Spear, Scott L. M.D.; Sher, Sarah R. M.D.; Al-Attar, Ali M.D., Ph.D.; Pittman, Troy M.D.
Acellular dermal matrix, the first human acellular dermis product, available in 1994, was initially used in burn reconstruction. Those early successful experiences in reconstructive surgery logically led innovative surgeons to explore its use for a variety of other applications. The use of acellular dermal matrix in implant-based breast reconstruction was first reported in 2005.1 It was placed as an inferolateral sling for implant coverage, to recreate the inframammary and lateral mammary folds, and to maintain implant position. In device-based breast reconstruction, acellular dermal matrix is attached to the chest wall, at the level of the inferior and lateral mammary folds, and is also joined to the caudal border of the pectoralis major muscle. The benefits of acellular dermal matrix in this application have been reported to include increased immediate tissue expander fill volumes, improved shape and projection of the reconstructed breast inferiorly and laterally, decreased rippling and palpability along the inferior pole, and better control of implant and breast fold position.2–5 There is also the impression that acellular dermal matrix may be associated with lower rates of capsular contracture compared with total muscle or unassisted partial muscle coverage techniques.3,6–8
With increased surgical experience and understanding of the mechanical and biological benefits of acellular dermal matrix, it is not surprising that plastic surgeons would eventually explore expanding the indications for acellular dermal matrix to revision breast reconstruction procedures.9–11 The reoperation rate for implant-based breast reconstruction has been reported to be as high as 51 percent at 6 years,12 and is likely driven by actual complications and the increasingly heightened aesthetic expectations on behalf of both surgeons and patients. Problems associated with prosthetic device–based breast reconstruction can be seen after the first stage of a two-stage expander/implant reconstruction or after a completed one- or two-stage reconstruction. In either scenario, some of the more common problems include inferior fold malposition, bottoming out, symmastia or medial malposition, capsular contracture, and rippling/implant palpability.
Previously, each of these problems could be addressed with one or more specific surgical solutions; however, many of these solutions are not only technically difficult, but the results have been widely perceived to be unpredictable or inconsistent. One indication of the difficulty and unreliability of these corrections is the published high complication and revision rates after revisions of breast reconstruction, as seen in the Allergan and Mentor breast implant premarket approval data.>12,13 For example, in the case of inferior fold malposition, a capsulotomy that attempts to lower the inframammary fold inherently loses control of the final fold position; and the eventual fold position in this instance risks descending lower than the position obtained or intended at the time of surgery. Similarly, when an implant has dropped, or bottomed out, and inframammary fold support is needed, a capsulorrhaphy that attempts to raise the inframammary fold relies on sutures and inconsistent capsular tissues to withstand the steady pressure from gravity on the breast implant. It is in these and other similar circumstances where we began adding acellular dermal matrix to reinforce or supplement our earlier revision techniques.
Although there are no specific data on the failure rate of fold and malposition repairs by the capsulorrhaphy technique, there is the general perception that these repairs have a significant failure rate. This is borne out of the high rate of revisions, which is 40 percent in the Allergan (Irvine, Calif.) and Mentor (Santa Barbara, Calif.) premarket approval data at 6 years.12,13
In this study, we discuss what we believe to be the advantages of using acellular dermal matrix in revision breast reconstruction surgery, including soft-tissue coverage, fold control, and the potential reduction in capsular contracture. Based on this early experience and our impressions, we are using acellular dermal matrix more frequently in revision breast reconstruction to facilitate these revisions in an effort to improve the ease of the procedure and to improve outcomes. Because at this time there are few published reports of acellular dermal matrix use in revision breast reconstruction, we chose to retrospectively study our experience with acellular dermal matrix in revision breast reconstruction cases.
PATIENTS AND METHODS
All cases of revision or second-stage breast reconstruction performed by the senior author (S.L.S.) were reviewed where AlloDerm (LifeCell Corp., Branchburg, N.J.) was used from January 1, 2007, through June of 2012. Information regarding patient demographics, indications for the use of AlloDerm, and surgical history were collected for all patients. Each patient’s postoperative course was evaluated critically to determine surgical outcomes and any complications. The study was institutional review board approved.
The use of acellular dermal matrix during revision breast reconstruction was performed for one or more of the following primary indications: (1) management of Baker class III or IV capsular contracture; (2) inferior fold malposition; (3) inferior pole support; (4) medial fold support or symmastia; and (5) rippling/palpability. Although some patients had multiple indications for the use of acellular dermal matrix during their revision procedure, only the primary indication was tabulated.
