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Breast: Original Articles

Comparing Outcomes of Wise-Pattern, Two-Stage Breast Reduction-Reconstruction with and without Acellular Dermal Matrix

Patel, Ashraf A. M.D.; Kayaleh, Hana B.S.; Sala, Luke A. B.S.; Peterson, Dylan J. B.A.; Upadhyaya, Prashant K. M.D.

Author Information
Plastic and Reconstructive Surgery: September 2021 - Volume 148 - Issue 3 - p 511-521
doi: 10.1097/PRS.0000000000008298

Abstract

Breast reconstructive techniques and technology have improved significantly in the past few decades, but reconstruction in obese and ptotic breasts continues to be a challenge when aiming for a successful reconstruction. Obesity inherently introduces additional risks for surgery, such as increased risk of developing postoperative infections and skin necrosis.1–3 In addition, the excess skin also makes prosthesis placement difficult. Compared to nipple-sparing mastectomies, Wise-pattern closures may provide a better mastectomy approach in this patient population, as this removes the excess skin to minimize postreconstruction breast ptosis.4,5 Although the “reduction-reconstruction” provides a better aesthetic result, this approach also has higher levels of complication and has been critiqued for removing too much tissue, leaving little structure to support the prosthesis.6,7

Acellular dermal matrix has been used to help address this issue and has played a significant role in reconstruction, with uses in breast, abdominal, and burn operations.8–12 It was first noted for use in breast reconstruction in 2005 and has since become an important tool in the reconstructive process.13 In addition to providing support, studies suggest that the use of acellular dermal matrix alleviates capsular contracture and is thought to buttress the mastectomy flap.14,15 Studies have also shown that it potentially improves the overall cosmetic outcome and allows for single-stage reconstruction.16,17 In many facilities, two-stage reconstruction with acellular dermal matrix is common, but cost is a major limitation, as acellular dermal matrix prices can surpass $5000, or $38 per cm2.18

There is evidence to suggest that patients with ptotic breasts generate more complications following breast reconstruction, notably when acellular dermal matrix is involved.19 A previous study has demonstrated that reconstructions requiring larger areas of acellular dermal matrix undergo more complications, including seroma, skin infection, and skin necrosis.20 Thus, in an effort to improve patient outcomes, we find it is important to appropriately assess the impact of acellular dermal matrix use, its necessity, and whether the benefits outweigh the cost. In this retrospective study, we compare reduction-reconstruction postoperative outcomes in two cohorts of patients: those who had acellular dermal matrix used in the surgery and those who did not. To the best of our knowledge, this is the first study that assesses reconstruction without acellular dermal matrix in this patient population.

PATIENTS AND METHODS

This study retrospectively reviewed the outcomes of patients who underwent two-stage implant-based breast reduction-reconstruction following Wise-pattern closures. All reconstructions were completed by the senior author (P.K.U.) between September of 2016 and October of 2019. The study was approved by the State University of New York Upstate Medical University Institutional Review Board (no. 1490947). Charts were accessed using Epic (Epic Systems Corp., Verona, Wash.), and all review was performed in a deidentified manner. Using CPT codes for two-stage, implant-based breast reconstruction and the exclusion of nipple-sparing mastectomies, 85 patients met criteria. Two cohorts were created based on whether acellular dermal matrix was used in reconstruction.

Basic demographics and medical comorbidities were collected for all patients at the time of the first stage of surgery (expander placement). Patient oncologic data including history of chest wall radiation therapy, chemotherapy, neoadjuvant chemotherapy, postmastectomy radiation therapy, and breast surgery were also collected.

Perioperative information was collected for all patients at both stages of surgery. This included the indication for the breast surgery and mastectomy type – which was Wise-pattern for all patients in this study. First-stage information included location of tissue expander plane (either prepectoral or subpectoral), tissue expander size and fill, and whether acellular dermal matrix was used. Second-stage perioperative data included the size of the final implant placed.

