Complications of Acellular Dermal Matrices in Breast Surgery:

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

Background

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

Methods

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

Results

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

Conclusions

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

Efficacy of Acellular Dermal Matrix Type in Treatment of Capsular Contracture in Breast Augmentation: A Systematic Review and Meta-Analysis

BACKGROUND

Capsular contracture is a known complication of breast augmentation and is among the top reasons for revisional breast augmentation procedures. The use of acellular dermal matrix (ADM) has been shown to reduce the rate of capsular contracture in breast reconstruction and augmentation, theorizing that it acts as a protective barrier between the implant capsule and inflammatory process responsible for capsular contracture. The role of ADM in treatment of capsular contracture has been investigated in numerous studies, with a variety of ADMs.

OBJECTIVES

The aim of this study was to perform a systematic review of existing literature on the use of ADM for treatment of capsular contracture in aesthetic breast augmentation patients to investigate differences in efficacy of ADM types.

METHODS

The PubMed, Embase, and CINAHL databases were systematically reviewed for articles pertaining to capsular contracture, acellular dermal matrices, and breast augmentation. Number of patients, type of ADM, Baker grade, follow-up time, complication rate, and capsular contracture rate were recorded from identified articles. Data was pooled from studies to calculate a capsular contracture rate for each ADM type, with a chi-squared test performed for analysis. Identified studies with a comparative group were included in a meta-analysis utilizing risk ratio (RR) to assess the efficacy of ADM.

RESULTS

Nine articles including ADM for treatment of capsular contracture in breast augmentation met criteria for inclusion, with a total of 481 breasts. Strattice was the most commonly utilized ADM (n = 391), followed by AlloDerm (n = 57). There was a statistically significant difference in efficacy of ADM among the studied ADM types (P < .001). AlloDerm, FlexHD, and DermaMatrix had the lowest capsular contracture rates (0%). NeoForm and SurgiMend had the highest capsular contracture rates (each 25%, but with n = 4 and n = 8, respectively). Strattice had a capsular contracture rate of 1.53% in the pooled data, and meta-analysis showed that Strattice reduced the risk of capsular contracture (RR 0.14 [95% CI 0.06, 0.31]) compared with conventional treatment.

CONCLUSIONS

Acellular dermal matrices appear to be effective at treating capsular contracture after breast augmentation while maintaining a low complication rate. Overall capsular contracture rates are low with the use of ADM. There is a statistically significant difference in efficacy among ADM types. Meta-analysis shows that Strattice is effective at reducing the risk of capsular contracture in breast augmentation patients when compared to conventional treatment. Future research, especially in the form of randomized controlled trials, is needed to further investigate the efficacy of various ADMs in the treatment of capsular contracture.

LEVEL OF EVIDENCE: 4

Impact of Chemotherapy and Radiation Therapy on Inflammatory Response, Neovascularization, and Capsule Formation of Acellular Dermal Matrix in Breast Reconstruction: Analysis of the BREASTrial Biopsy Specimens

BACKGROUND

The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a single-center, blinded, prospective, randomized, controlled trial established to compare outcomes using two popular types of acellular dermal matrices, AlloDerm and DermaMatrix, in tissue expander breast reconstruction. This study used the acellular dermal matrix biopsy specimens from the trial to evaluate how adjuvant therapy influences inflammation, neovascularization, and capsule formation of the acellular dermal matrix.

METHODS

Punch biopsy specimens were taken at the time of expander exchange and were analyzed by a blinded pathologist. The inflammatory response was quantified by the number of fibroblasts, giant cells, and lymphocytes. Neovascularization and capsule formation were similarly quantified by the number of new capillaries and capsule presence and thickness, respectively.

RESULTS

Histology specimens were collected from 109 patients (170 breasts). In the absence of adjuvant therapy, there was no significant difference between AlloDerm and DermaMatrix in terms of inflammation, neovascularization, or capsule thickness. Both acellular dermal matrices showed a significant decrease in inflammation and neovascularization with adjuvant therapy. When chemotherapy and radiation therapy were used, the decrease in inflammation was greatest for the group reconstructed with DermaMatrix (p < 0.039).

CONCLUSIONS

Adjuvant therapy influences the inflammatory response, neovascularization, and capsule formation in both acellular dermal matrices. Adjuvant therapy has a protective effect on the inflammatory response toward both acellular dermal matrices in breast reconstruction. In the setting of chemotherapy and radiation therapy, DermaMatrix produced the greatest reduction in inflammation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Postoperative Complications in Breast Reconstruction With Porcine Acellular Dermis and Polypropylene Meshes in Subpectoral Implant Placement

AIM

This research compares postoperative complication rates with Strattice™, SERAGYN^® BR, and TiLOOP^® Bra interposition devices for subpectoral implant placement after skin or nipple sparing mastectomy.

