title: Aesthetic outcomes of acellular dermal matrix in tissue expander/implant-based breast reconstruction.
abstract: BACKGROUND
  Tissue expander and implant-based breast reconstruction after mastectomy is the most common method of breast reconstruction. Modifications of the traditional total submuscular reconstruction (TSR) have been made using acellular dermal matrix (ADM) to create an inferolateral sling and a more natural implant pocket for superior aesthetic results. The objective of this study was to assess aesthetic outcomes when using ADM in breast reconstruction.
  
  
  METHODS
  A retrospective chart review identified all patients who underwent implant-based breast reconstruction from 2005 to 2009 at our institution. Demographic information, complications, reoperations, and aesthetic outcome data were collected for all patients meeting inclusion criteria related to adequate follow-up and postoperative photographs. Five aesthetic outcomes were evaluated for all study patients by 18 blinded evaluators using postoperative photographs. Outcomes were scored on a scale of 1 to 5, with 5 representing the best possible aesthetic score.
  
  
  RESULTS
  A total of 122 patients underwent 183 tissue expander-based reconstructions (ADM, n = 58; TSR, n = 125). The infection rate in patients with ADM was 16.2% compared to 5.9% in TSR patients, but this was not statistically significant (P = 0.09). Capsular contracture was more common in TSR patients (23.5%), compared to those with ADM (8.1%), P = 0.048. Aesthetic scores from the attending plastic surgeons were as follows: natural contour (ADM, 3.36; TSR, 3.02; P = 0.0001), symmetry of shape (ADM, 3.57; TSR, 3.27; P = 0.005), symmetry of size (ADM, 3.68; TSR, 3.42; P = 0.002), position on chest wall (ADM, 3.75; TSR, 3.45; P = 0.004), and overall aesthetic appearance (ADM, 3.56; TSR, 3.20; P = 0.0001).
  
  
  CONCLUSIONS
  For all 5 aesthetic parameters evaluated, the ADM group scored significantly higher than the TSR group by 18 blinded evaluators. These consistent findings suggest that the use of ADM in breast reconstruction does confer a significant advantage in aesthetic outcomes for breast reconstruction. This is likely at the cost of a higher infection rate when using ADM; however, that may be offset by the advantage of a lower rate of capsular contracture in patients with ADM.
authors.affiliation: From the *Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, NC; and†Department of Surgery, University of Louisville, Louisville, KY.
authors.forename: Clay G
authors.initials: CG
authors.lastname: Forsberg
authors.forename: David A
authors.initials: DA
authors.lastname: Kelly
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Wood
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Mastrangelo
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: DeFranzo
authors.forename: James T
authors.initials: JT
authors.lastname: Thompson
authors.forename: Lisa R
authors.initials: LR
authors.lastname: David
authors.forename: Malcolm W
authors.initials: MW
authors.lastname: Marks
mesh_terms: D062088:Acellular Dermis; D019928:Breast Implantation / Q000379:methods*; D001943:Breast Neoplasms / Q000453:epidemiology / Q000601:surgery; D015897:Comorbidity; D006801:Humans; D008297:Male; D008875:Middle Aged; D015626:Tissue Expansion; D016896:Treatment Outcome