Charts were reviewed for incidence of any complication that occurred 6 months following both stages of reconstruction. The complications included infection, dehiscence, seroma, hematoma, prosthesis malposition, and capsular contracture. Infection was categorized as either major or minor. Minor infections were defined as those managed with antibiotics and local wound care if necessary, whereas major infections required operative management. All infections requiring washout were categorized as “major infections”; washouts were also specified based on whether the prosthesis was salvaged, whether the reconstruction required prosthesis replacement, or whether the prosthesis was removed without replacement. Total follow-up time was calculated based on the last clinic visit.

Statistical Analysis

All data were collected and formatted into tables using Microsoft Excel (Microsoft Corp., Redmond, Wash.). Continuous data were described using means and standard deviations. After testing for normality using the Shapiro-Wilk method, p values were obtained using unpaired t tests for normally distributed variables and independent two-group Mann-Whitney U tests for nonnormally distributed variables. Categorical data were reported as frequencies, and the chi-square test was used to obtain p values. The Fisher’s exact test was used when frequencies were less than 5. Cohort demographics were compared against one another, and cohort differences that were statistically significant were entered into multivariable logistic regressions to assess their impact on complication rates at both stages of surgery. To test the predictive performance of these models, the area under the receiver operating characteristic curve was calculated. All advanced statistical analyses were performed using RStudio (RStudio, Inc., Vienna, Austria). Values of p < 0.05 were considered statistically significant.

Patient Selection

The decision to reconstruct the patient with a Wise-pattern closure without acellular dermal matrix was based on breast shape, individual breast size, and patient preference. We did not use particular breast size criteria, but factors that made this form of reconstruction an option included the following: (1) patients who wished to have smaller breasts, (2) breasts with grade 3 ptosis, (3) breasts with extensive stretch marks, and (4) large breasts (larger than bra size DD and/or patients who would require an implant size >800 cc). A majority of our patients opted for a nipple-areola complex reconstruction at the time of reconstruction, which was performed as a free nipple-areola graft.

Preoperative Markings

The patient is marked in the sitting position, beginning with the breast borders and meridians. The anticipated position of the nipple-areola complex is marked, and an arbitrary line is drawn 8 to 10 cm below this, transversely across the breast. A triangle is drawn from the new nipple-areola complex position to the marked line on both sides of the areola, very similar to an inferior pedicle reduction marking (Fig. 1). The area encompassed by these markings is used as our dermal flap that will be deepithelialized. This area also includes the nipple-areola complex, which is harvested; a small hole is created directly in the area of the nipple-areola complex that is submitted along with the mastectomy specimen.

Fig. 1.
Fig. 1.:
Triangle markings encompassing the area that will be used as our dermal flap once deepithelialized. The nipple-areola complex is included, which will be harvested.

Operative Technique

The surgery begins with nipple-areola harvesting. The undersurface of the nipple-areola complex is tumesced with local anesthesia, and the appropriately sized nipple-areola complex is harvested as a full-thickness graft. It is appropriately defatted and placed in a saline-soaked gauze. We then proceed to deepithelialize the dermal flap, using a pair of scissors (Fig. 2). The mastectomy surgeon then takes over and completes the mastectomy. We restart by assessing the mastectomy flap, with possible use of SPY Elite Fluorescence Imaging (Stryker Corp., Kalamazoo, Mich.). We measure the breast-base width and decide on the appropriate tissue expander size. The breast pocket is irrigated with antibiotic irrigation, and meticulous hemostasis is confirmed.

Fig. 2.
Fig. 2.:
Deepithelialized dermal flap that will be used in lieu of acellular dermal matrix to cover the tissue expander. The nipple-areola complex has been harvested.

The expander is sutured in place with multiple silk sutures. Further steps depend on the type of reconstruction used, as follows.

