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Henry N, Sebag V, Safran T, Viezel-Mathieu A, Dionisopoulos T, Davison P, Vorstenbosch J. Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy. Ann Plast Surg 2024; 93:172-177. [PMID: 38775386 DOI: 10.1097/sap.0000000000003945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). METHODS A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. RESULTS Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. CONCLUSIONS Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.
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Affiliation(s)
- Nader Henry
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Victoria Sebag
- McGill University, Faculty of Medicine, Montreal, Quebec, Canada
| | - Tyler Safran
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Alex Viezel-Mathieu
- Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Tassos Dionisopoulos
- Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Peter Davison
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joshua Vorstenbosch
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Quebec, Canada
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Ng TP, Loo BYK, Yong N, Chia CLK, Lohsiriwat V. Review: Implant-Based Breast Reconstruction After Mastectomy for Breast Cancer: A Meta-analysis of Randomized Controlled Trials and Prospective Studies Comparing Use of Acellular Dermal Matrix (ADM) Versus Without ADM. Ann Surg Oncol 2024; 31:3366-3376. [PMID: 38285304 DOI: 10.1245/s10434-024-14943-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/02/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Breast cancer is the world's most prevalent cancer, and many breast cancer patients undergo mastectomy as the choice of treatment, often with post-mastectomy breast reconstruction. Acellular dermal matrix (ADM) use has become a method to improve outcomes of reconstruction for these patients. We aimed to compare postoperative complications and patient-reported outcomes, which are still poorly characterized, between groups utilizing acellular dermal matrix during reconstruction and those without. MATERIALS AND METHODS We searched electronic databases from inception to 16 June 2022 for randomized controlled trials and prospective cohort studies comparing the outcomes of patients who have and have not received acellular dermal matrix in implant-based breast reconstruction. The results were quantitatively combined and analyzed using random-effects models. RESULTS A total of nine studies were included, representing 3161 breasts. There was no significant difference in postoperative outcomes, such as seroma formation (p = 0.51), hematomas (p = 0.20), infections (p = 0.21), wound dehiscence (p = 0.09), reoperations (p = 0.70), implant loss (p = 0.27), or skin necrosis (p = 0.21). Only two of the studies included evaluated patient-reported outcomes between the use and non-use of ADM in implant-based breast reconstruction using BREAST-Q questionnaire, as well as self-reported pain. There was no reported significant difference in BREAST-Q or pain scores. CONCLUSIONS This meta-analysis shows comparable short- and long-term outcomes between ADM and non-ADM breast reconstruction, suggesting that the use of ADM may not be necessary in all cases given their additional cost. However, there is a paucity of data for patient-reported outcomes, and further research is required to determine whether ADM use affects patient-reported outcomes.
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Affiliation(s)
- Trina Priscilla Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Breast Surgery Service, Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Brandon Yong Kiat Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Breast Surgery Service, Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Nicole Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Breast Surgery Service, Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Clement Luck Khng Chia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Breast Surgery Service, Department of Surgery, Khoo Teck Puat Hospital, Singapore, Singapore.
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
| | - Visnu Lohsiriwat
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Lee ZH, Diep GK, Brydges HT, Berman ZP, Alfonso AR, Ramly EP, Chaya BF, Thanik VD. Do Corporate Payments Influence Research Related to the Use of Acellular Dermal Matrices in Breast Surgery? Plast Reconstr Surg 2023; 152:376e-384e. [PMID: 36827475 DOI: 10.1097/prs.0000000000010320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs. METHODS The PubMed database was used to identify articles that reported on the use of ADM in breast surgery in four leading plastic surgery journals from January of 2014 to December of 2019. Financial COIs for authors were determined using the open payments database. RESULTS Fifty-five articles were included. Twenty-four articles (43.6%) supported use of ADM, 12 (21.8%) did not promote ADM use, and 19 (34.5%) were neutral. Fifty-one studies (92.7%) had either a first or senior author with a COI, and authors with a COI more commonly reported positive outcomes ( P = 0.02). Studies with positive outcomes featured first authors who received significantly larger financial payments ($95,955 versus $15,642; P = 0.029) compared with studies with negative or neutral outcomes. Receiver operating characteristic curve demonstrated that studies with first authors receiving over $376.28 were more likely to report positive results. Eight senior authors and three first authors received greater than $500 from ADM producers yet did not report any financial disclosure. CONCLUSIONS Financial COI is associated with higher likelihood of studies reporting benefit of using ADM in breast surgery. There remains inconsistent reporting of COIs, and better oversight is needed to ensure unbiased publication on the use of ADM in breast surgery.