In patients with capsular contracture, the first step is to perform a total or nearly total capsulectomy (Fig. 1). After the capsulectomy, the revision surgery proceeds like an immediate device-based breast reconstruction. If not already done, the pectoralis major is released from its origin inferiorly. When using an inframammary incision, the superior border of a sheet of 8 × 16-cm or 6 × 16-cm acellular dermal matrix is sutured to the inferior and lateral free borders of the pectoralis major muscle with running or interrupted sutures as appropriate. The implant is then placed underneath the acellular dermal matrix/pectoralis major muscle construct, and the inferior border of the acellular dermal matrix is then attached to either the chest wall or the superficial chest wall fascia as appropriate to best define the inferior and lateral breast shape. In the case of a central breast incision, the order is reversed and the inferior edge of the acellular dermal matrix is sutured to the inferior and lateral chest wall first, the implant is reinserted, and the upper border of the acellular dermal matrix is then sutured to the pectoralis major muscle edge.
In addressing cases where the inframammary fold is too low and needs to be raised, the procedure begins with an inferior capsulorrhaphy (Figs. 2 and 3). The capsulorrhaphy is performed using 2-0 polydioxanone or Vicryl (Ethicon, Inc., Somerville, N.J.) sutures, usually in multiple rows, beginning with a running horizontal mattress suture followed by a running locking suture back over the initial mattress repair. These two rows can be run in a continuous manner, using one long suture. Because the weight of an implant sitting on a capsulorrhaphy alone increases the risk of failure, acellular dermal matrix is used to reinforce the repair, with the intent of reducing the risk of recurrence. A sheet of acellular dermal matrix, typically 4 × 7 cm, is draped over the capsulorrhaphy repair. The acellular dermal matrix is first sutured to the posterior capsule on the chest wall using three or four interrupted 3-0 polydioxanone sutures. Next, interrupted half-mattress sutures are placed through the acellular dermal matrix, through the capsulorrhaphy repair, back through the acellular dermal matrix, and tied securely. Finally, the remaining free anterior border of acellular dermal matrix is sutured to the anterior capsule.
In cases where the inframammary fold is too high and needs to be lowered, a capsulectomy, capsulotomy, and/or creation of a neosubpectoral pocket is initially performed. One concern when making alterations to the inferior capsule to lower an inframammary fold is that, with time, control of the fold may be lost and the implant may descend beyond the desired level. For support following capsulotomy or capsulectomy while lowering the inframammary fold, the identical technique described above for raising the fold is used, with one exception. The acellular dermal matrix is secured both anteriorly to the flap and posteriorly to the chest wall; however, the acellular dermal matrix is not sewn to the lowest point of the created fold. The knots securing the acellular dermal matrix to the anterior and posterior capsules should be tied under appropriate tension to allow the material to incorporate into the newly created lower fold under the weight of the implant. Tethering the acellular dermal matrix too tightly to the anterior and posterior capsule risks creating a “hammock” effect, which could lead to a superiorly displaced implant postoperatively. This technique can be applied to reinforce changes made in cases of medial and lateral malposition as well.
In patients requiring inferior pole support at the inframammary fold, the acellular dermal matrix is added to reinforce the inferior mastectomy skin flap, much like an immediate breast reconstruction. Following a limited partial capsulectomy to dissect out and expose the caudal border of the pectoralis major muscle, the acellular dermal matrix is sutured superiorly to the inferior border of the pectoralis major muscle, the implant is then reinserted into the submuscular pocket, and the acellular dermal matrix is secured to the chest wall at the level of the desired inframammary fold with interrupted or running sutures as appropriate to achieve the desired effect on the table. In the case of a midbreast incision, the sutures to the inframammary fold are placed first.
Inferior pole support and support of an inferior fold repair are actually separate entities, and each can exist without the other (Figs. 4 and 5). Inferior pole support is actually implant support at the fold and can exist without repair of the inframammary fold. Whether the fold is repaired (in the case of bottoming out) or not, providing inferior pole support requires a larger piece of acellular dermal matrix (usually 6 × 16 cm or 8 × 16 cm) to support the implant and take pressure off of the lower pole skin flap. In contrast, smaller pieces of acellular dermal matrix are used to reinforce a capsulorrhaphy intended to raise the fold.
For cases of palpability or rippling, acellular dermal matrix can be used to provide additional tissue coverage, support, or both. Visible rippling most often occurs in the superior and medial regions of the breast. In the coverage technique, acellular dermal matrix is draped in an underlay fashion posterior to the anterior capsule providing additional thickness to the mastectomy flap to mask the rippling. The key to using acellular dermal matrix for rippling is to secure the acellular dermal matrix in place, under appropriate tension, with loosely tied sutures or “marionette,” or “parachute” percutaneous sutures, which can be adjusted after the implant is in. If the sutures attaching the acellular dermal matrix to the anterior capsule are too tight, the acellular dermal matrix may not redrape evenly and could potentially prevent acellular dermal matrix incorporation and may prevent the implant from assuming its ideal position. If they are too loose, the acellular dermal matrix may not provide the optimal support, especially inferiorly.
