Combination of acellular dermal matrix with a de-epithelialised dermal flap during skin-reducing mastectomy and immediate breast reconstruction

Abstract

Introduction Patients with large ptotic breasts undergoing immediate implant-based reconstruction often require skin-reducing mastectomy to optimise the aesthetic outcome. However, healing complications, especially at the resulting inverted T-junction, leading to wound dehiscence, infection, skin necrosis, implant exposure and failed reconstruction have been widely reported. We present an innovative approach for immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling to protect and support the implant, while improving clinical outcomes in this challenging group of patients. Materials and methods Demographic, tumour and surgical data were reviewed for patients undergoing Wise pattern (T-scar) skin-reducing mastectomies with immediate implant-based reconstruction combining porcine- or bovine-derived acellular dermal matrices with a de-epithelialised dermal sling. Results This technique was successfully employed to reconstruct five large pendulous breasts in four breast cancer patients with a median age of 50.5 years (range 34-61 years) who were not suitable for, or had declined, flap-based reconstruction. The acellular dermal matrices used were SurgiMend®, Strattice and Braxon® and the expandable implants were placed in the sub-pectoral (n = 3) and pre-pectoral (n = 1) planes. The technical steps and clinical outcomes are presented. One patient experienced T-junction breakdown overlying the de-epithelialised dermis without implant loss. Conclusion The combination of an acellular dermal matrix and a dermal sling provides a double-layer 'water-proofing' and support for the implants inferiorly, avoiding T-junction breakdown complications, since any dehiscence is on to well-vascularised dermis. Furthermore, the acellular dermal matrix stabilises the implant in the large mastectomy cavity (pocket control). This approach provides a viable option which facilitates mastectomy and immediate implant reconstruction in large-breasted patients.

Wise Pattern Direct Implant Breast Reconstruction: A Review and Improved Outcomes Using Dermal Matrix

“…This compares very favorably with other reports in the literature for implant-based breast reconstructions. 31–37 Our results are similarly consistent with smoking and preoperative radiation as significant risk factors. 2,7,13,16,21,22,24 Besides the 2 flap failures, the only revisions were for additional fat grafting.…”

Novel Design of the Chimeric Deep Inferior Epigastric Artery Perforator Flap that Provides for Three‐Dimensional Reconstruction of Composite Tissue Defects of the Heel in Children

“…However, the radical debridement itself creates a dead space in the depth of the wound, which may cause spread of infection and resultant loss of larger tissues if not filled adequately. The muscular flap is considered a stronger anti‐infective, vascularized tissue than other flaps like the de‐epithelialized skin flap because it has robust blood supply 45,46–51 . With the aim of dissecting the DIEA towards the distal end and including as many muscular branches as possible, the rectus muscle mass in our chimeric DIEP flap served well as no infection was found in our case series.…”

Pre-Pectoral One-Stage Breast Reconstruction with Anterior Coverage Using Superior Anterior Biological Acellular Dermal Matrix (ADM) and Inferior Anterior Dermal Sling Support

“…A Wise pattern mastectomy with a de-epithelialized dermal sling and submuscular direct-to-implant reconstruction to optimize implant-based reconstruction in patients with large ptotic breasts has been described by several authors [ 9 , 18 ]. The combination of a skin-reducing mastectomy through a Wise pattern incision and ADM implant reconstruction has been recently investigated in patients with large ptotic breasts [ 9 ].…”

“…A pre-pectoral pocket with a dermal flap overlapped to ADM for lower- and upper-pole coverage of the breast implant has been described by Maruccia et al (the inferior dermal flap is sutured on the anterior surface of the ADM) [ 19 ]. The combination of an acellular dermal matrix and a dermal sling has been investigated by KanKam et al [ 18 ], providing a double-layer ‘water-proofing’ and support for the implants inferiorly in order to avoid the T-junction breakdown complication.…”