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

Peled, Anne Warren M.D.; Foster, Robert D. M.D.; Garwood, Elisabeth R. M.D.; Moore, Dan H. Ph.D.; Ewing, Cheryl A. M.D.; Alvarado, Michael M.D.; Hwang, E. Shelley M.D., M.P.H.; Esserman, Laura J. M.D., M.B.A.

Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e31824ec447
Breast: Original Articles
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Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Author Information

San Francisco, Calif.; and Durham, N.C.

From the Department of Surgery, Divisions of Plastic and Reconstructive Surgery and Breast Surgery, and the Department of Epidemiology and Biostatistics, University of California, San Francisco; and the Department of Surgery, Duke University Medical Center.

Received for publication November 1, 2011; accepted December 21, 2011.

Presented at the 2011 Annual Meeting of the American Society of Clinical Oncology, in Chicago, Illinois, June 3 through 7, 2011, and at Plastic Surgery 2011, the Annual Meeting of the American Society of Plastic Surgeons, in Denver, Colorado, September 23 through 27, 2011.

Disclosure: The authors have no financial disclosures related to this work.

Laura J. Esserman, M.D., M.B.A.; University of California, San Francisco, Carol Franc Buck Breast Cancer Center, 1600 Divisadero Avenue, 2nd Floor, San Francisco, Calif. 94115, laura.esserman@ucsfmedctr.org

©2012American Society of Plastic Surgeons