PATIENTS AND METHODS

188 breast reconstructions in 157 patients after primary (n=96), secondary (n=71), or prophylactic (n=21) surgery were analyzed regarding major and minor complications.

RESULTS

With acellular dermal matrix (ADM) Strattice™, 27.5% major and 27.5% minor complications occurred. Implant loss rates were 27.3% in primary and 30.8% in secondary reconstructions. With SERAGYN^® BR, 11.1% major and 13,0% minor complications occurred. Implant losses (6.1%) occurred exclusively in primary reconstructions. With TiLOOP^® Bra, 14.9% major and 9.6% minor complications occurred. Implant loss rates were 7.7% in primary and 7.1% in secondary reconstructions.

CONCLUSION

ADM was associated with high complication rates in primary and secondary reconstructions. Low complication rates were seen with mesh interposition devices in primary, secondary, and prophylactic reconstructions.

The Biomechanical Properties of Meshed versus Perforated Acellular Dermal Matrices (ADMs)

Background:

Acellular dermal matrices (ADMs) are used for soft tissue augmentation across surgical specialties. Since allograft incorporation depends on direct opposition between the ADM and a vascular bed, seroma formation can be detrimental to incorporation. Since most ADM products are available in many meshed and perforated forms, there is a lack of consistency between manufacture designs. We set out to determine the fluid egress properties and increase in surface area resulting from common cut patterns.

Methods:

Three ADM cut patterns were studied: 1 meshed and 2 perforated. We calculated the surface area of these modified ADM samples. Fluid was passed through each ADM, and time required for fluid passage was recorded. An ANOVA (P < 0.05) was used to determine if there was a significant difference in egress properties across the 3 patterns.

Results:

Meshing in a 1:1 pattern resulted in a 97.50% increase in surface area compared with the uncut product. In comparison, only a 0.30% increase resulted from Perforation Pattern #1 and a 0.59% increase resulted from Perforation Pattern #2. There was a significant difference in egress properties across the three cut patterns (P = 0.000). The average egress time of Mesh Pattern #1 was 1.974 seconds. The average egress time of Perforation Pattern #2 was 6.504 seconds, and of Perforation Pattern #1 was 10.369 seconds.

Conclusions:

Quantitative comparison revealed that meshing ADM significantly improves fluid egress and increases the surface area. Therefore, the use of meshed ADM tissue could improve the incorporation of ADM with the recipient, with improved patient outcomes.

Dual-Plane Retro-pectoral Versus Pre-pectoral DTI Breast Reconstruction: An Italian Multicenter Experience

Background

The use of conservative mastectomies has risen significantly during the last few years. The reconstructive choice of direct-to-implant reconstruction has become more practicable with modern mastectomy techniques. The initial trend in Italian centers was to use dual-plane hybrid reconstruction. However, a high level of complications has been registered. From 2015 onward, in our centers, a pre-pectoral approach has been adopted. The authors sought to describe the Italian trend to gradually discard the sub-pectoral technique with lower lateral pole coverage of the prosthesis using ADMs comparing it with the pre-pectoral approach with ADMs, without any muscle dissection, in terms of complication rates.

Materials and Methods

A multicenter retrospective clinical study was performed from January 2010 to June 2018. The enrolled patients were divided into two groups: Cases with an ADM-only coverage pre-pectoral reconstruction made up the first group (Group 1). Those with the retro-pectoral muscular position + ADM implant coverage comprised the second one (Group 2). Complications such as seroma, hematoma, wound dehiscence, surgical site infection, reconstruction failure, animation deformity and capsular contracture were recorded.

Results

We performed 716 direct-to-implant reconstructions: 509 were partially sub-pectoral and 207 were pre-pectoral. Minimum follow-up was 1 year. Incidence of complications was higher in dual-plane reconstructions. There were statistical significant differences in the rates of seroma and hematoma.

Conclusion

Using the pre-pectoral approach, the authors have experienced favorable aesthetics and superior clinical and functional outcomes. Retro-pectoral muscular ADM implant coverage has to be considered only in specific complicated second-stage surgeries.

Level of Evidence V

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.

Electronic supplementary material

The online version of this article (10.1007/s00266-020-01892-y) contains supplementary material, which is available to authorized users.

