Prepectoral Two-Stage Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix: Do We See a Difference?

Abstract

Background: Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes. Methods: This is a single-surgeon retrospective review of patients who underwent staged prepectoral implant-based breast reconstruction following nipple-sparing mastectomy over two periods. Patients with well-perfused mastectomy skin flaps with a homogeneous thickness underwent reconstruction with acellular dermal matrix initially. On evolution of the practice, it was not used. Patient demographics, operative data, and complications were analyzed. Aesthetic outcome was measured by the BREAST-Q survey and the Aesthetic Item Scale. A cost analysis was also performed. Results: Forty patients were included (acellular dermal matrix group, n = 19; non–acellular dermal matrix group, n = 21). The nonmatrix group had one case (5 percent) of seroma and one case (5 percent) with hematoma; there were none in the acellular dermal matrix group. Average BREAST-Q and Aesthetic Item Scale scores were 82.3 versus 81.6 (p = 0.954) and 20.98 versus 20.43 (p = 0.640) for the matrix and nonmatrix groups, respectively. The direct cost savings for the authors’ institution over 1 year if matrix was not used in all cases of implant-based breast reconstruction would be estimated at $3,105,960 to $6,211,920 for unilateral and bilateral cases, respectively, for Medicare reimbursement. Conclusions: With adequate patient selection, acellular dermal matrix is not always required during two-stage prepectoral implant-based breast reconstruction for good aesthetic outcomes. The economic burden on patients and the health care system could be lessened with selective matrix use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Complication Rate of Prepectoral Implant-based Breast Reconstruction Using Human Acellular Dermal Matrices

“…Six of 18 studies had no conflicts of interest to declare. 28 , 30 , 33 , 35 , 36 , 38 However, no funding or financial support was received from any company for any of the included studies. The relative small sample size (<100 breasts) in 9 studies, the fact that many studies were set as retrospective analysis, and the lack of correction of the confounding factors limited the power of statistical analysis.…”

Long-Term Dynamic Changes in Cosmetic Outcomes and Patient Satisfaction after Implant-Based Postmastectomy Breast Reconstruction and Contralateral Mastopexy with or without an Ultrapro Mesh Sling Used for the Inner Bra Technique. A Retrospective Correlational Study

“…One of the most reported breast surgical topics is to analyze the optimal techniques of modern mastectomies and IPMBRs using pre- or subpectorally placed implants in combination with biological or synthetic meshes [ 7 , 8 ]. There is plenty of mid-level evidence that these techniques are able to provide safe oncological and high cosmetic outcomes [ 30 , 31 ]. One of the main advantages of modern breast reconstructive techniques is the ability to achieve immediate high-quality complete breast restoration in order to prevent the transitional period without a breast, to prevent the use of a partially filled tissue expander and to alleviate expander-to-implant changes that cause a second operation.…”

Immediate Prosthetic Breast Reconstruction after Nipple-Sparing Mastectomy: Traditional Subpectoral Technique versus Direct-to-Implant Prepectoral Reconstruction without Acellular Dermal Matrix

“…Traditionally, IPBR has been performed by placement of the prosthetic implant in a submuscular (SM) pocket created beneath the pectoralis major muscle, in order to protect the integrity of the implant and reduce its visibility and palpability [1,2]. Although this technique has shown increasingly good results, it still yields a higher risk of undesirable outcomes such as significant postoperative pain, injury-induced muscular deficit, breast animation deformity, lateral deviation of the breast mound with poor inframammary fold definition, and insufficient lower pole fullness [3,4].…”

“…In recent years, placement of the implant in a prepectoral (PP) plane has been increasingly employed. When this technique is performed, the implant is usually covered with an acellular dermal matrix (ADM) to shield it in the subcutaneous space underneath the skin flaps; however, the use of ADM has been reported to increase risks of seroma, infection, and skin/nipple-areola complex (NAC) necrosis, and associated with higher medical costs [1]. To limit these inconveniences, the use of implants with a special micropolyurethane-foamcoated shell surface (microthane) that does not require ADM coverage has recently been proposed [2,5].…”