Acellular dermal matrices and radiotherapy in breast reconstruction: a systematic review and meta-analysis of the literature

Abstract

The increasing use of commercially available acellular dermis matrices for postmastectomy breast reconstruction seems to have simplified the surgical procedure and enhanced the outcome. These materials, generally considered to be highly safe or with only minor contraindications due to the necessary manipulation in preparatory phases, allow an easier one-phase surgical procedure, in comparison with autologous flaps, offering a high patient satisfaction. Unfortunately, the claim for a higher rate of complications associated with irradiation at the implant site, especially when the radiation therapy was given before the reconstructive surgery, suggested a careful behaviour when this technique is preferred. However, this hypothesis was never submitted to a crucial test, and data supporting it are often discordant or incomplete. To provide a comprehensive analysis of the field, we searched and systematically reviewed papers published after year 2005 and registered clinical trials. On the basis of a meta-analysis of data, we conclude that the negative effect of the radiotherapy on the breast reconstruction seems to be evident even in the case of acellular dermis matrices aided surgery. However, more trials are needed to make solid conclusions and clarify the poor comprehension of all the factors negatively influencing outcome.

Figure 1

The strategy followed for the selection of the literature. All papers were carefully matched with the inclusion/exclusion criteria. Three search engines were used, for a total of 8 independent databases, as explained in the algorithm.

Figure 2

The use of different types of acellular dermis matrices in selected studies. Only the 60 papers included in the review were considered. The Alloderm (grey) was used in 65%, 20% used other acellular dermis matrices (fuchsia), 10% multiple ADM (pale blue), and 5% of authors did not specify the type of ADM they used (yellow).

Figure 3

Forest plot of 20 studies. The authors reported the complications occurring in ADM-assisted immediate implant breast reconstruction, with or without radiotherapy (RXT). Odds ratios and confidence intervals at 95% are plotted. The black diamond at the bottom is the pooled odds ratio and its CI 95%. It completely falls to the left of 1.0 (<1), meaning that RXT significantly increases the risk of complications.

Figure 4

Funnel plots of 20 studies. Complications in ADM-assisted immediate implant breast reconstruction with or without RXT, occurring with statistically significant difference. (B) Skin necrosis; (D) capsular contracture; (E) other complications, sparsely described; (F) failure.