Short-Term Complications Associated With Acellular Dermal Matrix-Assisted Direct-to-Implant Breast Reconstruction

Paradigm Shifts in Alloplastic Breast Reconstruction: A Nationwide Analysis of Direct-to-Implant Trends

BACKGROUND

Direct-to-implant breast reconstruction is an attractive choice for appropriately selected patients, as a single-stage procedure can enhance global metrics of care. In an era of high-value health care, therefore, it is important to investigate use of such procedures. This study investigated direct-to-implant trends over the past decade on a nationwide basis.

METHODS

This was a retrospective investigation of direct-to-implant reconstruction between 2010 and 2018 in the United States, using the National Inpatient Sample database. All study analyses were undertaken using Stata version 15.0.

RESULTS

The weighted sample included 287,093 women who underwent implant-based reconstruction between 2010 and 2018, of whom 43,064 (15%) underwent direct-to-implant reconstruction. Across the study period, the proportion of direct-to-implant procedures increased significantly ( P = 0.03), relative to staged and delayed implant-based procedures. Although direct-to-implant patients were younger and more likely to be White and privately insured, the proportion of non-White, publicly insured patients undergoing direct-to-implant reconstruction increased significantly by 2018 ( P < 0.05). Furthermore, direct-to-implant use among Medicaid patients was 2.2 times the rate in Medicaid expansion states compared with nonexpansion states. Direct-to-implant patients had significantly higher All Patient Refined Diagnosis Related Group risk scores in 2018 than in 2010 ( P = 0.02), indicating expanding clinical indications for this procedure. Direct-to-implant reconstruction had significantly lower inpatient charges than staged procedures ( P = 0.03), when considering expander placement and expander-to-implant exchange.

CONCLUSIONS

Overall, use of direct-to-implant breast reconstruction has significantly increased over the past decade, facilitated by expanding clinical indications and improved insurance coverage. However, certain disparities continue to exist. Further work should investigate drivers of disparities to allow continued expansion of direct-to-implant reconstruction as clinically appropriate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Interest of acellular dermal matrices in immediate breast reconstruction: Comparison of quality of life and complications with and without matrix

INTRODUCTION

Since 2001, acellular dermal matrices have been increasingly used in immediate breast reconstruction (IBR) because they allow for the placement of the ideal-sized definitive implant in one step. They are used in both retropectoral and prepectoral prosthetic breast reconstructions. The aim of this study was to evaluate the impact of dermal matrices on the quality of life and on complications.

MATERIALS AND METHODS

Two surveys were used to evaluate the quality of life: the BREAST-Q V2.0© and the QuickDASH. The surveys were sent to all patients who had an immediate prosthetic breast reconstruction at a University Hospital Center from 2010 to 2020. A case-control study was performed for comparison of responses between the "Matrix+" and "Matrix-" groups.

RESULTS

Seventeen IBR with matrix (23.6%) and 55 IBR without matrix (76.4%) were analyzed. Patients in the "Matrix+" group had a better quality of life in terms of sexual well-being (p = 0.038) and a significantly lower QuickDASH (p < 0.01). They had better breast satisfaction (p = 0.016) and better implant satisfaction (p < 0.01). The likelihood of encountering major complications later in time was more important in the group with matrix (p = 0.04).

CONCLUSION

We found a satisfactory quality of life with scores of sexual well-being and satisfaction with the breast and the implants, and a better satisfaction with care thanks to the use of the matrices. However, due to a higher number of major late complications and a lack of follow-up, we believe that immediate prosthetic breast reconstruction with matrix should be discussed according to the comorbidities, medical treatments, and the vitality of the skin flaps of each patient.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcomes of Negative Pressure Wound Therapy on Immediate Breast Reconstruction after Mastectomy

Immediate expander/implant-based breast reconstruction after mastectomy has become more sought after by patients. Although many patients choose this technique due to good aesthetic outcomes, lack of donor site morbidity, and shorter procedure times, it is not without complications. The most reported complications include seroma, infection, hematoma, mastectomy flap necrosis, wound dehiscence, and implant exposure, with an overall complication rate as high as 45%. Closed incision negative pressure therapy (ciNPT) has shown value in wound healing and reducing complications; however, the current literature is inconclusive. We aimed to examine if ciNPT improves outcomes for patients receiving this implant-based reconstruction.

Methods

This is a retrospective single-institution study evaluating the ciNPT device, 3M Prevena Restor BellaForm, on breast reconstruction patients. The study was performed between July 1, 2019 and October 30, 2020, with 125 patients (232 breasts). Seventy-seven patients (142 breasts) did not receive the ciNPT dressing, and 48 patients (90 breasts) received the ciNPT dressing. Primary outcomes were categorized by major or minor complications. Age, BMI, and final drain removal were summarized using medians and quartiles, and were compared with nonparametric Mann-Whitney test. Categorical variables were compared using chi-square or Fisher exact test.

Results

There was a statistically significant reduction in major complications in the ciNPT group versus the standard dressing group (P = 0.0247). Drain removal time was higher in the ciNPT group.

Conclusion

Our study shows that ciNPT may help reduce major complication rates in implant-based breast reconstruction patients.

