title: Does acellular dermal matrix really improve aesthetic outcome in tissue expander/implant-based breast reconstruction?
abstract: BACKGROUND
  The expectation for improved results by women undergoing postmastectomy reconstruction has steadily risen. A majority of these operations are tissue expander/implant-based breast reconstructions. Acellular dermal matrix (ADM) offers numerous advantages in these procedures. Thus far, the evidence to justify improved aesthetic outcome has solely been based on surgeon opinion. The purpose of this study was to assess aesthetic outcome following ADM use in tissue expander/implant-based breast reconstruction by a panel of blinded plastic surgeons.
  
  
  METHODS
  Mean aesthetic results of patients who underwent tissue expander/implant-based breast reconstruction with (n = 18) or without ADM (n = 20) were assessed with objective grading of preoperative and postoperative photographs by five independent blinded plastic surgeons. Absolute observed agreement as well as weighted Fleiss Kappa (κ) test statistics were calculated to assess inter-rater variability.
  
  
  RESULTS
  When ADM was incorporated, the overall aesthetic score was improved by an average of 12.1 %. In addition, subscale analyses revealed improvements in breast contour (35.2 %), implant placement (20.7 %), lower pole projection (16.7 %), and inframammary fold definition (13.8 %). Contour (p = 0.039), implant placement (p = 0.021), and overall aesthetic score (p = 0.022) reached statistical significance. Inter-rater reliability showed mostly moderate agreement.
  
  
  CONCLUSIONS
  Mean aesthetic scores were higher in the ADM-assisted breast reconstruction cohort including the total aesthetic score which was statistically significant. Aesthetic outcome alone may justify the added expense of incorporating biologic mesh. Moreover, ADM has other benefits which may render it cost-effective. Larger prospective studies are needed to provide plastic surgeons with more definitive guidelines for ADM use.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors.affiliation: Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA, aibrahim@bidmc.harvard.edu.
authors.forename: Ahmed M S
authors.initials: AM
authors.lastname: Ibrahim
authors.forename: Pieter G L
authors.initials: PG
authors.lastname: Koolen
authors.forename: Oren
authors.initials: O
authors.lastname: Ganor
authors.forename: Mark K
authors.initials: MK
authors.lastname: Markarian
authors.forename: Adam M
authors.initials: AM
authors.lastname: Tobias
authors.forename: Bernard T
authors.initials: BT
authors.lastname: Lee
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Lin
authors.forename: Marc A M
authors.initials: MA
authors.lastname: Mureau
mesh_terms: D062088:Acellular Dermis; D000328:Adult; D000368:Aged; D019928:Breast Implantation / Q000009:adverse effects / Q000379:methods*; D018427:Breast Implants; D016009:Chi-Square Distribution; D015331:Cohort Studies; D004954:Esthetics; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D015588:Observer Variation; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D015625:Tissue Expansion Devices / Q000706:statistics & numerical data*; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology