The emergence of ADMs has altered the practice patterns of many surgeons in various surgical disciplines.2 As this technology continues to advance, an abundance of new applications will develop. Currently, ADMs are used in a large spectrum of surgical procedures, including abdominal wall surgery, chest wall reconstruction, head and neck reconstruction, burns, and injuries of the extremities.5,6,18,19 ADMs have gained in popularity for use in breast reconstruction procedures, and they are now common practice in implant-based surgery.20 The rationale behind their application is to improve positioning of the prosthesis, to provide coverage of compromised muscle and fascia (pectoralis or serratus), to reduce the incidence of capsular contracture, to create a more defined inframammary fold, and notably to enhance the aesthetic outcome resulting from improved lower pole expansion.1,21,22 Despite their widespread use, there is an ongoing debate about incorporating ADM in breast reconstructive surgery, which primarily is attributed to a possible increased risk of postoperative complications. In this study, the practice pattern of plastic surgeons with ADM use in breast reconstruction was investigated.
An amount of literature has been published about the use of ADM in breast reconstruction. However, data about the demographics and its application in breast reconstructive surgery in the general plastic surgery population are less clear. In our study, the majority of responding plastic surgeons performing breast reconstruction have incorporated ADM into their practice (84.2%) regardless of practice type. This support for ADM use was attributed by most surgeons to its published safety and efficacy in the surgical literature. Interestingly, 100% of respondents aged 31–40 years, or less than 5 years in practice, use ADM in breast reconstruction, which may suggest a practice pattern that newer graduates are learning and/or choose to use ADM in breast reconstruction at greater rates than surgeons who did not learn to use it during their training. This assertion is somewhat confirmed by the finding that 57.4% of respondents suspected that the rate of infection did not change with ADM. However, a careful review of recent evidence indicates that opinion is divided on whether or not the use of ADM is associated with a higher incidence of postoperative complications.13,20,23–27 A chart review of 41 patients (65 breasts) by Bindingnavele et al26 found extremely low complication rates with biologic mesh use in postmastectomy breast reconstruction: seroma in 3 patients, wound infection in 2 patients, and hematoma and expander removal in 1 patient each. This finding is corroborated in a study by Preminger et al28 who reported that AlloDerm did not increase the risk of postoperative complications. In contrast, Chun et al12 and Liu et al13 observed statistically significant increases in infection rate and seroma rate with AlloDerm use, respectively. Only 26.4% of our survey participants reported an increase in postoperative complications, the most common of which were seroma (70.9%), surgical site infection (16%), and wound dehiscence (9.4%). A systematic review by Ho et al10 showed higher likelihood of seroma and infection in prosthetic-based breast reconstructions using traditional musculofascial flaps, whereas Adetayo et al29 identified the most common complications as wound infection (16%), seroma formation (8%), and breast implant failure (6%).
No consensus exists on antibiotics use following breast reconstructive surgery. Despite indications that there is no benefit in patients who receive treatment for more than 24 hours,33 a majority of plastic surgeons (87.8%) routinely use antibiotics for 6–10 days (45%) in the postoperative period. Avashia et al34 demonstrated a significant decrease in the rate of infection when postoperative antibiotics were taken for at least 48 hours following implant-based breast reconstruction with ADM. In a series of 321 implant-based reconstructions of which AlloDerm was used in 75, Nguyen et al35 reported no variations in the readmission rates for intravenous antibiotics. However, development of infected fluid collections resulting in explantation was found to be significantly higher in the AlloDerm group compared with the control group. The use of drains was also prevalent in our surveyed population (94.6%) with just over half (57.5%) leaving drains in for a longer period of time when they used ADM. This finding is consistent with findings by Collis et al36 who reported drains to have remained in situ for a significantly longer duration when using ADM.
Few studies have implemented ADM to aid in reconstruction of the nipple-areola complex with the goal of improving nipple projection.37–39 The survey found that only 18.5% of respondents reported to have used ADM for nipple reconstruction. Although experience with ADM in nipple reconstruction is limited, results thus far may be promising.39 Garramone and Lam37 demonstrated that AlloDerm use in a modified dermal flap pattern for 30 nipple reconstructions was a safe, reproducible, and easily performed approach for enhancing nipple projection. In contrast, a review of ADM use in nipple reconstruction by Israeli20 suggests limited success due to loss of nipple projection over time.