Direct to Implant Reconstruction

Implant-based breast reconstruction remains the most commonly performed type of restorative surgery after mastectomy for breast cancer. Placement of a tissue expander at the time of mastectomy allows gradual skin envelope expansion but requires additional surgery and time to completion of a patient's reconstruction. Direct-to-implant reconstruction provides a one-stage, final implant insertion, thereby bypassing the need for serial tissue expansion. With proper patient selection, successful preservation of the breast skin envelope, and accurate implant size and placement, direct-to-implant reconstruction has a very high rate of success and patient satisfaction.

Single Institution Evolution in Defining an Algorithm for Prevention and Management of Severe Complications in Direct-to-Implant Breast Reconstruction

BACKGROUND

Complications including infection and wound dehiscence are major concerns for direct-to-implant (DTI) breast reconstruction. However, the risk factors associated with severe complications and implant salvage remain unclear.

METHODS

Retrospective study of all patients undergoing unilateral DTI breast reconstruction from 2014 through 2019. The risk factors associated with complications and prosthesis explantation were identified using multivariate logistic regression modeling and interaction analyses.

RESULTS

Among 1027 patients enrolled, 90 experienced severe complications, 41of which underwent prosthesis explantation, while 49 were successfully salvaged. Multivariate analysis demonstrated that patients with larger implant size (p=0.003), use of bovine mesh (p<0.001), adjuvant radiotherapy (p=0.047), low plasma albumin (p=0.013), and elevated blood glucose (p=0.006) were significantly more likely to suffer complications. Adjuvant radiation (OR: 7.44; 95%CI, 1.49-37.18; p = 0.014) and obesity (OR, 4.17; 95%CI, 1.17-14.88; p = 0.028) had significantly lower rates of implant salvage as well as surgical site infection (SSI) and wound dehiscence, while mastectomy skin flap necrosis was not associated with device explanation. There were no differences in complication and explantation rates between nipple-sparing and skin-sparing mastectomies. However, the combined impact of SSI and wound dehiscence added over fourteen-fold higher risk of prosthesis explantation (95%CI, 9.97-19.53).

CONCLUSION

Success in direct-to-implant breast reconstruction is multifactorial. Larger implant size, adjuvant radiation therapy, diabetes, and malnutrition demonstrate increased risk of complications in the DTI approach. Surgical site infections and wound dehiscence should be treated aggressively, but the combination of both complications portends poor salvage rates.

Immunomodulation of Acellular Dermal Matrix Through Interleukin 4 Enhances Vascular Infiltration

BACKGROUND

Acellular dermal matrix (ADM) supported implant-based reconstruction remains the most commonly performed mode of reconstruction after breast cancer. Acellular dermal matrix clinical usage has reported benefits but requires rapid and efficient vascular and cellular incorporation into the recipient to have the best outcomes. Orderly transition from M1 to M2 macrophage phenotypic profile, coordinated in part by interleukin 4 (IL-4), is an important component of vascular stabilization and remodeling. Using the ADM substrate as a delivery device for immunomodulation of macrophage phenotype holds the potential to improve integration.

METHODS

Interleukin 4 was adsorbed onto ADM samples and drug elution curves were measured. Next, experimental groups of 8 C57BL/6 mice had 5-mm ADM discs surgically placed in a dorsal window chamber with a vascularized skin flap on one side and a plastic cover slip on the other in a model of implant-based breast reconstruction. Group 1 consisted of IL-4 (5 μg) adsorbed into the ADM preoperatively and group 2 consisted of an untreated ADM control. Serial gross examinations were performed with histology at day 21 for markers of vascularization, mesenchymal cell infiltration, and macrophage lineage.

RESULTS

Drug elution curves showed sustained IL-4 release for 10 days after adsorption. Serial gross examination showed similar rates of superficial vascular investment of the ADM beginning at the periphery by day 14 and increasing through day 21. Interleukin-4 treatment led to significantly increased CD31 staining of vascular endothelial cells within the ADM over the control group (P < 0.05) at 21 days. Although vimentin staining did not indicate a significant increase in fibroblasts overall, IL-4 did result in a significant increase in expression of α-smooth muscle actin. The expression of macrophage phenotype markers Arginase1 and iNOS present within the ADM were not significantly affected by IL-4 treatment at the day 21 time point.

CONCLUSIONS

Acellular dermal matrix has the potential to be used for immunomodulatory cytokine delivery during the timeframe of healing. Using implanted ADM as a delivery vehicle to drive IL-4 mediated angiogenesis and vascular remodeling significantly enhanced vascularity within the ADM substrate.

Risk of major postoperative complications in breast reconstructive surgery with and without an acellular dermal matrix; Development of a prognostic prediction model

Introduction

Acellular dermal matrices (ADM) have been suggested to allow for different approaches and reduce the risk of postoperative complications in implant-based breast surgery. Surgeons seem to embrace ADMs around the world, although a lack of consistent evidence regarding the factors that increase the risk of major postoperative complications remains.

Purpose

To develop and internally validate a model to predict the risk of a major postoperative complication in breast reconstructive surgery with and without an ADM.

