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BACKGROUND: Tissue expander breast reconstruction (TEBR) is the most common method of breast reconstruction in the United States1. The addition of acellular dermal matrix (ADM) slings for TEBR has gained popularity following reports of improved breast contour and shortened length of reconstruction time from more rapid expansion2-3. Although reported complication rates vary greatly, recent published series have shown increased complication rates using ADM. There is however little data comparing complication rates using different types of ADM aside from published series using Alloderm4-7. Non-significant complication rates with Alloderm and without ADM have been reported as 18% and 14% respectively8. We examined our institutional experience with ADM to compare DermaMatrix (DM) and FlexHD (FHD) complication rates. METHODS: An IRB approved retrospective review of all patients who underwent primary TEBR between January 30th, 2008 and March 30th, 2010. Complications were evaluated and compared using standard statistical analysis. RESULTS: 69 Patients underwent TEBR during the study period. Overall complication rate was 53.6% (37/69). Total complication rate for patients in the FHD group was 52.6% (20/38) and 54.8% (17/31) in the DM group (p=0.85). Complications which required hospitalization, re-operation, or expander removal were categorized as major complications. 23.1% (9/38) of FHD patients had major complications compared to 12.9% (4/31) of DM patients (p =0.25). There were 25 smokers and 44 nonsmokers. Smokers had a 32% major complication rate compared with 11.4% in nonsmokers (p=0.019). In nonsmokers, 0% of DM patients had major complications compared to 17.9% of FHD patients (p=0.073). CONCLUSIONS: A high overall complication rate was observed in TEBR. No difference in overall complications was detected between FHD and DM. A greater number of major complications were associated with FHD compared with DM however this was not statistically significant. Major complication rates between FHD and DM in the nonsmoking population approached statistical significance. Complications secondary to patient related factors with an inherent selection bias is a potential explanation. Tissue ischemia in mastectomy flaps, the use of ADM, closure type, drain placement and operative time may also provide some alternative explanations. Given that TEBR is frequently performed and with wide ranges of reported complication rates nationally, further examination and scrutiny is clearly warranted, and an ongoing 10 year review will hopefully elucidate the effect of ADM products as well as other potential factors involved in TEBR complications.