  • Subpectoral reconstruction with acellular dermal matrix: the acellular dermal matrix is sutured to the chest wall and the pectoralis major muscle in the form of a sling. The dermal flap is then draped over the acellular dermal matrix and sutured to the muscle edge.
  • Prepectoral reconstruction with acellular dermal matrix: the expander is covered by acellular dermal matrix first and then the dermal flap is placed over this and secured with sutures.
  • Subpectoral reconstruction without acellular dermal matrix: the dermal flap is draped over the expander in the form of a sling instead of acellular dermal matrix and sutured similarly. The excess dermal flap is excised, if needed.
  • Prepectoral reconstruction without acellular dermal matrix: the deepithelialized flap is draped over the expander, with the apex of the flap included within the suture stabilizing the superior tab of the expander (Fig. 3). Once the expander is secured, it is expanded to the appropriate size with air, to achieve maximal expansion of the expander without the added weight of the saline. To better define the lateral border in reconstructions without acellular dermal matrix, the lateral border of the flap is freed and rotated superiorly to recreate the lateral breast border and fill up the empty space lateral to this area (Fig. 4). The borders of the flap around the expander are sutured to the chest wall.
Fig. 3.
Fig. 3.:
Deepithelialized dermal flap draped over the tissue expander and sutured superiorly.
Fig. 4.
Fig. 4.:
The lateral border of the deepithelialized dermal flap is freed and rotated laterally to create the lateral breast border. (Below) Note that the medialmost aspect of the expander did not need to be completely covered. Note the rescue triangle, which is variable and can be trimmed later.

Two drains are placed in the appropriate position, and the wound is closed in two layers, resulting in an inverted-T–shaped incision, identical to the incision following Wise-pattern reduction closure. The position of the new recipient nipple-areola complex is confirmed and marked, typically at the apex of the vertical incision. The appropriately sized nipple-areola marker is used to mark the recipient nipple-areola complex and the area is deepithelialized. The nipple-areola complex graft is placed and secured with running sutures (Fig. 5). The SPY Elite Fluorescence Imaging is repeated (if needed) to assess mastectomy skin viability. A bolster dressing is applied, and the wounds are covered using the Dermabond Prineo Skin Closure System (Ethicon, Inc., Somerville, N.J.) or Prevena Incision Management System (KCI USA, Inc., San Antonio, Texas) as needed based on the SPY Elite findings.

Fig. 5.
Fig. 5.:
The wound is closed and results in scars similar to those seen with a Wise-pattern reduction closure. The nipple-areola raft is sutured in place.

RESULTS

A total of 164 breasts were reconstructed using Wise-pattern closures in 85 female patients. The mean patient age was 52.22 ± 10.67 years, and the mean body mass index was 33.75 ± 6.57 kg/m2. Among the 85 patients, 35 had acellular dermal matrix used during reconstruction, whereas 50 patients had not. Patient demographics and comorbidities were relatively similar between acellular dermal matrix and non–acellular dermal matrix cohorts, aside from diabetes, history of chest wall radiation, and chemotherapy (Table 1). In the nonmatrix cohort, diabetes was more prevalent (acellular dermal matrix, 8.57 percent; nonmatrix, 24.00 percent; p = 0.066). In the acellular dermal matrix cohort, chest wall radiation therapy (acellular dermal matrix, 25.71 percent; nonmatrix, 8.00 percent; p = 0.026) and chemotherapy (acellular dermal matrix, 28.57 percent; nonmatrix, 10.00 percent; p = 0.027) were more prevalent. Follow-up time was longer in the acellular dermal matrix cohort (520.16 days versus 392.11 days; p < 0.001).

