patients treated with the ICES protocol had a recurrent capsular contracture rate of 15%. The 43 patients treated with the SPICES protocol had a 2.7% recurrent capsular contracture incidence and an 2.7% complication rate.

CONCLUSIONS

Capsular contracture after breast augmentation, whether primary or recurrent, can be successfully treated with the SPICES protocol.

LEVEL OF EVIDENCE: 4

Epidemiology and Prevention of Breast Prosthesis Capsular Contracture Recurrence

INTRODUCTION

Baker grade III and IV breast prosthesis capsular contractures represent a major problem for patients undergoing mammoplasties. The risk factors involved in recurrence are debated, and the best surgical approach for their prevention is not established. The objective was to identify these.

MATERIALS AND METHODS

We carried out a retrospective study of patients operated on for capsular contracture at the Saint-Louis Hospital in Paris from 2012 to 2014. The characteristics at inclusion were compared so as to determine the risk factors of recurrence. The surgical approaches were compared between the patients with recurrence and those without at 5 years.

RESULTS

Of the 100 patients included, 24 had a recurrence. The minimal follow-up was 5 years. No risk factors of recurrence of capsular contracture were identified. The surgical approach associated with the lowest rate of recurrence was anterior capsulectomy [OR total capsulectomy = 2.36 (0.73; 8.037) OR capsulotomy = 4.33 (1.37; 14.81)] (p < 0.040) with alteration of the volume of the implant, whether greater or less than initially [OR greater volume = 0.30 (0.096; 0.83); OR smaller volume = 0.14 (0.008; 0.85)] (p < 0.018).

CONCLUSION

The occurrence of capsular contracture is a major problem with prosthetic breast surgery. The main risk factors identified to date are essentially in regard to the occurrence of a first episode. No significant risk factors for recurrence were identified. The best prevention appears to be an anterior capsulectomy with reducing the volume of the implant.

LEVEL OF EVIDENCE IV

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 . IV.

Comparison of irradiated and non-irradiated acellular dermal matrices in breast reconstruction under radiotherapy

Background

Acellular dermal matrices (ADMs) have become an essential material for implant-based breast reconstruction. No previous studies have evaluated the effects of sterility of ADM under conditions of radiation. This study compared sterile (irradiated) and aseptic (non-irradiated) ADMs to determine which would better endure radiotherapy.

Methods

Eighteen male Balb/C mice were assigned to the control group with no irradiation (group 1) or one of two other groups with a radiation intensity of 10 Gy (group 2) or 20 Gy (group 3). Both sterile and aseptic ADMs were inserted into the back of each mouse. The residual volume of the ADM (measured using three-dimensional photography), cell incorporation, α-smooth muscle actin expression, and connective tissue growth factor expression were evaluated. The thickness and CD3 expression of the skin were measured 4 and 8 weeks after radiation.

Results

In groups 2 and 3, irradiated ADMs had a significantly larger residual volume than the non-irradiated ADMs after 8 weeks (P<0.05). No significant differences were found in cell incorporation and the amount of fibrosis between irradiated and non-irradiated ADMs. The skin was significantly thicker in the non-irradiated ADMs than in the irradiated ADMs in group 3 (P<0.05). CD3 staining showed significantly fewer inflammatory cells in the skin of irradiated ADMs than in non-irradiated ADMs in all three groups after 4 and 8 weeks (P<0.05).

Conclusions

Under radiation exposure, irradiated ADMs were more durable, with less volume decrease and less deposition of collagen fibers and inflammatory reactions in the skin than in non-irradiated ADMs.

Tissue Expander-Based Breast Reconstruction in the Prepectoral Versus Subpectoral Plane: An Analysis of Short-Term Outcomes

BACKGROUND

Breast reconstruction is becoming an increasingly important and accessible component of breast cancer care. We hypothesize that prepectoral patients benefit from lower short-term complications and shorter periods to second-stage reconstruction compared with individuals receiving reconstruction in the subpectoral plane.

