Acellular dermal matrix in aesthetic revisionary breast surgery

Acellular dermal matrix in breast augmentation surgery: A systematic review

Background

The use of acellular dermal matrix (ADM) in breast reconstruction was described for the first time in 2000s. Recently, ADMs have been used not only in reconstructive surgery but also in cosmetic breast surgery for both primary and revision indications. Therefore, the matrices represent an important support to recent surgical techniques for breast augmentation in treatment or prevention of complications. Conversely, ADMs can affect operative times, costs, and additional complications related to their placement. A review of the literature was carried out to evaluate the efficacy, safety, and indication for the use of these matrices in cosmetic breast surgery.

Methods

A literature review was conducted including manuscripts published up to April 2023 on breast augmentation using ADM. PubMed and MEDLINE were the databases used for research. The keywords used were "Breast augmentation" and "Acellular Dermal Matrix." Non-English language articles have been excluded.

Results

The initial search for "breast augmentation" yielded 7900 results, which were further reviewed for "Acellular Dermal Matrices" in breast augmentation, selecting 74 articles. Following further screening, 12 articles were included in the review. A total of 787 patients were treated with breast augmentation and ADM placement. The main indication was capsular contracture (60%).

Conclusions

The current evidence from the published scientific literature, albeit limited, suggests the indication for the use of ADM in revision surgery, to support the prosthetic pocket, to minimize the risk of capsular contracture and its recurrence.

Management of Biofilm with Breast Implant Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand how bacteria negatively impact aesthetic and reconstructive breast implants. 2. Understand how bacteria infect breast implants. 3. Understand the evidence associated with common implant infection-prevention strategies, and their limitations. 4. Understand why implementation of bacteria-mitigation strategies such as antibiotic administration or "no-touch" techniques may not indefinitely prevent breast implant infection.

SUMMARY

Bacterial infection of aesthetic and reconstructive breast implants is a common and expensive problem. Subacute infections or chronic capsular contractures leading to device explantation are the most commonly documented sequelae. Although bench and translational research underscores the complexities of implant-associated infection, high-quality studies with adequate power, control groups, and duration of follow-up are lacking. Common strategies to minimize infections use antibiotics-administered systemically, in the breast implant pocket, or by directly bathing the implant before insertion-to limit bacterial contamination. Limiting contact between the implant and skin or breast parenchyma represents an additional common strategy. The clinical prevention of breast implant infection is challenged by the clean-contaminated nature of breast parenchyma, and the variable behavior of not only specific bacterial species but also their strains. These factors impact bacterial virulence and antibiotic resistance.

Prevention of Implant Malposition in Latissimus Dorsi Myocutaneous Flap Breast Reconstruction Using an Acellular Dermal Matrix With Pectoralis Muscle Following Mastectomy for Breast Cancer: A Clinical Review

BACKGROUND

Latissimus dorsi myocutaneous (LDM) pedicled flaps are a well-established method for breast reconstruction in women with inadequate soft tissue coverage following mastectomy for breast cancer. The robust nature of the latissimus blood supply can accommodate immediate implant placement to increase breast volume; however, a known risk factor with this technique is implant malposition. By utilizing an acellular dermal matrix (ADM) in subpectoral implant-based LDM reconstruction, it is hypothesized that patients will experience a lower incidence of implant malposition. This 13-year retrospective review aims to evaluate the effectiveness of breast reconstruction using this technique.

METHODS

A retrospective review was conducted to identify all patients who underwent breast reconstruction following mastectomy with a LDM flap, subpectoral implant, and an ADM from 2007 to 2020 by a single surgeon at a single institution. Demographic and clinical data were collected and analyzed.

RESULTS

A total of 40 patients (LDM flaps, N = 51) were identified. Mean participant age was 50.25 ± 9.67 years and mean body mass index (BMI) was 30.85 ± 6.15 kg/m². Comorbidities included hypertension (40.0%), diabetes mellitus (17.5%), and current smoking (25.0%). Mean follow-up was 31.52 ± 29.51 months. The most common complication was seroma formation (9.8%). No patients experienced implant malposition or flap necrosis.

