Supplemental Article
Acellular Dermal Matrix for Secondary
Procedures Following Prosthetic Breast
Reconstruction
Aesthetic Surgery Journal
31(7S) 38S­–50S
© 2011 The American Society for
Aesthetic Plastic Surgery, Inc.
Reprints and permission:
http://www​.sagepub.com/
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DOI: 10.1177/1090820X11418093
www.aestheticsurgeryjournal.com
Maurice Y. Nahabedian, MD; and Scott L. Spear, MD
Abstract
Acellular dermal matrices (ADM) have generated interest for their possible applications in secondary revisions following prosthetic breast reconstruction.
These materials can be effective in a variety of situations, including implant displacement, synmastia, capsular contracture, incisional support, and
pocket conversion. ADM can also be placed in the setting of delayed breast reconstruction and to augment nipple projection. These biomaterials have
demonstrated feasibility and success for many complex deformities. However, there is an associated learning curve that includes an understanding of
proper technique and patient selection. The authors review their cumulative experience between 2004 and 2010 with ADM for the correction of secondary
deformities following prosthetic breast reconstruction, focusing on the indications for repair, traditional management, and management with ADM.
Keywords
AlloDerm, Strattice, revision of breast reconstruction, acellular dermal matrix
Accepted for publication February 24, 2011.
The advent of acellular dermal matrices (ADM) has created a paradigm shift in the practice and technique of
prosthetic breast reconstruction.1,2 Many surgeons have
adopted these materials and incorporated them into their
reconstructive practices. As the mechanism of action and
the benefits of ADM have become better understood, their
applications in other areas of breast surgery have
expanded.3-8 Their placement in revisionary breast surgery
has facilitated the repair of many complex conditions that
historically have been difficult to manage or were associated with a high rate of recurrence following traditional
methods of repair.9
Although ADM materials have demonstrated success in
many situations, there is a learning curve associated with
their placement. Therefore, surgeons should understand the
indications for use and the various techniques by which
these materials are inserted. There are several important
concepts related to ADM placement, including adequate
hydration, proper orientation, drains, elimination of potential dead space or folds in the matrix, and antibiotic use. It
should also be noted that these materials may not perform
as well in obese patients or those who use tobacco products. In this article, we will review the various indications
for ADM placement, traditional methods of repair, techniques utilizing ADM, and our personal outcomes following
revisionary breast reconstruction. The specific and salient
details that generally allow surgeons to achieve predictable
and reproducible results will also be described.
Applications
Prior to placing ADM in patients, surgeons should be familiar
with several important features of these materials. First,
freeze-dried ADM materials require adequate hydration prior
to placement. This typically takes approximately 20 minutes
in a room-temperature saline solution. Also, freeze-dried
materials contain cryopreservatives that must be washed out
prior to placement. This is usually accomplished by one or
two sequential soaks in a saline/antibiotic solution. These
soaks last for approximately five to 10 minutes each. Once
From the Department of Plastic Surgery, Georgetown University
Hospital, Washington, DC.
Corresponding Author:
Dr. Maurice Y. Nahabedian, Georgetown University Hospital,
Department of Plastic Surgery, 3800 Reservoir Road NW,
Washington, DC 20007, USA.
E-mail: [email protected]
Nahabedian and Spear
39S
the ADM is in place, a single closed-suction drain is usually
placed between the ADM and the soft tissue. This drain will
typically remain in place for five to seven days and serves to
control fluid accumulation (seroma) and promote adherence
of the ADM to the surrounding soft tissue. It does not usually
interfere with the revascularization process.
Personal Experience
Between 2005 and 2010, we placed ADM materials in 51
women who were undergoing secondary procedures following prosthetic breast reconstruction. (Both authors perform
primary and revisionary breast reconstruction procedures on
a routine basis.) We selected either AlloDerm (LifeCell
Corporation, Branchburg, New Jersey) or Strattice (LifeCell
Corporation) for these patients. The indications for revisionary reconstruction included rippling and wrinkling (n =
five), capsular contracture (CC) (n = nine), implant displacement (inferior or lateral, n = nine), synmastia (n = five),
incisional support (n = 13), and pocket conversion or modification (n = nine). Other secondary applications for which
we placed ADM included nipple reconstruction and delayed
prosthetic reconstruction following mastectomy. The descriptions of techniques, indications, and common complications
that follow are based on our collective experience with these
patients.
