Subcutaneously Placed Breast Implants after a Skin-Sparing Mastectomy: Do We Always Need ADM?

Abstract

Background:Immediate breast reconstruction is an acceptable treatment option after mastectomy for prophylaxis of early breast cancer. Different options exist for implant placement, incision technique, patient suitability, and institutional experience. This article is a case series exploring the feasibility and outcomes of patients undergoing immediate breast reconstruction using skin-sparing mastectomy without mesh or acellular dermal matrix (ADM) and with a vertical inframammary incision.Methods:A single-institution retrospective analysis was performed for all patients who underwent immediate single-stage reconstruction with subcutaneous silicon implants without ADM between 2009 and 2014 inclusive. Patient, operative and treatment variables were extracted. All patients with viable mastectomy skin flaps intraoperatively and at least 5 mm of subcutaneous tissue were eligible except for patients who were deemed too slim by the senior surgeon preoperatively and thus at risk of implant visibility or skin rippling.Results:There were 26 patients (bilateral n = 12 and unilateral n = 14) eligible for analysis, with a median long-term follow-up of 51.5 months. The majority of complications were classified as minor affecting 46.2% of the cohort (n = 12). There were 20 episodes of complications overall. The most frequent episodes were contour defects (x = 5), minor seroma (x = 4), and malrotation and minor infection (x = 3). There was 1 episode of capsular contracture.Conclusion:Skin-sparing mastectomy with immediate subcutaneous silicon implant reconstruction with a vertical incision and without the need for mesh or ADM is an acceptable and safe treatment option. Accurate patient selection and skin flap viability is the key to achieving optimal outcomes with this approach.

The largest multicentre data collection on prepectoral breast reconstruction: The iBAG study

“…The study by Salibian et al 29 proposed a staged subcutaneous reconstruction without any expander cover, but it revealed 7.6% of capsular contracture (Baker III and IV) in a series of 155 patients (250 breasts) reconstructed with a “naked” prepectoral expander. The same doubt about the need of ADM to cover the implant in PPBR was the basis of the retrospective study by Singla et al 30 from the analysis of the immediate single‐stage subcutaneous reconstructions carried out without any coverage of the silicone implant raised the following complications rate: 15.3% of seroma, 15.3% of infections, 11.5% of implant rotation, 3.8% of capsular contracture and 19.2% of implant visibility and contour defects; far from the results of iBAG data collection. These results lead us to consider the complete ADM cover a crucial point in PPBR to reduce the risk of periprosthetic fibrosis.…”

Do We Need Support in Prepectoral Breast Reconstruction? Comparing Outcomes with and without ADM

“…Sigla et al reported a similar contracture rate of 3.8%, albeit with textured implants. 20 Other long-term studies with smooth, round implants in the prepectoral plane have demonstrated a 7.6% rate of Grade III/IV contracture, suggesting a time-dependent component, 19 though dual-plane ADM studies have shown static contracture rates after two years. 42 Larger and longer-term comparative studies are needed to further evaluate this outcome, particularly in the setting of more recent stringent contamination prevention measures and smooth tissue expanders.…”

“…There is no “one approach for all.” Hidalgo et al recently published a more selective and successful algorithm for using ADM in the treatment of capsular contracture. 29 Similarly, more selective use of ADM may be possible in two-stage tissue expander breast reconstruction, as evidence has shown the possibility of successful prepectoral breast reconstruction with low complication rates without ADM. 19 , 20 …”

Outcomes and quality of life in immediate one‐stage versus two‐stage breast reconstructions without an acellular dermal matrix: 17‐ years of experience

“…Although both studies demonstrated good results (with implant loss < 0.53%), both studies had either heterogenous reconstructive techniques or lacked relevant postoperative data and had a short follow‐up. Fully pre‐pectoral non‐ADM one‐stage reconstructions have also been of interest and recently evaluated by Singla et al, 35 who supported the approach in carefully selected patients. However, the authors reported a 19.2% contour deformity requiring later fat grafting.…”