No Advantages to Using ADM in Implant-Based Breast Reconstruction

Roxanne Nelson, RN, BSN

October 18, 2021

For women with breast cancer who undergo mastectomy and opt for implant-based breast reconstruction (IBBR), the use of a mesh device does not appear to offer any advantage over conventional techniques.

A European study involving 155 women found that the use of acellular dermal matrix (ADM) did not lead to fewer reoperations, nor was it superior in terms of health-related quality of life or patient-reported cosmetic outcomes.

"We feel that women considering implant-based reconstructions for breast cancer should be informed about the lack of evidence supporting its advantage," said lead author Fredrik Lohmander MD, Department of Breast and Endocrine Surgery, Section of Breast Surgery, Karolinska University Hospital, Stockholm, Sweden.

It is difficult to say generally whether ADM should be used in IBBR, he noted. "We can only conclude from our trial that there is no hard evidence that ADM is beneficial when performing breast reconstructions with implants," he told Medscape Medical News. "In selected patients, ADM might be indicated."

The study was conducted in Sweden and the United Kingdom. "Mostly because of high costs, ADM in implant-based breast reconstructions in Sweden is not frequently used," Lohmander said. "It is slightly more common in the UK, but much more common in the USA."

Although biological meshes have received regulatory approval by the US Food and Drug Administration for reconstructive purposes, ADM has not been approved for use in breast reconstruction surgery, and its use in this setting is off label.

The study was published online October 1 in JAMA Network Open.

Any Advantage to Using Mesh Device?

Previous studies of ADMs suggested that the mesh device conferred several benefits, including superior cosmetic results, less need for tissue expanders, fewer elective reoperations, and less capsular contracture. The use of a mesh device also enlarges the subpectoral pocket, which allows for larger fixed-volume implants, the authors note.

However, these suggested advantages have not been universally accepted, and the authors note that there have been reports of associated harm, such as higher rates of infection and implant loss.

The new study included 135 women from five centers in Sweden and the United Kingdom. The patients had breast cancer and had planned to undergo mastectomy and immediate IBBR between 2014 and May 2017.

The primary endpoint was the number of repeat surgeries at 2 years.

At the 2-year follow-up, 31 patients (48%) in the ADM group had undergone at least one reoperation on the ipsilateral side, vs 35 (54%) in the control group (P = .54). Results were similar for the contralateral side: 34 (53%) vs 31 (48%).

Two patients in the ADM group and three patients in the control group underwent a risk-reducing mastectomy on the contralateral side. These five surgeries were included in the final analysis.

For nine patients (14%) in the ADM arm, the implant was removed. Four of the removals took place within 6 months after early surgical complications. In the control group, seven patients (11%) underwent implant removal; four were removed within 6 months, owing to early surgical complications.

The secondary endpoint was postoperative health-related quality of life, including perception of body image and satisfaction with cosmetic outcome. There were no significant differences between the two groups.

Some Questions Remain

Approached for comment on the study, Sameer A. Patel, MD, FACS, chief of plastic and reconstructive surgery at Fox Chase Cancer Center, Philadelphia, Pennsylvania, noted that the practice of using AMD for breast reconstruction is quite common in the United States, so these data are informative and add to the current understanding of the value of ADM in breast reconstruction. "The study hypothesized that the use of ADM would reduce the number of reoperations within the first 24 months, which it did not," he said. "This is despite the fact that the ADM group had a significantly higher number of direct-to-implant reconstructions."

Importantly, the study showed that patient-reported outcomes, as opposed to surgeon's evaluation of outcomes, were also not different for the most part between the two groups, Patel pointed out. "The only exception of small favorable advantage in the ADM group was for fitting bras," he said.

However, there were limitations to the study's endpoint. "I would add that there are some purported advantages of using ADM, such as reduction in postoperative pain and reduction in length of hospital stay, which are not evaluated by this study," Patel explained. "Also, I am not certain that they can conclude from this study that capsular contracture is not reduced, because it is not designed to evaluate that."

But the biggest limitation is one that study authors point out in their discussion at the end of the article, he added. "The use of prepectoral reconstruction is rapidly replacing the dual plane reconstruction that this paper used in the ADM group," Patel said. "The role of ADM in prepectoral reconstruction is somewhat different than in the dual plane reconstruction, and so these results may not necessarily be extrapolated to prepectoral reconstruction."

The study was funded with grants from the Swedish Breast Cancer Association and Stockholm City Council. The trial was initiated by Karolinska University Hospital and Karolinska Institutet. Acelity (an Allergan company) supplied the study with acellular dermal matrix meshes. Lohmander and Patel have disclosed no relevant financial relationships.

JAMA Netw Open. Published online October 1, 2021. Full text

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