Methodology

The DBIR is an opt-out registry that holds characteristics of all breast implant surgeries in the Netherlands since 2015. Using a literature-driven preselection of predictors, multivariable mixed-effects logistic regression modelling was used to develop the prediction model.

Results

A total of 2939 breasts were eligible, of which 11% underwent an ADM-assisted procedure (single-stage or two-stage). However, 31% underwent a two-stage procedure (with or without the use of ADM). Of all breasts, 10.2% developed a major postoperative complication. Age (OR 1.01), delayed timing (OR 0.71), and two-stage technique (OR 4.46) were associated with the outcome.

Conclusion

The data suggest that ADM use was not associated with a major postoperative complication, while two-stage reconstructions were strongly associated with an increased risk of major complications. Despite these findings, ADMs are not as popular in the Netherlands as in the USA. The predictive capabilities of the developed model are mediocre to poor, but because of the above findings, we believe that the role of the two-stage technique as a golden standard should be put up for debate.

Direct-to-implant breast reconstruction following nipple-sparing mastectomy: predictive factors of adverse surgical outcomes in Asian patients

BACKGROUND

Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes.

METHODS

Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed.

RESULTS

There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025).

CONCLUSIONS

Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

In situ Adipogenesis in Biomaterials Without Cell Seeds: Current Status and Perspectives

For cosmetic and reconstructive purposes in the setting of small-volume adipose tissue damage due to aging, traumatic defects, oncological resections, and degenerative diseases, the current strategies for soft tissue replacement involve autologous fat grafts and tissue fillers with synthetic, bioactive, or tissue-engineered materials. However, they all have drawbacks such as volume shrinkage and foreign-body responses. Aiming to regenerate bioactive vascularized adipose tissue on biomaterial scaffolds, adipose tissue engineering (ATE) has emerged as a suitable substitute for soft tissue repair. The essential components of ATE include scaffolds as support, cells as raw materials for fat formation, and a tolerant local environment to allow regeneration to occur. The commonly loaded seeding cells are adipose-derived stem cells (ASCs), which are expected to induce stable and predictable adipose tissue formation. However, defects in stem cell enrichment, such as donor-site sacrifice, limit their wide application. As a promising alternative approach, cell-free bioactive scaffolds recruit endogenous cells for adipogenesis. In biomaterials without cell seeds, the key to sufficient adipogenesis relies on the recruitment of endogenous host cells and continuous induction of cell homing to scaffolds. Regeneration, rather than repair, is the fundamental dominance of an optimal mature product. To induce in situ adipogenesis, many researchers have focused on the mechanical and biochemical properties of scaffolds. In addition, efforts to regulate an angiogenic and adipogenic microenvironment in cell-free settings involve integrating growth factors or extracellular matrix (ECM) proteins onto bioactive scaffolds. Despite the theoretical feasibility and encouraging results in animal models, few of the reported cell-free biomaterials have been tested in humans, and failures of decellularized adipose tissues in adipogenesis have also been reported. In these cases, the most likely reason was the lack of supporting vasculature. This review summarizes the current status of biomaterials without cell seeds. Related mechanisms and influencing factors of in situ adipogenesis in cell-free biomaterials, dilemma in the development of biomaterials, and future perspectives are also addressed.

Comparison of one-stage direct-to-implant with acellular dermal matrix and two-stage immediate implant-based breast reconstruction-a cohort study

Background

The use of acellular dermal matrix (ADM) in one-stage immediate implant-based breast reconstruction (BR) may offer advantages over the two-stage expander-to-implant technique, but literature shows conflicting results. The aim of the present study was to compare these two techniques for immediate implant-based BR regarding postoperative complications, aesthetic correction procedures and aesthetic outcome.

Methods

The study was designed as an observational cohort study with 44 participants admitted for immediate implant-based BR at Department of Plastic Surgery, Aarhus University Hospital, Denmark. 21 patients underwent BR with a one-stage direct-to-implant technique using ADM and 23 patients underwent BR with a two-stage expander-to-implant technique. Follow-up time was 2 years.

Results

The risk of implant loss was equal between groups; one-stage group 16% and two-stage group 17% whereas the risk of implant exchange (but not loss of BR) was 13% in the one-stage group compared to 7% in the two-stage group. The risk of at least one major complication were equal between groups; 28% and 24% but the risk of at least one minor complication was significantly higher in the two-stage group (41%) compared to the one-stage group (3%). Number of aesthetic corrections were equally frequent in the two treatment groups (one-stage group 1.8, two-stage group 1.5). Patient and investigator assessed aesthetic outcome was very high in both groups as well as the degree of symmetry between breasts. No capsular contracture Baker grade 3 or 4 was observed.

Conclusions

The present study design sets limitations for drawing wide conclusions. This study did not reveal any significant differences between the two breast reconstructive techniques besides a higher risk of minor complications in the two-stage group, that did, however, not lead to a higher risk of implant loss. With equally high satisfaction with the aesthetic result and no significant difference in number of aesthetic corrections between the two groups we suggest, that the one-stage approach using ADM may be feasible and allows the patient to achieve an implant-based BR with a minimum of surgeries and outpatient visits. The study was registered in ClinicalTrials.gov (NCT04209010).