Novel Use of a Porcine Bladder Extracellular Matrix Scaffold to Treat Postoperative Seroma in a Total Knee Arthroplasty Patient

Seroma formation in a knee arthroplasty surgery is a rare complication. When seromas occur, they act as a nidus for bacterial growth and create an optimal environment for surgical site infections. In this case report, a 52-year-old woman presented with a seroma after multiple revision operations on the left knee. Owing to multiple failures of standard irrigation and drainage procedures to resolve the seroma, an orthoplastic colleague was consulted. Over five-and-a-half months, the patient underwent multiple procedures that failed to treat the seroma. However, in a final exploratory procedure, 3000 mg of urinary bladder matrix and negative pressure wound vacuum were placed. Seven months after the intervention, the patient had complete resolution.

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.

The Impact of Obesity on Patient-Reported Outcomes Following Autologous Breast Reconstruction

BACKGROUND

Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant.

OBJECTIVE

Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients.

METHODS

An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction.

RESULTS

Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04).

CONCLUSION

Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.

Acellular Dermal Matrices: Applications in Plastic Surgery

Modern advances in tissue engineering have transformed the plastic surgeon's management strategies across a wide variety of applications. Comprehension of the fundamentals of biologic constructs is critical to navigating the available armamentarium. It is essential that plastic surgeons become familiar with some of the existing methods for utilizing biologics as well as the advantages and limitations to their use. In this article, the authors describe the basic science of biologics with a focus on acellular dermal matrices (ADMs), and review the recent evidence behind their use for a variety of reconstructive and aesthetic purposes. The review is organized by system and examines the common indications, techniques, and outcomes pertaining to the application of ADMs in select anatomic areas. The final section briefly considers possible future directions for using biologics in plastic and reconstructive surgery.

[Acellular dermal matrix and synthetic mesh in implant-based immediate breast reconstruction: Current concepts]

The use of acellular dermal matrices and synthetic meshes is gaining popularity in direct-to-implant breast reconstruction, allowing the complete coverage of the prosthesis with greater pocket control and improved cosmesis. In this concise review, we present the advantages of acellular dermal matrices and resorbable or nonresorbable synthetic meshes in implant-based breast reconstruction, we discuss the risk of postoperative complications, and we raise their contribution in the growing interest of prepectoral breast reconstruction.

Impact of Acellular Dermal Matrix on Postsurgical Wound Fluid Biomarkers in Prosthetic Breast Reconstruction

BACKGROUND

Despite the widespread practice of using biologic scaffolds for soft tissue reinforcement over prosthetic implants, the impact of acellular dermal matrix (ADM) on surgical wound fluid biomarkers over the initial postoperative period after prosthetic breast reconstruction remains poorly understood.

METHODS

Patients undergoing prosthetic breast reconstruction surgery where ADM was likely to be used were consented to have fluid samples collected from surgical drains after surgery. Sample collections occurred at an "Early" time point at 24 to 48 hours after surgery and then a "Late" time point approximately 1 to 2 weeks after surgery. All procedures were performed by a single surgeon. Acellular dermal matrix was placed when prosthetic coverage with autologous tissue could not be achieved. Laboratory analyses were performed in blinded fashion without the knowledge of whether the samples came from the ADM "Present" or "Not Present" group.

RESULTS

Twenty-one patients were in the ADM Present group and 18 patients were in the Not Present group. Both groups showed similar demographics based on age and body mass index. Analyses for cell concentration, protein concentration, extracellular matrix protein levels, cell proliferation activity, and matrix metalloproteinase activity showed no significant differences between wound fluid samples from the 2 groups.

CONCLUSIONS

The presence of ADM does not appear to significantly impact wound biomarkers in prosthetic breast reconstruction. The current study provides useful data regarding the impact of ADM on surgical wound fluid during the initial postoperative period, laying important groundwork for more extensive future studies on the impact of biologic scaffolds on wound biology.

Analysis of factors influencing drain amount, time to drain removal, and seroma formation in patients undergoing immediate expander-implant breast reconstruction

BACKGROUND

Placement of a closed suction drain is a common cause of patient complaints, such as postoperative pain or discomfort following immediate expander-implant breast reconstruction. This study aims to identify factors that affect drainage volume, time to drain removal, and seroma formation.

METHODS

A retrospective chart review of prospectively collected data was conducted on patients who underwent immediate expander-implant breast reconstructions following nipple-sparing or skin-sparing mastectomy without skin excision (nipple areolar complex excision only) between February 2010 and April 2015. Daily drainage volume was measured until the drain was removed. Eight independent variables, including acellular dermal matrix (ADM) usage and inflation ratio (the rate of initial inflation volume to mastectomy weight) were analysed by univariable and multivariable analyses.

