Impact of Chemotherapy and Radiation Therapy on Inflammatory Response, Neovascularization, and Capsule Formation of Acellular Dermal Matrix in Breast Reconstruction: Analysis of the BREASTrial Biopsy Specimens

 

by Mendenhall, Shaun D.; Graham, Emily M.; Anderson, Layla A.; Ying, Jian; Liu, Ting; Agarwal, Jayant P. 

 

Plastic and Reconstructive Surgery: March 2022 - Volume 149 - Issue 3 - p 378e-385e

 

Background: 

The Breast Reconstruction Evaluation of Acellular Dermal Matrix as a Sling Trial is a single-center, blinded, prospective, randomized, controlled trial established to compare outcomes using two popular types of acellular dermal matrices, AlloDerm and DermaMatrix, in tissue expander breast reconstruction. This study used the acellular dermal matrix biopsy specimens from the trial to evaluate how adjuvant therapy influences inflammation, neovascularization, and capsule formation of the acellular dermal matrix.

Methods: 

Punch biopsy specimens were taken at the time of expander exchange and were analyzed by a blinded pathologist. The inflammatory response was quantified by the number of fibroblasts, giant cells, and lymphocytes. Neovascularization and capsule formation were similarly quantified by the number of new capillaries and capsule presence and thickness, respectively.

Results: 

Histology specimens were collected from 109 patients (170 breasts). In the absence of adjuvant therapy, there was no significant difference between AlloDerm and DermaMatrix in terms of inflammation, neovascularization, or capsule thickness. Both acellular dermal matrices showed a significant decrease in inflammation and neovascularization with adjuvant therapy. When chemotherapy and radiation therapy were used, the decrease in inflammation was greatest for the group reconstructed with DermaMatrix (p < 0.039).

Conclusions: 

Adjuvant therapy influences the inflammatory response, neovascularization, and capsule formation in both acellular dermal matrices. Adjuvant therapy has a protective effect on the inflammatory response toward both acellular dermal matrices in breast reconstruction. In the setting of chemotherapy and radiation therapy, DermaMatrix produced the greatest reduction in inflammation.

From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction

 

by Powers, Jeremy M.; Reuter Muñoz, Katherine D.; Parkerson, Jamie; Nigro, Lauren C.; Blanchet, Nadia P.

 

Plastic and Reconstructive Surgery: December 2021 - Volume 148 - Issue 6 - p 1201-1208

 

Background: 

Increasing amounts of acellular dermal matrix are being used with the adoption of prepectoral breast reconstruction. Postoperative infection remains a challenge in breast reconstruction, and the contribution of acellular dermal matrix type, processing, and sterility assurance level to risk of complications in prepectoral reconstruction is not well studied.

Methods: 

The authors performed a retrospective review of patients who underwent immediate prepectoral breast reconstruction from February of 2017 to July of 2020. Because of an increase in the rate of infection, the drain protocol was changed and acellular dermal matrix type was switched from AlloDerm (sterility assurance level, 10−3) to DermACELL (sterility assurance level, 10−6) in January of 2019. Demographic and surgical variables were collected, in addition to details regarding development and management of infection.

Results: 

Despite higher rates of direct-to-implant reconstruction and bilateral procedures and increased implant volumes, the rate of infection was significantly lower in patients who received DermACELL instead of AlloDerm [two of 38 (5.3 percent) versus 11 of 41 (26.8 percent); p = 0.014]. Drain duration was slightly longer in the DermACELL group, consistent with the change in drain protocol. Baseline demographic and clinical characteristics remained similar between the two groups.

Conclusions: 

With increased reliance on large amounts of acellular dermal matrix for prepectoral breast reconstruction, it directly follows that the properties of acellular dermal matrix with respect to incorporation, sterility, and implant support are that much more important to consider. There have been few studies comparing different types of acellular dermal matrix in prepectoral breast reconstruction, and further research is required to determine the contribution of acellular dermal matrix type and processing techniques to development of postoperative infection.

