Acellular Dermal Matrices: Algorithm to Prevent Overuse in Breast Reconstruction

            Much has been written about the benefits of the use of acellular dermal matrices (ADM) in prosthetic breast reconstruction.  There is universal agreement that ADM are safe to use, give excellent cosmetic results, and may help prevent or treat capsular contracture formation in cases of adjuvant radiation therapy ^{(1, 2)}.  The main drawback to the use of ADM is cost, and implant and materials costs are under ever increasing scrutiny in ASCs and hospital operating rooms. What follows is an algorithm to prevent the overuse of expensive ADM in prosthetic breast reconstruction.

            Most authors agree that ADM are indicated in the following breast reconstructive situations:

1.      Reconstruction of the inframammary fold (IMF)

2.      Maintenance of implant position

3.      Securing the inferior border of the pectoralis  muscle

4.      Extending the pectoralis in primary implant reconstruction

5.      Prevention of capsular contracture formation in cases of adjuvant radiation therapy

Cosmetic quality of the reconstructed breast definitely depends on the quality of

the mastectomy, and excellent results can be obtained without the use of expensive ADM (Fig. 1).

Figure 1. Two stage right breast reconstruction demonstrating excellent symmetry, implant position, and ptosis without use of ADM.

           

            From January 31, 2009 to January 31, 2011, 66 patients have undergone breast reconstructions (92 breasts) using the algorithm shown below.  ADM (8 x 16 cm) have been used in 25 patients (38%), and 16 of those required two pieces.  65 patients have been successfully reconstructed, though some are still in the tissue expander process. Complications include infection (5/5%), hematoma (1/1%), and extrusion (1/1%).  If ADM had been used in all of these cases, materials costs would be over $400,000.  Using ADM in only 38% resulted in a cost savings of approximately $227,000.

            Excellent cosmetic results can be obtained in breast reconstruction with or without ADM, though there are specific situations when ADM are beneficial.  Costs can be contained when anatomy following mastectomy are favorable, and ADM are not always necessary.

References:

 

1. Namnoum JD.  Expander/Implant Reconstruction with Alloderm: Recent Experience Plast Reconstr Surg.2009; 124:387-394.
2. Zienowicz RJ, Karacaoglu E. Implant-Based Breast reconstruction with Allograft Plast Reconstr Surg. 2007; 120:373-381.