A Sustainable Approach to Prepectoral Breast Reconstruction Using Meshed Acellular Dermal Matrix

Abstract

Background: Prepectoral implant-based breast reconstruction provides an alternative to submuscular reconstruction, but the increased acellular dermal matrix (ADM) required has the potential to lead to increased costs and decreased supply of this limited-resource material. We present a method for prepectoral reconstruction utilizing skin-graft meshing techniques to increase the surface area of usable ADM.

Methods: Forty-four patients underwent this technique from February 2019 to February 2020. Patient characteristics, operative details, and outcomes, including complications and patient satisfaction utilizing the BREAST-Q, were analyzed. Cost analysis relative to projected cost of nonmeshed techniques was performed.

Results: There were 20 unilateral and 24 bilateral procedures, for a total of 68 breast reconstructions. Mean age was 45.9 years (32-71). Mean implant volume was 485 cm³ (265-800), and one sheet of ADM was used for each breast with an average surface area of 161 cm². Median follow-up was 350 days (212-576). Minor complications included an infection treated with oral antibiotics. Major complications included one axillary hematoma and one delayed implant loss. One patient underwent revision for asymmetry. Mean BREAST-Q score was 47.4/60. Cost ranged from $4113 to 5025 per breast, compared with the projected $9125-18250 per breast for other techniques in the literature.

Conclusions: In contrast to previously described uses of ADM in prepectoral reconstruction, meshing maximizes resource utilization by expanding the coverage of a single sheet. Early findings demonstrate minimal complications and high patient satisfaction, suggesting the approach has potential to provide the benefits of prepectoral reconstruction while responsibly preserving product availability and tempering healthcare costs.

Fig. 1.

Perfusion assessed with indocyanine green angiography.

Fig. 2.

Implant and allograft construct on back table demonstrates (A) meshed ADM anteriorly and (B) polyglactin knitted mesh posteriorly.

Fig. 3.

Tacking sutures to approximate mesh to the lateral border of the pectoralis muscle.

Fig. 4.

A 44-year-old woman with left breast infiltrating ductal carcinoma. The patient underwent infra-areolar incision for bilateral nipple-sparing mastectomy with placement of 520 cm³ implants. Results are shown at 12 months postoperatively. A, C, and E are postperative photographs. B, D, and F, 12 months postoperative results.

Fig. 5.

A 40-year-old woman with right breast infiltrating ductal carcinoma. The patient underwent inframammary incision for bilateral nipple-sparing mastectomy with placement of 295 cm³ implants. Results are shown preoperatively (A, C, E) and 12 months postoperatively (B, D, F).

Fig. 6.

A 44-year-old woman with infiltrating ductal carcinoma of bilateral breasts underwent bilateral skin sparing mastectomies and immediate reconstruction with placement of 560cm3 implants. The patient is shown preoperatively (A, C, E) and postoperatively (B, D, F) 6 months after receiving 5040 cGy of radiation to the left chestwall.

Fig. 7.

Illustration of allograft integration demonstrates (A) appearance of capsule at 4 months and (B) histologic integration of ADM showing increased EVG (Elastic van Gieson) staining and capillary ingrowth.