Table 1. - Patient Demographics
Characteristic Total Patients (%) ADM Patients Non-ADM Patients (%) p
No. of patients 85 35 50
Average age ± SD, yr 52.22 ± 10.67 52.37 ±10.42 52.12 ± 10.93 0.916
Ethnicity
 Asian 1 (1.18) 1 (2.86) 0 (0.00) 0.229
 Black 6 (7.06) 4 (11.43) 2 (4.00) 0.188
 Other, Hispanic/Latino 1 (1.18) 0 (0.00) 1 (2.00) 0.400
 White 77 (90.59) 30 (85.71) 47 (94.00) 0.198
Mean BMI, kg/m2 33.75 ± 6.57 33.46 ± 6.52 33.95 ± 6.66 0.737
Obese (BMI >30 kg/m2) 56 (65.88) 21 (60.00) 35 (70.00) 0.339
Diabetes 15 (17.65) 3 (8.57) 12 (24.00) 0.066
Hypertension 41 (48.24) 17 (48.57) 24 (48.00) 0.959
Dyslipidemia 19 (22.35) 8 (22.86) 11 (22.00) 0.926
Coronary artery disease 0 (0.00) 0 (0.00) 0 (0.00)
Smoking history 0.368
 Yes 34 (40.00) 12 (34.29) 22 (44.00)
 No 51 (60.00) 23 (65.71) 28 (56.00)
History of XRT 13 (15.29) 9 (25.71) 4 (8.00) 0.026
Chemotherapy 15 (17.65) 10 (28.57) 5 (10.00) 0.027
Neoadjuvant chemotherapy 10 (11.76) 5 (14.29) 5 (10.00) 0.546
Breasts receiving PMRT 25 (15.24) 11 (16.18) 14 (14.58) 0.780
History of breast surgery 30 18.29) 11 16.18 19 19.79) 0.555
Final follow-up time, days 445.21 ± 218.19 520.16 ± 243.32 392.11 ± 180.54 <0.001
ADM, acellular dermal matrix; BMI, body mass index; XRT, chest wall radiation therapy; PMRT, postmastectomy radiation therapy (by breast, rather than by patient).

Perioperative data for mastectomy, first-stage, and second-stage operations are outlined in Table 2. There were 68 breasts in the acellular dermal matrix cohort and 96 in the non–acellular dermal matrix cohort. Mass of the resected specimen and tissue expander fill were similar in both cohorts.

Table 2. - Perioperative Information
Factor Total Patients (%) ADM Patients (%) Non-ADM Patients (%) p
No. of breasts reconstructed 164 68 96
Indication for breast surgery
 Breast cancer 72 (84.71) 31 (88.57) 41 (82.00) 0.714
 Prophylactic 13 (24.89) 4 (11.43) 9 (18.00) 0.415
Mastectomy type
 Wise pattern 164 (100.00) 68 (100.00) 96 (100.00)
Mean mass of resected specimen, g 862.69 ± 313.43 814.74 ± 261.90 862.69 ± 313.43 0.953
Reconstruction laterality 0.710
 Unilateral 5 (5.88) 3 (8.57) 2 (4.00)
 Bilateral 80 (94.12) 32 (91.43) 48 (96.00)
Nipple graft 134 (81.71) 51 (75.00) 83 (86.46) 0.061
Axillary lymph node dissection 23 (14.02) 8 (11.76) 15 (16.62) 0.483
Tissue expander plane 0.007
 Prepectoral 42 (25.61) 10 (14.71) 32 (33.33)
 Subpectoral 122 (74.30) 58 (85.29) 64 (67.67)
Mean TE size, ml 497.31 ± 70.79 487.87 ± 87.17 504.77 ± 53.28 0.557
Mean TE fill, ml 310.08 ± 129.94 293.39 ± 140.43 324.35 ± 118.39 0.129
ADM use
 Yes 68 (41.46) 68 (100.00) 0 (0.00)
 No 96 (58.54) 0 (0.00) 96 (100.00)
Mean implant size, cc 671.61 ± 127.92 673.28 ± 123.53 670.43 ± 130.95 0.943
ADM, acellular dermal matrix; TE, tissue expander.

Complication incidences following tissue expander placement are outlined in Table 3. Of all 164 breasts, 56 (34.15 percent) had one or more complication. The incidence of one or more complication was similar between cohorts (acellular dermal matrix, 32.4 percent; non–acellular dermal matrix, 35.4 percent; p = 0.684). Minor infection rates were significantly higher in the acellular dermal matrix cohort (16.2 percent versus 6.3 percent; p = 0.040). Following implant placement, complication incidence was calculated among both cohorts (Table 4). Overall, 24 breasts (14.6 percent) experienced one or more complication, with relatively similar rates occurring in both cohorts (acellular dermal matrix, 16.2 percent; nonmatrix, 13.5 percent; p = 0.638).

