title: Delayed hypersensitivity reaction to acellular dermal matrix in breast reconstruction: the red breast syndrome?
abstract: BACKGROUND
  Acellular dermal matrix (ADM) has become a valuable tool in reconstructive breast surgery, in part because it has been considered to be a non-reactive and non-immunogenic entity. However, some patients who undergo breast reconstruction with ADMs develop postoperative erythema overlying their ADM grafts. The etiology of this phenomenon is poorly understood.
  
  
  METHODS
  In this article, we summarize clinical cases in which patients developed localized breast erythema following reconstruction with ADMs. We review what is known about postoperative breast erythema after ADM-based breast reconstructions and the possible antigenicity of biologic mesh implants.
  
  
  RESULTS
  We report 4 implant-based breast reconstruction patients who developed erythematous reactions overlying the region where ADM was placed: one demonstrated a delayed-type hypersensitivity reaction on punch biopsy of the affected skin, leading to removal of the biologic product; 2 others had a similar clinical presentation that responded to corticosteroids without removal of the biologic material, with 1 patient experiencing recrudescence of erythema that responded fully to a second course of corticosteroids; and a fourth showed erythema that was only moderately responsive to antibiotic therapy but which improved consistently after the patient initiated chemotherapy.
  
  
  CONCLUSIONS
  We propose that the etiology of erythema overlying ADM grafts, and the so-called red breast syndrome, may in some patients be a delayed-type hypersensitivity reaction to the ADM product. Affected patients may benefit from treatment with corticosteroids or similar medications, and that such treatment may, in some cases, enable patients to retain the ADM grafts and enable salvage of the reconstructed breast.
authors.affiliation: From the *Harvard Combined Plastic Surgery Residency, Boston; †Harvard Medical School, Boston; ‡Beth Israel Deaconess Medical Center Pathology Residency, Boston; and §Division of Plastic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
authors.forename: Ingrid
authors.initials: I
authors.lastname: Ganske
authors.forename: Marguerite
authors.initials: M
authors.lastname: Hoyler
authors.forename: Sharon E
authors.initials: SE
authors.lastname: Fox
authors.forename: Donald J
authors.initials: DJ
authors.lastname: Morris
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Lin
authors.forename: Sumner A
authors.initials: SA
authors.lastname: Slavin
mesh_terms: D062088:Acellular Dermis / Q000009:adverse effects*; D019928:Breast Implantation / Q000009:adverse effects* / Q000379:methods; D004890:Erythema / Q000175:diagnosis / Q000209:etiology*; D005260:Female; D006801:Humans; D006968:Hypersensitivity, Delayed / Q000175:diagnosis / Q000209:etiology*; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology*; D013577:Syndrome