CONCLUSIONS

The use of a LDM flap and an ADM in implant-based breast reconstruction are each well described in the literature. This 13-year series supports the efficacy of these techniques utilized in combination to provide an aesthetic result while mitigating implant malposition during breast reconstruction of oncologic patients.

Revision Breast Augmentation

Breast augmentation is consistently one of the most commonly performed aesthetic operations every year. Unfortunately, revision rates following primary augmentation remain as high as 36%. There are several causes for revision breast augmentation; however, the most common and challenging of these include capsular contracture, implant malposition, and ptosis of the aging breast following augmentation. Successful management of these problems requires knowledge on how to best treat the implant and capsule with the corresponding soft tissue simultaneously. While surgical management is important, understanding the pathological causes of these entities during the primary operation can reduce the need for revision. This article utilizes the most up-to-date literature to review the appropriate clinical evaluation and surgical management of these complex cases.

An Algorithm for the Management of Explantation Surgery

Creating pleasing breast aesthetics after an explantation can be challenging, especially when performed with a total capsulectomy. The necessity of a capsulectomy for a variety of breast issues is not completely agreed on and can increase adverse events, patient morbidity, and cost of the operation and often impairs the final aesthetic result. In this article, an algorithm for the management of explantation patients provides a framework for treatment of the capsule and the breast to optimize outcomes.

The Nomenclature, Terminology and Lexicon of Breast Surgery: Are We Really Saying the Same Thing?

This study investigated inconsistencies in the use of descriptors in breast surgery and recommends a novel nomenclature that will be adopted and standardized among plastic surgeons. The study used a modified Delphi methodology to first identify redundant descriptors or those with multiple interpretations, and then achieve consensus on ideal recommended nomenclature in breast surgery. The Delphi panel agreed that there was misuse of and lack of a clear definition for several terms, and recommended removal of these subjective terms. Replacement with more anatomic nomenclature was suggested. Stretch deformity, pectoral banding, and implant-gland mismatch were introduced as new terms.

The Use of Synthetic Mesh in Reconstructive, Revision, and Cosmetic Breast Surgery

BACKGROUND

Recent evidence suggests that the use of acellular dermal matrices in prosthetic breast reconstruction, revision, or augmentation may be associated with an increased risk of complications. In this article we report our results of a potential alternative, using a new long-term resorbable synthetic matrix in these cases.

METHODS

A retrospective study was performed evaluating 11 primary breast reconstructions (19 breasts), 43 secondary reconstructions (77 breasts), 3 augmentation/augmentation mastopexys (6 breasts), and 5 mastopexys (10 breasts) in 62 patients using TIGR^® Matrix Surgical Mesh.

RESULTS

Follow-up ranged from 9.4 to 26.1 months with an average follow-up of 16.5 months. Average age was 54 years. The number of patients who had prior radiation was 9 (14.5 %). Four patients (6.5 %) were smokers. Postoperative breast complications included necrosis of two flaps (1.8 %), two seromas requiring drainage (1.8 %), four infection/extrusions (3.6 %), two relapses of inframammary fold/malposition (1.8 %), and two with rippling (1.8 %). Other complications included six cases of asymmetry that required a corrective procedure. In a variety of breast surgery cases very good aesthetic results were achieved.

CONCLUSION

The long-term absorbable synthetic matrix, TIGR^® Matrix Surgical Mesh, shows potential when used as temporary reinforcement in patients undergoing breast reconstruction or breast surgery revisions and in primary aesthetic procedures, and it appears to be a viable alternative to the use of acellular dermal matrices.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Clinically available reinforcing materials for soft tissue reconstruction

Navigating the rapidly evolving field of materials for soft tissue reinforcement is challenging given the volume of clinically available options. Additionally, the current generally accepted classifications of these mesh materials confound the understanding of their utility by grouping disparate materials that have attributes overlapping category boundaries and that do not fully consider their clinically functionality. This review article highlights, from a materials science perspective, the most important attributes of these materials to improve the clinical decision-making process in the selection of the most appropriate features and design for the patient, surgery and clinical need. These characteristics include the physical attributes that directly impact the surgical procedure and immediate postoperative mechanical requirements as well as the post-implantation properties such as an adequate reinforcement time, strength of the resulting tissue and infection risk profile.