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Affiliation(s)
- Z-Hye Lee
- From the Department of Plastic Surgery, University of Texas M. D. Anderson Cancer Center
| | - Gustave K Diep
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Hilliard T Brydges
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Zoe P Berman
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Elie P Ramly
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Bachar F Chaya
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Vishal D Thanik
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
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Graziano FD, Lu J, Sbitany H. Prepectoral Breast Reconstruction. Clin Plast Surg 2023; 50:235-242. [PMID: 36813401 DOI: 10.1016/j.cps.2022.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Prepectoral breast reconstruction has gained popularity due to numerous benefits in properly selected patients. Compared with subpectoral implant reconstruction, prepectoral reconstruction offers preservation of the pectoralis major muscle in its native position, resulting in decreased pain, no animation deformity, and improved arm range of motion/strength. Although prepectoral reconstruction is safe and effective, the implant sits closer to the mastectomy skin flap. Acellular dermal matrices play a critical role, allowing for precise control of the breast envelope and providing long-term implant support. Careful patient selection and intraoperative mastectomy flap evaluation are critical to obtaining optimal results with prepectoral breast reconstruction.
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Affiliation(s)
- Francis D Graziano
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jocelyn Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hani Sbitany
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Should Acellular Dermal Matrices Be Used for Implant-based Breast Reconstruction after Mastectomy? Clinical Recommendation Based on the GRADE Approach. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4821. [PMID: 36845868 PMCID: PMC9946425 DOI: 10.1097/gox.0000000000004821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/20/2022] [Indexed: 02/24/2023]
Abstract
Acellular dermal matrices (ADMs) entered the market in the early 2000s and their use has increased thereafter. Several retrospective cohort studies and single surgeon series reported benefits with the use of ADMs. However, robust evidence supporting these advantages is lacking. There is the need to define the role for ADMs in implant-based breast reconstruction (IBBR) after mastectomy. Methods A panel of world-renowned breast specialists was convened to evaluate evidence, express personal viewpoints, and establish recommendation for the use of ADMs for subpectoral one-/two-stage IBBR (compared with no ADM use) for adult women undergoing mastectomy for breast cancer treatment or risk reduction using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results Based on the voting outcome, the following recommendation emerged as a consensus statement: the panel members suggest subpectoral one- or two-stage IBBR either with ADMs or without ADMs for adult women undergoing mastectomy for breast cancer treatment or risk reduction (with very low certainty of evidence). Conclusions The systematic review has revealed a very low certainty of evidence for most of the important outcomes in ADM-assisted IBBR and the absence of standard tools for evaluating clinical outcomes. Forty-five percent of panel members expressed a conditional recommendation either in favor of or against the use of ADMs in subpectoral one- or two-stages IBBR for adult women undergoing mastectomy for breast cancer treatment or risk reduction. Future subgroup analyses could help identify relevant clinical and pathological factors to select patients for whom one technique could be preferable to another.
