In the past 10 years, acellular dermal matrix (ADM) has been widely used in various fields of surgery, including cleft palate repair, abdominal wall repair, tendon repair, hernia repair, facial and eyelid soft tissue augmentation surgery, ulcer repair, and vaginal sling repair, among others.1-3 ADM not only provides initial structural strength and bulk, but also allows relatively rapid vascular growth and serves as a scaffold for “new” tissue formation.4 These properties have led to its application to resolving surgical problems where tissue deficiency remains an issue.
Many surgeons have begun to use ADM-assisted breast reconstruction techniques. Compared with ADM, the traditional method of implant-based breast reconstruction is more straightforward but is more prone to postoperative complications. Generally speaking, breast revision surgery procedures are complex, challenging, and unpredictable as the potential for the development of serious complications, such as capsular contracture (CC), must be addressed. CC has plagued plastic surgeons as the most common complication of reconstructive breast surgery for many years.5-7 The application of ADM addresses these problems, and as a result, its popularity is growing: in the United States 73% of surgeons have some experience in the use of xenogeneic or allogeneic ADM in breast reconstruction.8 Furthermore, the use of ADM in nipple and areola reconstruction can achieve a more natural appearance and avoids complications of other more traditional techniques.1 In cases of breast reconstruction, techniques that incorporate the use of ADM have been used to treat and reduce the incidence of CC, determine the position of the inframammary fold and final breast contour, enhance the use of available mastectomy skin, and increase the thickness of the soft tissue to reduce implant visibility or palpability. These goals can be achieved by replacing or extending the tissue with ADM or using ADM as a supplement. In addition to the advantages afforded by the use of ADM, the safety and efficacy of these techniques have been widely reported.1-10 Tissue expander breast reconstruction consists of three major surgical steps: placement of the expander after mastectomy, exchange of the expander for an implant, and nipple-areola complex reconstruction. This article summarizes the main methods and different aspects of ADM-assisted breast reconstruction.
APPLICATION OF ADM IN BREAST RECONSTRUCTION
Breast cancer is the most common cancer in women. Patients who have undergone mastectomy are distressed by the diagnosis of cancer and the adverse body image caused by the loss of their breast. Breast reconstruction is an integral component of the physical and emotional recovery for many women.11 Traditional implant-based breast reconstruction is relatively simple to perform, but challenging to perform consistently well. The challenges include CC, rippling, or bottoming out of the implant. Since 2006, an increasing number of studies have highlighted the potential of ADM in primary prosthetic breast reconstruction.10 The reported benefits include better control of implant position, better implant support and coverage, and the suggestion of a decreased frequency of CC and other complications.9,10
Full ADM sling
There are two methods of breast reconstruction that use a full ADM sling. One is the common method with a two-stage ADM placement and the other is single-stage direct-to-implant breast reconstruction. Immediate two-stage breast reconstruction using a tissue expander and implant has become the preferred choice of many surgeons to treat patients who have undergone mastectomy. A new modification of this method incorporating the use of ADM makes this approach more reliable and effective. In this new technique, ADM provides inferior pole coverage of a tissue expander placed subpectorally, allows a greater initial filling volume, improves the definition of the inframammary fold, and results in less postoperative pain.12
Sbitany and Langstein13 developed the popular two-stage method of placing the ADM as an inferolateral hammock (Figure 1). The technique is carried out as follows. Upon completion of the mastectomy by the oncologic surgeon, the inferior border of pectoralis major is elevated from the chest wall along its inferior and lower medial borders, and a pocket is dissected beneath it sufficiently large to accommodate the tissue expander. After adequate hydration, a 6 cm × 16 cm piece of “thick” ADM is sewn to the released inferior and medial margins of the pectoralis major (Figure 2). This suture line continues for the length of the ADM and follows the curving lateral contour of the muscle. The medial and inferior edges of the ADM are then sutured to the chest wall along a line approximately 1.5 cm below the inframammary fold. The lateral extent of this suture line mimics the inferolateral contour of the future breast and extends onto the serratus anterior fascia. The lateral portion of the pocket may be left open and the expander is inserted through this opening. Alternatively, the lateral border of the ADM may be sutured to the chest wall to create a fully closed pocket within which the expander sits. Figure 1 shows the typical appearance after surgery. The investigators in this group have shown that ADM can be used successfully to correct a number of implant-related deformities, broadly categorized as CC, ptosis, implant malposition, and implant visibility or palpability.13,14
Salzberg et al15,16 reported ADM-assisted breast reconstruction in a single-stage direct-to-implant breast reconstruction or following skin, areolar, and nipple-sparing mastectomies. His approach is to place a permanent silicone gel prosthesis supported by AlloDerm or Strattice as an internal hammock.15,16 Over a 52-month follow-up period, there were no incidences of contracture or other serious complications, showing that the technique is safe as well as esthetic. The key to a successful outcome is judicious patient selection. A reliable mastectomy flap is essential. It also helps if the patient wishes to achieve a somewhat smaller breast size postoperatively, allowing the native breast skin to be draped on the implant pocket without undue tension. This approach is becoming popular in Europe, since it can avoid the need for a second stage and save costs, despite the initial expense of the bioprosthesis.13,15,16