METHODS

An institutional review board-approved retrospective review of all adult postmastectomy patients receiving tissue expanders (TEs) was completed for a 21-month period (n = 286).

RESULTS

A total of 286 patients underwent mastectomy followed by TE placement, with 59.1% receiving prepectoral TEs and 40.9% receiving subpectoral TEs. Participants receiving prepectoral TEs required fewer clinic visits before definitive reconstruction (6.4 vs 8.8, P <0.01) and underwent definitive reconstruction 71.6 days earlier than individuals with subpectoral TE placement (170.8 vs 242.4 days, P < 0.01). Anesthesia time was significantly less for prepectoral TE placement, whether bilateral (68.0 less minutes, P < 0.01) or unilateral (20.7 minutes less, P < 0.01). Operating room charges were higher in the prepectoral subgroup ($31,276.8 vs $22,231.8, P < 0.01). Partial necrosis rates were higher in the prepectoral group (21.7% vs 10.9%, P < 0.01).

CONCLUSIONS

Patients undergoing breast reconstruction using prepectoral TE-based reconstruction benefit from less anesthesia time, fewer postoprative clinic visits, and shorter time to definitive reconstruction, at the compromise of higher operating room charges.

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

Background

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

Methods

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

Results

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

Conclusions

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

Complication Rate of Prepectoral Implant-based Breast Reconstruction Using Human Acellular Dermal Matrices

Implant-based breast reconstruction (IBR) is currently the most frequently performed reconstructive technique post mastectomy. Even though submuscular IBR continues to be the most commonly used technique, mastectomy technique optimization, the possibility to check skin viability with indocyanine green angiography, the enhanced propensity of patients undergoing prophylactic mastectomies, and the introduction of acellular dermal matrices (ADMs) have paved the way to the rediscovery of the subcutaneous reconstruction technique. The aim of this article is to update the complication rate of immediate and delayed prepectoral IBR using human ADMs (hADMs).

METHODS

A literature search, using PubMed, Medline, Cochrane, and Google Scholar database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was conducted to evaluate complication rates of prepectoral implant-based reconstructions using hADMs. The following MeSH terms were used: "prepectoral breast reconstruction acellular dermal matrix," "prepectoral breast reconstruction ADM," "human ADM breast reconstruction," and "human acellular dermal matrix breast reconstruction" (period: 2005-2020; the last search took place on April 2, 2020).

RESULTS

This meta-analysis includes 1425 patients (2270 breasts) who had undergone immediate or delayed prepectoral IBR using different types of hADMs. The overall complication rate amounted to 19%. The most frequent complication was represented by infection (7.9%), followed by seroma (4.8%), mastectomy flap necrosis (3.4%), and implant loss (2.8%).

CONCLUSIONS

The overall complication rate was 19%. The most frequent complications were infection, seroma, and mastectomy flap necrosis, while capsular contracture was rare.

The Bovine Pericardium Matrix in Immediate Implant-Based Breast Reconstruction

BACKGROUND

Acellular dermal matrices have been introduced to optimize direct-to-implant breast reconstruction. We selected a bovine pericardium noncross-linked matrix.

METHODS

The study consists in the retrospective analysis of 123 patients (141 breasts) who underwent conservative mastectomy and immediate implant-based breast reconstruction with bovine pericardium matrix Veritas^® from March 2012 to October 2017.

RESULTS

The overall rates of early and late complications, after a median follow-up of 51.84 months, were, respectively, 37.6% and 24.1%. The most noticeable early complications were flap ischemia [n = 39 (27.7%)], hematoma [n = 5 (3.6%)], marginal skin flap necrosis [n = 5 (3.6%)] and dehiscence of the surgical wound [n = 2 (1.4%)]. The most common late complications were rippling [n = 18 (12.7%)] and seroma [n = 4 (2.8%)]. The rate of clinically relevant capsular contracture was low: 12.1% (n = 17) presented grade II and only 2.1%% (n = 3) grade III. Implant substitution became necessary for five patients (3.6%). Early complications occurred more frequently in patients undergoing therapeutic mastectomy (p = 0.031). Patients undergoing preoperative radiotherapy more frequently developed late complications (p = 0.012). A clinically relevant capsular contracture (grade II-III) was found in higher average patients age (p = 0.0019). The left side developed less frequently late complications except for rippling (p = 0.002). Rippling occurred more frequently in patients who sustained a nipple skin-sparing mastectomy (p = 0.035).