Retrospective analysis between complication and nipple areola complex preservation in direct-to-implant breast reconstruction

Background

Since the introduction of skin-sparing mastectomy (SSM), more breast surgeons have been preserving the areola and often nipple areolar complex (NAC) entirely. For better outcomes, more studies are necessary to analyze whether preserving the areola or NAC is unfavorable in breast reconstruction. The aim of this study was to assess the potential risk of areola or NAC preservation in direct-to-implant (DTI) breast reconstruction after SSM.

Methods

We retrospectively reviewed the medical records of patients who underwent immediate breast reconstruction from May 2011 to July 2017. Immediate breast reconstruction was performed with DTI procedure in all cases. In total, 213 breasts met the inclusion criteria and were divided into 3 groups: nipple-sparing mastectomy (NSM), aerola-sparing mastectomy (ASM) which only nipple is excised, and skin-sparing mastectomy (SSM) which whole NAC was excised. Complications including infection, capsular contracture, skin necrosis and explantation were measured.

Results

The mean patient age was 45.3 years, with a range of 27-62 years; the mean follow-up was 3.08 years. NSM, ASM and SSM groups consisted of 121, 30 and 62 breasts, respectively. The Infection rates were statistically lower in SSM group (4.8%) compared with NSM group (15.7%) (P=0.033) but not statistically different from ASM group (13.3%) (P=0.210). SSM group showed significantly lower rate of overall complication compared with both NSM and ASM groups (P=0.005, 0.025 respectively).

Conclusions

Our research suggests that preservation of the NAC increases the rate of infection and skin necrosis in DTI breast reconstruction.

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

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

Acute Postoperative Complications in Prepectoral versus Subpectoral Reconstruction following Nipple-Sparing Mastectomy

BACKGROUND

Nipple-sparing mastectomy is associated with improved aesthetics and oncologic safety. Recently, there has been a resurgence in prepectoral reconstruction. Because of limited data comparing complication rates on patients undergoing prepectoral breast reconstruction, this study compared 30-day postoperative complications by plane of prosthetic placement.

METHODS

A retrospective review was conducted on all consecutive patients undergoing nipple-sparing mastectomy with implant-based reconstruction with either prepectoral or subpectoral placement from 2014 to 2018. The primary outcome was a composite, acute 30-day postoperative complication, including nipple-areola complex necrosis, mastectomy flap necrosis, wound dehiscence, infection, hematoma, and seroma. Secondary outcomes included nipple loss and rates of unintended reoperations. Univariate and mixed effects multivariate logistic regression were used to compare outcomes.

RESULTS

A total of 228 patients and 405 breasts were included in the final cohort, with 202 in the subpectoral cohort and 203 in the prepectoral cohort. The overall complication rate was 7.65 percent, with no significant difference between subpectoral and prepectoral cohorts (9.41 percent versus 5.91 percent, respectively; p = 0.148). Prepectoral reconstruction was associated with significantly reduced ischemic complications, including nipple loss because of necrosis (2.97 percent versus 0.49 percent, respectively; p = 0.015) and mastectomy flap necrosis (5.45 percent versus 0 percent; p = 0.003). There were no significant differences in rates of infection, hematoma, seroma, or implant loss/exchange.

CONCLUSIONS

Prepectoral reconstruction is associated with similar overall 30-day postoperative complications and reoperations compared to traditional subpectoral implants. However, prepectoral reconstruction was associated with significantly decreased ischemic complications, including mastectomy flap necrosis and nipple-areola complex loss because of necrosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Complications after Perforated versus Nonperforated Acellular Dermal Matrix Use in Direct-to-Implant Breast Reconstruction: A Propensity Score Analysis

Acellular dermal matrices (ADMs) were first incorporated into direct-to-implant (DTI) breast reconstruction by the senior author in 2001 and have since become foundational to implant-based reconstruction. ADM composition has evolved recently and now includes perforated types, which some speculate decrease the likelihood of seroma. The authors performed a retrospective review of perforated (P-ADM) and nonperforated (NP-ADM) ADM-assisted direct-to-implant breast reconstruction patients to evaluate differences in complication rates.

In Vitro Characterization of a Novel Human Acellular Dermal Matrix (BellaCell HD) for Breast Reconstruction

In the past, acellular dermal matrices (ADMs) have been used in implant-based breast reconstruction. Various factors affect the clinical performance of ADMs since there is a lack of systematic characterization of ADM tissues. This study used BellaCell HD and compared it to two commercially available ADMs—AlloDerm Ready to Use (RTU) and DermACELL—under in vitro settings. Every ADM was characterized to examine compatibility through cell cytotoxicity, proliferation, and physical features like tensile strength, stiffness, and the suture tensile strength. The BellaCell HD displayed complete decellularization in comparison with the other two ADMs. Several fibroblasts grew in the BellaCell HD with no cytotoxicity. The proliferation level of fibroblasts in the BellaCell HD was higher, compared to the AlloDerm RTU and DermACELL, after 7 and 14 days. The BellaCell HD had a load value of 444.94 N, 22.44 tensile strength, and 118.41% elongation ratio, and they were higher than in the other two ADMs. There was no significant discrepancy in the findings of stiffness evaluation and suture retention strength test. The study had some limitations because there were many other more factors useful in ADM’s testing. In the study, BellaCell HD showed complete decellularization, high biocompatibility, low cytotoxicity, high tensile strength, high elongation, and high suture retention strengths. These characteristics make BellaCell HD a suitable tissue for adequate and safe use in implant-based breast reconstruction in humans.

