Prepectoral Breast Reconstruction Without the Use of Acellular Dermal Matrix: A 3-Year Review

Abstract

Introduction Acellular dermal matrix (ADM) is frequently used during prepectoral tissue expander–based breast reconstruction. However, there has been a paucity of literature describing the experience of prepectoral reconstruction without the accompanying use of ADM. We seek to highlight our institutional experience with immediate prepectoral tissue expander placement without the use of ADM in breast reconstruction. Methods A retrospective, single-institution review of patient records was performed to identify all patients who underwent either skin sparing or nipple-sparing mastectomy with immediate tissue expander placement without the use of ADM. Demographics including age, body mass index, comorbidities, history of smoking or steroid use, perioperative radiation or chemotherapy, intraoperative details, and complication profiles during the tissue expander stage were retrospectively collected and analyzed. At the time of tissue expander placement, all mastectomy flaps were evaluated clinically and with indocyanine green laser angiography. Postoperative outcomes were tracked. Results Between 2017 and 2020, 63 patients (for a total of 108 breasts) underwent either skin sparing (16%) or nipple-sparing mastectomy (84%) with immediate prepectoral tissue expander without ADM placement. Fourteen percent of breasts developed postoperative cellulitis, 19% of breasts developed skin compromise, and 5% required a postoperative revisional procedure that did not result in immediate expander explant. There was a 13% (n = 14 breasts) explant rate occurring at a mean time of 74 days. Of those breasts that developed skin compromise, 45% went on to require eventual explant. Patients in the study were followed for an average of 6.3 months. Conclusions Immediate prepectoral breast reconstruction using tissue expanders without ADM offers a viable alternative to established reconstructive paradigms. The major complication rate for prepectoral reconstruction without the use of ADM (17%) was found to be comparable with our historical subpectoral tissue expander reconstruction with ADM use. Tissue expander explant rates were also comparable between the prepectoral without ADM (13%) and the subpectoral with ADM cohorts. These preliminary data suggest that immediate breast reconstruction with tissue expander placement without accompanying ADM is viable alternative in the breast reconstructive algorithm.

Early Complications after Prepectoral Tissue Expander Placement in Breast Reconstruction with and without Acellular Dermal Matrix

“…However, enthusiasm for submuscular placement dampened following evidence of increased complications, more patient-reported postoperative pain, and animation deformity and has led to a shift toward the prepectoral approach. [18][19][20][21] Prepectoral tissue expander placement has been associated with shorter operative times, shorter recovery times, less narcotic consumption, and more predictable aesthetic outcomes and final volume estimation. 6,22,23 Advancements in surgical technique to oncologic resection have left patients with thicker, more robust mastectomy skin flaps, further supporting this shift.…”

The Utility of a Lateral Adipodermal Flap in Prepectoral Direct-to-implant Breast Reconstruction

“…Previous publications better address the issue of whether ADM is necessary in prepectoral reconstructions. [7][8][9][10] This approach may be of special relevance in less-developed countries where ADM cost may be prohibitive. The author presents this as a new, simple approach that may be of benefit in some patients with LBSE and is likely complementary to other strategies (ADM, fat grafting, cohesive implants, preserving of the oncoplastic plane) to improve aesthetic outcomes.…”

Reply: Catch-22: Acellular Dermal Matrix and U.S. Food and Drug Administration Premarket Approval – How Can We Construct Studies?

“…Specifically, the authors comment that ADM has “enabled prepectoral breast reconstruction,” implying that the procedure cannot feasibly be performed without ADM. Yet, several surgeons have reported reassuring results in patients without ADM. 4–8 We had previously performed a systematic review of the literature on all reported prepectoral patients undergoing reconstruction with and without ADM and identified no significant differences in complication rates. 9 In addition, several publications have identified possible safety concerns with the use of ADM in submuscular reconstruction.…”