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Chu CK, Davis MJ, Abu-Ghname A, Winocour SJ, Losken A, Carlson GW. Implant Reconstruction in Nipple Sparing Mastectomy. Semin Plast Surg 2019; 33:247-257. [PMID: 31632208 DOI: 10.1055/s-0039-1696988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Nipple sparing mastectomy has been popularized in the modern era of breast cancer treatment due to its touted advantages with regard to resultant body image and reconstructive outcome. Implant-based techniques remain the most prevalent means of breast reconstruction. Special considerations regarding patient selection and technique are reviewed for implant reconstruction in the setting of mastectomy with nipple preservation. Applications for prepectoral and direct-to-implant reconstruction are discussed and published outcomes are summarized.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Matthew J Davis
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Amjed Abu-Ghname
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sebastian J Winocour
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Albert Losken
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Grant W Carlson
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.,Division of Plastic and Reconstructive Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Kim H, Park SJ, Woo KJ, Bang SI. Comparative Study of Nipple-Areola Complex Position and Patient Satisfaction After Unilateral Mastectomy and Immediate Expander-Implant Reconstruction Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy. Aesthetic Plast Surg 2019; 43:313-327. [PMID: 30746565 DOI: 10.1007/s00266-018-1217-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 08/16/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple-areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander-implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM. METHODS Patients who underwent immediate expander-implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire. RESULTS Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p = 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p = 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (p = 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (p = 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (p = 0.003). Satisfaction with the reconstructed breast was similar (p = 0.913) after NSM and SSM. CONCLUSIONS We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer. 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 .
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Affiliation(s)
- Hyungsuk Kim
- Department of Plastic Surgery, Choonhae Hospital, Busan, South Korea
| | - Sun-June Park
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Kyong-Je Woo
- Department of Plastic Surgery, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Sa Ik Bang
- Department of Plastic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
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Porcine Acellular Peritoneal Matrix in Immediate Breast Reconstruction: A Multicenter, Prospective, Single-Arm Trial. Plast Reconstr Surg 2019; 143:10e-21e. [PMID: 30589773 DOI: 10.1097/prs.0000000000005095] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Use of biological implants such as acellular dermal matrices in tissue expander breast reconstruction is a common adjunct to submuscular implant placement. There is a paucity of published prospective studies involving acellular matrices. The authors sought to evaluate a porcine-derived acellular peritoneal matrix product for immediate breast reconstruction. METHODS A prospective, single-arm trial was designed to analyze safety and outcomes of immediate tissue expander-based breast reconstruction with a novel porcine-derived acellular peritoneal matrix surgical mesh implant. Twenty-five patients were enrolled in this industry-sponsored trial. Patient demographics, surgical information, complications, histologic characteristics, and satisfaction (assessed by means of the BREAST-Q questionnaire) were evaluated. RESULTS Twenty-five patients (44 breasts) underwent mastectomy with immediate breast reconstruction using tissue expanders with acellular peritoneal matrix. Sixteen reconstructed breasts experienced at least one complication (36 percent). Seroma and hematoma occurred in one of 44 (2.3 percent) and two of 44 breasts (4.6 percent), respectively. Wound dehiscence occurred in four of 44 breasts (9.1 percent). Three subjects experienced reconstruction failure resulting in expander and/or acellular peritoneal matrix removal (6.8 percent); all failures were preceded by wound dehiscence. Histologic analysis showed cellular infiltration and product resorption. Results of the BREAST-Q demonstrated a level of postoperative patient satisfaction consistent with results in the available literature. CONCLUSIONS Prepared porcine-derived acellular peritoneal matrix is a safe adjunct in immediate two-stage tissue expander-based breast reconstruction. Further studies are required to determine efficacy compared to current commercially available acellular matrices. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Smith JM, Broyles JM, Guo Y, Tuffaha SH, Mathes D, Sacks JM. Human acellular dermis increases surgical site infection and overall complication profile when compared with submuscular breast reconstruction: An updated meta-analysis incorporating new products✰. J Plast Reconstr Aesthet Surg 2018; 71:1547-1556. [DOI: 10.1016/j.bjps.2018.06.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 05/31/2018] [Accepted: 06/16/2018] [Indexed: 10/28/2022]
