Modern Approaches to Implant-Based Breast Reconstruction

The advent of skin- and nipple-sparing mastectomy in conjunction with the use of human acellular dermal matrix to provide lower pole coverage has made direct-to-implant immediate breast reconstruction following mastectomy feasible. The purpose of this study was to evaluate long-term complications associated with this technique. All human acellular dermal matrix-assisted direct-to-implant immediate reconstructions performed over an 8-year period were included in this analysis. Patient charts were reviewed for type of mastectomy (oncologic or prophylactic), incision type, complications during follow-up, length of follow-up, rate and type of revision surgery in breasts without postoperative complications, contralateral procedures, and adjuvant radiotherapy. A total of 466 breasts (260 patients) were reconstructed; 68 percent were prophylactic and 32 percent were oncologic cases. Twenty-one breasts (4.5 percent) received radiotherapy. Mean implant size placed was 412.8 ± 24.7 cc (range, 150 to 600 cc). Mean follow-up was 28.9 ± 21.3 months (range, 0.3 to 97.7 months). The overall complication rate was 3.9 percent (implant loss, 1.3 percent; skin breakdown/necrosis, 1.1 percent; hematoma, 1.1 percent; human acellular dermal matrix exposure, 0.6 percent; capsular contracture, 0.4 percent; and infection, 0.2 percent). Type, incidence, and overall rate of complications did not differ significantly between prophylactic and oncologic breasts. Irradiated breasts had a fourfold higher rate of complications. In 354 breasts with more than 1 year of follow-up (mean, 36.7 ± 18.6 months; range, 12.1 to 97.7 months), there were no long-term complications. Human acellular dermal matrix-assisted direct-to-implant breast reconstruction following mastectomy is safe and reliable, with a low overall long-term complication rate. The low incidence of capsular contracture supports the growing body of evidence that human acellular dermal matrix mitigates capsular contracture.

Nipple-sparing mastectomy is increasingly used for treatment and prevention of breast cancer. Few data exist on risk factors for complications and reconstruction outcomes.

Acellular dermal matrix is frequently used in implant-based breast reconstruction to cover the inferior aspect of the breast pocket. Its performance profile remains equivocal. The authors studied whether adding it in implant-based immediate breast reconstruction improved outcomes when compared with non-acellular dermal matrix reconstruction. Patients undergoing implant-based immediate breast reconstruction at a single academic medical center were evaluated. Aesthetic outcomes and postoperative complications were assessed and direct comparisons were made between acellular dermal matrix and non-acellular dermal matrix cohorts. A total of 203 patients underwent 337 immediate expander-based breast reconstructions [with acellular dermal matrix, n=208 (61.7 percent); without, n=129 (38.3 percent)]. Patient characteristics, including age at time of reconstruction (mean, 49±11 versus 47±10 years) and body mass index (mean, 23±5 versus 23±3 kg/m) were similar between groups (p>0.05). Complications occurred in one-third of patients (33.5 percent). In univariate analyses, acellular dermal matrix use had fewer overall complications (odds ratio, 0.61; 95 percent CI, 0.38 to 0.97). The incidences of seroma/hematoma (p=0.59), infection (p=0.31), and wound complications (p=0.26) did not differ. Aesthetic outcomes were higher in the acellular dermal matrix group. In multivariate logistic regression, acellular dermal matrix use was associated with less capsular contracture (odds ratio, 0.18; 95 percent CI, 0.08 to 0.43) and mechanical shift (odds ratio, 0.23; 95 percent CI, 0.06 to 0.78). Optimizing the inframammary fold with acellular dermal matrix creates a superior aesthetic result. Its use appears safe and is associated with less capsular contracture and mechanical shift and improvement in the inframammary fold appearance, without increasing postoperative complications. Therapeutic, III.