Soft Tissue Adjuncts in Revisionary Aesthetic Breast Surgery

Reconstructive breast surgery is challenging and continually evolving. In the past decade, numerous soft tissue adjuncts, such as acellular dermal matrices (ADMs), have revolutionized breast reconstruction serving as a tool to improve results and minimize the need for revision. The use of ADMs has been widely discussed in primary and secondary breast reconstruction after mastectomy. They have been shown to be an effective and safe option to correct complications; however, there is a relative paucity of literature on their use in revisional surgery after aesthetic breast procedures. The authors queried PubMed for existing literature regarding the use of ADMs in secondary breast surgery. Five case series from an initial search of 278 articles met the inclusion criteria. An overall infection rate of 2% and a complication rate of implant malposition was 0.8% with the use of ADMs. Although the literature is sparse regarding their use in this setting, early reports indicate that they are both safe and efficacious with a reasonable rate of complications.

Do Processing Methods Make a Difference in Acellular Dermal Matrix Properties?

BACKGROUND

The use of acellular dermal matrices (ADMs) has become the standard of practice in many reconstructive and aesthetic surgical applications. Different methods used to prepare the allograft tissue for surgical use can alter the ADMs natural properties. Aseptic processing has been shown to retain the natural properties of ADMs more favorably than terminally sterilized ADMs. Terminal sterilization has been historically linked to alteration of biological materials. In vitro work was conducted to compare ADM processing methods.

OBJECTIVES

Characterize aseptically processed ADMs and compare cell-matrix interaction characteristics to terminally sterilized ADMs.

METHODS

Two aseptically processed ADMs, FlexHD Pliable and BellaDerm, were characterized via histological evaluation, biomechanical integrity, enzymatic degradation, and in vitro cell studies. FlexHD Pliable was compared to Alloderm Ready-to-Use (RTU).

RESULTS

Histological evaluation revealed that FlexHD Pliable had a uniform, open structure compared to BellaDerm. Mechanical characterization demonstrated that BellaDerm had higher strength and stiffness compared to FlexHD Pliable, which maintained higher elasticity. Immunohistochemical analysis verified that key matrix proteins remained intact after aseptic processing. Cell studies found that fibroblasts attached more readily, and proliferated faster on FlexHD Pliable compared to BellaDerm. Additionally, fibroblasts infiltrated into FlexHD Pliable from both sides and on the dermal side in BellaDerm and produced an abundance of multi-layered matrix proteins (collagen, fibronectin) when compared to AlloDerm RTU which was sparse.

CONCLUSIONS

Aseptically processed FlexHD Pliable and BellaDerm provide a suitable, biocompatible option for tissue repair and regeneration in aesthetic and reconstructive surgical applications.

Techniques to Repair Implant Malposition after Breast Augmentation: A Review

BACKGROUND

Implant malposition is a complication of breast augmentation that adversely affects aesthetic outcomes. It is one of the most common reasons for revisionary aesthetic breast surgery yet there is a lack of peer reviewed literature dedicated to the management of this complication.

OBJECTIVES

The purpose of this article was to summarize the malposition literature, review the types and causes of this complication, and evaluate the strengths and weakness of procedures aimed at addressing it.

METHODS

A review of the literature was performed using the PubMed database. Articles describing surgical techniques for correction of implant malposition, as well as outcome data for patients undergoing revision with described techniques, were included. Articles describing revisionary surgery following breast reconstruction were excluded. A series of cases are presented to illustrate techniques discussed.

RESULTS

Search criteria resulted in 763 articles. Title and abstract review followed by application of inclusion and exclusion criteria resulted in a total of 21 clinical studies from 1988 to 2014 that were included in this review. All studies included in this study were of level IV or V evidence.

CONCLUSIONS

Despite the overall low level of evidence in the literature regarding secondary breast augmentation, a thorough understanding of the corrective techniques presented will allow surgeons to make the most informed judgments. Weighing the strengths and weakness of these surgical techniques in the context of each patient will allow surgeons to develop the most appropriate treatment strategy. LEVEL OF EVIDENCE 4: Therapeutic.