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Does the Use of Acellular Dermal Matrix Increase Postoperative Complications of the First-Stage Reconstruction of Immediate Expander-Implant Breast Reconstruction: A Matched Cohort Study. Ann Plast Surg 2018; 79:341-345. [PMID: 28509694 DOI: 10.1097/sap.0000000000001067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Controversy exists regarding complications associated with the use of acellular dermal matrix (ADM). This likely stems from the heterogeneous and unmatched patient characteristics in study groups. The purpose of this study was to analyze complications in a matched cohort to identify whether ADM use increased postoperative complications of the first-stage immediate expander-implant breast reconstructions. METHODS A retrospective matched-cohort study was performed. We retrospectively reviewed prospectively collected data from patients who underwent immediate expander-implant breast reconstruction after mastectomy between February 2010 and January 2016. Independent variables included clinical characteristics, mastectomy weight, mastectomy type, expander size, initial inflation volume, number of days to drain removal, and adjuvant or neoadjuvant therapies. Different independent variables between the ADM and non-ADM groups were used for propensity score matching. After matching, a pairwise comparison of the 2 cohorts' independent variables was carried out using the Wilcoxon signed rank test and McNemar test. Incidence of complications was evaluated for the 2 matched cohorts. To adjust for ablative and reconstructive surgeons, a multivariable generalized estimating equation analysis was performed. RESULTS A total of 574 immediate expander-implant breast reconstructions in 533 patients were included in this study. We identified 398 reconstructions (199 for each group; ADM and non-ADM group) of matched cohorts using propensity score matching. Characteristics were similar between the 2 matched cohorts. In the matched analysis, there were no significant differences in the rate of skin flap complications (16.1% vs 16.1%, P > 0.999), seroma (4.0% vs 8.5%, P = 0.065), infection (3.0% vs 3.5%, P = 0.781), and overall complications (21.1% vs 26.1%, P = 0.251). Acellular dermal matrix was not associated with increased risk of complication when ablative and reconstructive surgeon factors were considered in a multivariable analysis (P = 0.511). CONCLUSIONS A matched cohort analysis demonstrated that ADM usage is not associated with an increased risk of complications, including skin flap complications, seroma, and infection. Our result suggests that ADM can be safely used in immediate expander-implant breast reconstruction when necessary.
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Mitchell SD, Willey SC, Beitsch P, Feldman S. Evidence based outcomes of the American Society of Breast Surgeons Nipple Sparing Mastectomy Registry. Gland Surg 2018; 7:247-257. [PMID: 29998074 DOI: 10.21037/gs.2017.09.10] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The American Society of Breast Surgeons (ASBrS) Nipple Sparing Mastectomy Registry (NSMR) is a prospective, non-randomized, IRB approved, multi-institutional registry. The purpose of this Registry is to provide a large, prospective, non-randomized database of patient characteristics, tumor characteristics, surgical technique, and outcome (both aesthetic and oncologic) of the nipple sparing mastectomy (NSM). Methods Data is entered into the ASBrS NSMR, housed within the Mastery of Surgery Program, after patients consent to participation. Each investigator routinely offers NSM in their practice has obtained IRB approval and completed forms of agreement to participate in the ASBrS NSMR. Results This data set represents a total of 1,935 NSMs performed on 1,170 patients by 98 investigators from 70 institutions/sites. Of the 1,935 NSMs: 833 were performed for an indication of cancer [594 invasive carcinoma and 239 for ductal carcinoma in situ (DCIS)] and 1,102 were prophylactic. Of the 1,170 total patients, 352 underwent a unilateral and 818 underwent a bilateral NSM. Recurrence at a mean follow-up of 31 months/median follow-up of 27 months, with a range of 9.7 to 58.3 months since surgery was 1.4% with no recurrences at the nipple or nipple areola complex (NAC). Cancer occurrence (0.3%) also did not involve the nipple/NAC. Overall patient satisfaction of excellent/good: 94.9% and overall cosmesis (surgeon rated) of excellent/good was 96.4%. Overall infection rates included flap infection of 4.4%, NAC complication rate of 4.5% (defined as necrosis/other or ischemia/epidermolysis requiring surgery), and a 10% rate of NAC epidermolysis with full recovery. Conclusions NSMs were performed on breasts with a variety of sizes and degrees of ptosis, via multiple incisions, dissection and reconstruction techniques with low complication rates and high patient satisfaction and surgeon rated cosmesis.
