What is included in the preprocedural planning for 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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Answer

Arguably, ADM-assisted breast reconstructions yield results that are cosmetically superior—and more reproducibly so—to those achieved with traditional expander-based techniques. This is because of improvements in important functional variables (eg, intraoperative fill volumes), total postoperative clinic visits for filling, and control of expander-implant positioning. [1, 10, 12]

Several technical considerations should be taken into account in planning the procedure. The acellular dermis used must be the proper size—that is, it should be just large enough to cover the inferior pole of tissue expander or implant, providing complete coverage when sutured to the pectoralis. Excess acellular dermis creates the potential for graft inversion, which can become a nidus for chronic inflammation and giant cell foreign body reactions. [28]

In addition, ADMs that exhibit polarity must be properly inserted, with the dermal (porous) surface opposing the soft tissue and the epidermal (smooth) surface facing the tissue expander or implant. Failure to orient the dermis properly can lead to inflammatory processes that may mimic cellulitis. [12]

It is important to distinguish between traditional expander infections and the noninfectious erythema associated with the incorrect use of acellular dermis in the reconstruction. The latter is characterized by early erythema over the lower pole of the breast (superimposed over the anatomic extent of the acellular dermis) without systemic signs of infection and without any radiographic evidence of seroma or abscess. The etiology of this erythema has not been completely elucidated, but it may be a host inflammatory response to the acellular dermis itself.

Ideally, mastectomy flaps should be healthy enough to revascularize and integrate the acellular dermal graft. However, if the mastectomy flaps are relatively avascular or if the graft has a mechanical or physiologic impediment, the graft may fail to revascularize, and this failure may lead to an inflammatory reaction. An example of mechanical prevention of revascularization is the presence of fluid between the mastectomy flaps.

Alternatively, as noted (see above), inversion of the polarity of the graft can lead to physiologic retardation of the revascularization process because revascularization occurs from the mastectomy flap, and the epidermal surface has relatively poor porosity relative to the dermal surface. [28]

The same phenomenon even be seen even when thicker acellular dermal grafts are used. Revascularization may be further challenged by the deeper penetration required, and prolonged integration attempts may themselves stimulate a host inflammatory response. A more chronic form of this inflammatory process can be seen with occasional inversion or with the formation of granulomas around the folded acellular dermis. [28]

Nahabedian further discussed the importance of differentiating between mechanical and infectious complications. [11] The interventions required for a true primary infection are not the same as those required for a secondary mechanical complication, and the 2 conditions differ significantly with respect to complication rates and outcomes. These distinctions become significant because of the potential controversy regarding increased infection and seroma rates when acellular dermis is used in breast reconstructions.

Chun et al noted that the desire to increase intraoperative volume or to perform single-stage reconstructions using acellular dermis leads to a tendency to retain and use more native breast skin, thereby giving rise to increased seroma and infection rates. [13] They pointed out that acellular dermis does not protect against standard postoperative risks and recommended that surgical treatment be adjusted accordingly.

Chun et al also stated that the increased seroma rate may be related to proper drain placement when using acellular dermis. [13] Careful drain placement in both subcutaneous and subacellular dermal planes, along with longer postoperative drain time, should be used to minimize postoperative risk of seroma. [29]

Finally, the effects of radiation on breast reconstructions merit discussion. Generally, rates of radiation-effect complications, particularly capsular contracture, are lower in ADM-assisted reconstructions than in traditional tissue expander reconstructions. [11, 27] The protective effects have been reproduced and quantified in various mammalian studies. [30]

Although these initial results are by no means conclusive, establishing a significant expander volume early may be of benefit, providing a “stretch effect.” The incidence of capsular contracture may also be reduced as a result of a physiological “barrier effect” exerted by the acellular dermis, perhaps in combination with the aforementioned stretch effect. To date, no definitive explanation has been adduced to account for these behaviors, but future studies will help confirm these phenomena and elucidate the underlying physiologic processes.


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