Conservative mastectomies and immediate reconstruction with the use of ADMs

Abstract

Background: In recent years, a novel approach to immediate breast reconstruction has been introduced with the advent of acellular dermal matrix (ADM). In the setting of conservative mastectomies where the native skin envelope is preserved, placement of ADM at the lower pole in continuity with the pectoralis major muscle (PMM) provides additional support, allowing direct-to-implant breast reconstruction. The following manuscript presents the senior author's experience with ADM-assisted reconstruction and provides a detailed description of surgical technique along with a comprehensive discussion of patient selection and potential complications.

Methods: A retrospective chart review of patients undergoing direct-to-implant breast reconstruction following skin sparing or nipple sparing mastectomy with the use of ADM (AlloDerm; LifeCell Corp., Branchburg, USA) was conducted at Women's College Hospital in Toronto over a 5-year period [2008-2013]. Demographic data, previous radiation therapy and post-operative complications were recorded.

Results: A total of 72 patients representing 119 breasts were identified. Average follow-up was 16 months (range, 3-51 months). Twenty-seven complications were recorded for a complication rate of 22.7% (27/119). Complications included six cases of capsular contracture (Baker III/IV), five cases of red skin syndrome, four cases of rippling, three cases of dehiscence and two cases of seroma. Overall, direct-to-implant reconstruction was successfully completed in 97.5% of breasts (116/119). One case of infection was treated with explantation and conversion to autogenous reconstruction. Two breasts with tissue necrosis or dehiscence had the implants removed and replaced with tissue expanders. Overall reoperation rate was 9.7% (7/72 patients).

Conclusions: ADM assisted direct-to-implant breast reconstruction has been shown to be a safe option for women who are candidates for skin sparing or nipple sparing mastectomies. Judicious patient selection, effective collaboration between the oncologic and reconstructive surgeon, careful evaluation of post-mastectomy skin flaps and precise surgical technique are paramount to the success of this technique.

Keywords: Acellular dermis; breast reconstruction; conservative mastectomy; direct to implant; implant-based.

Figure 1

Incision options for nipple sparing mastectomy. NSM, nipple-sparing mastectomies; IMF, infra-mammary fold; LMF, lateral mammary fold.

Figure 2

(A) Following completion of the mastectomy, the pectoral muscle is released along the IMF and raised in continuity with the serratus fascia; (B) a perforated contour piece of ADM ready for insertion; (C) implant inserted and ADM secured to pectoral muscle followed by the IMF. ADM, acellular dermal matrix; IMF, infra-mammary fold.

Figure 3

(A-C) Preoperation photos of patient with BRCA1 for prophylactic NSM through periareola incision with lateral extension. Reconstructed with MF420 shaped implant and ADM; (D-F) results at 2 years. NSM, nipple-sparing mastectomies; ADM, acellular dermal matrix.

Figure 4

(A-C) Preoperation photos of patient for prophylactic skin reduction pattern mastectomy using an inverted T pattern. Direct to implant with round 500 cc implants and ADM; (D-F) results at 6 months prior to NAC reconstruction. ADM, acellular dermal matrix.

Figure 5

(A-C) Preoperation photos of patient with small left invasive cancer undergoing SSM and reconstruction with round 400 cc implant and ADM; (D-F) results at 4 months; (G-I) results at 15 months following NAC reconstruction. SSM, skin-sparing mastectomies; ADM, acellular dermal matrix.

Figure 6

(A-C) Preoperation photos of patient with BRCA1 for bilateral areola sparing mastectomy through IMF incision with additional circular excision around base of nipple. Reconstructed with shaped MF295 implants and ADM; (D-F) results at 6 months. Note the slight prominence at the site of the nipple which was closed with a purse string suture. IMF, infra-mammary fold; ADM, acellular dermal matrix.

Figure 7

Red breast syndrome 3 weeks following skin reduction mastectomy and reconstruction with tissue expanders and ADM. Note that the redness is primarily over the location of the ADM. ADM, acellular dermal matrix.