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Three Hundred Thirty-one Consecutive Immediate Single Stage Breast Implant Reconstructions with Acellular Dermal Matrix in 211 Patients: Indications, Complications, Trends, and Patient Satisfaction
Amy S. Colwell, MD, Branimir Damjanovic, MD, Richard Reish, MD, Bita Zahedi, Laura Medford-Davis, Catherine Hertl, MD, William G. Austen, Jr., MD.
Massachusetts General Hospital, Boston, MA, USA.
Purpose: Immediate implant breast reconstruction with acellular dermal matrix (ADM) optimizes aesthetics by preserving the mastectomy skin envelope and controlling implant position. However, costs of ADM, infectious risks, and concerns of aesthetic result have deterred some surgeons from performing single stage implant reconstruction. We report the largest series of single stage implant reconstructions with ADM in the literature and describe indications, complications, trends, and patient satisfaction compared to two-stage tissue expander-implant reconstruction without ADM.
Methods: Retrospective review of three surgeon’s experience from a single institution was performed for immediate single stage breast reconstruction with ADM and tissue expander reconstruction without ADM from January 2006-April 2010. The Breast-Q was administered to assess patient satisfaction.
Results: Two hundred eleven patients (average 49 years old, range 27-81) had 331 single stage implant reconstructions using AlloDerm following nipple-sparing (66) or skin-sparing (265) mastectomy for cancer treatment (216) or prophylaxis (115). The number of single stage implant reconstructions increased from 7 in 2006 to 116 in 2009 (Figure 1). The percentage of reconstructions performed for prophylaxis increased from 29% to 41%. Fifty-one patients had preoperative (33) or postoperative (18) radiation treatment. Indications for single stage reconstruction included small to moderate sized breasts, a healthy skin envelope, and patient desire to be a similar or smaller size (Figure 2). Implant volume ranged from 125-800cc (average 420cc) and >97% were silicone compared to <3% saline. Total complications (13.6%) included 10 (3.02%) infections, 5 (1.6%) seromas, and 30 (9%) reconstructions with skin necrosis requiring operative revision (3 requiring implant removal and 5 with wound dehiscence). Tissue expander reconstruction without ADM had a similar rate of total complications (17.7%) (158 reconstructions): 9 (5.7%) infections, 3 (1.9%) seromas, and 16 (10%) reconstructions with skin necrosis (3 requiring tissue expander removal and 5 with wound dehiscence) (p=0.2). A higher total complication rate occurred in the surgeons’ combined first year performing single stage implant reconstruction 21.4% compared to subsequent years 10.9% (p<0.02) suggesting a learning curve with the technique. Patients had similar high scores in satisfaction with breasts (69 vs. 65) and psychosocial well-being (76 vs. 74) as measured by the Breast-Q in 125 patients with immediate implant vs. immediate tissue expander reconstruction.
Conclusions: Immediate single-stage implant reconstruction using AlloDerm offers a safe, aesthetically pleasing reconstruction with a low rate of complications and infections and a high degree of patient satisfaction. In patients with an adequate skin envelope and who are happy with their current breast size, this may be the procedure of choice.
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