Table 3. - First-Stage Complications
Complication Total Patients (%) ADM Patients (%) Non-ADM Patients (%) p
Any complication 56 (34.15) 22 (32.35) 34 (35.42) 0.684
Infection 30 (18.29) 15 (22.06) 15 (15.62) 0.294
 Major infection* 13 (7.93) 4 (5.88) 9 (9.36) 0.415
 Minor infection 17 (10.37) 11 (16.18) 6 (6.25) 0.040
 Washout and salvaged TE 10 (6.10) 2 (2.94) 8 (8.33) 0.155
 Washout and TE removal 3 (1.82) 2 (2.94) 1 (1.04) 0.371
Dehiscence 19 (11.59) 5 (7.35) 14 (14.58) 0.154
Seroma 21 (12.80) 6 (8.82) 15 (15.62) 0.199
Hematoma 3 (1.83) 1 (1.47) 2 (2.08) 0.773
Malposition 0 (0.00) 0 (0.00) 0 (0.00)
ADM, acellular dermal matrix; TE, tissue expander.
*Defined as requiring operative washout.
Defined as managed with antibiotics and/or local wound care.

Table 4. - Second-Stage Complications
Complication Total Patients (%) ADM Patients (%) Non-ADM Patients (%) p
Any complication 24 (14.63) 11 (16.18) 13 (13.54) 0.638
Infection 17 (10.30) 7 (10.3) 10 (10.4) 0.980
 Major infection* 8 (4.88) 4 (5.9) 4 (4.2) 0.615
 Minor infection 9 (5.49) 3 (4.4) 6 (6.3) 0.611
 Washout plus salvaged implant 6 (3.66) 3 (4.4) 3 (3.1) 0.665
 Washout plus implant removal 2 (1.22) 1 (1.5) 1 (1.0) 0.805
Dehiscence 12 (7.32) 8 (11.76) 4 (4.17) 0.066
Seroma 1 (0.61) 1 (1.47) 0 (0.00) 0.233
Hematoma 4 (2.44) 1 (1.47) 3 (3.12) 0.499
Malposition 1 (0.61) 0 (0.00) 1 (1.04) 0.399
Capsular contracture 6 (3.66) 3 (4.41) 3 (3.12) 0.665
*Defined as requiring operative washout.
Defined as managed with antibiotics and/or local wound care.

Variables that differed significantly between cohorts were entered into multivariable logistic regressions to assess their impact on the incidence of complications. These variables included a history of diabetes mellitus, chest wall radiation therapy, chemotherapy, tissue expander placement plane, and acellular dermal matrix use. No variables were found to be significant predictors of complications following either tissue expander placement (Table 5) or implant placement (Table 6).

Table 5. - Logistic Multivariable Regression of Factors Predictive of One or More Breast Complications following First-Stage Reconstruction (Insertion of Tissue Expander)*
Factor OR p Model Coefficient Reference
Diabetes mellitus 1.362 0.483 0.309
XRT 2.430 0.143 0.888
PP TE 1.542 0.267 0.433 SP TE
Chemotherapy 1.844 0.184 0.612
ADM use 0.787 0.531 −0.239
XRT, chest wall radiation history; PP, prepectoral; TE, tissue expander; SP, subpectoral; ADM, acellular dermal matrix.
*n = 164 breasts; model area under the receiver operating characteristic curve = 0.631.

Table 6. - Logistic Multivariable Regression of Factors Predictive of One or More Breast Complications following Second-Stage Reconstruction (Insertion of Implant)*
Factor OR p Model Coefficient Reference
Diabetes mellitus 0.966 0.954 −0.035
XRT 1.021 0.980 0.021
PP TE 1.030 0.955 0.030 SP TE
Chemotherapy 0.880 0.839 −0.128
ADM use 1.262 0.634 0.233
XRT, chest wall radiation therapy; PP, prepectoral; TE, tissue expander; SP, subpectoral; ADM, acellular dermal matrix.
*n = 164 breasts; model area under the receiver operating characteristic curve = 0.5381.