Figure 1. This 41-year-old woman’s preoperative photograph
demonstrates upper pole rippling of the left breast.
Rippling And Wrinkling
Indications
Rippling and wrinkling following prosthetic breast reconstruction after total mastectomy are relatively common
because the patient’s skin flaps are generally thin and
predisposed to implant visibility. Initially following reconstruction, rippling and wrinkling may not be visible; however, over time, as the swelling subsides and the tissues
relax, it can become more evident. It occurs most commonly superiorly but can also occur in the middle or lower
pole of the reconstructed breast. Although rippling can
occur with any type of device, it has been reported more
often with saline or textured-surface implants.10,11
Traditional Management
Traditional methods for correction of rippling have
included converting from a saline implant to a silicone gel
implant, placement of smooth-surface devices, and autologous fat grafting.12-14 Although these methods can be effective in certain situations, persistent rippling and wrinkling
are not uncommon. More aggressive methods of correction include conversion to autologous reconstruction.
ADM Technique
The placement of ADM for rippling and wrinkling
has been previously evaluated.4 The techniques for this
Figure 2. The ADM is placed in the implant pocket with an
onlay technique, with the dermal surface along the capsule.
purpose are relatively simple and can be completed via one
of two methods. The first method is a capsular onlay graft,
and the second is a lower pole suspension technique.
When ADM will be placed as an onlay graft, the area of
rippling and wrinkling is marked preoperatively with the
patient standing (Figure 1). In the operating room, the
implant is removed and placed in an antibiotic saline solution. Usually, the capsule is relatively thin and does not
need to be scored or removed. In these cases, we prefer to
place the ADM directly on the capsule, between the capsule and the implant. The dermal side is placed in direct
contact with the capsule and anchored to the periphery of
the capsule with a monofilament suture (Figure 2). The
implant is then reinserted into the breast pocket, and the
ADM is redraped over the implant. The edges of the dermal graft are sutured to the overlying capsule with a 3-0
monofilament suture in an interrupted fashion. The pocket
is irrigated with an antibiotic saline solution. A closedsuction drain is usually inserted and left until the effluence
subsides. Postoperative results have been generally good
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Aesthetic Surgery Journal 31(7S)
Figure 3. The ADM demonstrates adherence to the surface
of the capsule.
Figure 4. The 41-year-old woman featured in Figure 1 shows
no evidence of rippling one year after a secondary correction
with ADM.
Figure 5. This 48-year-old woman’s preoperative
photograph demonstrates rippling and wrinkling.
Figure 6. The ADM material is inserted with the
reconstructive technique. It is sutured to the inframammary
fold and to the edge of the pectoralis major muscle.
to excellent, demonstrating adherence of the ADM and
improvement of rippling and wrinkling (Figures 3 and 4).
This onlay technique has been employed for rippling and
wrinkling located in the upper pole, midpole, and lower pole
of the breast. There are two explanations for ADM’s mechanism of action in these settings. The first is that the ADM
provides additional thickness to the tissues, making the
device less visible. The second is that the interface between
the implant and the ADM is modified and thereby different
than that of the device and the capsule. This difference may
result in decreased visibility of the device.
The second option for ADM placement in this setting is
as a lower pole suspension graft, also known as the
“reconstructive technique.” As with the onlay technique,
the area of rippling is delineated (Figure 5). This technique
is very similar to those used for primary prosthetic reconstruction, in which the ADM is sutured to the inframammary fold and to the inferior edge of the pectoralis major
muscle (Figure 6). The goal of this operation is to support
the lower pole of the breast and elevate the device to fill
the upper pole. Postoperative results have generally demonstrated improved outcomes with less rippling (Figure 7).