RESULTS

A total of 162 breasts in 148 patients were included in this study. The inflation ratio did not influence the drain amount or days to drain removal. Although the use of ADM was significantly associated with increased drainage during the first 5 postoperative days (p = 0.015), it was not significant when adjusted for time. Old age, larger expander size, and larger drain amount on the first postoperative day were predictors for longer days to drain removal (p < 0.001). Old age had a trend toward higher risk of seroma formation that approached statistical significance (p = 0.057).

CONCLUSIONS

The use of ADM and initial inflation ratio do not influence days to drain removal or seroma formation. A longer period of drain placement is expected when a larger expander is used or in elderly patients.

Autologous Collagen Matrix (ACM): Lower Pole Support With a Supero-Anterior Capsular Flap in Secondary Subpectoral Breast Augmentation

Background

Secondary aesthetic breast surgery is a complex and challenging scenario. It requires the surgeon to identify contributing factors, provide patient education, make a further management plan, and optimize the conditions for a favorable result. Various techniques have been described in literature but the rate of reoperation is still high. The first author has been using a supero-anterior capsular flap with a neopectoral subcapsular pocket and an implant change in these cases.

Objectives

To review the patient characteristics, indications, and early results of using part of the existing implant capsule for secondary subpectoral breast augmentations.

Methods

All patients who underwent secondary breast augmentation, over a period of 2 years by the first author (P.M.), using the supero-anterior capsular flap technique were included. The technique involves dissection of a new subpectoral pocket and uses the existing implant capsule as an internal brassiere.

Results

A total of 36 patients were operated by this technique. Of these, 17 patients had developed a complication while 19 patients wanted a change in size only. At a mean follow up of 10.2 months, there was no bottoming out, double bubble, or capsular contracture.

Conclusions

This reliable technique provides stable results as shown by low rate of complications with the existing follow up.

Level of Evidence 4

Innovative Management of Implant Exposure in ADM/Implant-Based Breast Reconstruction with Negative Pressure Wound Therapy

INTRODUCTION

One-stage implant-based breast reconstruction has been recently improved by the introduction of biological [acellular dermal matrix (ADM)] and synthetic meshes. Advantages of ADMs in implant-based breast reconstruction derive from the expansion of the space available for the direct positioning of an implant, but their use could be associated with several complications. Although the majority of complications can be easily managed, mistakes in dealing with the first clinical signs of a potential adverse event can lead to implant loss.

CASE PRESENTATION

We report a case of ADM/implant exposure following NAC-sparing mastectomy and immediate implant-based reconstruction, successfully managed with an innovative staged treatment using negative pressure wound therapy, which allowed a rapid re-positioning of the prosthesis after complete clearance of bacteria from the implant pocket.

DISCUSSION

The safest strategy to manage implant exposure and concomitant bacterial growth is reported to be implant removal and delayed re-positioning after several months, following prolonged targeted antibiotic therapy. Our case shows how a short-time implant re-positioning following implant removal for implant exposure could be successfully pursued thanks to the shrewd use of negative pressure wound therapy with great advantages in terms of patient satisfaction and post-operative quality of life, offering women experiencing this complication the option of not delaying reconstruction for months after resolution of the complication, potentially avoiding major surgical procedures such as autologous tissue reconstructions.

LEVEL OF EVIDENCE V

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 .

Impact of obesity on outcomes in breast reconstruction: A systematic review protocol

•

Summarise the risks related to breast reconstruction among obese women.

•

Both implant based and autologous reconstruction will be investigated.

•

Determine optimal methods of breast reconstruction.

•

Refine patient selection for each procedure.

Introduction

The worldwide obesity epidemic is creating new challenges for surgeons involved in breast reconstruction. This systematic review aims to summarise the research available in order to determine the surgical and medical complications, the duration of surgery and post-operative hospital stay and the likelihood of reoperation in each of the different techniques of breast reconstruction in women with obesity. To our knowledge, no systematic review is currently available that assesses the impact of obesity on breast reconstruction outcomes.

Methods and analysis

Electronic searches will be conducted on Cochrane, PUBMED and EMBASE, from their inception to 1 June 2016. All cohort studies, case series, randomised controlled trials, and case-control studies on women undergoing breast reconstruction post mastectomy for oncological reasons will be included. Articles must mention at least one of the primary outcomes of interest. Full exclusion and inclusion criteria are described within this protocol. Primary and secondary outcomes are described within this protocol. The search strategy, described within this protocol, aims to identify all articles on “obesity and breast reconstruction.”

Discussion

This paper outlines the study protocol for a systematic literature review that will identify and summarise currently available evidence on the effectiveness and complications of breast reconstructive procedures in women with a BMI >30 kg/m². This review aims to provide an overview of the evidence in order to create a guide for healthcare professionals involved in the breast reconstruction of obese women.

