The effects of acellular dermal matrix in expander-implant breast reconstruction after total skin-sparing mastectomy:  results of a prospective practice improvement study.
BACKGROUND
Neither outcome after total skin-sparing mastectomy and expander-implant reconstruction using acellular dermal matrix nor a strategy for optimal acellular dermal matrix selection criteria has been well described.


METHODS
Prospective review of three patient cohorts undergoing total skin-sparing mastectomy with preservation of the nipple-areola complex and immediate expander-implant reconstruction from 2006 to 2010 was performed. Cohort 1 (no acellular dermal matrix) comprised 90 cases in which acellular dermal matrix was not used. Cohort 2 (consecutive acellular dermal matrix) included the next 100 consecutive cases, which all received acellular dermal matrix. Cohort 3 (selective acellular dermal matrix) consisted of the next 260 cases, in which acellular dermal matrix was selectively used based on mastectomy skin flap thickness. Complication rates were compared using chi-square analysis.


RESULTS
The study included 450 cases in 288 patients. Mean follow-up was 25.5 months. Infection occurred in 27.8 percent of the no-acellular dermal matrix cases, 20 percent of the consecutive cases, and 15.8 percent of the selective cases (p = 0.04). Unplanned return to the operating room was required in 23.3, 11, and 10 percent of cases, respectively (p = 0.004). Expander-implant loss occurred in 17.8, 7, and 5 percent of cases, respectively (p = 0.001). Additional analysis of the odds ratios of developing complications after postmastectomy radiation therapy demonstrated a specific protective benefit of acellular dermal matrix in irradiated patients.


CONCLUSIONS
Acellular dermal matrix use in expander-implant reconstruction after total skin-sparing mastectomy reduced major postoperative complications in this study. Maximal benefit is achieved with selected use in patients with thin mastectomy skin flaps and those receiving radiation therapy.


METHODS
Therapeutic, III.
San Francisco, Calif.; and Durham, N.C. From the Department of Surgery, Divisions of Plastic and Reconstructive Surgery and Breast Surgery, and the Department of Epidemiology and Biostatistics, University of California, San Francisco; and the Department of Surgery, Duke University Medical Center.
Anne Warren
AW
Peled
Robert D
RD
Foster
Elisabeth R
ER
Garwood
Dan H
DH
Moore
Cheryl A
CA
Ewing
Michael
M
Alvarado
E Shelley
ES
Hwang
Laura J
LJ
Esserman
D000328:Adult; D001943:Breast Neoplasms / Q000601:surgery; D020405:Dermis / Q000637:transplantation*; D005109:Extracellular Matrix / Q000637:transplantation*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008408:Mastectomy; D008875:Middle Aged; D009558:Nipples / Q000601:surgery; D011182:Postoperative Care / Q000379:methods*; D011446:Prospective Studies; D058996:Quality Improvement; D016038:Skin Transplantation / Q000379:methods*; D013524:Surgical Flaps; D015626:Tissue Expansion / Q000379:methods*