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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e3181a83c69
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Diagnostic Dilemma: Acellular Dermis Mimicking a Breast Mass after Immediate Tissue Expander Breast Reconstruction

Buck, Donald W. II M.D.; Heyer, Kamaldeep B.S.; Wayne, Jeffrey D. M.D.; Yeldandi, Anjana M.D.; Kim, John Y. S. M.D.

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Division of Plastic and Reconstructive Surgery (Buck)

Division of Plastic and Reconstructive Surgery (Heyer)

Division of Surgical Oncology (Wayne)

Department of Surgical Pathology (Yeldandi)

Division of Plastic and Reconstructive Surgery; Northwestern University; Feinberg School of Medicine; Chicago, Ill. (Kim)

Correspondence to Dr. Kim, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 675 North St. Clair Street, Galter 19-250, Chicago, Ill. 60611, jokim@nmh.org

Sir:

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Immediate placement of tissue expanders and implants is currently the most common method of breast reconstruction after mastectomy.1 This form of reconstruction offers many advantages, including quick recovery, limited morbidity, and preservation of more invasive options in the event of implant failure.2 Variations in technique have attempted to address the disadvantages of this reconstructive method, including need for repeated expansion and additional surgery, rippling, capsular contracture, and lack of lower breast pole control.3

One such variation gaining popularity is the use of acellular dermis as an interposition graft between the chest wall and inferolateral edge of the pectoralis. Preliminary reports have been promising, but there are currently no long-term data available to verify long-term durability and/or establish adverse event profiles.

In this article, we present a patient who developed a new, palpable, fixed breast mass after mastectomy and immediate tissue expander breast reconstruction with acellular dermis. Histologic examination of the mass revealed dense foreign body giant cell infiltrate secondary to acellular dermis and no evidence of recurrent cancer. This is the first report of a potential diagnostic dilemma with acellular dermis mimicking a new breast mass in the context of prior mastectomy.

A 35-year-old woman with newly diagnosed right ductal carcinoma in situ underwent bilateral skin-sparing mastectomies with sentinel lymph node biopsy and immediate tissue expander reconstruction with an acellular dermis pectoral sling.

Two months after her initial procedure, she noted a new, palpable, fixed left breast mass. Given her history, diagnostic imaging was obtained, which revealed a 1-cm superficial mass adjacent to the left tissue expander. The patient elected to have the mass excised at the time of her expander/implant exchange. Intraoperatively, the mass was easily localized and excised with its surrounding soft tissue (Fig. 1). Histologic examination revealed fibroconnective tissue with chronic inflammation, dense foreign body giant cell reaction secondary to acellular dermis, and no evidence of recurrent cancer (Fig. 2).

Fig. 1
Fig. 1
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Fig. 2
Fig. 2
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Acellular dermis has been used successfully in multiple surgical scenarios.2,5 Several case series have been published within the plastic surgery literature over the past year detailing its use in breast reconstruction.2–4 These series have reported favorable results with respect to cosmesis and overall complication profiles.2–4

This is the first report of acellular dermis presenting as a new breast mass and represents an important finding, as a new mass in a patient with a history of breast cancer generates significant patient and patient family anxiety, and is associated with increased risks related to proper evaluation of the mass.

The intrinsic nature of acellular dermis lends itself to the development of masses and inflammatory nodules within the breast as a result of a paucity of significant subcutaneous fat in this area, along with relatively thin mastectomy skin flaps.

This is an important consideration for patients undergoing immediate reconstruction with acellular dermis. Patients should be informed that natural reaction to acellular dermis can lead to induration, palpable scarring, and the potential for further diagnostic studies and/or invasive procedures, to properly rule out recurrent disease.

Donald W. Buck, II, M.D.

Division of Plastic and Reconstructive Surgery

Kamaldeep Heyer, B.S.

Division of Plastic and Reconstructive Surgery

Jeffrey D. Wayne, M.D.

Division of Surgical Oncology

Anjana Yeldandi, M.D.

Department of Surgical Pathology

John Y. S. Kim, M.D.

Division of Plastic and Reconstructive Surgery

Northwestern University

Feinberg School of Medicine

Chicago, Ill.

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DISCLOSURE

The authors have no research relationship or conflict of interest to report with regard to this research.

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REFERENCES

1. American Society of Plastic Surgeons. Reconstructive Breast Statistics 2006. Available at: http://www.plasticsurgery.org/media/statistics/2006-Statistics.cfm. Accessed March 24, 2008.

2. Breuing KH, Colwell AS. Inferolateral AlloDerm hammock for implant coverage in breast reconstruction. Ann Plast Surg. 2007;59:250–255.

3. Zienoiwcz RJ, Karacaoglu E. Implant-based breast reconstruction with allograft. Plast Reconstr Surg. 2007;120:373–380.

4. Spear SL, Parikh PM, Reisin E, Menon NG. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg. 2008:32;418–425.

5. Bellows CF, Albo D, Berger DH, Awad SS. Abdominal wall repair using human acellular dermis. Am J Surg. 2007;194:192–198.

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