The most popular reasons to use ADM in breast reconstruction are to improve consistency and reproducibility in implant-based reconstruction and to afford the surgeon greater control over the pocket dimensions by utilizing ADM as a pectoralis major muscle “extension.” The result is fewer secondary operations, specifically, pocket manipulation at the time of implant exchange and long-term revision. The most effective strategy is to place the ADM as an inferior or inferolateral sling to cover the lower pole of the implant. In doing so, an additional volume may be instilled at the time of expander placement, maximizing the use of available preserved mastectomy skin, thus reducing the overall number of expansions. This technique also offers a more precise control of the inframammary fold, better preservation of implant location, and potentially faster completion of reconstruction.17-19 Theoretically, increased pocket size, higher initial filling volume, and fewer expansions should lead to a shorter reconstruction time. At present, there is insufficient evidence to support this claim. As a baseline for comparison, Nguyen et al19 reviewed a case series of 1522 non-ADM reconstructions performed over 12 years. They found that the average time from expander placement to insertion of the final implant was 5.9 months (range 0.9-27.0 months).20 The average time to completion of reconstruction using ADM has been reported as 5.4 and 5.7 months by Namnoum21 and Bindingnavele et al,22 respectively. In a comparison of two types of ADMs, such as AlloDerm and DermaMatrix (Synthes Inc., USA), the average time to completion of expansion was 201 (6.7 months) for AlloDerm and 183 days (6.1 months) for DermaMatrix.23 Individual surgeons have different preferences for length of expansion time, which makes it hard to compare results between surgeons.
The ADM technique, however, has been shown to be an effective means of treating CC. ADM may act as a barrier between the implant and the host defense mechanism, which limits the degree of inflammation and scarring.24 In many reports of breast reconstruction, an ADM technique leads to a near-zero CC rate.21,23,25,26 A retrospective study that examined the outcome of 10 patients who had undergone breast reconstructions with ADM 8 years beforehand found no CC or other complications.27
Compared with traditional methods, ADM-assisted breast reconstruction has several advantages which can be summarized as follows: (1) a reduction in the incidence of CC; (2) it can function as a tissue replacement; (3) an increased ability for the surgeon to define placement of both the inframammary fold and the expander/implant position; (4) an increased layer of protection between the prosthetic implant and the potentially poorly vascularized mastectomy skin; (5) a larger initial submuscular pocket leading to improved utilization of native mastectomy flaps; (6) more rapid expansion and shorter delay before a second-stage operation can be undertaken; (7) improved management of the threatened implant; (8) a reduced need for explantation; and (9) improved esthetic outcomes13,28,29
Partial ADM sling
As the most important factor limiting the application of the ADM technique is its high cost,30 a partial ADM sling method has emerged. This approach was first reported by Chepla et al31 and aims to minimize the quantity of ADM required. Its use has been reported in a cohort of 145 consecutive patients undergoing 197 breast reconstructions. To create a partial sling, a submuscular pocket is first created. Then, if the planned inframammary fold is <1 cm from the caudal margin, a small portion of the rectus fascia or the extension of the pectoralis fascia is elevated in continuity to lower the inferior pocket margin. Serratus anterior is left in situ. The distance from the most lateral aspect of the attached pectoralis to the lateral margin of the breast is measured to determine the size of the ADM required and then reinforced with a running 2/0 polydioxanone suture from medial to lateral. All expanders are soaked in an antibiotic solution, placed in the pocket and then the ADM is sutured to the inferior aspect of the pectoralis with 2/0 polydioxanone. The expander is then filled until the appearance of the skin flaps and tension across the skin closure is satisfactory. A single round 19-French Blake drain is placed within the expander pocket and subcutaneous space. The skin is closed in layers with monofilament glycomer.31
The potential benefits of using a partial ADM sling technique are: (1) the use of less ADM and lower cost; (2) a reduction in postoperative pain due to less extensive muscular dissection; (3) the need for fewer sutures and thus reduced operative times; and (4) a reduced quantity of foreign material reduces the risk of seroma formation.31
Problems and solutions
Despite many benefits, the more widespread adoption of techniques using ADM in breast wall reconstruction has been tempered mainly because of limits to indications for its use and some reports of postoperative complications:
(1) In most cases of ADM-assisted breast reconstruction, patient selection is key to achieving good results. This limits the number of patients who should undergo ADM-assisted operations. The ideal patients are those with medium- or large-sized breasts undergoing bilateral reconstructions. Obese patients with large breasts are usually poor candidates. Even with aggressive flap trimming and large intraoperative implant fill volumes, those with redundant mastectomy flaps will have a large dead space above the acellular dermis, predisposing to seroma formation and delayed vascularization of the matrix, thus increasing complication rates.13 On the other hand, patients with evidence of poorly perfused mastectomy flaps are at increased risk of complications with ADM-assisted reconstruction. These patients will often require aggressive mastectomy flap debridement and will likely not tolerate the excessive filling of the implant afforded by the ADM. They are best served by complete submuscular coverage of the expander/implant or immediate latissimus dorsi flap replacement of the threatened mastectomy flap. These patients benefit most from the release of the pectoralis muscle and subsequent maintenance of excess mastectomy skin.13
