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Predictors of Explantation in Tissue Expander and Direct to Implant Reconstructions with Acellular Dermal Matrix: How to Avoid Early Reconstructive Failures
Leslie E. Cohen, MD, Joseph J. Disa, MD.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.

BACKGROUND: Acellular dermis(ADM) inset as a pectoralis muscle extension in implant-based reconstruction after oncologic resection can provide improved inframammary control, rapid fill of an expander and may prevent capsular contracture. The literature cites implant failure rates using ADM up to 7.25%. Although the benefits of using ADM is enticing, we investigate predictors of explantation in these reconstructions.
METHODS:A retrospective study of all patients undergoing immediate breast reconstruction with ADM via a tissue expander (TE) or a direct-to-implant (DTI) approach over five years was conducted. Demographic data, surgical complications and explantation rates and culture results were noted.
241 patients with 355 individual breast reconstructions with ADM met criteria. There was an overall 23% complication rate including cellulitis, seroma, skin necrosis and hematoma. There was a 3.3%(12/355) explantation rate, 66.6%(8/12) TE, 33.3%(4/12) DTI. 5.8% of patients were reconstructed with a perforated ADM which a negative predictor of surgical complications (p<0.04). Skin necrosis was a predictor for explantation (p<0.001) while cellulitis and seroma were not. Of the 21 patients with any skin necrosis, 10(48%) were explanted while 11(52%) were salvaged with local excision of the eschar and primary closure. BMI>25 and breast resection weight >400g were associated with higher rates of explantation while a nipple-sparing approach was not. 71.4% of isolates from seroma fluid or OR cultures from the time of explantation were gram-negative bacteria, 75% of which were sensitive to a flouroquinolone antibiotic.
CONCLUSIONS: Skin necrosis is a risk factor for explantation and should be excised early in implant reconstructions with ADM. If a patient with ADM and an implant-based reconstruction presents with cellulitis that fails to improve on standard outpatient oral antibiotics, consider adding gram negative coverage early.

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