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A Meta-analysis of Studies Comparing Outcomes of Diverse Acellular Dermal Matrices for Implant-Based Breast Reconstruction. Ann Plast Surg 2018; 79:115-123. [PMID: 28509698 DOI: 10.1097/sap.0000000000001085] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The current diversity of the available acellular dermal matrix (ADM) materials for implant-based breast reconstruction raises the issue of whether there are any differences in postoperative outcomes according to the kind of ADM used. The present meta-analysis aimed to investigate whether choice of ADM products can affect outcomes. METHODS Studies that used multiple kinds of ADM products for implant-based breast reconstruction and compared outcomes between them were searched. Outcomes of interest were rates of postoperative complications: infection, seroma, mastectomy flap necrosis, reconstruction failure, and overall complications. RESULTS A total of 17 studies met the selection criteria. There was only 1 randomized controlled trial, and the other 16 studies had retrospective designs. Comparison of FlexHD, DermaMatrix, and ready-to-use AlloDerm with freeze-dried AlloDerm was conducted in multiple studies and could be meta-analyzed, in which 12 studies participated. In the meta-analysis comparing FlexHD and freeze-dried AlloDerm, using the results of 6 studies, both products showed similar pooled risks for all kinds of complications. When comparing DermaMatrix and freeze-dried AlloDerm with the results from 4 studies, there were also no differences between the pooled risks of complications of the two. Similarly, the meta-analysis of 4 studies comparing ready-to-use and freeze-dried AlloDerm demonstrated that the pooled risks for the complications did not differ. CONCLUSIONS This meta-analysis demonstrates that the 3 recently invented, human cadaveric skin-based products of FlexHD, DermaMatrix, and ready-to-use AlloDerm have similar risks of complications compared with those of freeze-dried AlloDerm, which has been used for longer. However, as most studies had low levels of evidence, further investigations are needed.
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Lee KT, Eom Y, Mun GH, Bang SI, Jeon BJ, Pyon JK. Efficacy of Partial- Versus Full-Sling Acellular Dermal Matrix Use in Implant-Based Breast Reconstruction: A Head-to-Head Comparison. Aesthetic Plast Surg 2018; 42:422-433. [PMID: 29368031 DOI: 10.1007/s00266-018-1084-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/15/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND Acellular dermal matrix (ADM), popularly used in tissue expander-based breast reconstruction, is applied either as a partial or full sling, but without any consensus regarding which method of application produces better outcomes. We aimed to compare the outcomes between two patient groups who underwent tissue expander-based breast reconstruction using these techniques. METHODS A retrospective review was conducted for consecutive patients who underwent immediate two-stage implant-based breast reconstruction using ADM between January 2013 and June 2016. They were categorized into two cohorts: cohort 1 included patients in whom ADM was applied using the partial-sling technique, insetting it obliquely after releasing the pectoralis major muscle from its costal origin, and cohort 2 included those who underwent a full-sling technique, insetting it transversely after releasing the muscle from its costal and lower sternal origin. Postoperative complications and aesthetic outcomes were compared between the two groups. RESULTS We analysed 329 cases (167 in cohort 1 and 162 in cohort 2) with similar baseline characteristics in both cohorts. Reconstruction failure occurred in 2.4% of overall patients. The rates of each and overall acute complications did not differ significantly between the cohorts. Cohort 2 showed significantly lower rates of tissue expander displacement and malposition following the first-stage operation and rippling following the second-stage operation, differences that retained the influences in multivariate analyses. Higher aesthetic scores were obtained in cohort 2. CONCLUSION Using the full-sling ADM might reduce unintended migration of prostheses and enable proper tissue expansion, resulting in better overall outcomes without increasing morbidities. 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 .