Capsular Contracture
Indications
The optimal management of CC continues to challenge
plastic surgeons.15 It is generally accepted that the incidence of Baker Grade 3 to 4 CC cases will increase over
time and ranges from 10% to 15% after 10 years in the
nonradiated breast.16 These capsules usually require surgical intervention. Grade 2 capsules are more common but
usually do not require surgical management. The etiology
of CC is multifactorial and includes, but is not limited to,
myofibroblast activity, radiation injury, biofilm, low-grade
infection, foreign body reaction, and blood products.
Nahabedian and Spear
Figure 7. The 48-year-old woman featured in Figure 5 shows
no evidence of rippling or wrinkling three months after a
secondary correction with ADM.
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Figure 8. This 38-year-old woman’s preoperative
photograph demonstrates capsular contracture of the left
breast following breast conservation therapy.
Traditional Management
There have been several maneuvers designed to alleviate
the effects of CC. Traditional options have included capsulectomy, capsulotomy, implant exchange, pocket conversion, mechanical manipulation, and most recently,
ADM placement.15,17,18 Although these techniques have
occasionally proven successful, issues remain with consistency, long-term stability, and recurrence. The search
for alternative techniques continues.
ADM Technique
ADM materials have shown some promise in the management of CC. The idea of placing ADM for this indication
stems from the observation that there has been very little
if any capsule formation around the portion of the implant
in contact with ADM. The ADM materials that have been
used for this purpose include AlloDerm and Strattice, both
of which have demonstrated some benefit. Although there
are several theories as to why ADM may be beneficial, the
one that deserves mention is based on the elastic properties of the materials.18 Given that one of the primary needs
in the setting of CC is elasticity, the ideal ADM is one with
inherent elasticity, such as AlloDerm. The ability of revascularized and recellularized AlloDerm to stretch once
implanted into the body has been previously documented.19 Its role in the management of CC is currently
under study, but the premise for its placement is to prevent capsule formation, provide elasticity in an inelastic
environment, and theoretically inhibit or minimize the
spherical contractile process.
The technique of using ADM for CC is relatively straightforward and can be completed with one of two methods. The
first method is the “reconstructive technique,” which can be
performed following a total or posterior capsulectomy. The
second method is the “patch technique,” which can be performed after a large capsulectomy. In some situations, such
as when the capsule is of intermediate thickness, a neosubpectoral pocket may be dissected.
The initial evaluation includes an assessment of the
skin thickness and texture (Figure 8). Following capsular
Figure 9. The ADM is placed as an onlay/inlay graft
following partial capsulectomy.
release, excision, or neosubpectoral pocket formation,
the ADM is placed within the breast implant pocket,
with the dermal surface facing the soft tissue (Figure 9).
The edge of the ADM is sutured to the adjacent perimeter of the breast implant pocket. The new device is
inserted, the ADM is redraped over the device, and the
ADM is then sutured to the surrounding tissue. A
closed-suction drain is placed and remains for five to
seven days. Early experience has demonstrated success
with an overall improvement in breast contour and skin
texture (Figure 10).
Implant Displacement
Indications
Malposition of an implant is another condition that
can sometimes pose a challenge to the reconstructive
surgeon.20 Malposition, for the purpose of this section,
is defined as inferior or lateral displacement of an implant.
The etiology of malposition is multifactorial. Inferior
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Figure 10. The 38-year-old woman featured in Figure 8
shows improvement in the degree of capsular contracture at
three-month follow-up.
Aesthetic Surgery Journal 31(7S)
Figure 11. This 40-year-old woman’s preoperative
photograph demonstrates inferior displacement of the left
breast implant following two-stage prosthetic reconstruction.
including both single or multilayer repairs. These methods
are often effective; however, there may be a relatively high
recurrence rate associated with these methods because the
capsule and underlying soft tissues that lead to the malposition in the first place are often of poor quality or thickness, which can cause failure.