CONCLUSION

Our results further support the safety of Veritas^® in immediate implant-based breast reconstruction.

LEVEL OF EVIDENCE IV

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 .

Direct-to-Implant, Prepectoral Breast Reconstruction: A Single-Surgeon Experience with 201 Consecutive Patients

BACKGROUND

The resurgence of prepectoral breast reconstruction has brought strict patient inclusion and exclusion criteria by numerous authors. This article provides an overview of a single surgeon's experience with 201 patients, 313 breasts using immediate, direct-to-implant prepectoral breast reconstruction. The article compares surgical outcomes of different patient cohorts to elucidate risk factors that may predispose patients toward developing complications.

METHODS

A retrospective chart review was performed, identifying all patients who underwent prepectoral, direct-to-implant breast reconstruction from June of 2016 to June of 2018.

RESULTS

A total of 201 patients representing 313 breasts were included. A midlateral incision was used in 157 breasts (50.2 percent), followed by a skin-reducing, Wise-pattern in 90 breasts (28.8 percent). Acellular dermal matrix was used in 243 breasts (77.6 percent), free nipple grafts were used in 39 breasts (12.5 percent), and postmastectomy radiation therapy was used in 58 breasts (18.5 percent). Complications requiring operative intervention occurred in 24 breasts (7.7 percent), and minor complications occurred in 23 breasts (7.3 percent). There were no significant differences in complication rates for (1) acellular dermal matrix use versus non-acellular dermal matrix use, (2) Wise-pattern versus other incision, or (3) postmastectomy radiotherapy (p > 0.05).

CONCLUSIONS

This represents the largest single-surgeon, direct-to-implant prepectoral cohort in the literature. Surgical complications did not differ with acellular dermal matrix use, incision selection, and the use of postmastectomy radiation therapy. There may be an association between acellular dermal matrix use and major complications and radiotherapy with minor complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[New surgical strategy in breast reconstruction with implants for bilateral prophylactic mastectomies with BRCA gene mutation]

BACKGROUND

For the past decades, number of prophylactic bilateral mastectomies using reconstruction with implants increases. We describe a new surgical strategy and analyse its safety and feasability.

METHOD

It is a retrospective, descriptive and monocentric study. The first step of surgery consisted in obteining a peri-prosthetic capsule with implants and if there was a mammary hypertrophy and/or ptosis, it was corrected at the same time. The second step of surgery was the nipple-sparing mastectomy with change of implants for bigger ones. Third step consisted in a lipofilling.

RESULTS

Seven patients were included. 6 women had a BRCA1 gene mutation. Mean age was 35.6 year-old [29.6; 41.6], mean BMI was 23.8kg/m² [20.6; 27], mean chest circumference was 93.7cm [87.4; 100], mean cup was C- [B-; D-]. 4 women had mammary hypertrophy and/or ptosis. Mean number of procedure per woman was 3.6 [2.5; 4.7]. Mean volume of implants used at the first step was 248.6ml [211.3; 285.9]. The second step was performed mean 33.9 weeks [22.3; 45.5] later. Mean increase of implants volume was 120ml [80.4; 159.6]. 4 patients had complications including 1 who had implant exposure. Six patients had lipofilling of mean volume per breast of 175ml [116; 234].

CONCLUSION

This new strategy could decrease complication rate, improve aesthetic outcome and decrease psychological impact of surgery.

