ACELLULAR DERMIS ASSISTED PROSTHETIC BREAST RECONSTRUCTION VERSUS COMPLETE SUBMUSCULAR COVERAGE: A HEAD TO HEAD COMPARISON OF OUTCOMES
Hani Sbitany, M.D., Sven Sandeen, M.D., Ashley N. Amalfi, B.A., Mark Davenport, M.D., Howard N. Langstein, M.D..
University of Rochester, Rochester, NY, USA.
BACKGROUND: Implant breast reconstruction with complete submuscular coverage is commonly practiced, but techniques involving acellular dermis to assist in implant coverage are rapidly becoming popular. Complete submuscular coverage affords the best protection against implant exposure, but suffers from the limitation of restricting lower pole expansion. Techniques that utilize acellular dermis as a pectoralis muscle extension can potentially allow for more rapid fill of the expander, and better control of the inframammary fold, thus leading to more predictable outcomes. This study is a head to head comparison of both techniques with regard to relevant outcomes.
METHODS: Results of 100 consecutive breast expander reconstructions performed by two surgeons at a single institution between 2004 and 2007 were retrospectively reviewed. Patient demographics, expander coverage type, adjuvant treatment, and length of expansion process were recorded. The incidence and types of complications were compared, as were average number of fills required to complete the reconstruction. Outcome variables included expander infection and removal, seroma, hematoma, wound healing problems, and mastectomy flap necrosis.
RESULTS: A total of 100 women underwent breast reconstruction with 172 expanders; 50 using complete subpectoral placement and 50 using partial subpectoral placement with acellular dermis to complete implant coverage. The patient groups were similar in terms of age, body mass index, smoking status, preoperative chest wall irradiation, and cancer stage. The mean time to complete reconstruction was 136 days in the subpectoral group (mean 4.1 fills) and 211 days in the acelluar dermis group (mean 1.76 fills). An average of 122 cc saline was instilled into each expander in the subpectoral group on day of initial surgical placement, compared to 407 cc per expander in the acellular dermis group. Fisher’s exact test demonstrated no significant difference in total complication rate between the two groups (14 % vs. 18%; p=.79). Specifically, there was no difference in seroma rate (6% each). There were 3 infections requiring expander removal in the subpectoral group, compared to 4 in the acellular dermis group (6% vs. 8%, p=.78). No patient characteristics were predictive of time to complete reconstruction or complication rate.
CONCLUSIONS: While the use of acellular dermis in implant breast reconstruction had an analogous overall complication rate when compared to complete submuscular coverage, the use of acellular dermis did allow for a greater initial fill of saline, thus reducing the need for subsequent expansions. We believe that this improves the overall cosmetic outcome, as it better capitalizes on preserved mastectomy skin for reconstruction. The acellular dermis further assists with implant positioning, and may reduce the incidence of capsular contracture, as measured by easier and more predictable secondary operations in this group. These observations are currently being evaluated. We thus conclude that acellular dermis-assisted implant breast reconstruction has a safety profile no worse than complete submuscular coverage, but offers the benefit of fewer expansions, and the potential for more predictable secondary revisions, and likely improved cosmetic outcome.