DISCUSSION

Acellular dermal matrix has become a widely used tool in the world of breast surgery as a means to support the prosthetic breast and improve cosmetic outcomes in ptotic breast reconstructions.9,10,12 The Wise-pattern closure provides an excellent mastectomy option for patients desiring a reduction during reconstruction, and acellular dermal matrix is typically used to help support the prosthesis following removal of the excess tissue in obese or ptotic breasts. However, its use comes with a significant cost and potentially an increased risk of complications postoperatively.18–20 This study examined the complication rates associated with both acellular dermal matrix and non–acellular dermal matrix reduction-reconstructions to better understand the impact and necessity of acellular dermal matrix in this form of reconstruction.

Our data reveal that complication rates following the first stage were relatively similar between both the acellular dermal matrix and non–acellular dermal matrix cohorts (32.4 percent versus 35.4 percent, respectively; p = 0.684). A majority of the patients (65.9 percent) in our study were considered obese (body mass index ≥30 kg/m2), and compared to previously reported complication rates in obese breast reconstructions, we find our first-stage complication rates to be comparable.6,7,21 All individual complication rates were also statistically similar, with the exception of minor infection rate, which was higher in the acellular dermal matrix cohort (16.2 percent versus 6.3 percent; p = 0.040) and defined as infection resolving with only antibiotics or local wound care. One explanation for the higher incidence of minor infections in the acellular dermal matrix cohort could be that these cases were performed initially and were still part of a learning curve. However, the overall complication rate being similar supports the idea that acellular dermal matrix may be an unnecessary expense in reduction-reconstructions.

Seroma rates in the non–acellular dermal matrix cohort were 15.6 percent, but we found our rates of postoperative seromas to decrease with experience after implementing a new step. When acellular dermal matrix is not used, recreating the boundaries of the breast pocket is more challenging—especially at the lateral border. To better define the pocket, we propose rotating the lateral portion of the dermal flap to the lateral aspect of the breast pocket, and placing sutures to further solidify the pocket boundaries and limit potential dead-space (Fig. 4). Our rates of postoperative seromas and subsequent infections diminished significantly after implementing this step.

By rotating the lateral aspect of the dermal flap, a majority of the tissue expander is covered, but it may not have full coverage, which is typically achievable when acellular dermal matrix is used. However, we believe that the entire expander does not need to be covered for a safe reconstruction, which has also been proposed by other studies that use acellular dermal matrix.22 From our experience, covering a majority of the implant, especially the inferior aspect, is sufficient to provide ample coverage and support (Fig. 4). This can be seen in Supplemental Digital Content 1 through 4, where the breast capsule is fully formed at the second stage without entire expander coverage at the first stage. (See Figure, Supplemental Digital Content 1, which shows the healed incision seen at the time of second-stage surgery, http://links.lww.com/PRS/E557. See Figure, Supplemental Digital Content 2, which shows that the expander is visible after opening the capsule for second-stage surgery, http://links.lww.com/PRS/E558. See Figure, Supplemental Digital Content 3, which shows an intraoperative photograph showing excellent capsule formation throughout, including the medial border, which was not fully covered by the dermal flap at first-stage surgery, http://links.lww.com/PRS/E559. See Figure, Supplemental Digital Content 4, which shows the superior border of the capsule is dissected to enlarge the breast pocket, http://links.lww.com/PRS/E560.)