 

 

 

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

 

by Patel, Ashraf A.; Kayaleh, Hana; Sala, Luke A.; Peterson, Dylan J.; Upadhyaya, Prashant K

Plastic and Reconstructive Surgery: September 2021 - Volume 148 - Issue 3 - p 511-521

Background: Aesthetic results in breast reconstruction for ptotic/obese breasts may be improved when using Wise-pattern closures compared with nipple-sparing mastectomies. In two-stage reconstruction, acellular dermal matrix is commonly used to support the prosthesis. This study tests the efficacy of an alternate technique that uses deepithelialized excess breast skin in lieu of acellular dermal matrix. To better understand whether acellular dermal matrix is necessary, the authors compared postoperative outcomes from reduction-reconstructions that used matrix to those that did not.

Methods: The authors retrospectively reviewed the outcomes of patients who underwent staged breast reconstruction following Wise-pattern closures between September of 2016 and October of 2019. Two cohorts were created based on whether acellular dermal matrix was used. Charts were reviewed for incidence of postoperative complications.

Results: A total of 164 breasts were reconstructed in 85 female patients. The acellular dermal matrix cohort consisted of 68 breasts, whereas the non–acellular dermal matrix cohort included 96 breasts. After the first stage, the incidence of one or more complications was similar between cohorts (acellular dermal matrix, 32.4 percent; nonmatrix, 35.4 percent; p = 0.684). Minor infection rates were significantly higher in reconstructions using acellular dermal matrix (16.2 percent versus 6.3 percent; p = 0.040). After the second stage, the complication incidence was also similar between cohorts (acellular dermal matrix, 16.2 percent; nonmatrix, 13.5 percent; p = 0.638). Final follow-up time was 445.2 days.

Conclusions: Overall complication rates following both stages of reconstruction were similar with and without acellular dermal matrix. When acellular dermal matrix was used, minor infection rates were higher following expander placement. In patients desiring a reduction-reconstruction, the authors find the deepithelialized dermal flap provides ample prosthesis support, without the need for acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Comparison of Strattice and SurgiMend in Acellular Dermal Matrix–Assisted, Implant-Based Immediate Breast Reconstruction

The Comparison of Strattice and SurgiMend in Acellular Dermal Matrix–Assisted, Implant-Based Immediate Breast Reconstruction
Mazari, F et alPlastic and Reconstructive Surgery: February 2018 - Volume 141 - Issue 2 - p 283–293Background: Strattice (porcine derivative) and SurgiMend (bovine derivative) are the two most common acellular dermal matrices used in breast reconstruction in the United Kingdom. This retrospective study compared clinical outcomes in immediate implant-based breast reconstruction patients. 
Methods: The study, conducted across three hospitals, included all patients who underwent immediate implant-based breast reconstruction using Strattice and SurgiMend. The primary outcome measure was implant loss rate. Secondary outcome measures included acellular dermal matrix loss rate, seroma formation, and minor and major complication rates. Intergroup comparison was performed. 
Results: Eighty-two patients (Strattice, n = 45; SurgiMend, n = 37) underwent 97 immediate implant-based breast reconstructions (Strattice, n = 54; SurgiMend, n = 43). There were no differences between groups for age, comorbidities, specimen weight, or implant volume. Drains were used in all Strattice and 36 (84 percent) SurgiMend cases. The implant loss rate was higher for Strattice (n = 10, 20 percent) compared with SurgiMend (n = 3, 7 percent) but failed to reach statistical significance (chi-square test, p = 0.077). The acellular dermal matrix loss rate was significantly higher (Fisher’s exact test, p = 0.014) in the Strattice group (n = 7, 14 percent), with no acellular dermal matrix loss with SurgiMend. The reoperation rate was also significantly higher (chi-square test, p = 0.002) in the Strattice group (n = 17, 33 percent, versus n = 3, 7 percent). The incidence of red breast was significantly higher (chi-square test, p = 0.022) in the SurgiMend group (n = 9, 21 percent, versus n = 3, 6 percent). Seroma, wound problems, and infection rates were similar. 
Conclusions: Clinical outcomes, including implant loss, acellular dermal matrix loss, and reoperation rates, are significantly better when using SurgiMend in immediate implant-based breast reconstruction compared with Strattice. An appropriately powered randomized trial is needed to provide further information. 