The most frequently used ADM is AlloDerm (71.6%), which is not surprising given it is the most commonly reported mesh for use in breast reconstruction in the literature.1 Moreover, 72.8% of surgeons used ADM in both immediate and staged breast reconstruction procedures owing to its many reported benefits.1,21,40 One major deterrent against ADM use in breast procedures is cost, which can range from $3536 to $4856 per breast16; it was implicated as the main reason for not using ADM in practice at all by 37.5% of participants. Regardless, Salzberg40 found AlloDerm use in immediate reconstruction to be less costly than transverse rectus abdominis myocutaneous flap surgery and expander/implant reconstruction after mastectomy. Although ADM can be expensive, various reports have demonstrated that in the long-term, it is cost effective in breast reconstruction.1,17,40
There are limitations to our study. Despite the number of plastic surgeons who completed the survey, only 57 did not use ADM for breast reconstruction. This finding was perhaps due to the voluntary sampling of participants which was utilized and may have resulted in bias toward ADM use. A small sample size may reduce the chances of detecting a true effect by overestimating it. Also, it may decrease the likelihood that a statistically significant result reflects a true effect. Therefore, this may be an incomplete assessment of the actual prevalence of plastic surgeons who do not use ADM in practice. Patient satisfaction with the aesthetic result was solely based on surgeon opinion, which may have also contributed toward bias with ADM use. Another limitation may be interpretation of the term “breast reconstruction” used in our survey, which some surgeons may have found to mean reconstruction following mastectomy only rather than also its use in aesthetic cases. Furthermore, the term “revision” may be have been interpreted differently by the study participants with some considering it to be further surgical intervention in the operating room and others deeming it a simple outpatient “touch-up.” Nevertheless, a majority of our respondents claimed that patients rarely came back for a revision maintaining consistency of our result. Finally, recall bias of the surveyed plastic surgeons may be a factor; however, this issue could potentially be overcome by our sample size and subgroup analysis excluding patients who did not use ADM for breast reconstruction.
Plastic surgeons use ADM in breast reconstruction for both immediate and staged procedures. Younger generations of plastic surgeons seem more willing to include ADMs in their practice. A majority of responding plastic surgeons incorporate drains and use postoperative antibiotics for more than 48 hours. ADM use for nipple reconstruction is not yet widely accepted. The occurrence of seroma, surgical site infection, and wound dehiscence are the most commonly implicated complications when ADM is incorporated necessitating return to the operating room. Despite this, a good number of respondents believe that overall infection rate remains unchanged. In addition, the majority of participants who reported use of ADM in previously radiated patients found that it did not contribute to a difference in complication rate. Most responding plastic surgeons believe that based on existing evidence, ADM use is safe and effective in preventing complications and that the data against its use are weak. The main deterrent against ADM use is its cost. In future studies, a larger participant population is needed to eliminate potential bias regarding ADM use.
1. Ibrahim AM, Ayeni OA, Hughes KB, et al. Acellular dermal matrices in breast surgery: a comprehensive review. Ann Plast Surg. 2013;70:732–738
2. Janis JE, Nahabedian MY.. Acellular dermal matrices in surgery. Plast Reconstr Surg. 2012;130(5 Suppl 2):7S–8S
3. JoAnna Nguyen T, Carey JN, Wong AK.. Use of human acellular dermal matrix in implant-based breast reconstruction: evaluating the evidence. J Plast Reconstr Aesthet Surg. 2011;64:1553–1561
4. Chang HS, Lee D, Taban M, et al. “En-glove” lysis of lower eyelid retractors with AlloDerm and dermis-fat grafts in lower eyelid retraction surgery. Ophthal Plast Reconstr Surg. 2011;27:137–141
5. Iorio ML, Shuck J, Attinger CE.. Wound healing in the upper and lower extremities: a systematic review on the use of acellular dermal matrices. Plast Reconstr Surg. 2012;130(5 Suppl 2):232S–241S
6. Janis JE, O’Neill AC, Ahmad J, et al. Acellular dermal matrices in abdominal wall reconstruction: a systematic review of the current evidence. Plast Reconstr Surg. 2012;130:183S–193S
7. Sajjadian A, Naghshineh N, Rubinstein R.. Current status of grafts and implants in rhinoplasty: part II. Homologous grafts and allogenic implants. Plast Reconstr Surg. 2010;125:99e–109e
8. Haddock N, Levine J.. Breast reconstruction with implants, tissue expanders and AlloDerm: predicting volume and maximizing the skin envelope in skin sparing mastectomies. Breast J. 2010;16:14–19
9. Nahabedian MY.. Acellular dermal matrices in primary breast reconstruction: principles, concepts, and indications. Plast Reconstr Surg. 2012;130:44S–53S
