The Use of Human Acellular Dermal Matrix in the First Stage of Implant-Based Breast Reconstruction Simplifies the Exchange Procedure

Sir: The use of acellular dermal matrices in breast reconstruction was first described over 10 years ago.1 A recent survey found that approximately 56 percent of implant-based breast reconstructions use a biological mesh.1 The proposed advantages of acellular dermal matrix use pertain to both one- and two-stage implant-based breast reconstructions.1–4 Although a single-stage reconstruction is both desirable and less expensive,5 many patients require a two-stage procedure. The improved control of the implant pocket hypothesized with acellular dermal matrix is particularly advantageous when a two-stage operation is deemed necessary. This study hypothesizes that the increased pocket control afforded by acellular dermal matrix will simplify the second stage of the operation by decreasing the need for and extent of capsular modifications. All patients undergoing immediate implant-based breast reconstruction with and without acellular dermal matrix performed by the senior author (H.N.L.) were reviewed over a 5-year period. Human acellular dermal matrix was used exclusively. Patient demographics and medical comorbidities were collected. Capsular procedures were graded as follows: 0, no revision; 1, capsulotomy; 2, capsulectomy; and 3, capsulorrhaphy. Inframammary fold adjustment (raised or lower) and implant repositioning (medial or lateral) was recorded. Continuous or binary outcomes and multinomial variables were analyzed with the appropriate statistical test using SAS 9.3 (SAS Institute, Inc., Cary, N.C.). Fifty-seven patients underwent 92 implant-based reconstructions using human acellular dermal matrix and 15 patients underwent 17 implant reconstructions without human acellular dermal matrix. There were no significant differences between demographics or comorbidities. Frequency of capsule revision grades in the human acellular dermal matrix versus non–acellular dermal matrix groups, respectively, were: 0, 40 (43 percent) versus four (24 percent), p = 0.04; 1, 23 (25 percent) versus eight (47 percent), p = 0.06; 2, 24 (26 percent) versus four (24 percent), p = 0.62; and 3, five (5 percent) versus one (5 percent), p = 0.81. The odds ratio of having a lower capsular score given a unit increase in non–acellular dermal matrix use was 3.1 (p = 0.2). An inframammary fold adjustment procedure (up or down) was performed 19 (21 percent) versus two times (12 percent) in the human acellular dermal matrix group versus non–acellular dermal matrix group (OR, 1.82; p = 0.4), whereas implant repositioning (medial or lateral) occurred 12 (13 percent) versus four times (24 percent) in the human acellular dermal matrix versus non–acellular dermal matrix group (OR, 0.49; p = 0.3). Increasing age (OR, 0.96; p = 0.02) and medical comorbidities (OR, 0.35; p = 0.001) were significantly associated with increasing capsule revision grade in the human acellular dermal matrix group. In examining this series, it was found that the second stage of the procedure was made simpler with human acellular dermal matrix use. Reconstructions using human acellular dermal matrix were significantly more likely to require either no capsular revision or a simple capsulotomy and were less likely to require a capsulectomy or capsulorrhaphy. In fact, with a unit increase in human acellular dermal matrix use, a patient has 3.1-fold greater odds (OR, 3.1) of having a lower capsular revision rate using the grading scale used in this study. In deciding whether to use human acellular dermal matrix in a two-stage implant-based breast reconstruction, a thorough risk-to-benefit analysis is required.4,5 This study demonstrates that, in the setting of a low likelihood of success with a single-stage reconstruction, human acellular dermal matrix use at expander insertion increases the chances of a simple exchange procedure but does not eliminate the need to adjust the pocket. DISCLOSURE Dr. Langstein is on the speaker’s bureau for LifeCell Corporation. The other authors have no financial interests to declare. Peter F. Koltz, M.D. Jordan D. Frey, B.S. Howard N. Langstein, M.D. Division of Plastic Surgery University of Rochester Medical Center Rochester, N.Y.