Dissemination

This review will be published in a peer-reviewed journal and will be presented at various national and international conferences.

Aseptic versus Sterile Acellular Dermal Matrices in Breast Reconstruction: An Updated Review

BACKGROUND

As the use of acellular dermal matrices in breast reconstruction has become more commonplace and efforts are made to improve on postoperative outcomes, the method of acellular dermal matrix (ADM) processing (aseptic versus sterile) has become a subject of interest. This article provides an updated overview of the critical aspects of ADM processing in addition to application of ADMs in single- and two-stage breast reconstruction, a review of the morbidity associated with ADM use, and alternatives.

METHODS

A literature review was performed in PubMed identifying recent systematic reviews, meta-analyses, and head-to-head comparisons on aseptically processed ADM and sterile-processed ADM in implant-based breast reconstruction.

RESULTS

Recent meta-analyses have shown a 2- to 3-fold increase in infections and tissue expander/implant explantation rates and a 3- to 4-fold increase in seroma formation compared with non-ADM reconstruction techniques. Comparisons of aseptic and sterile ADMs in multiple studies have shown no significant difference in infection rates and equivocal findings for other specific complications such as seroma formation.

CONCLUSIONS

Current evidence on the impact of processing techniques that improve ADM sterility on postoperative morbidity in implant breast reconstruction is unclear. Deficiencies of the available data highlight the need for well-designed, multicenter, randomized controlled studies that will aid in optimizing outcomes in implant-based breast reconstruction.

Biological and synthetic mesh use in breast reconstructive surgery: a literature review

Mesh use in surgical breast reconstruction is becoming increasingly common; however, there is still no consensus on whether synthetic matrices or biological matrices produce the best outcomes. This review analyses these outcomes, namely the differences in aesthetic outcomes, cost, and the rates of the most commonly reported complications.

The results indicate that breast reconstruction with a synthetic matrix produces comparable aesthetic outcomes to a biological matrix, with lower costs and complication rates. The individual results for complication rates show that biological matrixes are associated with lower infection rates and slightly lower capsular contracture, but higher haematoma rates, and slightly higher rates of skin necrosis and explantation—although many had post-op radiotherapy.

The majority of the studies evaluated used biological matrices, and there are no randomised controlled trials directly comparing the two types of meshes; definite conclusions cannot be drawn from the available evidence. The authors suggest that a randomised controlled trial comparing these outcomes in synthetic and biological matrix use is needed.

Remodeling Characteristics and Collagen Distributions of Biologic Scaffold Materials Biopsied From Postmastectomy Breast Reconstruction Sites

OBJECTIVE

The study purpose was to evaluate the associations between patient characteristics and the histologic remodeling scores of acellular dermal matrices (ADMs) biopsied from breast reconstruction sites in the first attempt to generate a multivariable risk prediction model of nonconstructive remodeling. It was hypothesized that host characteristics and surgical site assessments predict the degree of graft remodeling for ADMs used during breast reconstruction.

METHODS

The ADMs were biopsied from the breast reconstruction sites of n = 62 patients during a subsequent breast procedure, stained with hematoxylin-eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell types, cell infiltration, extracellular matrix deposition, scaffold degradation, fibrous encapsulation, and neovascularization) and a mean composite score. Biopsies were stained with Sirius Red and Fast Green, and analyzed to determine the collagen I:III ratio. Based on univariate analyses between subject clinical characteristics and the histologic remodeling scores, cohort variables were selected for multivariable regression models using a P value of 0.20 or less.

RESULTS

The composite score model yielded 3 variables: pack-year history, corticosteroid use, and radiation timing (r pseudo = 0.81). The model for collagen I yielded 2 variables: corticosteroid use and reason for reoperation (r pseudo = 0.78). The model for collagen III yielded 1 variable: reason for reoperation (r pseudo = 0.35).

CONCLUSIONS

These preliminary results constitute the first steps in generating a risk prediction model that predicts the patients and clinical circumstances most likely to experience nonconstructive remodeling of biologic grafts used to reconstruct the breast.

Mesh versus acellular dermal matrix in immediate implant-based breast reconstruction - A prospective randomized trial

BACKGROUND

Comparative studies on the use of meshes and acellular dermal matrices (ADM) in implant-based breast reconstruction (IBBR) have not yet been performed.

METHODS

This prospective, randomized, controlled, multicenter pilot study was performed at four Austrian breast cancer centers. Fifty patients with oncologic or prophylactic indication for mastectomy and IBBR were randomized to immediate IBBR with either an ADM (Protexa(®)) or a titanized mesh (TiLOOP(®) Bra). Complications, failed reconstruction, cosmetic outcome, patients' quality of life and the thickness of the overlying tissue were recorded immediately postoperatively and 3 and 6 months after surgery.