ADM Technique
Figure 12. The 40-year-old woman featured in Figure 10
demonstrates good symmetry following capsulorraphy and
support of the inframammary fold with ADM.
displacement may result from undermining below the level
of the inframammary fold during the mastectomy. It can
also occur with the placement of a larger device that
exceeds the capacity of the soft tissues to adequately support it. Lateral displacement can occur because of inadequate control of the lateral mammary fold during the initial
reconstruction. Other unproven and less likely etiologies
include excessive pectoral muscle contraction during exercise as well as sleeping in the prone position with pressure
and shear forces that may result in lateral displacement.
Traditional Management
Traditional management of displacement has included
capsulorraphy of the inferior or lateral breast pocket.20,21
There are a variety of different techniques of capsulorraphy,
ADM has shown promise for implant displacement repair.
The ADM has been used as a primary method of repair
as well as following failure of other techniques. Given
that the principal need in this situation is support, inelastic ADM formulations such as Strattice may be preferred.
The goal of treatment is to produce a “cul-de-sac” inferiorly or laterally to prevent the device from migrating. The
initial evaluation includes an assessment of tissue quality
and degree of displacement (Figure 11). The most durable management is achieved through a two-maneuver
technique. The first surgical maneuver is to perform a
capsulorraphy or a neopocket dissection in the standard
fashion. The second maneuver is to reinforce this repair
with ADM. Various-sized grafts may be placed, ranging
from small to large (ie, a 16 × 6-cm sheet) depending on
the circumstance. The ADM is prepared in the standard
fashion. The material is positioned in the breast pocket
lengthwise such that half of the ADM is resting on the
posterior chest wall and the other half is over the mastectomy skin flap or capsule. The authors’ preferred
technique includes placing absorbable monofilament
sutures, anchoring the ADM to the chest wall. The device
or temporary sizer is inserted, after which the ADM is
redraped over that device and sutured to the inferior or
lateral mastectomy skin flap or capsule. A single drain
may be inserted. The space is copiously irrigated with an
antibiotic saline solution. The dermis and epidermis are
Nahabedian and Spear
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Figure 13. This patient shows evidence of synmastia
following bilateral mastectomy.
Figure 14. The ADM is sutured to the lateral sternal border
and redraped over the medial mastectomy skin flaps.
closed in the standard fashion. Early results with this
technique are encouraging (Figure 12).
is performed immediately (Figure 13) either in the setting
of prosthetic or autologous reconstruction. The first step is
to determine exactly how the skin should be positioned
over the sternum in order to restore the natural contour of
the breast. This is accomplished by sitting the patient up
approximately 45° to 60°, allowing the skin to redrape
over the sternum naturally. Sutures are placed to anchor
the overlying skin to the midsternum. This repair is then
reinforced with ADM. The size will be based on the length
of the synmastia defect. Typically, a single 16 × 5-cm
sheet of Strattice or a 16 × 6-cm sheet of AlloDerm is cut
in half, resulting in two sheets that are 8 cm in length. (An
8 × 8-cm piece of Strattice is also commercially available.)
The sheets are positioned medially along the sternal border, making a “cul-de-sac” on the right and left breast
(Figure 14). The ADM is then sutured along its perimeter.
A closed-suction drain is often included. The prosthetic
space is copiously irrigated with an antibiotic saline solution. Following this repair, autologous or prosthetic reconstruction is completed. Early results have been especially
encouraging with this technique (Figure 15).
Synmastia can also occur in a delayed fashion following
prosthetic reconstruction. The technique for repair is
similar in these cases. The devices are removed and placed
in an antibiotic saline solution. The length of the synmastia deformity is measured, and an appropriate length of
ADM is obtained. The initial sutures are placed either
along the medial chest wall (abutting the sternal edge) or
along the sternal edge. The devices or sizers are reinserted, and the remaining sutures are placed along the
edge of the ADM to the capsule. A closed-suction drain
may be placed.
