What are the expected outcomes of breast reconstruction with acellular dermis?

Updated: Jul 29, 2021
  • Author: John Y S Kim, MD, FACS; Chief Editor: James Neal Long, MD, FACS  more...
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Outcomes have been reported in pelvic, abdominal, and chest wall reconstructions [8] ; dural repair [9] ; hand surgery; [14] urethral reconstruction; [15] burn surgery [16] ; and gingival graft procedures [17] . Few authors have argued against the overall safety of acellular dermis–based reconstruction. Most studies have reported improved aesthetic outcomes and acceptable complication rates. [2, 18, 19]

In the literature, comparisons of ADM-assisted reconstruction with traditional expander reconstruction generally do not show statistically relevant differences in overall complication rates. The overall complication rates for reconstructions using ADM range from 3.2% to 48.7%. [12, 13, 20, 19]

In a study of 269 ADM-assisted breast reconstructions, Chun et al reported the following complication profile for ADM: 8.9% rate of infection, 23.4% rate of necrosis, 14.1% rate of seroma, and 2.2% rate of hematoma. [13] The investigators also found that ADM-assisted breast reconstructions were associated with higher rates of postoperative seroma and infection than complete submuscular breast reconstruction were.

In a study of 153 breast reconstructions, Antony et al reported an overall complication rate of 23.6%, with rates of 7.2% for seroma, 2.0% for hematoma, 3.9% for cellulitis, 4.6% for flap necrosis, and 3.3% for infection. [19] In a study of 121 breast reconstructions, Rawlani reported an overall complication rate of 16.5%, with rates of 7.4% for infection, 1.7% for seroma, and 6.6% for flap necrosis. [12]

A literature review by Smith et al indicated that patients who undergo tissue expander/implant breast reconstruction with a human ADM have a significantly greater risk of flap necrosis (relative risk [RR] = 2.39) and infection (RR = 1.5) than do individuals in whom submuscular reconstruction is performed. However, the two groups were not found to significantly differ with regard to seroma, hematoma, or implant explantation risk. [21]

A study by Belmonte and Campbell indicated that the safety profile for breast reconstruction with a prepectoral expander-to-implant technique employing meshed ADM is comparable to that associated with a partially submuscular ADM-assisted procedure. Moreover, the early aesthetic ratings for the prepectoral procedures were similar to those reported with other implant-based reconstructions. [22]

A prospective cohort study by Dave et al reported that in patients who undergo a prepectoral implant-based breast reconstruction—most of which in this study were one-stage direct-to-implant procedures employing an ADM—medium-term outcomes with regard to complications and implant loss are acceptable. Over a median 21-month follow-up period, minor and major complications occurred following 11.2% and 5.9% of reconstructions, respectively, while by 3-month follow-up, the rate of implant loss was 3.1%. The study also found that independent risk factors for major complications in these procedures include sentinel node biopsy, axillary clearance, and adjuvant radiotherapy, with sentinel node biopsy was also being an independent risk factor for implant loss. [23]

Unfortunately, few studies have compared and stratified differences in outcomes with respect to type of acellular dermis, body mass index (BMI), radiation exposure, or intraoperative expander fill. Becker et al reported an overall complication rate of 4%. [24] Losken reported only 1 complication of native skin necrosis in a study of 31 breasts. [20] Because of differences in the processing and sterilization of the various ADMs, there is a possibility of alterations in collagen and protein structure that may ultimately affect revascularization and recellularization.

A study by Paprottka et al did look at complications of breast reconstruction using human, porcine, or bovine ADMs, finding the highest complication rate with the bovine variety. The study, with median 3-year follow-up, involved 52 ADM breast reconstructions (41 patients), with human, porcine, and bovine ADM complication rates of 7%, 14%, and 31%, respectively. [25]

Rawlani et al reported an overall complication rate of 30.7% in women who received adjunct breast irradiation, compared with 13.7% in nonirradiated breasts. [12] They also noted that outcomes and complication rates with prehydrated ADM were generally comparable to those with freeze-dried ADM.

A study by Winocour et al indicated that in patients who undergo immediate tissue expander breast reconstruction, the 30-day surgical site infection rate is higher when ADM is used. The study reported that the national rate of surgical site infections in such operations is 4.5% when ADM is used, compared with 3.2% in non-ADM cases, with the investigators finding that at their own institution, these rates were 2.1% and 1.6%, respectively. [26]

Breuing et al [27] noted that despite a higher rate of complications, ADM-assisted tissue expander reconstructions seemed to resist radiation effects better than standard tissue expander reconstructions did—a phenomenon that has been observed by a number of authors and is currently being explored in the literature. [11]

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