Following the second stage of reconstruction, our data show that complication rates between both cohorts were also similar (acellular dermal matrix, 16.2 percent; non–acellular dermal matrix, 13.5 percent; p = 0.638). Although individual complication rates were not significantly different, dehiscence rates came closest to statistical significance, which is surprising, as breast pocket and flap sizes were larger in nonmatrix patients (acellular dermal matrix, 11.8 percent; nonmatrix, 4.2 percent; p = 0.066). This once again understates the necessity for acellular dermal matrix in these types of reconstructions. We also find our overall second-stage complication rates to be lower than those previously reported in the literature for obese breast reconstructions.6,7,21

Although complication rates are not the only metric used to test the impact of acellular dermal matrix, we find that a lack of increased complication incidence supports the safety of our proposed operative technique. We believe the use of acellular dermal matrix may be redundant in Wise-pattern reduction-reconstructions, as the dermal flap provides adequate support for the prosthesis. The deepithelialized dermal flap may actually be superior, as it not only provides coverage but is more resilient because it comes well perfused. The dermal flap is the patient’s native tissue, which may be integrated into the reconstruction more seamlessly and could potentially avoid the risk of minor infection that was seen in our study. Patients also achieve an excellent aesthetic result when the Wise-pattern closure is used (Figs. 6 and 7), with superior aesthetic results when compared to a nipple-sparing mastectomy in ptotic or obese breasts, although our study did not objectively measure aesthetic result.23,24

Fig. 6.
Fig. 6.:
Preoperative and 6-month-postoperative photographs from a Wise-pattern, two-stage prepectoral breast reconstruction with acellular dermal matrix.
Fig. 7.
Fig. 7.:
Preoperative and 6-month-postoperative photographs from a Wise-pattern, two-stage prepectoral breast reconstruction without acellular dermal matrix.

With the recent reemergence of prepectoral breast reconstruction, we believe that this technique is safe even in prepectoral reconstructions, which was recently also shown by Thuman et al.25 Our initial practice placed the tissue expander in the subpectoral plane along with acellular dermal matrix in form of a sling, and the deepithelialized flap was draped over the acellular dermal matrix. A patient opposed to using acellular dermal matrix in her reconstruction initiated our transition to not using acellular dermal matrix underneath the deepithelialized flap. This patient had a successful reconstruction, encouraging us to continue using this technique that excluded acellular dermal matrix use.

Keeping with the overall shift of breast reconstruction into the prepectoral plane, all of our reconstructions are now performed prepectorally.26,27 We initially used acellular dermal matrix to cover the prepectoral expander in addition to the deepithelialized dermal flap. We felt that this, too, was redundant and excluded its use, initiated again with a patient who did not want to use it in her reconstruction. Because of these changes in our practice with time, our non–acellular dermal matrix cohort consisted of significantly more prepectoral reconstructions than the acellular dermal matrix cohort (acellular dermal matrix, 14.7 percent; nonmatrix, 33 percent; p = 0.007). Nonetheless, complication rates were similar or trended lower in the nonmatrix cohort. This challenges the notion that prepectoral breast reconstructions with Wise-pattern reductions require acellular dermal matrix, as logistic multivariable regressions showed that prepectoral placement did not significantly increase the odds of complication incidence at either the first stage (OR, 1.542; p = 0.267) or the second stage (OR, 1.262; p = 0.634).

Although we report low complication rates without the use of acellular dermal matrix in many of our patients with an excellent aesthetic outcome, it is important to consider the limitations of this study. This study was a retrospective study and as such is subject to record-keeping biases. Our follow-up time is also limited. Further studies will be of use to assess the long-term impact of this reconstructive technique without acellular dermal matrix.

CONCLUSIONS

Our study found that in two-stage breast reconstructions performed with Wise-pattern closures, overall complication rates at both the first and second stages were similar when comparing reconstructions with and without acellular dermal matrix. No individual complication varied significantly between cohort groups, aside from minor infection following the first stage, which was more prevalent in the acellular dermal matrix cohort. Thus, we believe in patients desiring a reduction-reconstruction, the deepithelialized dermal flaps provide ample support for the prosthesis without need for acellular dermal matrix. Our non–acellular dermal matrix cohort also had more prepectoral reconstructions, so we find this reconstructive method is a viable option in both prepectoral and subpectoral reconstructions. Further studies will be of use to assess the long-term impact of this method of reconstruction.

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