Preliminary Results Supporting the Bacterial Hypothesis in Red Breast Syndrome following Postmastectomy Acellular Dermal Matrix- and Implant-Based Reconstructions

Acellular dermal matrices have become a mandatory tool in reconstructive breast surgery. Since their introduction, they have been considered to be nonreactive and nonimmunogenic scaffolds. However, some patients who undergo implant-based breast reconstruction with acellular dermal matrices develop postoperative cutaneous erythema overlying their matrices, a condition commonly referred to as red breast syndrome. The aim of this study was to gain a better understanding of this phenomenon. An analysis was conducted on consecutive patients who underwent acellular dermal matrix- and implant-based breast reconstructions and developed red breast syndrome that was treated surgically between April of 2017 and June of 2018 at the authors' institution. During surgery, 1-cm specimens of acellular dermal matrix were sampled and analyzed by scanning electron microscopy. Observations were charted to score and record the presence and thickness of biofilm, and for identification of bacteria. These measurements were performed using Adobe Photoshop CS6 Extended software. Six postmastectomy breast reconstruction patients were included, all with AlloDerm Ready-to-Use-based reconstructions. All specimens were colonized by various bacteria ranging from Gram-negative bacilli to Gram-positive microorganisms. Biofilm was present in all studied specimens. The cause of skin erythema overlying acellular dermal matrix grafts, and the so-called red breast syndrome, may be related to contamination with various bacteria. Although contamination was omnipresent in analyzed samples, its clinical significance is variable. Even if acellular dermal matrix-based reconstructions are salvaged, this could come at the price of chronic local inflammation.

PROMs in post-mastectomy care: Patient self-reports (BREAST-Q™) as a powerful instrument to personalize medical services

One of the goals of immediate breast reconstruction (IBR) is to satisfy the patient's outcome. Recent studies therefore tended to focus on the patient's perception of the care and on the impact on quality of life using patients-reported-outcome-measures (PROMs), able to measure the health status directly without the clinician's interposition. We present a preliminary prospective study on 333 patients who underwent mastectomy with IBR in a two-year period, in a single Italian centre, using a dedicated PROMs, the BREAST-Q™, to determine the patient's satisfaction. We studied two groups of IBR: Group A (two-step with tissue-expander) and Group B (one-step: prosthesis/mesh) and conducted a pre- and post-operative comparison for each group to evaluate score-gain over time, and a group-score comparison to determine whether differences were significant between reconstruction types. Two-hundred-and-nine were actually enrolled and 132 completed all the questionnaires. The response rate was 62.8% and the compliance rate (completion of all the questionnaires) was 63.1%. In both groups all the analyzed domains worsened comparing the pre and post-operative period; the differences were statistically significant only for physical and sexual-wellbeing. In the comparison between the two groups, none of the detected differences reached the statistical significance. According to our experience, we can state that PROMs could improve the health concept redefining the variables to be monitored even if data is still insufficient to draw any definitive conclusion. PROMs can help surgeons and patients decide the most appropriate surgery for a particular patient-profile and to identify those who require further support.

Direct to implant breast reconstruction: visualized technique

Over the past 19 years, direct to implant (DTI) breast reconstruction has been found to decrease medical system cost, improve psychosocial morbidity, and optimize cosmetic outcomes. Acellular dermal matrices (ADMs) have further improved reconstructive outcomes, as the tissue incorporates with new angiogenesis and tissue regeneration. ADMs have been used by the senior author since 2000, and have since become a cornerstone of implant-based reconstruction. The senior author began using contoured perforated ready to use ADM in 2015 and is currently studying the effect of this change on breast reconstruction outcomes. This article details the senior author's technique in performing DTI breast reconstruction and highlights the operative components necessary for success.

Short-term cost-effectiveness of one-stage implant-based breast reconstruction with an acellular dermal matrix versus two-stage expander-implant reconstruction from a multicentre randomized clinical trial

Background

Implant‐based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure and its economic impact is significant. This study aimed to analyse whether a direct one‐stage IBBR with use of an acellular dermal matrix (ADM) is more cost‐effective than two‐stage (expander‐implant) breast reconstruction.

Methods

The BRIOS (Breast Reconstruction In One Stage) study was an open‐label multicentre RCT in which women scheduled for skin‐sparing mastectomy and immediate IBBR were randomized between one‐stage IBBR with ADM or two‐stage IBBR. Duration of surgery and hospital stay, and visits for the primary surgery, unplanned and cosmetic procedures were recorded. Costs were estimated at an institutional level. Health status was assessed by means of the EuroQol Five Dimensions 5L questionnaire.