(2) There have been several reports of increased risk of infection, seroma, and flap necrosis with ADM-assisted techniques. However, the findings of these studies differ greatly. Newman et al32 conducted a meta-analysis to combine the results of 11 published articles describing ADM-assisted breast reconstruction to ascertain more precise complication rates. They reported that the overall complication rate was 12.0%, the main complications being flap necrosis (3.3%), seroma formation (3.3%), and infection (5.6%). An analysis of nine recent articles that compared the outcomes of ADM techniques in prosthetic breast reconstruction with standard submuscular techniques found similar rates of infection and flap necrosis, but that the rate of seroma formation was higher if ADM was used (8.4% vs. 4.3% after standard techniques).33 With effective measures, complication rates can be reduced. To prevent infections, attention should be given to the appropriate use of antibiotics in high-risk patients, and future modifications to the technique may also be beneficial. It is rare for a seroma to accumulate beneath the ADM and impair the vascularization of the matrix but may require aspiration if persistent. Many seromata are preventable and there is clearly a learning curve-seroma rates drop with increased experience, as surgeons learn that the correct amount of intraoperative filling reduces the dead space above the matrix, leading to improved vascularization.34,35
Application of ADM in nipple and areola reconstruction
Nipple and areola reconstruction is an important component of breast reconstruction, and acceptable projection of the new nipple is a key determinant of patient satisfaction.36 A breast without a nipple can only be regarded as a breast mass. Achieving realistic projection in a reconstructed nipple is a vexing and challenging goal. Although there are many techniques described to reconstruct nipples and areolae, none is entirely satisfactory. To date, the best methods of providing projection have depended on the use of autograft materials to augment local nipple flaps. This not only lengthens operative time, but is also found to exacerbate patients' distress and often leaves distinct scars after surgery. Reconstructed nipples may also rapidly lose projection.11
ADM can be a multifunctional tool in nipple constructions, but few studies examining its benefits have been reported. To examine the means of improving long-term projection of nipple flaps, Holton et al11 has successfully transplanted several simulated nipples onto athymic mice with human ADM. The nipples were designed and implanted in a bell flap with a cylinder of implanted ADM or a bell flap with intraflap injection of micronized ADM (MADM). By 12 weeks, the control nipples maintained 44% of their initial projection compared with 70% for ADM nipples, suggesting that ADM grafts maintain better long-term projection than local tissue flaps alone. The injected MADM is more effectively retained within the nipple flap (no MADM nipples extruded). Based on the promising results of this study, clinical trials are warranted using human ADM and/ or human MADM for nipple reconstruction as the dermal attachments in humans are formidable. In 2005, Garramone and Lam37 undertook nipple constructions with MADM in humans and achieved satisfactory appearances with no evidence of long-term inflammatory reactions or other obvious complications. In 2011, 19 nipple reconstructions were performed in 11 patients with retrieved AlloDerm.14 The investigators did not consistently orient the AlloDerm with either the basement membrane side or the dermal side facing out, as this does not appear to influence the outcome. In all reconstructions, the stored AlloDerm pieces were easily retrieved without signs of structural disintegration, no significant shrinkage was observed, and satisfaction rates were very high. Recently, Seaman et al38 presented a series of 12 nipple-areola complex reconstructions using ADM as an onlay graft; using this technique is especially beneficial when no ideal skin graft donor site that also avoids donor-site morbidity is available. The technique achieves very natural appearances and avoids the complications of other reconstruction methods. Once epithelialization is achieved, there is good demarcation of the nipple-areola complex and noticeable transition in texture. Tattooing can further enhance the appearance. ADM onlay grafting is a valuable addition to the techniques available to plastic surgeons for nipple-areola complex reconstruction and should be considered in appropriate cases. Although the results are encouraging, further studies are needed to evaluate long-term projection of nipples reconstructed with ADM inserts.
In conclusion, ADM offers great advantages for both full ADM sling and partial ADM sling in implant-based breast reconstruction. Compared with other tissue substitutes, ADM-assisted techniques for mammary and nipple reconstruction processes are more compatible and effective in preventing complications such as CC. Patients benefit from a more consistently achievable esthetic outcome, a more timely completion of reconstruction, a reduced need for expander fills, and less maintenance.13 Because it is safe and reliable and can be easily implemented, the technique of “banking” AlloDerm allows its use in breast and nipple reconstruction without incurring additional costs to the patient or the surgeon. Although there have been many reports about the indications, approaches, and results of ADM techniques, some short-term postoperative complications still exist, long-term observational data are still lacking,13,14,36 and the cost can be prohibitive. When ADM is used for reconstruction of both breasts and nipples, few patients can afford the high operation cost.14 Despite minor variations in technique, the use of ADM is gaining rapid acceptance in breast reconstruction.39 Together with improvements in preparation methods and surgical techniques, ADM is likely to become a fundamental feature of breast reconstruction.
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