Bovine Acellular Dermal Matrix in Immediate Breast Reconstruction: A Retrospective, Observational Study with SurgiMend

Bovine Acellular Dermal Matrix in Immediate Breast Reconstruction: A Retrospective, Observational Study with SurgiMend

Scheflan, M et al
Plastic and Reconstructive Surgery: January 2018 - Volume 141 - Issue 1 - p 1e–10e

Background: Acellular dermal matrices can be combined with implant-based breast reconstruction to help optimize outcomes. SurgiMend PRS is a fetal bovine dermis–derived acellular dermal matrix composed of type I collagen and approximately 30 percent type III collagen, sharing many of the properties of human cadaveric acellular dermal matrix. 
Methods: This was a retrospective, single-center analysis of 111 adult patients (147 breasts) undergoing one-stage (83.7 percent) or two-stage (16.3 percent) immediate breast reconstruction after mastectomy. The aims were to characterize the safety profile of SurgiMend and investigate associations between risk factors and complications.
Results: The mean age of the patients was 47.9 years and the mean body mass index was 24.7 kg/m2. After a median follow-up of 24.3 months, the overall rates of minor and major complications were 25.2 percent (n = 37 of 147) and 12.9 percent (n = 19 of 147), respectively. The most common major complications were seroma [n = 12 (8.2 percent)] and necrosis [n = 9 (6.1 percent)]. All occurred within 3 months after surgery. The rate of capsular contracture was 2.7 percent (n = 4). A total of 2.7 percent of implanted breasts (n = 4) required explantation. In a univariate analysis, smokers had a greater risk of major complications (p = 0.013), and postoperative radiation therapy and obesity were associated with an increased risk of capsular contracture (p = 0.006) and explantation (p = 0.006), respectively. In a multivariate analysis, several factors were associated with complications or explantation, including obesity (p < 0.05), preoperative chemotherapy (p < 0.001), and mastectomy weight (p < 0.05). These associations align with other studies of implant-based reconstruction and do not appear to be specific to this acellular dermal matrix. 
Conclusion: The results are consistent with previous analyses of SurgiMend, and support its value in implant-based breast reconstruction. 

Acellular Dermal Matrix in Immediate Expander/Implant Breast Reconstruction: A Multicenter Assessment of Risks and Benefits

Acellular Dermal Matrix in Immediate Expander/Implant Breast Reconstruction: A Multicenter Assessment of Risks and Benefits

Sorkin M et al

Plastic and Reconstructive Surgery: December 2017 - Volume 140 - Issue 6 - p 1091–1100

Background: Acellular dermal matrix has gained widespread acceptance in immediate expander/implant reconstruction because of perceived benefits, including improved expansion dynamics and superior aesthetic results. Although previous investigators have evaluated its risks, few studies have assessed the impact of acellular dermal matrix on other outcomes, including patient-reported measures. Methods: The Mastectomy Reconstruction Outcomes Consortium Study used a prospective cohort design to evaluate patients undergoing postmastectomy reconstruction from 10 centers and 58 participating surgeons between 2012 and 2015. The analysis focused on women undergoing immediate tissue expander reconstruction following mastectomies for cancer treatment or prophylaxis. Medical records and patient-reported outcome data, using the BREAST-Q and Numeric Pain Rating Scale instruments, were reviewed. Bivariate analyses and mixed-effects regression models were applied. Results: A total of 1297 patients were evaluated, including 655 (50.5 percent) with acellular dermal matrix and 642 (49.5 percent) without acellular dermal matrix. Controlling for demographic and clinical covariates, no significant differences were seen between acellular dermal matrix and non–acellular dermal matrix cohorts in overall complications (OR, 1.21; p = 0.263), major complications (OR, 1.43; p = 0.052), wound infections (OR, 1.49; p = 0.118), or reconstructive failures (OR, 1.55; p = 0.089) at 2 years after reconstruction. There were also no significant differences between the cohorts in the time to expander/implant exchange (p = 0.78). No significant differences were observed in patient-reported outcome scores, including satisfaction with breasts, psychosocial well-being, sexual well-being, physical well-being, and postoperative pain. Conclusions: In this multicenter, prospective analysis, the authors found no significant acellular dermal matrix effects on complications, time to exchange, or patient-reported outcome in immediate expander/implant breast reconstruction. Further studies are needed to develop criteria for more selective use of acellular dermal matrix in these patients.