Synmastia
Indications
Synmastia is defined as a medial displacement of the implant
beyond the sternal midline. Typically, this is seen in the setting of bilateral reconstruction, where the respective implant
pockets for right and left devices appear to or actually communicate. This can occur immediately following bilateral
mastectomy in which the mastectomy pocket has been overdissected, resulting in a monopocket, or it can occur following completion of the reconstructive process because of
attenuation of the medial pocket/capsule.
Traditional Management
Traditional management of synmastia in the setting of breast
reconstruction has involved suture techniques. The adipocutaneous layer over the sternum is sutured to the lateral aspect
of the sternum. Although this may be successful in some
situations, there is a common tendency for the condition to
recur, especially when the quality of the soft tissues is poor
or when the devices are too large for the pocket dimensions.
Another more recently-described management option is the
dissection of a neosubpectoral pocket.20
ADM Technique
The technique of placing ADM for the correction of synmastia is similar to that of inferior or lateral implant displacement. The goal of ADM is to provide structural
support to the pocket; therefore, the more collagen-dense
materials such as Strattice may be preferable. When synmastia is noted at the time of mastectomy, the correction
Incisional Support
Indications
Incisional support in the setting of prosthetic breast reconstruction is sometimes necessary. Incisional dehiscence
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Figure 15. This 54-year-old woman demonstrates a
natural sternal cleavage plane following bilateral breast
reconstruction with deep inferior epigastric perforator (DIEP)
flaps.
Figure 16. Impending incisional dehiscence following
prosthetic breast reconstruction and radiation therapy.
can occur in some situations and has, on occasion,
resulted in loss of the implant. These scenarios are more
common in the setting of previous radiation therapy, such
as in cases of recurrence following breast conservation
managed via mastectomy and prosthetic reconstruction.23
Other situations where incision dehiscence is a risk
include women with thin skin or thin mastectomy flaps
that have large or high-profile implants in place. The pressure placed on the incision over time may cause the incisional scar to attenuate and eventually dehisce.
Reinforcement of these incisions is often necessary.
The placement of ADM for incision support has become
acceptable based on its successful implementation in
some of these situations, both when the patient has
undergone previous radiation and when she has not
(Figure 16). The technique involves excision of the old
mastectomy scar and conservative excision of the adjacent attenuated skin. Overexcision will result in a contour difference. The device can be downsized by 50 to
100 mL in order to minimize the pressure applied on the
repair. In the event that downsizing the diameter is undesirable, downsizing can be accomplished by switching
from a high-profile to a lower-profile device. Patients are
usually understanding when the reasons for this maneuver are explained.
Typically, a marginal capsulectomy is included, and the
capsule above and below the incision is scored. The size of
the ADM is variable but can be as large as 16 × 6 cm. The
dermal surface is placed along the capsule and secured with
absorbable monofilament sutures (Figure 17). A single
closed-suction drain is recommended. The space is irrigated
with an antibiotic saline solution. In these cases, the skin
closure is modified. Typically, the skin is closed with subcuticular sutures; however, with incisional dehiscence, the
skin is closed with deep dermal absorbable sutures as well
as epidermal nonabsorbable sutures placed with a vertical
mattress technique. These sutures remain in place for 10 to
14 days. Early results have demonstrated success with this
technique (Figure 18).
Traditional Management
Optimal management of incisional dehiscence requires an
appreciation and understanding of the etiology. The first
requirement is to rule out infection. If there is purulence
in the pocket upon exploration, the reconstruction should
be aborted, the pocket debrided and irrigated, the tissues
closed, and a delayed reconstruction is recommended. If
infection is ruled out, then mechanical factors such as
increased tension due to thin skin or a large implant are
considered. Salvage of the reconstruction is possible in
this setting, but the device is almost always exchanged
because of the likelihood of contamination or subclinical
infection. In the case of previous radiation with thin skin,
future recurrence is likely because of the poor quality of
the soft tissues. Usually, one or two attempts at repair are
attempted; however, in the event of recurrent dehiscence,
conversion to an autologous form of reconstruction is considered. Surgical maneuvers directed at minimizing this
occurrence include approaching the device pocket through
an alternate incision such as the lateral mammary fold or
inframammary fold outside the zones of injury.