RESULTS

48 patients participated in the study (Protexa(®) group: 23; TiLOOP(®) Bra group: 25 patients). The overall complication rate was 31.25% with similar rates in both groups (Protexa(®) group: 9 versus TiLOOP(®) Bra group: 6; p = 0.188). There was a higher incidence of severe complications leading to failed reconstructions with implant loss in the Protexa(®) group than in the TiLOOP(®) Bra group (7 versus 2; p < 0.0001). An inverted T-incision technique led to significantly more complications and reconstructive failure with Protexa(®) (p = 0.037, p = 0.012, respectively). There were no significant differences in patients' satisfaction with cosmetic results (p = 0.632), but surgeons and external specialists graded significantly better outcomes with TiLOOP(®) Bra (p = 0.034, p = 0.032).

CONCLUSION

This pilot study showed use of TiLOOP(®) Bra or Protexa(®) in IBBR is feasible leading to good cosmetic outcomes and high patient satisfaction. To validate the higher failure rates in the Protexa(®) group, data from a larger trial are required. NCT02562170.

Critical Evaluation of Risk Factors and Early Complications in 564 Consecutive Two-Stage Implant-Based Breast Reconstructions Using Acellular Dermal Matrix at a Single Center

BACKGROUND

Acellular dermal matrix for implant-based breast reconstruction appears to cause higher early complication rates, but long-term outcomes are perceived to be superior. This dichotomy is the subject of considerable debate. The authors hypothesized that patient characteristics and operative variables would have a greater impact on complications than the type of acellular dermal matrix used.

METHODS

A retrospective cohort study was performed of consecutive patients who underwent two-stage, implant-based breast reconstruction with human cadaveric or bovine acellular dermal matrix from 2006 to 2012 at a single institution. Patient characteristics and operative variables were analyzed using logistic regression analyses to identify risk factors for complications.

RESULTS

The authors included 564 reconstructions in the study. Radiation therapy and obesity increased the odds of all complications. Every 100-ml increase in preoperative breast volume increased the odds of any complication by 1 percent, the odds of infection by 27 percent, and the risk of explantation by 16 percent. The odds of seroma increased linearly with increasing surface area of acellular dermal matrix. Odds of infection were higher with an intraoperative expander fill volume greater than 50 percent of the total volume. Risk of explantation was twice as high when intraoperative expander fill volume was greater than 300 ml.

CONCLUSIONS

Radiation therapy, obesity, larger breasts, higher intraoperative fill volumes, and larger acellular dermal matrices are all independent risk factors for early complications. Maximizing the initial mastectomy skin envelope fill must be balanced with the understanding that higher complication rates may result from a larger intraoperative breast mound.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Use of latissimus dorsi muscle onlay patch alternative to acellular dermal matrix in implant-based breast reconstruction

BACKGROUND

An acellular dermal matrix (ADM) is applied to release the surrounding muscles and prevent dislocation or rippling of the implant. We compared implant-based breast reconstruction using the latissimus dorsi (LD) muscle, referred to as an "LD muscle onlay patch," with using an ADM.

METHOD

A total of 56 patients (60 breasts) underwent nipple sparing mastectomy with implant-based breast reconstruction using an ADM or LD muscle onlay patch. Cosmetic outcomes were assessed 4 weeks after chemotherapy or radiotherapy, and statistical analyses were performed.

RESULTS

Mean surgical time and hospital stay were significantly longer in the LD muscle onlay patch group than the ADM group. However, there were no statistically significant differences between groups in postoperative complications. Cosmetic outcomes for breast symmetry and shape were higher in the LD muscle onlay patch group.

CONCLUSIONS

Implant-based breast reconstruction with an LD muscle onlay patch would be a feasible alternative to using an ADM.

Does acellular dermal matrix really improve aesthetic outcome in tissue expander/implant-based breast reconstruction?

BACKGROUND

The expectation for improved results by women undergoing postmastectomy reconstruction has steadily risen. A majority of these operations are tissue expander/implant-based breast reconstructions. Acellular dermal matrix (ADM) offers numerous advantages in these procedures. Thus far, the evidence to justify improved aesthetic outcome has solely been based on surgeon opinion. The purpose of this study was to assess aesthetic outcome following ADM use in tissue expander/implant-based breast reconstruction by a panel of blinded plastic surgeons.