Results

Fifty‐nine patients (91 breasts) underwent one‐stage IBBR with ADM and 62 patients (92 breasts) two‐stage IBBR. The mean(s.d.) duration of surgery in the one‐stage group was significantly longer than that for two‐stage IBBR for unilateral (2·52(0·55) versus 2·02(0·35) h; P < 0·001) and bilateral (4·03(1·00) versus 3·25(0·58) h; P = 0·017) reconstructions. Costs were higher for one‐stage compared with two‐stage IBBR for both unilateral (€12 448 (95 per cent c.i. 10 722 to 14 387) versus €9871 (9373 to 10 445) respectively; P = 0·025) and bilateral (€16 939 (14 887 to 19 360) versus €13 383 (12 414 to 14 669); P = 0·002) reconstructions. This was partly related to the use of relatively expensive ADM. There was no difference in postoperative health status between the groups.

Conclusion

One‐stage IBBR with ADM was associated with higher costs, but similar health status, compared with conventional two‐stage IBBR. Registration number: NTR5446 ( http://www.trialregister.nl).

The use of acellular dermal matrix in breast reconstruction: evolution of techniques over 2 decades

Acellular dermal matrices (ADMs) are biotechnologically derived tissues that have become a cornerstone of implant-based breast reconstruction over the last 2 decades. Their use in both dual-plane and prepectoral approaches have provided greater soft tissue coverage and implant support with good cosmetic outcomes and low rates of complication. This review describes the evolution of notable ADM-assisted surgical techniques that have advanced the field and broadened implant-based reconstructive options.

The breast surgeons' approach to mastectomy and prepectoral breast reconstruction

The purpose of this review article is to discuss and highlight the data, techniques and our experience performing mastectomies in the setting of prepectoral breast reconstruction. Using a systematic review of the approach to mastectomy in the oncologic setting encompassing patient selection, safety, anatomy and methods including a literature review of mastectomy trends, safety data and outcomes, anatomy and our experience, we are able to illustrate the safety and utility of this technique. The literature strongly supports the oncologic safety of these methods. This review also supports the use of these techniques as a surgical approach to any mastectomy, with or without reconstruction, and addresses many of the factors involved in improving and maximizing outcomes. While, there are multiple and equally efficacious approaches to mastectomy, several surgical techniques can be used to improve outcomes and ensure optimal flap viability.

Immediate Implant-based Breast Reconstruction with Acellular Dermal Matrix Compared with Tissue-expander Breast Reconstruction: Rate of Infection

Background

The risk of infection continues to be a subject of discussion within the field of implant-based breast reconstruction. Studies have shown the feasibility of immediate single-stage procedures with acellular dermal matrix (ADM), yet 2-stage tissue expander techniques continue to be the procedure most often performed. The purpose of this study was to evaluate postoperative infections and to identify associated predictors.

Methods

A retrospective study at Papa Giovanni XXIII Hospital was conducted between 2013 and 2017. Patients' demographic data were compared between single-stage and 2-stage procedures. Rate of infection and predictors were examined. Minor infections could be treated by oral antibiotics only, major infections required inpatient treatment. Healing was considered a successful treatment with antibiotics only, whereas any supplementary surgical intervention resulting in the preservation of an implant device was considered salvage. Breast reconstruction was defined a failure in case of implant loss or need for autologous reconstruction.

Results

Three hundred ninety-three patients underwent 336 monolateral and 57 bilateral implant-based breast reconstruction. Ninety-two patients had a submuscular direct-to-implant reconstruction with ADM with an infection rate of 11.4% compared with an infection rate of 7.8% among the 268 patients with a 2-stage tissue expander procedure. Beta-binomial regression showed obesity and preoperative radiotherapy as significant predictors for infection (OR, 4.65, P = 0.038, and OR, 7.13, P = 0.015, respectively). Average time of onset of infection among the submuscular direct-to-implant with ADM group was 67.1 days compared with 80.1 days among tissue-expander group with postoperative chemotherapy and preoperative radiotherapy having a significant effect on time of infection onset (P = 0.014, P = 0.034, respectively).

Conclusions

Direct-to-implant breast reconstruction with ADM is a procedure with acceptable risks of infection in comparison to tissue expander procedures. A profound patient selection pre- and intraoperatively is the basis of successful breast reconstruction.

Is single-stage implant-based breast reconstruction (SSBR) with an acellular matrix safe?: Strattice™ or Meso Biomatrix® in SSBR

Background

Acellular matrices (AM) might enable a direct single-stage breast reconstruction procedure resulting in an improved efficacy of the reconstruction phase for patients. Safety concerns are an important issue due to a recent study which shows that single-stage breast reconstruction with Strattice™ resulted in more complications versus a two-stage reconstruction. Therefore, the goal of this study is to compare the short- and long-term complications of a single-stage breast reconstruction with the use of two types of AM (Strattice™ and Meso Biomatrix®) versus two-stage breast reconstruction without the use of an AM.

Methods

Cohort study with single-stage breast reconstruction with Strattice™ (n = 28) or Meso BioMatrix® (n = 20) or two-stage breast reconstruction without an AM (n = 36) at the Maastricht Academic Hospital, the Netherlands. All complications, in particular major complications with the need for re-admission to the hospital, re-exploration, and implant explantation, were the primary outcome measures. A 1-year follow-up was achieved for all patients.

Results

Baseline characteristics of all 52 patients were similar between groups. There was a significantly higher complication rate in the single-stage AM groups with loss of the implant in 40.0% of the breasts from the Meso BioMatrix® group and in 10.7% of the Strattice™ group compared to no implant loss in the control group.