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Hallberg H, Rafnsdottir S, Selvaggi G, Strandell A, Samuelsson O, Stadig I, Svanberg T, Hansson E, Lewin R. Benefits and risks with acellular dermal matrix (ADM) and mesh support in immediate breast reconstruction: a systematic review and meta-analysis. J Plast Surg Hand Surg 2018; 52:130-147. [PMID: 29320921 DOI: 10.1080/2000656x.2017.1419141] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In modern implant-based immediate breast reconstruction, it has become common to use biological acellular dermal and synthetic matrices in combination with a tissue expander or an implant. The aim of this systematic review was to examine differences in recurrence of cancer, impact on oncological treatment, health related quality of life, complications and aesthetic outcome between matrix and no matrix in immediate breast reconstruction. Systematic searches, data extraction and assessment of methodological quality were performed according to predetermined criteria. Fifty-one studies were eligible and included in the review. The certainty of evidence for overall complication rate and implant loss is low (GRADE ⊕⊕□ □). The certainty of evidence for delay of adjuvant treatment, implant loss, infection, capsular contraction and aesthetic outcome is very low (GRADE ⊕□ □ □). No study reported data on recurrence of cancer or health related quality of life. In conclusion, there is a lack of high quality studies that compare the use of matrix with no matrix in immediate breast reconstruction. Specifically, there are no data on risk of recurrence of cancer, delay of adjuvant treatment and Health related quality of life (HRQoL). In addition, there is a risk of bias in many studies. It is often unclear what complications have been included and how they have been diagnosed, and how and when capsular contracture and aesthetic outcome have been evaluated. Controlled trials that further analyse the impact of radiotherapy, type of matrix and type of procedure (one or two stages) are necessary.
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Affiliation(s)
- Håkan Hallberg
- a Department of clinical sciences , University of Gothenburg, The Sahlgrenska Academy , Gothenburg , Sweden.,b Department of Reconstructive Plastic Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Svanheidur Rafnsdottir
- a Department of clinical sciences , University of Gothenburg, The Sahlgrenska Academy , Gothenburg , Sweden.,c Department of Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Gennaro Selvaggi
- a Department of clinical sciences , University of Gothenburg, The Sahlgrenska Academy , Gothenburg , Sweden.,b Department of Reconstructive Plastic Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Annika Strandell
- d Health Technology Assessment centre , Region Västra Götaland , Gothenburg , Sweden
| | - Ola Samuelsson
- d Health Technology Assessment centre , Region Västra Götaland , Gothenburg , Sweden
| | - Ida Stadig
- e Medical Library , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Therese Svanberg
- d Health Technology Assessment centre , Region Västra Götaland , Gothenburg , Sweden
| | - Emma Hansson
- a Department of clinical sciences , University of Gothenburg, The Sahlgrenska Academy , Gothenburg , Sweden.,b Department of Reconstructive Plastic Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
| | - Richard Lewin
- a Department of clinical sciences , University of Gothenburg, The Sahlgrenska Academy , Gothenburg , Sweden.,b Department of Reconstructive Plastic Surgery , Sahlgrenska University Hospital , Gothenburg , Sweden
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Heidemann LN, Gunnarsson GL, Salzberg CA, Sørensen JA, Thomsen JB. Complications following Nipple-Sparing Mastectomy and Immediate Acellular Dermal Matrix Implant-based Breast Reconstruction-A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e1625. [PMID: 29464161 PMCID: PMC5811291 DOI: 10.1097/gox.0000000000001625] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 11/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acellular dermal matrix was introduced in breast reconstruction in 2001 and is gradually becoming a standard component for immediate breast reconstruction and nipple-sparing mastectomy. The reconstructive technique allows for improved aesthetic outcomes. However, there seems to be uncertainty regarding complication rates. The aim of this review was to systematically evaluate complication rates related to this method. METHODS This systematic review was conducted according to the recommendations outlined in the Cochrane Handbook for reviews and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Relevant databases were searched for in the literature concerning the use of acellular dermal matrix in implant-based nipple-sparing mastectomy and immediate breast reconstruction. All studies underwent detailed quality assessment. Summarized outcome rates were computed using meta-analysis. RESULTS Nine of 1,039 studies were eligible for inclusion yielding 778 procedures. The quality was acceptable for all included studies. The meta-analysis found the rate of skin necrosis to be 11%, nipple necrosis 5%, infection in 12%, hematoma in 1%, treated seroma in 5%, explantation 4%, and unplanned return to the operating room in 9%. CONCLUSION The use of acellular dermal matrix in nipple-sparing mastectomy and implant-based breast reconstruction can be done with acceptable complication rates in selected patients. We recommend future studies to include specific definitions when reporting complication rates. Furthermore, future studies should elaborate on demographic characteristics of the included study samples and include predictor analysis to enhance knowledge of high risk patients.
