Prepectoral Implant-Based Breast Reconstruction Using Meshed ADM

To acellular dermal matrix or not to acellular dermal matrix?-outcomes of pre-pectoral prosthetic reconstruction after nipple-sparing mastectomy with and without acellular dermal matrix

Background

Acellular dermal matrix (ADM) has been the go-to biomaterial in post-mastectomy breast reconstruction, particularly in pre-pectoral reconstruction. ADM is thought to decrease capsular contracture, control the pocket, and increase soft tissue, but may yield more complications. This study evaluated whether ADM is even needed.

Methods

All patients undergoing immediate breast reconstruction with pre-pectoral tissue expander (TE) or direct-to-implant (DTI) after nipple-sparing mastectomy (NSM) by the senior author between April 2013 and January 2021, were included in this study. Cohorts were stratified into breasts with ADM or no-ADM. Complications within 30 days post-operatively were analyzed.

Results

A total of 115 pre-pectoral reconstructions were performed in 66 patients. ADM was applied to 75 breasts. TEs were used in 80 breasts and DTI in 35 breasts. Controlling for implant type, breasts with ADM exhibited more nipple necrosis (28.0% vs. 10.0%, P=0.02). Controlling for ADM status, DTI compared to TE was associated with less necrosis of the nipple (11.4% vs. 26.3%, P=0.04), implant loss (5.7% vs. 38.8%, P=0.004), and surgery for any complication (14.3% vs. 27.5%, P=0.04).

Conclusions

Outcomes of prosthetic reconstructions with ADM and no-ADM were similar. DTI reconstruction was associated with less complications, which was likely due to intraoperative bias and placement of TEs more often in breasts with perceived poorer vascularity.

Immediate post-mastectomy prepectoral breast reconstruction with animal derived acellular dermal matrices: A systematic review

BACKGROUND

Animal-derived acellular dermal matrices (ADMs) are increasingly being used in prepectoral direct-to-implant (DTI) breast reconstruction. However, the indications and complication profile associated with this type of reconstruction remain unclear. This study aimed to perform a systematic review of the available literature on the use of animal-derived ADM in prepectoral DTI breast reconstruction.

METHODS

Three different literature databases, namely, PubMed, Web of Sciences, and Embase were screened using the following keywords: "immediate" AND "pre-pectoral" OR "prepectoral" AND "ADM breast reconstruction." Animal-derived ADM used (porcine - Braxon® and non-Braxon® - and bovine - Surgimend®) anthropometric information, clinical data, and complications profile were considered.

RESULTS

A total of 340 articles were initially identified, of which only 45 articles (5089 patients and 6598 reconstructed breasts) satisfied our inclusion criteria. The most widely used ADM was Braxon® in the context of conservative mastectomies. In most studies, a subcutaneous layer > 1 cm and lack of previous radiotherapy were considered prerequisites for this type of reconstruction. An increased risk of complications was found in smokers, patients who underwent radiation treatment, patients with high breast volumes, and patients with cancers requiring axillary dissection. Data related to the role of diabetes, high body mass index, and breast implant size on surgical outcomes were instead inconcludent. Age was not directly proportional to the complications.

CONCLUSION

The complications associated with different animal-derived ADMs are generally comparable. The profile of patients required for eligibility for this type of reconstruction appears to have been identified and is in line with current recommendations.

Red Breast Syndrome and Acellular Dermal Matrix

Increasingly popular for use in breast reconstruction, acellular dermal matrix (ADM) can provide support and protection to implants. However, use of ADM may be associated with infection and complications, including red breast syndrome (RBS). RBS is an inflammatory event that typically presents with cutaneous erythema over the domain where the ADM is surgically implanted. As ADM use increases, presumably, more cases of RBS will occur. Thus, techniques and tools to mitigate or manage RBS are needed to improve patient outcomes. Here, we describe a case where RBS was diagnosed and interestingly resolved after exchange for a different brand of dermal matrix. This surgical resolution maintained excellent reconstructive results with no recurrent erythema over a follow-up period of 7 months. Although we cannot rule out RBS due to other variables, RBS due to patient hypersensitivity to certain ADMs has been documented in the literature. In this instance, our results suggest that revision with an alternate ADM brand may serve as a potential solution.

Direct-to-Implant Subcutaneous Breast Reconstruction: A Systematic Review of Complications and Patient's Quality of Life

BACKGROUND

The use of direct-to-implant subcutaneous breast reconstruction has increased over the last years. The goal of this systematic review is to deliver an updated review of the safety of this technique and its impact on quality of life. We also compare subcutaneous vs submuscular complications, through meta-analysis.

METHODS

Literature review through PubMed and Cochrane Library databases were performed by PRISMA criteria. Thirty-nine studies met inclusion criteria for subcutaneous review and 15 studies met inclusion criteria for meta-analysis. All included studies were evaluated for complications and answers to the BREAST-Q. Data were analysed using Microsoft Excel, IBM SPSS, and Cochrane RevMan.

RESULTS

In 2863 patients and 3988 breasts that undergone direct to implant subcutaneous breast reconstruction, 8,21% had rippling, 5,64% seroma, 1,74% hematoma, 3,40% infection, 3,01% wound dehiscence, 3,93% skin necrosis, 3,34% nipple-areolar-complex (NAC) necrosis, 3,07% capsular contracture, 0,00% animation deformity, and 3,83% an implant removal. Meta-analysis showed a statistically significant decrease in the odds ratio of animation deformity, a but statistically significant higher odds ratio of rippling. Subcutaneous and submuscular reconstructions had similar BREAST-Q scores.

CONCLUSIONS

Direct-to-implant subcutaneous breast reconstruction does not harm the patient's quality of life, comparatively with submuscular, saving the pectoral muscle from dissection and preventing animation deformity, but increasing the risk of rippling.

LEVEL OF EVIDENCE III

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

Braxon®-assisted prepectoral breast reconstruction: A decade later

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

The Failed Breast Implant in Postmastectomy Reconstruction: A Systematic Literature Review of Complications of Implant-Based Breast Reconstruction

BACKGROUND

Breast cancer is the most diagnosed malignant neoplasia of female patients worldwide in 2019. Survival has increased making it necessary to offer breast reconstructive procedures to improve quality of life and self-esteem. Implant-based breast reconstruction is the most common approach, making it necessary to quantify the associated complications.

METHODS

A systematic literature review of the PubMed, Cochrane, and Web of Science databases was performed. A total of 9608 citations were identified, and 44 studies met the inclusion criteria.

RESULTS

Studies included reported the incidence of complications either per patient or per breast leading consequently to 2 complication rates depending on the type of reporting. A total of 14.3% of patient-related and 28.8% of breast-related complications while undergoing implant-based reconstruction were reported.Among total complications reported, 72.6% of patient-related and 48.5% of breast-related complications were classified as major complications.A total of 37.6% of patients respectively 15.1% of breasts required prosthesis explantation due to severe complications. Depending on reporting, 9.7% of patients and 4% of breasts required autologous flap reconstruction due to reconstructive failure.

CONCLUSIONS

High complication and failure rates are associated with implant-based breast reconstruction. Lacking randomized controlled trials, the choice between implant-based and autologous breast reconstruction has to be made individually for each patient.