Nine-Year Core Study Data for Sientra's FDA-Approved Round and Shaped Implants with High-Strength Cohesive Silicone Gel

BACKGROUND

Since approval in March 2012, data on Sientra's (Santa Barbara, CA) silicone gel implants have been updated and published regularly to provide immediate visibility to the continued safety and performance of these devices. The 9 year follow-up data support the previously published data confirming the ongoing safety and efficacy of Sientra silicone gel breast implants.

OBJECTIVES

The authors provide updated 9 year study data for Sientra's round and shaped silicone gel breast implants.

METHODS

The Core Study is an ongoing 10 year study that enrolled 1788 patients with 3506 Sientra implants across four indications (primary augmentation, revision-augmentation, primary reconstruction, and revision-reconstruction). For the safety analysis, Kaplan-Meier risk rates were calculated to evaluate postoperative complications, including all breast implant-related adverse effects. For the effectiveness analyses, results were presented through 8 years as patient satisfaction scores were assessed at even years.

RESULTS

Through 9 years, the overall risk of capsular contracture was 12.6%. Smooth devices (16.6%, 95% CI, 14.2%, 19.5%) had a statistically significantly higher rate of capsular contracture compared to textured devices (8.0%, 95% CI, 6.2%, 10.4%). Out of the 610 reoperations in 477 patients, over half of all reoperations were due to cosmetic reasons (n = 315; 51.6%). Patient satisfaction remains high through 8 years, with 90% of primary augmentation patients indicating their breast implants look natural and feel soft.

CONCLUSIONS

The 9-year follow-up data from the ongoing Core Study of the Sientra portfolio of HSC and HSC+ silicone gel breast implants reaffirm the very strong safety profile as well as continued patient satisfaction.

LEVEL OF EVIDENCE

2 Therapeutic.

Secondary augmentation-mastopexy: indications, preferred practices, and the treatment of complications

Increasing the volume of the breast while simultaneously decreasing the skin envelope equates to surgery involving opposing forces. Increasing patient demand and the evolving perceptions of surgeons have led to the growing popularity of the combined augmentation-mastopexy operation. In turn, secondary augmentation-mastopexies and revisional surgeries of primary augmentation-mastopexies also have increased in popularity. In this article, the authors describe indications for secondary augmentation-mastopexy, techniques for performing this combined procedure safely and effectively, adjunctive procedures, potential pitfalls, and the treatment of complications.

Non-cross-linked porcine acellular dermal matrix in revision breast surgery: long-term outcomes and safety with neopectoral pockets

BACKGROUND

Revision breast surgery represents a significant problem among patients who have undergone augmentation mammaplasty. Current techniques do not adequately prevent recurrence, thus requiring novel approaches, including placement of Strattice (LifeCell, Branchburg, New Jersey), a non-cross-linked porcine acellular dermal matrix, to minimize recurrence.

OBJECTIVE

The authors review their experience and long-term outcomes with placement of Strattice in revision breast surgery patients who underwent previous augmentation mammaplasty.

METHODS

All patients in the authors' practice with a previous history of augmentation mammaplasty who underwent revision breast surgery with placement of Strattice between January 2007 and December 2011, and who had a minimum of 12 months of follow-up, were included in this retrospective study. A total of 106 patients met the study's inclusion criteria.

RESULTS

Average patient age was 42.3 years and average follow-up time was 3.1 years. Indications for revision surgery included capsular contracture (51.9%), implant malposition (38.7%), and ptosis (8.5%); approximately 40% had ≥1 previous attempts to correct the presenting complaint. Revision surgery included creation of neosubpectoral pockets with retention of previous noncalcified capsules in 81% of patients with subpectoral implants. Presenting complaints were successfully resolved in all patients. The overall complication rate was 0.9%.

CONCLUSIONS

Adding Strattice to traditional revision surgery procedures results in reliable, durable repair of the presenting complaint with minimal associated complications. Treatment with Strattice in conjunction with noncalcified capsules retained during site change also appears to be safe. The data support a role for Strattice in revision breast surgery for patients who have undergone previous augmentation mammaplasty.

