We read with great interest the article entitled “Acellular Dermal Matrix–Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience” published by Salzberg et al. in the August edition of the Journal.1 We agree with the authors affirming that the cumulative incidence of capsular contracture with acellular dermal matrix–assisted reconstruction remains low, even in irradiated breasts.
In the literature, there are many publications regarding the use of acellular dermal matrices in both reconstructive and cosmetic surgery. Our indications for using them are as follows: nipple- and skin-sparing mastectomy, nonptotic contralateral breast, nonhypertrophic contralateral breast, good quality of the residual skin envelope, and postoperative adjuvant radiotherapy. The functions are as follows: reconstruction of the inframammary fold, maintenance of implant position, securing the inferior border of the pectoralis muscle, extending the pectoralis in primary implant reconstruction, and prevention of capsular contracture in cases of adjuvant radiation therapy. The disadvantages are as follows: the cost of the device, the size of the device should be chosen according to the size of the breast, and a thinner size would result in increased pliability. The advantages are as follows: collagen fibers and extracellular matrix components; the device promotes cellular colonization and integrates with host tissues; it is hydrated, thus reducing the risk of intraoperative contamination; it provides a better definition of the inframammary fold; it allows better symmetrization with the contralateral side; it increases the thickness of the skin flap; it prevents rippling and waving in the inferior pole; it decreases the rate of capsular contracture; it allows achievement of a pleasant aesthetic outcome; and it reduces the incidence of capsular contracture in patients undergoing adjuvant radiotherapy. The assessment of quality of life before and after surgery cannot be based on personal considerations of the attending physician, but must necessarily be expressed through objective studies, such as evaluation by means of the BREAST-Q.2 The operation should be chosen not only based on the anatomical part to be rebuilt but also according to what the patient expects. We applied the BREAST-Q Reconstruction module,3 with 10 patients undergoing immediate breast reconstruction surgery with implants and acellular dermal matrix (group A) and 10 patients undergoing immediate breast reconstruction with implants without acellular dermal matrix (group B), 1 year after surgery, at the end of all radiation therapy or chemotherapy. Paired t tests were conducted for each scale to assess individual change in patient satisfaction.
The study sample (n = 20) was characterized by a mean age of 45.1 ± 10.9 years; 75 percent underwent unilateral reconstruction, and 45 percent did not receive radiotherapy. On paired analysis, between postimplant surgery with and without acellular dermal matrix, patients reported a higher mean score (Fig. 1) for Satisfaction with Breasts (75 versus 38; p = 0.0001), Satisfaction with Outcome (80 versus 43; p = 0.0001), Sexual Well-being (67 versus 39; p = 0.0001), and Physical Well-being (88 versus 46; p = 0.0001). Achieving patient satisfaction and improving or maintaining health-related quality of life are important outcomes of breast reconstruction surgery4; patients require more attention in presurgical consultations, and clear communication should be prioritized to ensure that the surgeon understands the patient’s expectations.5 This study suggests that patients who underwent implant-based breast reconstruction with acellular dermal matrix report significant improvements in satisfaction and health-related quality of life following surgery and oncologic treatment.
The authors have no commercial associations that might pose or create a conflict of interest with information presented in this communication. No intramural or extramural funding supported any aspect of this work.
Mauro Barone, M.D.
Annalisa Cogliandro, M.D., Ph.D.
Paolo Persichetti, M.D., Ph.D.
Plastic and Reconstructive Surgery Unit
Campus Bio-Medico University
1. Salzberg CA, Ashikari AY, Berry C, Hunsicker LMAcellular dermal matrix–assisted direct-to-implant breast reconstruction and capsular contracture: A 13-year experience. Plast Reconstr Surg. 2016;138:329–337.
2. Cagli B, Cogliandro A, Barone M, Persichetti PQuality-of-life outcomes between mastectomy alone and breast reconstruction: Comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg. 2014;133:594e–595e.
3. Cohen WA, Mundy LR, Ballard TN, et alThe BREAST-Q in surgical research: A review of the literature 2009-2015. J Plast Reconstr Aesthet Surg. 2016;69:149–162.
4. Scott AM, Mehrara BJ, Pusic AL, Matros E, McCarthy CM, Dis JJLess patient-reported satisfaction and health related-quality of life in patients converting from prosthetic to autologous breast reconstruction. Plast Reconstr Surg. 2014;134(Suppl 1):89.
5. Barone M, Cogliandro A, La Monaca G, Tambone V, Persichetti PCognitive investigation study of patients admitted for cosmetic surgery: Information, expectations, and consent for treatment. Arch Plast Surg. 2015;42:46–51.
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