METHODS

Mean aesthetic results of patients who underwent tissue expander/implant-based breast reconstruction with (n = 18) or without ADM (n = 20) were assessed with objective grading of preoperative and postoperative photographs by five independent blinded plastic surgeons. Absolute observed agreement as well as weighted Fleiss Kappa (κ) test statistics were calculated to assess inter-rater variability.

RESULTS

When ADM was incorporated, the overall aesthetic score was improved by an average of 12.1 %. In addition, subscale analyses revealed improvements in breast contour (35.2 %), implant placement (20.7 %), lower pole projection (16.7 %), and inframammary fold definition (13.8 %). Contour (p = 0.039), implant placement (p = 0.021), and overall aesthetic score (p = 0.022) reached statistical significance. Inter-rater reliability showed mostly moderate agreement.

CONCLUSIONS

Mean aesthetic scores were higher in the ADM-assisted breast reconstruction cohort including the total aesthetic score which was statistically significant. Aesthetic outcome alone may justify the added expense of incorporating biologic mesh. Moreover, ADM has other benefits which may render it cost-effective. Larger prospective studies are needed to provide plastic surgeons with more definitive guidelines for ADM use.

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 .

Acellular Dermal Matrix in Reconstructive Breast Surgery: Survey of Current Practice among Plastic Surgeons

Background:

Acellular dermal matrices (ADMs) in plastic surgery have become increasingly popular particularly for breast reconstruction. Despite their advantages, questions exist regarding their association with a possible increased incidence of complications. We describe a collective experience of plastic surgeons’ use of ADMs in reconstructive breast surgery using an internet-based survey.

Methods:

Members of the American Society of Plastic Surgeons were recruited through voluntary, anonymous participation in an online survey. The web-based survey garnered information about participant demographics and their experience with ADM use in breast reconstruction procedures. After responses were collected, all data were anonymously processed.

Results:

Data were ascertained through 365 physician responses of which 99% (n = 361) completed the survey. The majority of participants were men (84.5%) between 51 and 60 years (37.4%); 84.2% used ADM in breast reconstruction, including radiated patients (79.7%). ADM use was not favored for nipple reconstruction (81.5%); 94.6% of participants used drains, and 87.8% administered antibiotics postoperatively. The most common complications were seroma (70.9%) and infection (16%), although 57.4% claimed anecdotally that overall complication rate was unchanged after incorporating ADM into their practice. High cost was a deterrent for ADM use (37.5%).

Conclusions:

Plastic surgeons currently use ADM in breast reconstruction for both immediate and staged procedures. Of those responding, a majority of plastic surgeons will incorporate drains and use postoperative antibiotics for more than 48 hours.

Pectus excavatum in adult women: repair and the impact of prior or concurrent breast augmentation

BACKGROUND

Women present with pectus excavatum five times less frequently than men. Adult women may have additional, associated cosmetic factors, including hypoplastic or asymmetric breasts, or prior augmentation. The authors evaluated the impact of prior or concurrent cosmetic breast surgery in an adult female cohort undergoing repair of pectus excavatum deformity.

METHODS

A retrospective review was performed of women (≥18 years old) who underwent pectus excavatum repair at a single institution from January of 2010 to September of 2013.

RESULTS

Pectus excavatum repair was performed on 47 women with a median age of 35 years (range, 18 to 63 years). Mean pectus severity index was 6.2 (range, 3.1 to 16). All patients had physiologic symptoms as the primary purpose for seeking repair. Twenty patients (43 percent) presented with existing implants or the desire for implants at the time of repair. Fifteen patients (32 percent) had a history of implant placement including prior breast augmentation (n = 14) and/or pectus implant (n = 4). Concurrent augmentation (n = 5), breast implant exchange (n = 8), and/or removal of chest wall implants (n = 4) was performed during repair. Morbidity included one implant-related hematoma. Complications and hospital stay were not significantly different for patients undergoing primary repair alone versus those with prior or concurrent augmentation.

CONCLUSIONS

Breast cosmesis was a concern in nearly half of adult women presenting for pectus excavatum repair. The authors' experience suggests neither prior nor concurrent breast augmentation increases the risk of complications in repair. The authors recommend that cosmetic breast surgery be performed concurrently with pectus excavatum repair.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

TiLoop® Bra mesh used for immediate breast reconstruction: comparison of retropectoral and subcutaneous implant placement in a prospective single-institution series

BACKGROUND

Immediate implant reconstruction after a conservative mastectomy is an attractive option made easier by prosthetic devices. Titanized polypropylene meshes are used as a hammock to cover the lower lateral implant pole. We conducted a prospective nonrandomized single-institution study of reconstructions using titanium-coated meshes either in a standard muscular mesh pocket or in a complete subcutaneous approach. The complete subcutaneous approach means to wrap an implant with titanized mesh in order to position the implant subcutaneously and spare muscles.

