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BACKGROUND:
Acellular dermal matrix (ADM) has become a commonly used adjunct in immediate implant based breast reconstruction. It was popularized for its proposed benefits, which include lower pole coverage and greater initial tissue expansion. Several recent studies have revealed increased perioperative complications associated with its use. As a result of these findings, our institution placed strict limitations regarding the use of ADM. Recently, sterile “ready to use”(RTU) ADM was introduced and utilized as an alternative to the aseptic predecessor. The purpose of this investigation is to compare the infectious complications of breasts undergoing reconstruction with aseptic ADM and sterile “ready to use” ADM.
METHODS:
After obtaining IRB approval and instituting strict guidelines for ADM use, a review of all patients undergoing immediate implant based breast reconstruction at New York University Medical Center over a two-year period, November 2010-October 2012, was conducted. Alloderm (Life Cell. Branchburg, NJ) was used solely as the source of ADM and RTU alloderm was introduced into use one year after initiating guidelines. Breasts were divided into three cohorts: total submuscular coverage, aseptic ADM, and sterile RTU ADM. These were then analyzed in comparison based on age, specimen weight, body mass index (BMI), the need for lymph node dissection, medical history, indication for surgery, breast cancer stage, use adjuvant/neoadjuvant chemotherapy and radiation, history of recent and remote breast surgery, smoking history, tissue expander (TE) size, initial TE fill, percentage TE fill, and complications including mastectomy skin flap necrosis, infection and need for explantation.
RESULTS:
546 breasts underwent immediate implant based breast reconstruction, including tissue expanders and immediate permanent implants, during the study period. 64.2% (n=351) had reconstruction without ADM, 16.4% (n=90) had reconstruction with aseptic ADM and 19.2% (n=105) had reconstruction with RTU ADM. When comparing breasts reconstructed with aseptic ADM to those with RTU ADM patients were similar in age, BMI, incidence of TE and implant reconstructions, indication for surgery, TE size, fill, and percentage fill, medical comorbidities and smoking status. However, patients undergoing reconstruction with RTU ADM were found to have a significant decrease in overall infection (8.5% versus 20.0% (p=0.0088)), major infection requiring IV antibiotics (4.7% versus 12.2% p=0.069), and need for explantation (1.9% versus 6.6% (p=0.1470) when compared to the aseptic cohort. The incidence of seroma and mastectomy skin flap necrosis was similar in both cohorts. When comparing patients undergoing reconstruction with RTU ADM to those having total submuscular coverage patients had similar overall infectious complications at 8.5% versus 5.7% (p=0.3602) respectively. Diabetes mellitus, postoperative seroma, mastectomy skin flap necrosis, and reconstruction with aseptic ADM were found to be independent predictors of infectious complications.
CONCLUSIONS:
While not indicated for all patients, the use of RTU ADM in immediate implant based breast reconstruction provides an acceptable and useful adjunct. Additionally, RTU ADM mitigates the risks of infectious complications in patients undergoing immediate implant based breast reconstruction when compared to aseptic ADM.