Conclusions

This cohort study clearly suggests that the use of a single-stage breast reconstruction is not safe with the use of these AMs. Well-designed prospective studies that guarantee the safety of those matrices should be published before these AMs are used in implant-based surgery.

Level of Evidence: Level III, risk / prognostic study.

Predictors of complications after direct-to-implant breast reconstruction with an acellular dermal matrix from a multicentre randomized clinical trial

BACKGROUND

In the multicentre randomized trial BRIOS (Breast Reconstruction In One Stage), direct-to-implant (DTI) breast reconstruction with an acellular dermal matrix (ADM) was associated with a markedly higher postoperative complication rate compared with two-stage tissue expander/implant breast reconstruction. This study aimed to identify factors that contribute to the occurrence of complications after DTI ADM-assisted breast reconstruction.

METHODS

Data were obtained from the BRIOS study, including all patients treated with DTI ADM-assisted breast reconstruction. Logistic regression analyses were performed to identify factors predictive of postoperative complications.

RESULTS

Fifty-nine patients (91 breasts) were included, of whom 27 (35 breasts) developed a surgical complication. Reoperations were performed in 29 breasts (32 per cent), with prosthesis removal in 22 (24 per cent). In multivariable analyses, mastectomy weight was associated with complications (odds ratio (OR) 1·94, 95 per cent c.i. 1·33 to 2·83), reoperations (OR 1·70, 1·12 to 2·59) and removal of the implant (OR 1·55, 1·11 to 2·17). Younger patients (OR 1·07, 1·01 to 1·13) and those who received adjuvant chemotherapy (OR 4·83, 1·15 to 20·24) more frequently required reoperation. In univariable analyses, adjuvant radiotherapy showed a trend towards more complications (OR 7·23, 0·75 to 69·95) and removal of the implant (OR 5·12, 0·76 to 34·44), without reaching statistical significance.

CONCLUSION

Breast size appeared to be the most significant predictor of complications in DTI ADM-assisted breast reconstruction. The technique should preferably be performed in patients with small to moderate sized breasts. Registration number: NTR5446 ( http://www.trialregister.nl).

Comparing the Outcome of Different Biologically Derived Acellular Dermal Matrices in Implant-based Immediate Breast Reconstruction: A Meta-analysis of the Literatures

Background:

Acellular dermal matrices (ADMs) have been used extensively in implant-based breast reconstruction. It was reported that due to the different sources and processing methods, the outcomes of ADMs in implant-based breast reconstructions are expected to differ. We designed this study to statistically analyze and discuss the outcome of 3 commonly used ADMs, Alloderm, Strattice, and Surgimend in implant-based breast reconstruction.

Methods:

Comprehensive review of the literatures searched on electronic databases was done to identify studies published between 2006 and 2017 comparing the outcome of ADMs. Pooled random effect estimates for each complication and 95% confidence interval (CI) were calculated. One-way analysis of variance and Bonferroni test were used to compare statistical significance between and within groups, respectively. Multiple linear regression was done to include confounding factors and R statistic program for forest plot.

Results:

Twenty-one studies met the inclusion with a total of 1,659, 999, and 912 breasts reconstructions in Alloderm, Strattice, and Surgimend, respectively. Seven complications extracted including major and minor infection, seroma, implant loss, hematoma, capsular contracture, and localized erythema. Pooled total complication rates were 23.82% (95% CI, 21.18–26.47%) in Strattice, 17.98% (95% CI, 15.49–20.47%) in Surgimend, 16.21% (95% CI, 14.44–17.99%) in Alloderm. Seroma rate was the highest in Strattice group (8.61%; 95% CI, 6.87–10.35%). There was no statistical significance between and within groups.

Conclusion:

Although Strattice exhibited a higher overall pooled complication rate compared with Alloderm and Surgimend, the incidence of individual complication varies between studies. A cost analysis of different ADMs may aid in choosing the type of ADMs to be used.

Patient-reported Outcomes after ADM-assisted Implant-based Breast Reconstruction: A Cross-sectional Study

Background

Although the use of acellular dermal matrices (ADMs) in implant-based reconstruction increases, there is a lack of studies evaluating patient-reported outcome measures after this reconstruction method. We aim to evaluate the patient satisfaction after ADM-assisted implant-based breast reconstruction (IBBR) in 1 of the largest series of patients undergoing ADM-assisted IBBR.

Methods

Patients with ADM-assisted IBBR were invited to fill out the BREAST-Q, a validated and standardized questionnaire to measure patient satisfaction after a breast reconstruction. A retrospective chart review was performed to identify patient and surgical characteristics.

Results

In total, 208 patients (38.4%) responded and reported a mean satisfaction of 70.6 ± 20.2 with their breasts and 78.0 ± 20.5 with the outcome. An overall complication rate of 7.7% was noted, with 1.5% severe complications leading to hospital readmission (0.5%) and implant removal (0.5%). Patients with complications and unilateral reconstruction for oncological reasons reported overall less satisfaction rates compared with patients with bilateral, preventive surgery, and an uncomplicated postoperative course. Strongly related domains indicate the importance of patient satisfaction with their breasts and outcome on psychosocial and sexual functioning and satisfaction with information on satisfaction with breasts, outcome, and surgeon.