METHODS

Between November 2011 and January 2014, we performed immediate implant breast reconstructions after conservative mastectomies using TiLoop® Bra, either with the standard retropectoral or with a prepectoral approach. Selection criteria included only women with normal Body Mass Index (BMI), no large and very ptotic breasts, no history of smoking, no diabetes, and no previous radiotherapy. We analyzed short-term outcomes of such procedures and compared the outcomes to evaluate implant losses and surgical complications.

RESULTS

A total of 73 mastectomies were performed. Group 1 comprised 29 women, 5 bilateral procedures, 34 reconstructions, using the standard muscular mesh pocket. Group 2 comprised 34 women, 5 bilateral procedures, 39 reconstructions with the prepectoral subcutaneous technique. Baseline and oncologic characteristics were homogeneous between the two groups. After a median follow-up period of 13 and 12 months, respectively, no implant losses were recorded in group 1, and one implant loss was recorded in group 2. We registered three surgical complications in group 1 and two surgical complications in group 2.

CONCLUSIONS

Titanium-coated polypropylene meshes, as a tool for immediate definitive implant breast reconstruction, resulted as safe and effective in a short-term analysis, both for a retropectoral and a totally subcutaneous implant placement. Long-term results are forthcoming. A strict selection is mandatory to achieve optimal results. Level of Evidence: Level II, therapeutic study.

The scarless latissimus dorsi flap provides effective lower pole prosthetic coverage in breast reconstruction

Background:

The evolution of surgical breast cancer treatment has led to the oncologically safe preservation of greater amounts of native skin, yet we are still often using flaps with large skin paddles, thereby resulting in significant donor-site scars. This explains the increasing appeal of acellular dermal matrix reconstructions. Acellular dermal matrices can, however, have significant problems, particularly if there is any vascular compromise of the mastectomy skin flaps. We have developed a method of raising the latissimus dorsi flap through the anterior mastectomy incisions without requiring special instruments or repositioning. This can provide autologous vascularized cover of the prosthesis.

Methods:

A clear surgical description of the scarless latissimus dorsi flap harvest is provided, and our results of a retrospective cohort review of 20 consecutive patients with 27 traditional latissimus dorsi breast reconstructions were compared with those of 20 consecutive patients with 30 scarless latissimus dorsi breast reconstructions.

Results:

Operative time, length of stay, and complication rates were reduced in the scarless group. Patients Breast-Q scores were equivalent in each group. The aesthetic assessment was good/excellent in 77% of both groups; however, subscale assessment was better in the scarless group. This was statistically significant (P = 0.0).

Conclusions:

Breast reconstruction using the scarless latissimus dorsi flap is time effective, requires no patient repositioning, and uses standard breast instrumentation. It is safe and versatile while reducing the risk of exposed prosthesis if native skin necrosis occurs. It is a vascularized alternative to acellular dermal matrices.

Preserving the posttrapeziectomy space with a human acellular dermal matrix spacer: a pilot case series of patients with thumb carpometacarpal joint arthritis

Supplemental Digital Content is available in the text.

Background:

Advanced thumb carpometacarpal arthritis is widely treated with trapeziectomy and tendon interposition despite donor-site morbidities. Trapeziectomy alone leaves a postresection space, leading to proximal metacarpal migration and scaphoid/trapezoid impingement. Prosthetic implants have been unsuccessful due to particulate debris, silicone synovitis, osteolysis, and migration. Recent studies have shown successful use of allograft for interposition material in the posttrapeziectomy space both in animal and human models. To obviate the need for autologous tissue, maintain thumb length, and reduce the risk of scaphoid impingement, the senior author developed an interposition arthroplasty technique using a spacer constructed from human acellular dermal matrix (HADM).

Methods:

Sixteen patients with Eaton stage III–IV thumb carpometacarpal osteoarthritis received the above procedure from the 2 senior authors. HADM was imbricated to fill the posttrapeziectomy space and secured to the volar capsule and metacarpal base. Pre- and postoperative trapezial space on radiograph, pain scores, and grip strength were recorded.

Results:

Six months postoperatively, radiographs showed an average joint space loss of 11%. Heights postoperatively were not significantly different from immediate postoperative heights (P ≥ 0.01). At 6 months, patients had improved pain and grip strength (P ≤ 0.01). No infections, foreign body reactions, or other complications occurred.

Conclusions:

HADM has been used extensively in other forms of reconstruction and has been shown to incorporate into surrounding tissues through neovascularization. Our early results illustrate that HADM can safely fill the dead space left by trapeziectomy.