Porcine-derived acellular dermal matrix in primary augmentation mammoplasty to minimize implant-related complications and achieve an internal mastopexy: a case series

Introduction

Patients who present for augmentation mammoplasty with poor quality mammary soft-tissue support may be at increased risk for post-operative complications. Non-crosslinked intact porcine-derived acellular dermal matrix (Strattice™ Reconstructive Tissue Matrix, LifeCell Corp., Branchburg, NJ, USA) may enhance soft-tissue support in such patients and reduce implant-related complications, including capsular contracture, rippling, palpability, and malposition. The objective of this case report series was to describe the outcomes of three patients with poor quality mammary soft-tissue support who underwent primary cosmetic breast augmentation with pre-emptive implantation of porcine-derived acellular dermal matrix.

Case presentation

Case 1 concerns a 40-year-old Caucasian woman with post-partum soft tissue laxity and grade II ptosis. Case 2 concerns a 30-year-old Caucasian woman with congenital soft-tissue laxity and grade I + ptosis. Case 3 concerns a 49-year-old Caucasian woman with post-partum and post-weight-loss-induced laxity and grade III ptosis. In all three of our patients, porcine-derived acellular dermal matrix was sutured to the chest wall along the infra-mammary and/or a neo-infra-mammary fold and then laid passively superiorly or sutured under tension to the breast parenchyma or caudal edge of the pectoralis major muscle. In cases 1 and 2, a modified internal mastopexy technique was performed. Suturing the porcine-derived acellular dermal matrix to the posterior aspect of the breast parenchyma and/or caudal pectoralis muscle under appropriate tension in conjunction with radial plication of the porcine-derived acellular dermal matrix created a snug ‘hand-in-glove’ pocket and resulted in only minimal peri-areolar scarring. Case 3 required a vertical scar mastopexy. During a mean of 18 months of follow-up, all three patients had positive outcomes and no complications (that is, infection, hematoma, seroma, rippling, malposition, or capsular contracture). The surgeon and patients were generally highly satisfied with the aesthetic outcome of the breasts.

Conclusions

Pre-emptive use of porcine-derived acellular dermal matrix may be beneficial in patients with primary augmentation with poor quality mammary soft-tissue support.

The use of synthetic mesh in reconstructive, revision, and cosmetic breast surgery

Background

Recent evidence suggests that the use of acellular dermal matrices in prosthetic breast reconstruction, revision, or augmentation may be associated with an increased risk of complications. In this article we report our results of a potential alternative, using a new long-term resorbable synthetic matrix in these cases.

Methods

A retrospective study was performed evaluating 11 primary breast reconstructions (19 breasts), 43 secondary reconstructions (77 breasts), 3 augmentation/augmentation mastopexys (6 breasts), and 5 mastopexys (10 breasts) in 62 patients using TIGR^® Matrix Surgical Mesh.

Results

Follow-up ranged from 9.4 to 26.1 months with an average follow-up of 16.5 months. Average age was 54 years. The number of patients who had prior radiation was 9 (14.5 %). Four patients (6.5 %) were smokers. Postoperative breast complications included necrosis of two flaps (1.8 %), two seromas requiring drainage (1.8 %), four infection/extrusions (3.6 %), two relapses of inframammary fold/malposition (1.8 %), and two with rippling (1.8 %). Other complications included six cases of asymmetry that required a corrective procedure. In a variety of breast surgery cases very good aesthetic results were achieved.

Conclusion

The long-term absorbable synthetic matrix, TIGR^® Matrix Surgical Mesh, shows potential when used as temporary reinforcement in patients undergoing breast reconstruction or breast surgery revisions and in primary aesthetic procedures, and it appears to be a viable alternative to the use of acellular dermal matrices.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Acellular dermal matrices: Use in reconstructive and aesthetic breast surgery

Acellular dermal matrices (ADMs) were first described for use in breast surgery in 2001. Since this initial report, ADMs have become an increasingly common component of implant-based breast procedures. ADMs have shown promise for use in both aesthetic and reconstructive breast surgery; however, concerns about their use remain because of the significant costs associated with these products. The present article reviews the history of ADM use in breast surgery and the outcomes reported to date. Common techniques for placement of ADMs in aesthetic revisionary and breast reconstruction surgery are provided, and use in the setting of chest wall irradiation and capsular contracture is discussed. Finally, the authors comment on the cost implications of these products in the Canadian and American health care systems.