Conclusion

There is an increased demand for patient-reported outcome measures in a changing practice to which the opinion of the patient assumes a larger role. With high satisfaction rates, ADM-assisted IBBR is a valuable reconstruction method, provided that complication rates remain low. Hence, it should only be performed in a selected group of women.

A 3D Mammometric Comparison of Implant-Based Breast Reconstruction With and Without Acellular Dermal Matrix (ADM)

This retrospective study utilizes 3D imaging and mammometrics to compare implant-based breast reconstruction with and without the use of ADM. Previous studies have suggested improved aesthetic outcomes with the use of ADM, but none have been able to quantify this difference. Images were obtained at early and late time points following the expander-implant exchange procedure. Measurements included the point of maximum projection, the superior, inferior, medial and lateral volumetric distribution, and the distance from the point of maximum projection to the inframammary fold along the breast meridian. The patients' demographic information, implant size, and complication rate between the two cohorts were similar. In the early post-operative period, the patients with ADM demonstrated higher medial pole volume; however, this difference did not persist in the late post-operative period. Patients with ADM demonstrated a small but statistically significant greater point of maximum projection and length of lower pole curvature in comparison with the non-ADM cohort. In summary, the results of this study demonstrate improved mammometric measurements when ADM is used in implant-based breast reconstruction, supporting superior aesthetic outcomes in early and late post-operative time points.

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 .

Benefits and risks with acellular dermal matrix (ADM) and mesh support in immediate breast reconstruction: a systematic review and meta-analysis

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.

Patient-Reported Outcomes of Aesthetics and Satisfaction in Immediate Breast Reconstruction After Nipple-Sparing Mastectomy With Implants and Fat Grafting

Background

Direct-to-implant (DTI) and tissue expander/implant (TE/I) reconstructions are the most common implant-based reconstructions after nipple-sparing mastectomy (NSM). However, there are little data beyond complication rates comparing these options. Fat grafting has emerged as an adjunct in NSM reconstructions to improve aesthetic results; however, its impact on patient perceptions of aesthetic outcomes remain unknown. To improve patient-centered care, aesthetic outcomes must be considered from the patients' perspective.

Objectives

To evaluate patient-reported outcomes of aesthetic satisfaction and quality of life in patients undergoing immediate DTI vs TE/I reconstruction after NSM and to assess the role of fat grafting on these outcomes.

Methods

This is a prospective cohort study comparing NSM patients undergoing DTI or TE/I reconstruction. Patient-reported outcomes were evaluated using the BREAST-Q. Continuous and categorical variables were analyzed using t test and Fisher's exact test, respectively.

Results

Fifty-nine patients underwent 113 reconstructions with either DTI (n = 41) or TE/I (n = 18). Mean follow up was 12.1 months. DTI and TE/I patients had comparable satisfaction with outcome, though TE/I patients had significantly larger final implant sizes. TE/I who underwent fat grafting also had significantly higher satisfaction with outcome and psychosocial wellbeing.

Conclusions

Patient-reported outcomes are comparable between DTI and TE/I reconstructions after NSM. In order for TE/I patients to achieve a similar level of satisfaction, they may require a larger final implant and additional operations compared to DTI patients. Additionally, fat grafting improves overall satisfaction. TE/I patients may have different aesthetic expectations than DTI patients, emphasizing patient-centered discussions are essential to optimizing outcomes after NSM.

Level of Evidence

3.

A Limited Submuscular Direct-to-Implant Technique Utilizing AlloMax

This study evaluates a novel limited submuscular direct-to-implant technique utilizing AlloMax where only the upper few centimeters of the implant is covered by the pectoralis, whereas the majority of the implant including the middle and lower poles are covered by acellular dermal matrix.

Surveillance and Prevention of Surgical Site Infections in Breast Oncologic Surgery with Immediate Reconstruction

Surgical site infection (SSI) after immediate breast reconstruction is much more common than would be expected after a clean surgical procedure. Although the SSI rates reported in individual studies are quite variable, there are no obvious explanations for the variation in infection rates between institutions. The microbiology of these SSIs is unusual, with higher proportions of infections caused by atypical Myobacterium species and Gram-negative bacilli than would be expected for this anatomic site. In an effort to prevent SSIs, many surgeons use a variety of different practices including irrigation and soaking of implants with antibiotic solutions and prolonged duration of prophylactic antibiotics, although the literature to support these practices is very sparse. In particular, prolonged use of antibiotics post-discharge is concerning due to the potential for harm, including increased risk of Clostridium difficile infection, development of antibiotic resistant organisms, and drug-related allergic reactions. With higher rates of mastectomy and breast implant reconstruction in women with early-stage breast cancer, including greater utilization of reconstruction in higher-risk individuals, the number of women suffering from infection after oncologic reconstruction will likely continue to increase. It is imperative that more research be done to identify modifiable factors associated with increased risk of infection. It is also essential that larger studies with rigorous study designs be performed to identify optimal strategies to decrease the risk of SSI in this vulnerable population.