Between 2007 and 2012, the senior author (S.L.S.) performed 135 revision breast reconstruction operations on 118 patients, using acellular dermal matrix on 154 breasts (Table 1). The average follow-up period was 207 ± 318 days (range, 41 days to 6.6 years). The revision procedure was performed either at the second stage (i.e., exchange of tissue expander to implant) or as a distinct revision operation. For those patients who had a mastectomy, the mastectomy was prophylactic in 39 breasts (25 percent) and therapeutic in 112 breasts (73 percent). Three women had Poland syndrome (2 percent), and acellular dermal matrix was used to correct one of their breasts. Forty-five breasts (29 percent) had previously undergone radiation therapy. Eighty-two of the patients (69 percent) had unilateral reconstruction; the other 36 patients (31 percent) had bilateral reconstruction. The average age of the patients was 49.6 ± 10.8 years (range, 18 to 74 years), and the average body mass index was 23.5 ± 4 kg/m2 (range, 16.5 to 42.4 kg/m2). Of the 118 patients who underwent revision breast reconstructive surgery, 43 [36.4 percent; 57 breasts (37 percent)] had their primary operation performed by another surgeon.
This study reports the use and success rates of acellular dermal matrix as it was used for the primary revision indication during revision or second-stage surgery (Table 2). Of the 154 breasts, acellular dermal matrix was used as an adjunct during repair of inferior fold malposition in 57 breasts (37 percent), inferior pole support in 40 breasts (25.9 percent), as a replacement capsule following capsulectomy for Baker class III or IV capsular contracture in 42 breasts (27.2 percent), for rippling/palpability in 10 breasts (6.4 percent), and for symmastia or medial malposition in five breasts (3.6 percent).
In 147 of the 154 breasts (95.5 percent) in which acellular dermal matrix was used, the surgical indication was achieved and sustained for the duration of the follow-up period (Table 3). In seven breasts (4.5 percent) in five patients (3.2 percent), the indication for which acellular dermal matrix was placed was not achieved (Table 4). The most common complication was Baker class III or IV capsular contracture, occurring in five breasts (3.2 percent). Failure to lower the inframammary fold occurred in one breast (0.6 percent) and persistent rippling was noted in one breast (0.6 percent). One patient developed an infection in one breast (0.6 percent), which led to explantation. The overall complication rate was 5 percent. Forty-five breasts (29 percent) had a history of radiation therapy, although only two of 45 irradiated breasts (4 percent) went on to develop a complication (one with infection and one with recurrent capsular contracture).
The complications are stratified in Table 4 and are discussed below. One of the 10 patients (10 percent) who underwent revision to correct rippling experienced persistence of rippling and chose to not undergo further surgery. One patient whose primary indication for revision surgery was inferior fold malposition (implant too high) in the right breast and inframammary fold support (implant too low) in the left breast developed right breast cellulitis that progressed to an infected prosthesis, which was removed. This same patient’s left breast developed persistent lack of inframammary fold support in the left breast and chose to have this implant removed as well in the same procedure.
Five of 42 breasts (11.9 percent) underwent revision to correct class III or IV capsular contracture and developed a subsequent capsular contracture. At this time, none of these patients has opted to undergo further revision surgery.
AlloDerm grafts are commercially available in a variety of sizes, thicknesses, and processing styles; different types were used in this series based on anatomical needs. All of the acellular dermal matrix used was of the “thick” type, between 1.04 and 2.08 mm in thickness. The most common size of acellular dermal matrix that was used was the 4 × 7-cm graft [48 breasts (30.8 percent)], which fit the requirements for fold repairs. Other larger sizes that were used mostly for support and capsular contracture correction included 4 × 12 cm [40 breasts (25.6 percent)], 6 × 16 cm [22 breasts (14.1 percent)], and 6 × 12 cm [14 breasts (9 percent)]. Twelve of the 154 acellular dermal matrix grafts were of the ready-to-use processing variety, with 6 × 16 cm being the most common size of that material style used (Table 5).
