Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost

Abstract

Background: Approximately 250,000 new cases of breast cancer are diagnosed yearly in the U.S. resulting in more postmastectomy breast reconstructions (PMBRs). The acellular dermal matrix (ADM) expander-implant method became popular in the mid-2000s, but newer techniques such as the inferior deepithelialized flap (IDF) has more recently been described. We hypothesize that ADMs and IDFs provide comparable aesthetic outcomes, with no difference in complication rates and operative characteristics.

Methods: A retrospective, single-institution study was performed between July 1, 2012, and June 30, 2014, examining all PMBR's (ADM and IDF). Outcomes were categorized as clinical (e.g., complications requiring surgical intervention) or aesthetic.

Results: A total of 65 patients (41 ADM; 24 IDF; mean age, 53.4 ± 10.7 years) were included, with 101 PMBR's evaluated (63 ADM and 38 IDF). Patients who underwent IDFs had higher body mass index (32 versus 25; P < 0.01) and higher grades of breast ptosis. Major complication rates were similar between ADM and IDF groups (22% versus 31.5%; P = 0.34). There were no differences in aesthetic outcomes between groups (rater intraclass correlation, 0.92). The average IDF breast reconstruction took nearly 30 minutes longer per reconstructed side (192 minutes versus 166 minutes; P = 0.02), but operative costs were more expensive for the ADM breast reconstruction.

Conclusions: The IDF procedure took 30 minutes longer for each reconstructed side, without significant differences in complications or aesthetic outcomes between the 2 PMBRs. IDF reconstructions may be more suitable for patients with grade 3 breast ptosis and higher body mass index. Further studies should focus on long-term outcomes and value-based approaches to PMBR.

Fig. 1.

Schematic drawing of an ADM procedure for a right BR. A, Represents the tissue expander exposed under the pectoralis major muscle, with the dermal sling created by the biological graft where the implant will sit. B, The tissue expander is covered by the pectoralis major and biological graft once they are sutured together.

Fig. 2.

IDF procedure for a right BR. A, Represents the area that inferio-lateral portion before the deepithelialization process. The mastectomy incision is indicated where the arrow is pointing. B, Demonstrates a completed deepithelialized flap. C, The inferio-lateral sling is mobilized and lateral attachments are removed keeping the inframammary fold intact. D, The IDF is created ready for the tissue expander. E, The tissue expander has been placed with the IDF and pectoralis major sutured together. F, Completed reconstruction. Photos courtesy of Dr. Michael Morrissey.

Fig. 3.

Grades of ptosis. A, Grade 1 breast ptosis. B, Grade 2 breast ptosis. C, Grade 3 breast ptosis. Photos courtesy of Dr. Michael Morrissey.

Fig. 4.

IDF reconstruction, 13-month follow-up. A, Breasts prior to IDF reconstruction. B, Breasts post reconstruction at 13-month follow-up. Photos courtesy of Dr. Michael Morrissey.

Fig. 5.

ADM reconstruction, 15-month follow-up. A, Breasts prior to ADM reconstruction. B, Breasts post reconstruction at 15-month follow-up. Photos courtesy of Dr. Michael Morrissey.