ADM Technique
Pocket Conversion/Modification
Indications
Pocket conversion or modification is a valuable tool in the
setting of prosthetic breast reconstruction. This technique
Nahabedian and Spear
Figure 17. Following skin edge debridement, a sheet of
ADM material is placed along the capsular surface above and
below the incision.
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Figure 18. This 50-year-old woman demonstrates no further
incisional problems at two-year follow-up.
has been effective in these cases.22 Animation deformities
due to pectoral muscle contraction are challenging in a
way that can be difficult to manage. Traditional maneuvers
have included device placement above the muscle or temporary agents to paralyze the muscle.
ADM Technique
Figure 19. This 43-year-old woman is shown after bilateral
prosthetic breast reconstruction with a total submuscular
pocket prior to secondary reconstruction.
is considered for subpectoral to subcutaneous conversions, total subpectoral to partial subpectoral with ADM,
and partial subpectoral without ADM to partial subpectoral with ADM. The reasons for pocket conversion or
modification include but are not limited to CC, pocket
displacement, chronic pain, a high-riding implant, animation deformity, and rippling/wrinkling.5
Traditional Management
There are several methods by which pocket conversion or
modification is accomplished.21,22 Perhaps the most notable is conversion from a subglandular device position to a
subpectoral position because of CC. Capsulorraphy with
marionette sutures for stabilization of the pectoral muscle
ADM has been applied for total subpectoral to partial subpectoral and for subpectoral to prepectoral conversions.
The specific technical details for pocket conversion are
similar to primary reconstruction. The initial evaluation
includes information about the degree of CC, relative position of the implants, location of the inframammary folds,
and symmetry (Figure 19). First, the breast pocket is
accessed through existing incisions. The implant is temporarily removed and placed in an antibiotic saline solution.
For devices that were placed in the total submuscular position, the old implant is removed, and the subpectoral portion of the pocket is entered. A new subcutaneous pocket
is dissected inferiorly and inferolaterally to the edge of the
pectoralis major muscle. The old submuscular pocket
beyond the inframammary fold is then closed off. The
superior capsule is incised to permit better redraping, and
the inframammary fold is defined. The ADM is placed
along the lower pole of the new portion of the pocket
(along the inframammary fold) and tacked down with an
absorbable monofilament suture. The device is replaced,
the pocket is irrigated, and a closed-suction drain is
inserted (Figure 20). The superior edge of the ADM is
sutured to the inferior edge of the pectoralis major muscle,
followed by skin closure. The implant is then in a partially-subpectoral or dual-plane space (Figure 21).
For animation deformities, the technique for ADM
placement is modified. The initial assessment includes
documentation of the location and degree of animation; it
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Aesthetic Surgery Journal 31(7S)
Figure 21. This 43-year-old woman’s early postoperative
photograph demonstrates better inframammary fold definition.
This patient was featured in Figures 19 and 20.
Figure 20. The reconstruction is converted to partial muscle
coverage and ADM.
is also important to ensure that the adipocutaneous layer
is of sufficient thickness (Figure 22). Following temporary
removal of the device, the prepectoral plane is recreated
(Figure 23). The pectoralis major muscle is returned to its
natural position on the chest wall. A sheet of ADM is
placed along the upper and/or lower pole of the breast for
additional support of the device as well as to increase the
thickness of the surrounding soft tissues (Figure 24). The
pocket is irrigated with a standard antibiotic solution, and
a closed-suction drain is inserted. The device is reinserted,
and the skin is closed in the standard fashion. Although
this technique can be successful, careful patient selection
is important (Figure 25).
Figure 22. This 51-year-old woman’s preoperative
photograph demonstrates animation deformity with pectoral
contraction after prosthetic reconstruction of the right breast.
