N. Sobti1, E. Ji1, R. L. Brown1, C. L. Cetrulo1, A. S. Colwell1, J. M. Winograd1, W. G. Austen1, E. C. Liao1 1Massachusetts General Hospital,Division Of Plastic And Reconstructive Surgery,Boston, MA, USA
Introduction: The number of mastectomy procedures has risen 5.1% within the past decade, where nearly one-third of patients undergo immediate breast reconstruction. Prosthesis-based reconstruction using a staged approach, where tissue expander (TE) is placed at the time of mastectomy followed by tissue expansion and subsequent operation for exchange for implant, is the most common method of breast reconstruction. Over the last decade, TE placement has been increasingly performed utilizing acellular dermal matrix (ADM), such that 60% of alloplastic breast reconstructions are ADM-based. ADM is a de-cellularized cadaveric soft tissue graft that provides structural support and controls prosthesis positioning. Although numerous studies have reported safety outcomes of breast reconstruction using ADM, this study uniquely evaluates the efficacy of ADM as soft tissue reinforcement by examining the objective parameters of initial fill volume at the time of mastectomy, number of expander fill, and time duration between exchange of TE for final implant.
Methods: Retrospective chart review of immediate breast reconstruction cases with TE was conducted at a tertiary academic medical center over 12 years. Procedures were performed by placing TE in the sub-pectoral position, with either ADM or serratus and myo-fascial flaps (non-ADM) to support the implant in the lower pole of the breast. Univariate and binomial regression analyses were performed to compare endpoints between ADM and non-ADM groups.
Results: Patients who underwent ADM-based breast reconstruction achieved a significantly higher initial TE fill volume when compared to those in the non-ADM cohort (180.8 ± 150.0 v. 45.8 ± 74.4 respectively, p = 0.00). Normalizing for final implant size, the ADM group exhibited significantly higher perioperative fill volume than the non-ADM group (0.33 ± 0.24 v. 0.11 ± 0.16, p = 0.00). Additionally, the ADM cohort experienced fewer TE expansion visits (5.0 ± 2.0 fills v. 6.7 ± 2.6 fills, p = 0.00) and shorter time interval between TE placement and implant exchange (5.4 ± 3.6 months v. 7.0 ± 4.9 months, p = 0.00). Complication rates were comparable between groups. In addition, we observed a collinear trend between ADM use and direct-to-implant single stage procedures during the study period.
Conclusion: This study demonstrated efficacy of ADM in immediate TE-mediated breast reconstruction. These results suggest that ADM-based procedures are associated with greater perioperative fill volume and shorter time duration between TE placement and implant exchange. Furthermore, the increased use of ADM correlated with the rise of single-stage breast reconstruction at our institution, thereby removing need for expansion and second stage implant exchange procedure. This work serves as a framework for future studies evaluating ADM efficacy in breast reconstruction and can guide development of emerging biomaterials and techniques.