Infectious Complications Associated With the Use of Acellular Dermal Matrix in Implant-Based Bilateral Breast Reconstruction

Division of Plastic Surgery, University of Kentucky College of Medicine, Lexington, KY, USA.
Annals of plastic surgery (Impact Factor: 1.49). 05/2012; 68(5):432-4. DOI: 10.1097/SAP.0b013e31823b6ac6
Source: PubMed


The use of acellular dermal matrix (ADM) has become a routine practice in implant-based breast reconstruction. Bilateral mastectomy is becoming more popular in cases of unilateral breast cancer. ADM has been associated with an increased incidence of complications.
We identified cases of bilateral implant-based breast reconstruction over a 5-year period. Data collection included medical comorbities, details of operative management, and details of postoperative cancer treatment.
On univariate analysis, the use of ADM (31% vs. 7%, P = 0.018), smoking (37% vs. 13%, P = 0.045), and open wound (55% vs. 13%, P = 0.006) were significantly associated with increased risk of infection. Multivariate analysis revealed open wound as the strongest predictor of infection.
The use of ADM is associated with an increased risk of infection in bilateral implant-based breast reconstruction. However, it does not appear to be an independent risk factor by itself.

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    • "It allows the pectoralis muscle to be released, expands the space, allows fixation of the inframammary fold, and fills in the tissue void between the inferior edge of the pectoralis muscle and the inframammary fold. However, due to recently reported problems encountered with ADM, including seroma, infection, slow vascularization, disruption, reconstructive failure, patient concerns, and costs, we looked at a new long-term resorbable synthetic mesh as a potential alternative [10, 13, 17, 19, 40–43]. Surgical mesh has multiple fixation points thus offering greater tissue fixation compared to sutures. "
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    ABSTRACT: Background: Acellular dermal matrix (ADM) has been associated with an increased incidence of complications after implant-based breast reconstruction. Recently, sterile ADM has been introduced in an attempt to minimize these complications. To analyze the impact of this product on patient outcomes, we created a database of patients undergoing implant-based breast reconstruction. Methods: Patients undergoing implant-based breast reconstruction at the University of Kentucky Medical Center from January 1, 2011, to December 31, 2011 were identified. A database of patient characteristics and outcomes was created. Outcomes investigated included mastectomy flap necrosis, dehiscence, infection, red breast, capsular contracture, hematoma, and seroma. Statistical analysis was performed. Results: Fifty-eight patients underwent breast reconstruction with implants or tissue expanders. Of the 58 patients, 9 had the sterile form of ADM placed, 25 had the original aseptic but not sterile ADM, and 24 were not reconstructed with ADM. The most frequent complication noted was seroma, occurring in 6/9 patients with sterile ADM as compared to 2/25 with the aseptic ADM. This was statistically significant (P = 0.003). Conclusions: The use of sterile ADM is associated with a statistically significant increase in seroma formation. The etiology of this increased incidence remains unknown, but it correlates with the introduction of the sterile form of ADM at our institution. A different preparation or sterilization process, or some other variable as yet unknown, may be responsible. Further studies comparing the different forms of ADM in an animal model may serve to clarify this issue.
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    ABSTRACT: An alternative to implant-based breast reconstruction using acellular dermal matrix is the use of a titanium-coated polypropylene mesh. The mesh was approved for implant-based breast reconstruction in Europe in 2008, but only limited clinical data are available. Two hundred seven patients (231 breasts) with skin-sparing/nipple-sparing or modified radical mastectomy and immediate or delayed implant-based breast reconstruction using titanium-coated polypropylene mesh were evaluated retrospectively. The primary endpoints were identification of patient-related and surgical factors that were predictive for an adverse outcome and the development of recommendations for patients eligible for implant-based breast reconstruction using the mesh. Complications were divided into major (need for additional surgery), minor (conservative treatment), and implant loss. Univariate and multivariate logistic regression analyses were performed to determine the influence of the patient- and procedure-related characteristics on postoperative complications and implant loss. No risk factors were observed for patient-associated complications. Major complications occurred in 13.4 percent, minor complications in 15.6 percent, and implant loss in 8.7 percent of patients. Univariate analysis revealed procedure-related risk factors for postoperative complications with a bilateral procedure (p = 0.013) or skin expansion before implant surgery (p = 0.043). Multivariate analysis confirmed these risk factors and revealed an increased risk for implant loss in patients with skin necrosis (p < 0.001) and capsule fibrosis (p < 0.001). This titanium-coated polypropylene mesh shows acceptable complication rates and can be a helpful device in implant-based breast reconstruction. The mesh should only be used in primary cases and, when adhering to the proposed indications, is a safe and convenient option in implant-based breast reconstruction. Risk, III.
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