Developing an Evidence-Based Approach to Using Acellular Dermal Matrix in Expander-Implant-based Breast Reconstruction
Nishant Ganesh Kumar, MD1, Nicholas L. Berlin, MD1, Ji Qi, MS1, Hyungjin M. Kim, ScD1, Koki Sagiyama, PhD1, Jennifer B. Hamill, MPH1, Jeffrey H. Kozlow, MD, MS1, Andrea L. Pusic, MD, MHS2, Edwin G. Wilkins, MD, MS1.
1University of Michigan Health System, Ann Arbor, MI, USA, 2Brigham Health, Boston, MA, USA.
PURPOSE: Although acellular dermal matrix (ADM) is widely used in expander-implant (E/I) breast reconstructions, previous analyses have been unable to demonstrate improvements in patient-reported outcomes (PROs) with this approach over non-ADM E/I procedures. Attempting to develop a more selective, evidence-based approach to the use of ADM, we sought to identify patient subgroups in which ADM improved outcomes for E/I reconstruction.
METHODS: The Mastectomy Reconstruction Outcomes Consortium (MROC) Study prospectively evaluated immediate E/I reconstructions at 11 centers from 2012 to 2015. Complications (total and major), and PROs (satisfaction, physical, psychosocial and sexual well-being) were assessed two years postoperatively using medical records and the BREAST-Q, respectively. Using mixed-models accounting for centers and with interaction terms, we analyzed for differential ADM effects across various clinical subgroups, including age categories, BMI categories, radiation timing, and chemotherapy.
RESULTS: Expander/implant reconstruction was performed in 1451 patients, 738 with and 713 without ADM. Major complication risk was higher in ADM users vs. non-users (22.9% vs. 16.4%, p=0.04). Major complication risks with ADM increased with higher BMI (p=0.02; BMI=30, OR=1.54; BMI=35, OR=2.07). No significant ADM effects were observed on breast satisfaction, psychosocial, sexual and physical well-being within any subgroups.
CONCLUSION: In immediate Expander/Implant reconstruction, ADM was associated with greater risk of major complications, particularly in high-BMI patients. We were unable to identify any patient subgroups where ADM use was associated with significant improvements in patient-reported outcomes. Given these findings and the attendant costs of ADM, a more critical approach to the use of ADM may be warranted.
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