Nipple reconstruction is usually the last phase in the
reconstructive process. Expectations are that the reconstructed nipple will resemble the natural nipple to some
degree. Patient satisfaction studies have demonstrated that
the primary area of dissatisfaction involves lack of projection.24 It is also well known that nipple projection will
decrease from 30% to 70% by two years.25
concerns over lack of projection, various materials have
been suggested to supplement or augment projection of
the reconstructed nipple. These include dermis, fat,
bone, and cartilage. These materials can be placed at
the time of primary nipple reconstruction or secondarily
in the event of flattening. Despite some success, there
are drawbacks of these materials that limit their
efficacy, including resorption of autologous dermis and
fat as well as erosion of the skin flaps following placement of cartilage or bone. The search for an ideal filler
material has led to the placement of ADM.
Traditional Management
ADM Technique
There are various techniques described for creation of a
nipple.26 Most rely on autologous tissue in the form of
local flaps or remote grafts. In an attempt to overcome
The technique of nipple reconstruction with ADM is
relatively simple and has been previously described.6,27
The concept is based on placing the ADM between the
Nipple Reconstruction
Indications
Nahabedian and Spear
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Figure 23. The subpectoral space is obliterated, and a
prepectoral pocket is created.
Figure 24. A sheet of ADM is placed between the implant
and the lower mastectomy skin flap.
Figure 25. The 51-year-old woman featured in Figure
22 demonstrates resolution of the animation deformity
and improved symmetry six months after prosthetic
reconstruction of the right breast.
Figure 26. An outline of a CV flap for secondary nipple
reconstruction following premature flattening.
opposing vascularized local skin flaps. If a local flap
technique is employed, the design for the nipple flap
(usually a CV flap) is delineated (Figure 26). The ADM
is hydrated with a two-bath technique. If the local flaps
are thick (eg, latissimus dorsi flaps), the ADM is usually
inserted between the opposing skin flaps as a strut
(Figure 27). If the local skin flaps are thin (eg, prosthetic breast reconstruction), then the ADM is folded in
half or rolled into a small sphere. In the setting of
autologous reconstruction, it is recommended to suture
the upper edge of the ADM to the tip of the nipple flap
to prevent displacement or sinking. This maneuver is
less necessary in the setting of prosthetic reconstruction
because the implant usually prevents downward displacement. It is imperative to avoid excessive tension at
the time of closure to minimize the incidence of skin
necrosis. The typical projection of the nipple ranges
from 8 to 12 mm (Figure 28). Final projection ranges
from 3 to 5 mm. Placement of ADM is not recommended in radiated tissues.
Other techniques with ADM for nipple reconstruction
have been described. Some authors have advocated
placing the ADM directly under the nipple, obviating
the need for opposing skin flaps.28 A 10-mm curved incision is made, and a subdermal pocket is dissected. The
ADM is formed into the shape of a cylinder or oblong
construct and placed into the pocket. Others have advocated placing the leftover fragments of ADM on the
pectoralis major muscle following primary prosthetic
reconstruction.29 This banked ADM is later retrieved
for nipple reconstruction with the opposing skin flap
techniques.
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Figure 28. This immediate postoperative photograph of the
reconstructed nipple demonstrates good projection.
ADM Technique
Figure 27. A small piece of ADM is inserted between the
opposing skin flaps of the nipple reconstruction.
Delayed Reconstruction
Indications
Delayed reconstruction is often recommended in cases of
locally-advanced breast cancer and sometimes preferred
by patients regardless of the tumor’s stage. Despite the
widespread acceptance of immediate reconstruction, there
are several advantages for delaying reconstruction. One
advantage is to allow for adequate healing of the mastectomy skin flaps prior to the reconstruction. In some ways,
this can yield improved results and fewer local complications. Another advantage is to allow for completion of all
adjuvant treatments such as chemotherapy and radiation
therapy. Although chemotherapy does not usually limit
reconstructive options, radiation therapy can.
Traditional Management
Fortunately, delayed reconstruction can provide excellent
outcomes with either prosthetic devices or autologous tissues. In patients who have not undergone postoperative
radiation, either a prosthetic device or autologous tissue
can be utilized. After postoperative radiation has been
completed, prosthetic devices do not fare as well because
it is difficult to expand the skin of the radiated chest wall.
