Secondary Acellular Dermal Matrix Application to Integrated Primary Acellular Dermal Matrix in Implant-Based Breast Reconstruction

Abstract

 Acellular dermal matrices (ADMs) are commonly used in implant-based breast reconstruction to supplement the lack of pectoralis muscle.¹ The incidence of capsular contracture has decreased with the use of ADMs.² Cases with a lack of pectoralis muscle can be supplemented with ADM to release the tightness of the pectoralis muscle and ADM sling can improve tissue expander inflation during the postoperative period.³ At the time of completion of tissue expansion, the skin becomes very thin, especially in the lower pole of the breast in two-staged breast reconstruction. An indicating mark located in the lower pole of an implant, can be palpated and observed as a lump on the skin surface through the thin skin, especially in slim patients with low body mass index (BMI).

 Therefore, we tried to add an additional sheet of ADM to the lower pole of the breast to enhance the thickness of the skin flap during an implant exchange operation after the tissue expander was removed. We applied the secondary ADM sized from 16 x 4~5 cm, thickness; 2.0 mm, to the lower pole in 11 breasts of 9 patients. We evaluated the outcomes of cases undergone the secondary ADM application and the change of the skin flap thickness by ultrasonography.

 As a result, none of the cases had associated complications such as seroma, hematoma, infection, flap necrosis and reconstructive failure. Most patients had a low BMI, ranged from 18.9 to 24.9 (mean BMI; 20.9). The mean area of the primary ADM was 109±18 cm² and the area of the secondary ADM was 70±12 cm². The number of drain maintenance days after an implant exchange were 5.5±2.0 days. Ultrasonographic examination showed that the layer of subcutaneous fat tissue became thinner at the time the tissue expansion procedure was completed. At postoperative 4~6 months after the implant exchange, the thickened subcutaneous fat layer was found between the skin and the ADM layers in all patients, and the primary and secondary ADM sheets were well-incorporated between the subcutaneous tissue and the breast implant. The entire skin flap thickness was increased (mean amount of increase; 3.43± 0.67 mm). In general, the supplement with a secondary ADM and the proliferation of subcutaneous fat tissue contributed to an increase of skin flap thickness.

 The application of an additional ADM sheet to overlap the primary ADM sheet in implant-based breast reconstruction remains challenging but can be successful with meticulous intraoperative care and adequate postoperative management.

References

1. Jagsi R, Jiang J, Momoh AO, et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol 2014; 32:919-26.
2. 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
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