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BACKGROUND: Immediate direct-to-implant breast reconstruction has gained popularity in recent years. The increased prevalence of skin/nipple-sparing mastectomy techniques and the availability of acellular dermal matrix (ADM) has allowed for placement of a full-sized permanent implant at the time of mastectomy. Success in immediate single-stage implant reconstruction using an ADM sling has been demonstrated in multiple studies, including a large published series from our own institution. However, other studies have demonstrated significant complications related to the use of ADMs, particularly an increased rate of infection and seroma. Additionally, ADMs are expensive.
We hypothesize that single-stage reconstruction is possible with absorbable mesh in place of ADM, providing for a reliable and cost-effective reconstruction. Similar to ADMs, absorbable mesh (Vicryl) allows for positioning of the implant on the chest wall, definition of the IMF/lateral breast border, and prevents window-shading of the pectoralis muscle, maximizing sub-muscular coverage and decreasing skin tension. This report describes our early results from a series demonstrating that comparable aesthetic results can be achieved using a readily available, cost-effective absorbable mesh without significant complications.
METHODS: A retrospective review was performed of 40 consecutive single-stage direct-to-implant breast reconstructions performed by the authors at the Massachusetts General Hospital.
RESULTS: Sixty-one breasts in 40 consecutive patients have been reconstructed using an immediate direct-to-implant approach with an absorbable mesh sling. All implants were smooth silicone (Mentor) with a mean implant size of 465 (range 150 - 800) cubic centimeters. In cases were the mastectomy specimen weight was recorded, the mean implant size (cc)/specimen weight (gms) ratio was 90%. Mean follow-up is 4.1 months (range 13-252 days). Nineteen (47%) cases were unilateral and 21 (53%) cases were bilateral. Three patients developed complications. One patient who underwent bilateral reconstruction developed a unilateral implant infection on POD #18 ultimately requiring explantation. One patient developed diffuse medication-induced dermatitis. The third patient who underwent bilateral reconstruction was dissatisfied with the size of her implants and underwent exchange for larger implants 6 months after her original reconstruction. No patients developed skin necrosis or seroma. Implant position and aesthetic results were acceptable in all patients. Cost analysis using Vicryl in place of Alloderm in single-stage reconstruction demonstrated a 33% overall cost reduction in unilateral cases and 41% in bilateral cases.
CONCLUSIONS: Analysis of our experience with immediate single-stage implant reconstruction using absorbable mesh demonstrates an excellent early aesthetic result and low complication rate. These early results are very promising and longer follow-up of a larger prospective series of patients may lead to a novel cost-effective approach to immediate implant reconstruction.