The Effects of Acellular Dermal Matrix in Expander-Implant Breast Reconstruction after Total Skin-Sparing Mastectomy: Results of a Prospective Practice Improvement Study

Department of Surgery, University of California, San Francisco, San Francisco, California, United States
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 06/2012; 129(6):901e-908e. DOI: 10.1097/PRS.0b013e31824ec447
Source: PubMed

ABSTRACT Neither outcome after total skin-sparing mastectomy and expander-implant reconstruction using acellular dermal matrix nor a strategy for optimal acellular dermal matrix selection criteria has been well described.
Prospective review of three patient cohorts undergoing total skin-sparing mastectomy with preservation of the nipple-areola complex and immediate expander-implant reconstruction from 2006 to 2010 was performed. Cohort 1 (no acellular dermal matrix) comprised 90 cases in which acellular dermal matrix was not used. Cohort 2 (consecutive acellular dermal matrix) included the next 100 consecutive cases, which all received acellular dermal matrix. Cohort 3 (selective acellular dermal matrix) consisted of the next 260 cases, in which acellular dermal matrix was selectively used based on mastectomy skin flap thickness. Complication rates were compared using chi-square analysis.
The study included 450 cases in 288 patients. Mean follow-up was 25.5 months. Infection occurred in 27.8 percent of the no-acellular dermal matrix cases, 20 percent of the consecutive cases, and 15.8 percent of the selective cases (p = 0.04). Unplanned return to the operating room was required in 23.3, 11, and 10 percent of cases, respectively (p = 0.004). Expander-implant loss occurred in 17.8, 7, and 5 percent of cases, respectively (p = 0.001). Additional analysis of the odds ratios of developing complications after postmastectomy radiation therapy demonstrated a specific protective benefit of acellular dermal matrix in irradiated patients.
Acellular dermal matrix use in expander-implant reconstruction after total skin-sparing mastectomy reduced major postoperative complications in this study. Maximal benefit is achieved with selected use in patients with thin mastectomy skin flaps and those receiving radiation therapy.
Therapeutic, III.

1 Follower
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Tissue reinforcement with allogeneic or xenogeneic acellular dermal matrices (ADMs) is increasingly used in single-stage (direct-to-implant) and 2-stage implant-based breast reconstruction following mastectomy. ADMs allow surgeons to control implant position and obviate the need for submuscular implant placement. Here, we review the benefits and risks of using ADMs in implant-based breast reconstruction based on available data. A comprehensive analysis of the literature with focus on recent publications was performed. Additional information regarding the proper use of ADMs was based on our institutional experience. ADM use may improve definition of the lateral confines of the breast and lower pole projection. It may facilitate direct-to-implant procedures and improve aesthetic outcomes. The effect of ADMs on complication rates remains controversial. Known patient risk factors such as obesity, smoking, and radiotherapy should be considered during patient selection. For patients with healthy, well-vascularized skin envelopes, ADM-assisted direct-to- implant reconstruction is a safe and cost-effective alternative to 2-stage implant reconstruction, with low complication rates. ADMs may be used to treat capsular contracture, and limited available data further suggest the possibility that ADMs may reduce the risk of capsular contracture. Novel synthetic or biosynthetic tissue reinforcement devices with different physical and ease-of-use properties than ADMs are emerging options for reconstructive surgeons and patients who seek to avoid tissue products from human or mammalian cadavers. ADM-assisted implant-based breast reconstruction may improve aesthetic outcomes. However, appropriate patient selection, surgical technique, and postoperative management are critical for its success, including minimizing the risk of complications.
    08/2014; 2(8):e192. DOI:10.1097/GOX.0000000000000140
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Immediate implant reconstruction after a conservative mastectomy is an attractive option made easier by prosthetic devices. Titanized polypropylene meshes are used as a hammock to cover the lower lateral implant pole. We conducted a prospective nonrandomized single-institution study of reconstructions using titanium-coated meshes either in a standard muscular mesh pocket or in a complete subcutaneous approach. The complete subcutaneous approach means to wrap an implant with titanized mesh in order to position the implant subcutaneously and spare muscles.
    European Journal of Plastic Surgery 11/2014; 37(11):599-604. DOI:10.1007/s00238-014-1001-1
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Reported infection rates in breast reconstruction with acellular dermal matrix (ADM) can exceed 31%. Prophylactic antibiotics remain controversial due to the absence of evidence-based literature. The purpose of this study was to examine published antibiotic regimens and their associated infection rates in this population. Systematic electronic searches were performed in PubMed, OVID, and the Cochrane databases for studies that reported on prophylactic antibiotic use and infection in patients undergoing ADM breast reconstruction. Two independent authors reviewed studies between 1970 and 2012 for inclusion and data extraction. A total of 863 studies were identified and abstracts reviewed. A total of 24 articles were included, with 2148 patients and 3189 ADM reconstructions. Mean infection rates varied between 0% and 31.25%, with a combined average of 11.59%. When comparing antibiotic protocols of less than 24 hours and more than 24 hours, the average infection rate was 2.48% and 13.21%, respectively. The current literature lacks consensus on the necessary duration for postoperative antibiotic prophylaxis following breast reconstruction. The potential increased risk of infection associated with ADM remains controversial. Because of the lack of supportive evidence, we do not recommend prolonged postoperative antibiotics in ADM breast reconstruction. Therapeutic level III evidence.
    Eplasty 11/2014; 14:e42.