The option of using acellular dermal matrix in revision implant breast reconstruction was a natural response to our growing experience and confidence with acellular dermal matrix in immediate breast reconstruction, our awareness of the difficulty in correcting certain implant-related problems, and the rising expectations by patients and surgeons regarding breast reconstruction outcomes. Increased patient expectations have blurred the line between reconstructive and aesthetic breast surgery, challenging surgeons to find innovative and reproducible ways to create favorable, reproducible, and durable results, similar more and more to the results obtainable with cosmetic breast surgery.14-17 With over 8 years of evidence regarding acellular dermal matrix in immediate breast reconstruction, especially in direct-to-implant reconstruction, the next logical step was to take what we have learned and apply it to revision surgery, both cosmetic and reconstructive.
The most common problems seen with cosmetic and reconstructive breast implant surgery typically include malposition, capsular contracture, bottoming-out, and palpability/rippling. Following breast reconstruction, implant malposition either vertically or horizontally is not uncommon. Earlier experience with capsulotomy or capsulectomy to lower a superiorly malpositioned implant has shown that that procedure can lead to implant descent beyond the level originally intended.18 Our use of an interpositional rectangle of acellular dermal matrix to control the new inframammary fold has proven to be a helpful addition to this procedure.
Similarly, in cases of inferior or medial (symmastia) malposition, earlier experience with capsulorrhaphy correction has often been associated with relapse and technical challenges in performing the procedure. An alternative technique known as a “neosubpectoral approach” has proven easier to perform and likely more reliable as well.9 Mindful of the high complication and revision rates associated with revision of previous reconstructions, it seemed appropriate to take additional steps to ensure the success of the known procedures for correcting fold malposition. The data from this review suggest that adding acellular dermal matrix to these repair techniques is worthwhile. For these applications, acellular dermal matrix is used to buttress the capsulorrhaphy as an onlay graft, or in the case of the neopocket technique, the acellular dermal matrix provides a barrier to prevent redescent or errant migration of the implant into the old space.
It has been our experience that the capsule provides sufficient blood supply capable of supporting vascular ingrowth from the capsule into the acellular dermal matrix. By buttressing the capsulorrhaphy or neopocket repairs with acellular dermal matrix, a unique mature lining is provided to support the implant and help prevent recurrence. This provided a higher level of reliability, reproducibility, and durability than relying on sutures alone to support the repair.
Capsular contracture remains a significant issue, with recent data reporting an incidence of 8.3 to 15.9 percent after primary breast reconstruction and 16.3 percent after revision breast reconstruction.6 Results of in situ biopsies after implantation have shown that acellular dermal matrix lacks the inflammatory reaction, fibrosis, and scar compared with the native breast capsule and instead retains its native dermis-like appearance and histologic characteristics. The hypothesis that replacing the capsule and avoiding formation of a new capsule by inserting a mature dermal barrier appears validated by our experience.17
Regarding rippling and palpability, it has yet to be conclusively shown that placement of acellular dermal matrix over the anterior surface of the implant provides sufficient additional thickness to the soft tissues to mask the underlying rippling of the implant. However, given what is known regarding the ability of acellular dermal matrix to incorporate into well-vascularized tissue, one can extrapolate that in the face of thin mastectomy flaps, an additional overlay of material may act to reduce the visibility of implant wrinkling. It is likely that this problem may require an additional multiprong approach, including fat grafting, more cohesive silicone gel implants, and better implant support inferolaterally.
With our use of acellular dermal matrix for revision reconstruction, success of the surgical indication was achieved in 95.9 percent of cases, and the reoperation rate following the first revision was 1.2 percent. By comparison, the Inamed/Allergan premarket approval data reported that, at 6 years, the revision-augmentation group had a 40.3 percent rate of additional reoperations following the first revision.12
The lower reoperation rates and higher success rates reported here resulting from addition of acellular dermal matrix to revision breast reconstruction with implants are encouraging. These problems are often technically challenging, hard to correct, prone to relapse, and associated with a high rate of additional revisions.
The authors report a 5-year experience in 154 breasts where acellular dermal matrix was a component of a revision of a previous breast reconstruction procedure. Although there were complications, there was a high frequency of success in managing these challenging problems. Particularly interesting was the low rate of relapse or need for subsequent surgery demonstrated in this series.9–16,18–23
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16. Bengtson BP, Baxter RA. Emerging applications for acellular dermal matrices in mastopexy. Clin Plast Surg. 2012;39:159–166
17. Yoo G, Lee PK. Capsular flaps for the management of malpositioned implants after augmentation mammoplasty. Aesthetic Plast Surg. 2010;34:111–115
18. Chasan PE. Breast capsulorrhaphy revisited: A simple technique for complex problems. Plast Reconstr Surg. 2005;115:296–301 discussion 302
19. Basu CB, Leong M, Hicks MJ. Acellular cadaveric dermis decreases the inflammatory response in capsule formation in reconstructive breast surgery. Plast Reconstr Surg. 2010;126:1842–1847
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