title: Subcutaneous Implant-based Breast Reconstruction with Acellular Dermal Matrix/Mesh: A Systematic Review.
abstract: BACKGROUND
  The availability of acellular dermal matrix (ADM) and synthetic mesh products has prompted plastic surgeons to revisit subcutaneous implant-based breast reconstruction. The literature is limited, however, with regards to evidence on patient selection, techniques, and outcomes.
  
  
  METHODS
  A systematic review of the Medline and Cochrane databases was performed for original studies reporting breast reconstruction with ADM or mesh, and subcutaneous implant placement. Studies were analyzed for level of evidence, inclusion/exclusion criteria for subcutaneous reconstruction, reconstruction characteristics, and outcomes.
  
  
  RESULTS
  Six studies (186 reconstructions) were identified for review. The majority of studies (66.7%) were level IV evidence case series. Eighty percent of studies had contraindications for subcutaneous reconstruction, most commonly preoperative radiation, high body mass index, and active smoking. Forty percent of studies commenting on patient selection assessed mastectomy flap perfusion for subcutaneous reconstruction. Forty-five percent of reconstructions were direct-to-implant, 33.3% 2-stage, and 21.5% single-stage adjustable implant, with ADM utilized in 60.2% of reconstructions versus mesh. Pooled complication rates included: major infection 1.2%, seroma 2.9%, hematoma 2.3%, full nipple-areola complex necrosis 1.1%, partial nipple-areola complex necrosis 4.5%, major flap necrosis 1.8%, wound healing complication 2.3%, explantation 4.1%, and grade III/IV capsular contracture 1.2%.
  
  
  CONCLUSIONS
  Pooled short-term complication rates in subcutaneous alloplastic breast reconstruction with ADM or mesh are low in preliminary studies with selective patient populations, though techniques and outcomes are variable across studies. Larger comparative studies and better-defined selection criteria and outcomes reporting are needed to develop appropriate indications for performing subcutaneous implant-based reconstruction.
authors.affiliation: Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, N.Y.
authors.forename: Ara A
authors.initials: AA
authors.lastname: Salibian
authors.affiliation: Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, N.Y.
authors.forename: Jordan D
authors.initials: JD
authors.lastname: Frey
authors.affiliation: Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, N.Y.
authors.forename: Mihye
authors.initials: M
authors.lastname: Choi
authors.affiliation: Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, N.Y.
authors.forename: Nolan S
authors.initials: NS
authors.lastname: Karp