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Affiliation(s)
- Lene Nyhøj Heidemann
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - Gudjon L. Gunnarsson
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - C. Andrew Salzberg
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - Jens Ahm Sørensen
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
| | - Jørn Bo Thomsen
- From the Department of Plastic- and Reconstructive Surgery, Odense University Hospital, Denmark; Department of Plastic Surgery, Telemark Hospital, Skien, Norway; and Division of Plastic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, N.Y
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Abstract
Prepectoral breast reconstruction has emerged as an excellent technique for postmastectomy reconstruction, as it allows for full preservation of a patient's pectoralis major muscle and chest wall function. This reduces pain, eliminates animation deformity, and results in high patient satisfaction. Safely performed prepectoral breast reconstruction requires a careful patient selection process before committing to the procedure, taking into account comorbidities, radiation status, and oncologic criteria such as tumor location and breast cancer stage. Furthermore, a thorough intraoperative assessment of mastectomy skin flaps is critical, with careful and precise confirmation that the skin is viable and well perfused, prior to proceeding with prepectoral breast reconstruction. This can be done both clinically and with perfusion assessment devices. The use of acellular dermal matrix (ADM) has enhanced outcomes and aesthetics of prepectoral reconstruction, by providing implant coverage and soft-tissue support. The ADM also adds the benefit of reducing capsular contracture rates and offers full control over the aesthetic definition of the newly reconstructed breast pocket. Aesthetic enhancement of results requires routine use of oversizing implants in the skin envelope, careful selection of full capacity or cohesive gel implants, and autologous fat grafting. In this way, patients in all clinical scenarios can benefit from the full muscle-sparing technique of prepectoral breast reconstruction, including those undergoing immediate reconstruction, delayed reconstruction, and delayed conversion from a subpectoral to prepectoral plane to correct animation deformity.
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18
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Nipple-Areola Complex Malposition in Nipple-Sparing Mastectomy: A Review of Risk Factors and Corrective Techniques from Greater than 1000 Reconstructions. Plast Reconstr Surg 2017; 140:247e-257e. [PMID: 28369015 DOI: 10.1097/prs.0000000000003507] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Nipple-areola complex malposition after nipple-sparing mastectomy can be a challenging issue to correct. The current literature is largely limited to smaller series and implant-based reconstructions. METHODS A retrospective review of all nipple-sparing mastectomies from 2006 to 2016 at a single institution was performed. Incidence, risk factors, and corrective techniques of nipple-areola complex malposition were analyzed. RESULTS One thousand thirty-seven cases of nipple-sparing mastectomy were identified, of which 77 (7.4 percent) underwent nipple-areola complex repositioning. All were performed in a delayed fashion. The most common techniques included crescentic periareolar excision [n = 25 (32.5 percent)] and directional skin excision [n = 10 (13.0 percent)]. Cases requiring nipple-areola complex repositioning were significantly more likely to have preoperative radiation therapy (p = 0.0008), a vertical or Wise pattern incision (p = 0.0157), autologous reconstruction (p = 0.0219), and minor mastectomy flap necrosis (p = 0.0462). Previous radiation therapy (OR, 3.6827; p = 0.0028), vertical radial mastectomy incisions (OR, 1.8218; p = 0.0202), and autologous reconstruction (OR, 1.77; p = 0.0053) were positive independent predictors of nipple-areola complex repositioning, whereas implant-based reconstruction (OR, 0.5552; p < 0.0001) was a negative independent predictor of repositioning. Body mass index (p = 0.7104) and adjuvant radiation therapy (p = 0.9536), among other variables, were not predictors of nipple-areola complex repositioning. CONCLUSIONS Nipple-areola complex malposition after nipple-sparing mastectomy can be successfully corrected with various techniques. Previous radiation therapy, vertical mastectomy incisions, and autologous reconstruction are independently predictive of nipple-areola complex malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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19
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Coopey SB, Mitchell SD. Nipple-Sparing Mastectomy: Pitfalls and Challenges. Ann Surg Oncol 2017; 24:2863-2868. [PMID: 28766226 DOI: 10.1245/s10434-017-5962-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Indexed: 01/27/2023]
Affiliation(s)
- Suzanne B Coopey
- Division of Surgical Oncology, Massachusetts General Hospital, Boston, MA, USA.
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20
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Tran BNN, Fadayomi A, Lin SJ, Singhal D, Lee BT. Cost analysis of postmastectomy reconstruction: A comparison of two staged implant reconstruction using tissue expander and acellular dermal matrix with abdominal-based perforator free flaps. J Surg Oncol 2017; 116:439-447. [PMID: 28591940 DOI: 10.1002/jso.24692] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 04/08/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. METHODS A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. RESULTS Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. CONCLUSIONS DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated.
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Affiliation(s)
- Bao Ngoc N Tran
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts
| | - Ayotunde Fadayomi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts
| | - Samuel J Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts
| | - Dhruv Singhal
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts
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21
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Comparison of Outcomes with Tissue Expander, Immediate Implant, and Autologous Breast Reconstruction in Greater Than 1000 Nipple-Sparing Mastectomies. Plast Reconstr Surg 2017; 139:1300-1310. [DOI: 10.1097/prs.0000000000003340] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Nahabedian MY. Implant-based breast reconstruction following conservative mastectomy: one-stage vs. two-stage approach. Gland Surg 2016; 5:47-54. [PMID: 26855908 DOI: 10.3978/j.issn.2227-684x.2015.06.08] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Conservative mastectomy with preservation of the nipple areolar complex is now considered a safe and effective technique in properly selected patients. Good candidates for this procedure include women with small to moderate breast volume having therapeutic or prophylactic mastectomy. Both autologous and prosthetic options are available; however prosthetic techniques are performed more frequently. Prosthetic approaches include immediate 1-stage (direct to implant) or 2-atge (tissue expander/implant) techniques. Delayed prosthetic reconstruction is also possible with conservative mastectomy. This manuscript will review the 1-stage and 2-stage methods with an emphasis on indication, surgical techniques, and outcomes.
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Affiliation(s)
- Maurice Y Nahabedian
- Department of Plastic Surgery, Georgetown University Hospital, Washington DC 20007, USA
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23
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Vu MM, Kim JYS. Current opinions on indications and algorithms for acellular dermal matrix use in primary prosthetic breast reconstruction. Gland Surg 2015; 4:195-203. [PMID: 26161304 DOI: 10.3978/j.issn.2227-684x.2015.05.07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 05/05/2015] [Indexed: 11/14/2022]
Abstract
Acellular dermal matrix (ADM) is widely used in primary prosthetic breast reconstruction. Many indications and contraindications to use ADM have been reported in the literature, and their use varies by institution and surgeon. Developing rational, tested algorithms to determine when ADM is appropriate can significantly improve surgical outcomes and reduce costs associated with ADM use. We review the important indications and contraindications, and discuss the algorithms that have been put forth so far. Further research into algorithmic decision-making for ADM use will allow optimized balancing of cost with risk and benefit.
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Affiliation(s)
- Michael M Vu
- Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - John Y S Kim
- Division of Plastic and Reconstructive Surgery, Feinberg School of Medicine, Northwestern University, Chicago, USA
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