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

What’s New in Acellular Dermal Matrix and Soft-Tissue Support for Prosthetic Breast Reconstruction

Kim, J et al
Plastic and Reconstructive Surgery: November 2017 - Volume 140 - Issue 5S - p 30S–43S

Of the nearly 90,000 implant-based breast reconstructions performed in the United States, the majority use internal soft-tissue support. Aesthetically, these constructs may allow for better positioning of prosthesis, improve lower pole expansion, and increase projection. They may have particular utility in direct-to-implant, nipple-sparing mastectomies, and prepectoral reconstructions. In recent years, new permutations of acellular dermal matrices have evolved with diverse shapes, sizes, form-factor innovations, and processing characteristics. The literature is largely limited to retrospective studies (and meta-analyses thereof), making robust comparisons of 1 iteration vis-à-vis another difficult. Although synthetic mesh may provide a cost-effective alternative in primary and secondary reconstruction, comparative studies with acellular dermal matrix are lacking. This review aims to provide a balanced overview of recent biologic and synthetic mesh innovation. As this technology (and concomitant techniques) evolve, the reconstructive surgeon is afforded more—and better—choices to improve care for patients.

Comparison of Different Acellular Dermal Matrices in Breast Reconstruction: The 50/50 Study

Comparison of Different Acellular Dermal Matrices in Breast Reconstruction: The 50/50 Study
Pittman, T et al
Plastic & Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 521–528

Background: Acellular dermal matrix has enjoyed extensive use in primary and secondary alloplastic breast aesthetic and reconstructive surgery. The objective of this study was to examine clinical outcomes between available acellular dermal matrix products: DermACELL (LifeNet Health, Virginia Beach, Va.) and AlloDerm Ready To Use (LifeCell Corp., Branchburg, N.J.). 
Methods: A retrospective chart review was performed on 58 consecutive patients (100 breasts) reconstructed with either DermACELL (n = 30 patients; 50 breasts) or AlloDerm Ready To Use (n = 28 patients; 50 breasts). The mastectomies were performed by three different breast surgeons. All reconstructions were performed by the same plastic surgeon (T.A.P.). Statistical analysis was performed by means of Fisher’s exact test. 
Results: Differences in the average age, body mass index, percentage having neoadjuvant/adjuvant chemotherapy or breast irradiation, and numbers of therapeutic and prophylactic mastectomies between the two groups were not statistically significant (p < 0.05). Complications in both cohorts of patients were clinically recorded for 90 days after immediate reconstruction. When comparing outcomes, patients in the DermACELL group had a significantly lower incidence of “red breast syndrome” (0 percent versus 26 percent; p = 0.0001) and fewer days before drain removal (15.8 days versus 20.6 days; p = 0.017). No significant differences were seen in terms of seroma, hematoma, delayed healing, infection, flap necrosis, or explantation. 
Conclusion: Patients reconstructed with DermACELL as compared with AlloDerm Ready To Use have significantly decreased number of days to drain removal and red breast syndrome and equivalent rates of other complications, including seroma, infection, flap necrosis, and explantation. 

Acellular Dermal Matrix–Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience

Acellular Dermal Matrix–Assisted Direct-to-Implant Breast Reconstruction and Capsular Contracture: A 13-Year Experience
Plastic and Reconstructive Surgery
Salzburg C et al

Background: Use of acellular dermal matrix for implant-based breast reconstruction appears to be associated with a lower incidence of capsular contracture compared with standard reconstruction. The majority of acellular dermal matrix studies were, however, of short duration; thus, long-term incidence of capsular contracture with acellular dermal matrix use is unknown. Methods: Patients undergoing acellular dermal matrix–assisted breast reconstruction from December of 2001 to May of 2014 at two institutions were evaluated. Cumulative incidence of capsular contracture was determined by the performing surgeon. A retrospective chart review was performed on prospectively gathered data on patient-, breast-, surgery-, and implant-related characteristics that were analyzed as potential risk factors for the development of capsular contracture. Results: A total of 1584 breast reconstructions in 863 patients were performed.....................

Discussion: Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal?

Discussion:  Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices CreatedEqual?



Plastic & Reconstructive Surgery: October 2015 - Volume 136 - Issue 4 - p 654–656


A discussion article about the use of acellular dermal matrix.

Use of Acellular Dermal Matrix in Postmastectomy Breast Reconstruction: Are All Acellular Dermal Matrices Created Equal?

