Immediate breast reconstruction with acellular dermal matrix: Factors affecting outcome

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Summary

Background

The use of acellular dermal matrix (ADM) for coverage of the lower pole in immediate implant-based breast reconstruction has changed surgeons' practice. We present our experience using a porcine ADM (Strattice), focusing on short-term outcomes, patient selection, and technique adaptations that may influence outcome.

Methods

A two-center, retrospective, cohort study was performed from December 2008 to October 2012 at Guy's and St. Thomas' Hospitals, London, and Clinic Pyramide, Zürich. The study period was divided into two periods: Period 1 which spanned from December 2008 to October 2010 and Period 2 from January 2011 to October 2012 wherein technique adaptations were introduced. Short-term complications after reconstructive surgery were compared between Periods 1 and 2.

Results

A total of 149 patients underwent 200 reconstructions (110 one-stage and 90 two-stage) following oncologic (134 breasts) or prophylactic (66 breasts) mastectomy. The mean follow-up was 22.2 months. The total complication rate was 32.5%, including infection, 11.5%; hematoma, 5%; seroma, 10.5%; skin necrosis, 3.5%; and serious wound breakdowns with implant exposure, 1.5%. Complications resulted in 3% requiring an early exchange of implant/expander and in 12.5% requiring explantation. A significant reduction in total complications, infection, implant exposure, and implant loss were noted in Period 2. Multivariate analysis showed time period of surgery (Period 1), single-stage reconstruction, and patient characteristics (mastectomy weight >600 g, or body mass index (BMI) > 30, or smoking) to be statistically significant risk factors for the development of postoperative complications. Neoadjuvant chemotherapy showed a trend towards higher complication rates.

Conclusion

The high rate of early complications in this study was mostly related to patient characteristics and learning curves and highlights the importance of patient selection and technique principles in optimizing the outcome.

Introduction

Over the past decade, the use of acellular dermal matrix (ADM) in immediate implant-based breast reconstruction has gained acceptance. Currently, half of all implant-based reconstructions are performed with the use of an ADM.1 The reported benefits of using human ADM (HADM) include better aesthetic outcome due to better control of the inframammary fold and coverage of the implant,2, 3 creation of a larger implant pocket allowing for single-stage reconstruction,4, 5, 6, 7, 8, 9, 10, 11 and possible decrease in capsular contracture.2, 3, 10, 12, 13, 14

The majority of the evidence base for the use of ADM in breast reconstruction lies with human ADMs and particularly AlloDerm® (LifeCell Corp., Branchburg, NJ, USA).2, 4, 6, 10, 12, 15, 16, 17, 18 However, a number of other nonhuman ADMs, derived from bovine pericardium, bovine dermis, porcine dermis, and porcine small intestinal submucosa, are now available and are used in a similar capacity as human ADMs in breast reconstruction. Published experience with theses matrices is, however, limited and highlights a need to evaluate their efficacy and safety before widespread adoption.14, 19, 20, 21, 22, 23 The aim of this study was to report our early outcome using Strattice™ (LifeCell Corp., Branchburg, NJ, USA), a porcine ADM, in immediate implant-based breast reconstruction with particular emphasis on technique adaptations and learning curves that may influence outcomes.

Section snippets

Patients and methods

All patients who underwent Strattice-assisted implant-based breast reconstructions at Guy's and St. Thomas' Hospitals, London, and at Clinic Pyramide, Zürich, from December 2008 to October 2012 were retrospectively reviewed. Single-stage reconstruction was offered unless there was concern with skin viability or when patient had opted for simultaneous augmentation; in these cases, a two-stage procedure was performed.

Mastectomy was performed via a skin-sparing or nipple-sparing approach by breast

Results

A total of 149 patients with a mean age of 48 years (range: 27–76 years) who underwent 200 immediate Strattice-assisted implant-based breast reconstruction following a skin-sparing (n = 163) or nipple-sparing (n = 37) mastectomy were included in this study. Patient demographic data are summarized in Table 1.

After reconstructive surgery, patients were followed up for a mean of 22.2 months (range: 1.6–48.1 months). Early complications occurred in 65 breasts for an overall complication rate of

Discussion

Our institutional experience with Strattice-assisted implant-based breast reconstruction was associated with an early total complication rate of 32.5% which is two to five times higher than those in previously published studies involving the use of Strattice (6.3–16.9%, Table 9).14, 20, 21, 25 The seroma (10.5% vs. 1.4–5.2%), hematoma (5% vs. 0–1.5%), infection (11.5% vs. 2.1–10.4%), and implant loss (12.5% vs. 1.4–13%) rates in this study were most notably higher. Additionally, our rates were

Conflict of interest

Alessia M. Lardi, MD, received an educational grant (LifeCell Corporation). All other authors have no disclosure. No funds were received or utilized for this research. Ethic approval was not required for this study.

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