Povidone-iodine Does Not Affect Acellular Dermal Matrix Integration in Patients Undergoing 2-staged, Prepectoral, Breast Reconstructive Surgery

Background:

Povidone-iodine has been traditionally used as an antimicrobial agent to irrigate the breast pocket and rinse the prosthesis before placement in the pocket. Use of povidone-iodine with breast implants was banned from 2000 to 2017. During this period, acellular dermal matrix (ADM) was introduced to breast surgery. In nonclinical studies, povidone-iodine can impair collagen synthesis and kill fibroblasts. Cellular repopulation was critical for ADM integration. Whether povidone-iodine impacts ADM integration was unknown.

Methods:

Patients who underwent immediate, prepectoral, 2-staged breast reconstruction were included in this retrospective study. Study population was divided into povidone-iodine–treated patients and triple-antibiotic–treated patients. The breast pockets were rinsed with the antimicrobial agent, and the prostheses and ADMs were presoaked in the agent perioperatively. At implant exchange, the extent of ADM integration was clinically assessed. ADM integration was defined as >25% of matrix vascularization. ADM integration and postoperative complications were compared between the groups.

Results:

A total of 111 patients (257 reconstructions) were included—58 patients (111 reconstructions) were exposed to povidone-iodine and 53 patients (97 reconstructions) to triple-antibiotic solution. ADM integration was noted in 97% of breasts in each group. Integrated matrices appeared healthy, had no signs of foreign body reaction, and demonstrated punctate bleeding. Complications did not differ between the groups, including the rate of infections, seroma, and expander loss.

Conclusion:

Irrigation of the breast pocket and presoaking of the prosthesis and ADM with povidone-iodine appear to have no adverse consequences on clinical outcomes and did not impede matrix integration.

Surgical Outcomes in Prepectoral Breast Reconstruction

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Direct to implant breast reconstruction with biological acellular dermal matrices

Breast cancer is the most commonly diagnosed female cancer in the UK, with one in eight women receiving a cancer diagnosis during their lifetime. Forty per cent of women diagnosed with breast cancer undergo mastectomy as their primary therapeutic procedure. While a full range of choices is offered, breast reconstruction using implants is the patient-preferred method of reconstruction following mastectomy. This review discusses the evolution of implant-based reconstruction, focusing on the recent trend towards prepectoral breast reconstruction. Key quality indicators in the current literature are considered, including oncological outcomes, aesthetics and patient-related outcome measures, as are the health-care economics of this emerging surgical technique.

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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

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

Comparison of inflammatory response and synovial metaplasia in immediate breast reconstruction with a synthetic and a biological mesh: a randomized controlled clinical trial

The aim of this study was to compare inflammatory response and synovial metaplasia in implant-based immediate breast reconstruction with a biological mesh (Veritas^®) with that of a synthetic mesh (TIGR^® Matrix Surgical Mesh). We hypothesize that the inflammatory response and formation of synovial metaplasia might be different and the rate of capsular contracture therefore different. The patients were recruited from the Gothenburg TIGR^®/Veritas^® Study (ClinicalTrials.Gov identifier NCT02985073). All referrals for bilateral immediate breast reconstruction were assessed for inclusions. During the operation, the patients were randomized to which sides the biological and the synthetic mesh were going to be applied. During the implant exchange biopsies were taken. Biopsies were taken from 30 breasts in 15 patients. There seem to be more myofibroblast and neovascularization in the biological meshes than in the synthetic and the collagen fibers seem to be aligned in an irregular pattern with both parallel and vertical fibers. In the synthetic meshes, there were more giant cells and foreign body reaction and the collagen fibers were loosely and well aligned, oriented parallel to the surface of the implant. Synovial metaplasia was seen in the majority of both the biological and the synthetic meshes. The histological patterns in early capsules from biological and synthetic meshes vary considerably. Nonetheless, it is unknown what role different cell types have in capsular formation in the long run and there was no difference in clinical capsular contracture at the clinical follow-up in this study.