Autologous tissue options are more frequently considered.
When delayed prosthetic reconstruction is selected, it is
almost always completed in two stages. A tissue expander
is placed first, followed a few months later by a permanent
implant. Postoperative complications can include CC,
implant displacement, and breast asymmetry.
ADM has been useful in the setting of delayed reconstruction with prosthetic devices. The relative contraindications
include previous radiation and obesity. Ideal candidates are
those who have had skin- or nipple-sparing mastectomy
with some degree of skin redundancy (Figure 29). The purpose of placing ADM in these cases is to redefine the
inframammary fold and allow for increased skin recruitment and expansion with a partial muscle coverage technique. The mastectomy defect is addressed by first elevating
the adipocutaneous layer off the pectoralis major muscle.
This may include undermining and recruiting adjacent skin
inferiorly and laterally. The subpectoral plane is then dissected. The hydrated ADM is placed into the breast pocket,
with the inferior edge sutured to the inframammary fold
and lateral mammary fold (just as it is with immediate
reconstruction). The tissue expander is then inserted, and
the pocket is irrigated in the standard fashion. Two closedsuction drains are usually placed above and below the ADM
at the level of the inframammary fold. The upper edge of
the ADM is sutured to the inferior edge of the pectoralis
major muscle (Figure 30). Unlike in primary reconstruction,
where the device is typically filled to 50% to 70% of capacity, the expander is usually filled to 25% to 50% of capacity
with delayed reconstruction. The benefits of this approach
are to compartmentalize the device, avoid total muscle coverage, theoretically minimize the incidence of CC, and
improve aesthetic outcomes. Early results have demonstrated success with this technique (Figure 31).
Managing Complications
Associated With Adm
Complications following revisions with ADM can sometimes occur. These include but are not limited to cutaneous erythema, seroma, and exposure. The etiology of
cutaneous erythema associated with ADM is poorly understood but is most likely related to inadequate hydration
Nahabedian and Spear
Figure 29. This 45-year-old woman is shown prior to
secondary reconstruction but following bilateral skin-sparing
mastectomy. The patient was not radiated postoperatively.
and persistent cryopreservatives. This erythema is likely
secondary to an inflammatory reaction, but infection
must be ruled out. A course of antibiotic is recommended,
but the erythema is typically self-limiting and resolves
spontaneously.
The occurrence of a seroma can be troublesome. The
presence of a small seroma (less than 20 mL) typically
does not require aggressive management and usually
spontaneously resolves. However, larger seromas may
require aspiration or surgical evacuation. Exposure of
the ADM can be problematic and tends to occur more
frequently in patients who have thin skin flaps following mastectomy. When the exposure is small (less than
3 cm), the wound is usually debrided in the office under
sterile conditions, and the skin is secondarily closed.
Larger areas of exposure are usually managed in the
operating room. Exposure in the setting of purulence
almost always requires removal of the ADM and device.
Exposure in the setting of tobacco use and radiation can
also occur. With tobacco use, the problem is primarily
vascular in origin and often requires debridement of the
necrotic skin and removal of the ADM. With radiation,
the exposure may be secondary to poor wound healing
and tension, and it can be managed with debridement
and tension-free closure.
Conclusions
The placement of ADM for secondary revisions following
prosthetic breast reconstruction has proven beneficial.
ADM has facilitated the correction of many deformities
associated with varying degrees of treatment difficulty and
recurrence. ADM is well tolerated and appears to yield
long-lasting results. There is a learning curve associated
with ADM placement that includes proper technique and
patient selection. Plastic surgeons should consider these
materials when appropriate.
49S
Figure 30. After addressing the mastectomy defect, the
ADM is secured to the inframammary fold and inferior edge
of the pectoralis major muscle.
Figure 31. The 45-year-old woman featured in Figure 29 is
shown six months after permanent implant placement.
Disclosures
The authors declared no potential conflicts of interest with
respect to the research, authorship, and publication of this
article.
Funding
Publication of the articles in this supplement was supported
by a grant from LifeCell.
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