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Limited Use of ADM Directly Correlates with a Decreased Rate of Infectious Complications in Immediate Implant Based Breast Reconstruction: A Single Institutional Experience
Katie Weichman, Stelios Wilson, BS, Alexes Hazen, MD, Jamie Levine, MD, Mihye Choi, MD, Nolan Karp, MD.
New York University, New York, NY, USA.
BACKGROUND: A recent institutional retrospective review of immediate implant based breast reconstructions revealed increases in all major postoperative complications including major infection, mastectomy skin flap necrosis, and explantation associated with the use of Acellular dermal matrix (ADM). As a result of this investigation, strict guidelines were developed at our institution as a Quality Improvement Initiative. Indications for use included clear need of additional soft tissue support, inadequate inferior pectoralis muscle, and immediate permanent implant reconstruction. This study was conducted to assess the effects of these guidelines on patient outcomes and use of ADM.
METHODS: After obtaining IRB approval and instituting guidelines, 344 consecutive immediate implant based breast reconstructions at a single institution over a 14 month period were prospectively gathered. The reconstructions were divided into two cohorts: those having reconstruction with ADM and those having reconstruction without ADM. The demographic information, preoperative breast size, use of methylene blue dye, need for lymph node dissection, breast cancer stage, use of adjuvant/neo-adjuvant chemotherapy and radiation, history of recent and remote breast surgery, surface area of ADM, and complications were analyzed and compared. This data was then compared to the previous retrospective review of 747 consecutive immediate implant based breast reconstructions in the three-year period prior to institution of guidelines looking at the same variables.
RESULTS: A total of 344 reconstructions were performed, 94% traditional two-stage tissue expander reconstructions and 6% one-stage immediate implants. The use of ADM decreased from 74.7% to 29.6%. The ADM and non-ADM cohorts had similar characteristics when compared: including mean age, mean BMI, percentage of small and large breasted women, cancer stage, medical co-morbidities, and smoking history. Overall infection rates fell from 14.1% to 6.8% (p<0.05) and major infection fell from 7.8% to 3.0% (p<0.05). Explantation also fell from 6.4% to 2.3% (p<0.05). Mastectomy skin flap necrosis was stable in both cohorts at 8.5% prior to guidelines and 9.9% (p=.255) after the implementation of guidelines. Breast undergoing reconstruction with ADM continued to have higher rates of mastectomy skin flap necrosis (12.8% vs 8.1% p<0.05), major infection 8.9% vs 0.5% p <0.05), and explantation (6.4% vs 0.5% p <0.05) when compared to those without ADM. Rates of overall infection, mastectomy skin flap necrosis, and explantation were similar when comparing ADM cohorts pre and post guidelines respectively (14.6% vs 12.8%, 10.4% vs 12.8%, and 7.5% vs 6.4%).
CONCLUSION: Placing limitations on the use of ADM in immediate implant based breast reconstruction resulted in decreased major postoperative infectious complications. ADM, however, continued to render an increased risk of major complications when compared to reconstructions without ADM. This may be attributable to the fact that ADM is used in more demanding cases such as in large breast reconstruction, lack of muscle coverage, and nipple sparing mastectomy. We advise using ADM in select cases with clear indications.
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