Plastic and Reconstructive Surgery October 2015 - Volume 136 - Issue 4 - p 647–653

Ranganathan, Kavitha et al

AlloDerm and FlexHD are two types of acellular dermal matrices commonly used in implant-based reconstruction. Although the use of acellular dermal matrix has revolutionized immediate breast reconstruction in the setting of breast cancer, it remains unclear which type of acellular dermal matrix is best. The purpose of this retrospective cohort study was to compare postoperative complication rates between these two types of acellular dermal matrix. The authors reviewed the records of all patients who underwent implant-based breast reconstruction at their institution between 1998 and 2013. Dependent variables of seroma, hematoma, infection, delayed wound healing, implant exposure, and return to the operating room for management of complications were recorded.

The breast reconstruction evaluation of acellular dermal matrix as a Sling Trial

The breast reconstruction evaluation of acellular dermal matrix as a Sling Trial: Design and methods of a prospective randomized trial. Plastic and Reconstructive Surgery, Jan 2015, Vol. 135(1), p.20e-28e.

Agarwal, J.P., et al.

http://journals.lww.com/plasreconsurg/Abstract/2015/01000/The_Breast_Reconstruction_Evaluation_of_Acellular.8.aspx

Recent literature has focused on the advantages and disadvantages of using acellular dermal matrix in breast reconstruction. Many of the reported data are from low level-of-evidence studies, leaving many questions incompletely answered. The present randomized trial provides high-level data on the incidence and severity of complications in acellular dermal matrix breast reconstruction between two commonly used types of acellular dermal matrix.

An algorithmic approach for selective acellular dermal matrix use in immediate two-stage breast reconstruction

An algorithmic approach for selective acellular dermal matrix use in immediate two-stage breast reconstruction: Indications and outcomes. Plastic and Reconstructive Surgery Aug 2014, Vol. 134(2), p.178-88.

Jordan, S.W., et al.

http://journals.lww.com/plasreconsurg/Fulltext/2014/08000/An_Algorithmic_Approach_for_Selective_Acellular.4.aspx

Acellular dermal matrix use has gained widespread acceptance—despite higher material costs—because of its ease of use and potential for enhanced cosmesis. The authors developed a resource-sensitive algorithm for selective acellular dermal matrix use with indications and contraindications based on body mass index, breast size, radiation therapy, flap vascularity, and pectoralis anatomy. Methods: The algorithm incorporates preoperative and intraoperative decision points. Complication rates and aesthetic scores were compared for procedures performed before and after adoption of the algorithm. Multiple logistic regression was used to determine the independent influence of the algorithm on postoperative outcomes.

Plastic and Reconstructive Surgery Vol 127 Iss 3 March 2011

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Acellular Dermal Matrix for the Treatment and Prevention of Implant-Associated Breast Deformities.
pg. 1047-1058
Spear, Scott L. M.D et al.

A Reliable Method for the Preoperative Estimation of Tissue to Be Removed during Reduction Mammaplasty.
pg. 1059-1064
Kocak, Ergun M.D et al.

Effect of Intraoperative Saline Fill Volume on Perioperative Outcomes in Tissue Expander Breast Reconstruction.
pg. 1065-1072
Crosby, Melissa A. M.D et al.

Preventing Venous Congestion of the Nipple-Areola Complex: An Anatomical Guide to Preserving Essential Venous Drainage Networks.
pg. 1073-1079
le Roux, Cara Michelle B.Biomed.Sc., B.Sc.(Hons.) et al.

Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Decreases Flap Loss and Improves Rate of Flap Salvage.
pg. 1080-1085
Lin, Samuel J. M.D et al.

Morbidity of Microsurgical Breast Reconstruction in Patients with Comorbid Conditions.
pg. 1086-1092
Seidenstuecker, Katrin M.D et al.

Stacked Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Review of 110 Flaps in 55 Cases over 3 Years.
pg. 1093-1099
DellaCroce, Frank J. M.D et al.

Optimal Timing of Delayed Free Lower Abdominal Flap Breast Reconstruction after Postmastectomy Radiation Therapy.
pg. 1100-1106
Baumann, Donald P. M.D et al.

Contouring the Inferior Pole of the Breast in Vertical Mammaplasty: Suction-Assisted Lipectomy versus Direct Defatting.
pg. 1314-1322
Akyurek, Mustafa M.D., Ph.D.

Sentinel Lymph Node Detection in a Patient with Subungual Melanoma after Transaxillary Breast Augmentation.
pg. 65e-66e
Graf, Ruth Maria M.D., Ph.D et al.