10. Ho G, Nguyen TJ, Shahabi A, et al. A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction. Ann Plast Surg. 2012;68:346–356
11. McCarthy CM, Lee CN, Halvorson EG, et al. The use of acellular dermal matrices in two-stage expander/implant reconstruction: a multicenter, blinded, randomized controlled trial. Plast Reconstr Surg. 2012;130(5 Suppl 2):57S–66S
12. Chun YS, Verma K, Rosen H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg. 2010;125:429–436
13. Liu AS, Kao HK, Reish RG, et al. Postoperative complications in prosthesis-based breast reconstruction using acellular dermal matrix. Plast Reconstr Surg. 2011;127:1755–1762
14. Hvilsom GB, Hölmich LR, Steding-Jessen M, et al. Delayed breast implant reconstruction: is radiation therapy associated with capsular contracture or reoperations? Ann Plast Surg. 2012;68:246–252
15. Padubidri AN, Yetman R, Browne E, et al. Complications of postmastectomy breast reconstruction in smokers, ex-smokers, and nonsmokers. Plast Reconstr Surg. 2001;107:350–351
16. Hartzell TL, Taghinia AH, Chang J, et al. The use of human acellular dermal matrix for the correction of secondary deformities after breast augmentation: results and costs. Plast Reconstr Surg. 2010;126:1711–1720
17. Jansen LA, Macadam SA.. The use of AlloDerm in postmastectomy alloplastic breast reconstruction: part II. A cost analysis. Plast Reconstr Surg. 2011;127:2245–2254
18. Askari M, Cohen MJ, Grossman PH, et al. The use of acellular dermal matrix in release of burn contracture scars in the hand. Plast Reconstr Surg. 2011;127:1593–1599
19. Sodha NR, Azoury SC, Sciortino C, et al. The use of acellular dermal matrices in chest wall reconstruction. Plast Reconstr Surg. 2012;130(5 Suppl 2):175S–182S
20. Israeli R.. Complications of acellular dermal matrices in breast surgery. Plast Reconstr Surg. 2012;130(5 Suppl 2):159S–172S
21. Ayeni OA, Ibrahim AM, Lin SJ, et al. Acellular dermal matrices in breast surgery: tips and pearls. Clin Plast Surg. 2012;39:177–186
22. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012;129:28–41
23. Spear SL, Parikh PM, Reisin E, et al. Acellular dermis-assisted breast reconstruction. Aesthetic Plast Surg. 2008;32:418–425
24. Nahabedian MY.. AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation. Plast Reconstr Surg. 2009;124:1743–1753
25. Komorowska-Timek E, Oberg KC, Timek TA, et al. The effect of AlloDerm envelopes on periprosthetic capsule formation with and without radiation. Plast Reconstr Surg. 2009;123:807–816
26. Bindingnavele V, Gaon M, Ota KS, et al. Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction. J Plast Reconstr Aesthet Surg. 2007;60:1214–1218
27. Ibrahim AM, Shuster M, Koolen PG, et al. Analysis of the National Surgical Quality Improvement Program database in 19,100 patients undergoing implant-based breast reconstruction: complication rates with acellular dermal matrix. Plast Reconstr Surg. 2013;132:1057–1066
28. Preminger BA, McCarthy CM, Hu QY, et al. The influence of AlloDerm on expander dynamics and complications in the setting of immediate tissue expander/implant reconstruction: a matched-cohort study. Ann Plast Surg. 2008;60:510–513
29. Adetayo OA, Salcedo SE, Gupta SC.. The use of acellular dermal matrix in breast and abdominal wall surgery: a meta-analysis of outcomes and risk factors predictive of complications. Plast Reconstr Surg. 2011;127:9
30. Clemens MW, Kronowitz SJ.. Acellular dermal matrix in irradiated tissue expander/implant-based breast reconstruction: evidence-based review. Plast Reconstr Surg. 2012;130(5 Suppl 2):27S–34S
31. Colwell AS, Damjanovic B, Zahedi B, et al. Retrospective review of 331 consecutive immediate single-stage implant reconstructions with acellular dermal matrix: indications, complications, trends, and costs. Plast Reconstr Surg. 2011;128:1170–1178
32. Salzberg CA, Ashikari AY, Koch RM, et al. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg. 2011;127:514–524
33. Phillips BT, Bishawi M, Dagum AB, et al. A systematic review of antibiotic use and infection in breast reconstruction: what is the evidence? Plast Reconstr Surg. 2013;131:1–13
34. Avashia YJ, Mohan R, Berhane C, et al. Postoperative antibiotic prophylaxis for implant-based breast reconstruction with acellular dermal matrix. Plast Reconstr Surg. 2013;131:453–461
35. Nguyen MD, Chen C, Colakoğlu S, et al. Infectious complications leading to explantation in implant-based breast reconstruction with AlloDerm. Eplasty. 2010;10:e48
36. Collis GN, TerKonda SP, Waldorf JC, et al. Acellular dermal matrix slings in tissue expander breast reconstruction: are there substantial benefits? Ann Plast Surg. 2012;68:425–428
37. Garramone CE, Lam B.. Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection. Plast Reconstr Surg. 2007;119:1663–1668
38. Nahabedian MY.. Secondary nipple reconstruction using local flaps and AlloDerm. Plast Reconstr Surg. 2005;115:2056–2061
39. Chen WF, Barounis D, Kalimuthu R.. A novel cost-saving approach to the use of acellular dermal matrix (AlloDerm) in postmastectomy breast and nipple reconstructions. Plast Reconstr Surg. 2010;125:479–481
40. Salzberg CA.. Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm). Ann Plast Surg. 2006;57:1–5