Preliminary Results Supporting the Bacterial Hypothesis in Red Breast Syndrome following Postmastectomy Acellular Dermal Matrix– and Implant-Based Reconstructions

Abstract

Summary: Acellular dermal matrices have become a mandatory tool in reconstructive breast surgery. Since their introduction, they have been considered to be nonreactive and nonimmunogenic scaffolds. However, some patients who undergo implant-based breast reconstruction with acellular dermal matrices develop postoperative cutaneous erythema overlying their matrices, a condition commonly referred to as red breast syndrome. The aim of this study was to gain a better understanding of this phenomenon. An analysis was conducted on consecutive patients who underwent acellular dermal matrix– and implant-based breast reconstructions and developed red breast syndrome that was treated surgically between April of 2017 and June of 2018 at the authors’ institution. During surgery, 1-cm2 specimens of acellular dermal matrix were sampled and analyzed by scanning electron microscopy. Observations were charted to score and record the presence and thickness of biofilm, and for identification of bacteria. These measurements were performed using Adobe Photoshop CS6 Extended software. Six postmastectomy breast reconstruction patients were included, all with AlloDerm Ready-to-Use–based reconstructions. All specimens were colonized by various bacteria ranging from Gram-negative bacilli to Gram-positive microorganisms. Biofilm was present in all studied specimens. The cause of skin erythema overlying acellular dermal matrix grafts, and the so-called red breast syndrome, may be related to contamination with various bacteria. Although contamination was omnipresent in analyzed samples, its clinical significance is variable. Even if acellular dermal matrix–based reconstructions are salvaged, this could come at the price of chronic local inflammation.

DermACELL Acellular Dermal Matrix in Oncologic Breast Reconstruction: A Cohort Study and Systematic Review

“…These findings support the direction of other studies which have reported significant differences in the total number of days to drain removal in favor of DermACELL. 24,[33][34][35][36] This trend may be explained by subtle differences in the fenestrations of the natural material, which could allow fluid from the ADM to escape and facilitate more efficient drainage. 37 This could also be due to DermACELL's advantage in promoting host tissue integration and revascularization.…”

“Oncologic Safety of Staged Pre-Pectoral Implant Reconstruction Following Nipple-Sparing Mastectomy: a Mean 9-Year Follow-Up.”

“…29 Bacterial contamination has also been implicated in an inflammatory condition, the red breast syndrome, in 4 to 14 percent of patients undergoing acellular dermal matrix implant reconstruction, as evidenced by the presence of bacteria in cultures and electron microscopy from biofilm specimens surrounding the implant. 30 In addition, bacteria have been present in the biofilm of asymptomatic patients with acellular dermal matrix reconstruction. 31 Other experimental bioassay studies have shown a significant increase in Staphylococcus aureus adherence to acellular dermal matrix compared to nonbiological synthetic compounds such as prolene.…”

Understanding the Evidence and Improving Outcomes with Implant-Based Prepectoral Breast Reconstruction

“…Six series describing early outcomes after prepectoral breast reconstruction also include outcomes to describe patient function and/or postoperative pain during recovery with favorable results when compared to partially submuscular patient cohorts. 20,21,35,[43][44][45][46][47][48][49][50][51] The studies were similarly powered, with 24 to 39 patients per study undergoing prepectoral breast reconstruction. Five of the six patient series reported significantly lower patient-reported pain scores in the prepectoral groups than partially submuscular comparison cohorts.…”

“…Currently, there are no studies describing red breast syndrome in prepectoral breast reconstruction, potentially because of its now lower incidence in acellular dermal matrix-assisted breast reconstruction as a whole (1.7 to 14 percent) with improved technique and technology. 44…”