Prepectoral Breast Reconstruction Using Meshed Acellular Dermal Matrix: A Resource-Conscious Approach
Emma Vartanian, MD1, Meghan McCullough, MD1, James S. Andersen, MD2, Mark Tan, MD2.
1USC Plastic and Reconstructive Surgery, Los Angeles, CA, USA, 2City of Hope Comprehensive Cancer Center, Los Angeles, CA, USA.
PURPOSE: In the setting of robust soft-tissue coverage and appropriate patient selection, prepectoral implant breast reconstruction provides a viable alternative to partial or total submuscular reconstruction. This approach avoids breast animation deformity, reduces postoperative pain, and achieves favorable cosmetic outcomes. However, most prepectoral placement techniques describe complete acellular dermal matrix (ADM) coverage of the implant. Full coverage requires a greater surface area of ADM than comparable subpectoral implant procedures, increasing healthcare expenditures as well as consumption of a limited resource. Given the ongoing manufacturer shortages of ADM, our institution sought to find a more sustainable approach. We present a method of prepectoral breast reconstruction that applies a skin graft meshing technique to increase the surface area of usable dermal matrix, while still maintaining structural support.
METHODS: We performed a retrospective review of all patients who underwent prepectoral implant breast reconstruction using meshed ADM at our institution. Surgical technique was uniform across cases. Adequate mastectomy flap perfusion was first confirmed intraoperatively with indocyanine green angiography. The size of the allograft sheet was chosen based on implant volume, then the ADM was passed through a 2:1 skin graft mesher. In all cases, a single sheet of allograft was sufficient to provide total anterior coverage of the device.
RESULTS: We identified 28 female patients who underwent prepectoral breast reconstruction using meshed ADM, over a one-year period. There were 8 unilateral procedures and 20 bilateral, for a total of 48 breasts reconstructed with this technique. 23 of the 48 mastectomies were performed prophylactically. Average patient age was 45 years old (range 32-71 years old), and average BMI was 27.0 kg/m2 (range 19-45 kg/m2). There was no history of radiation in any of the reconstructed breasts. No patients were active smokers or insulin-dependent diabetics. Two patients had tissue expanders placed while the rest were direct-to-implant, with volumes ranging from 275 cc to 745 cc (median volume 450 cc). The average surface area of ADM used per breast reconstruction was 165 cm2. Average duration of follow-up was 3 months. Postoperative complications included one suture abscess, and one patient who developed unilateral implant infection. She underwent breast washout and implant exchange with an identical prepectoral construct, followed by a course of intravenous antibiotics, after which her infection fully resolved. To date, no patients have lost their reconstructions or experienced capsular contracture. All patients have expressed satisfaction with the aesthetic appearance of their breasts.
Prepectoral reconstruction with meshed ADM offers reliable and aesthetically pleasing outcomes. In contrast to previously described techniques of prepectoral breast reconstruction requiring multiple pieces of ADM, meshing optimizes resource utilization by facilitating the use of a single sheet of allograft. Although our data lacks long term follow-up, early findings demonstrate minimal complications and high patient satisfaction, suggesting that this approach can provide the benefits of prepectoral implant reconstruction while responsibly preserving product availability and tempering healthcare costs.
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