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Minimizing Complications Associated With Use of Acellular Dermal Matrix in Implant-Based Breast Reconstruction
Ingrid Ganske, M.D., M.P.A.1, Kapil Verma, M.D.2, Heather Rosen, M.D., M.P.H.3, Elof Eriksson, M.D., Ph.D.4, Yoon S. Chun, M.D.4.
1Harvard Plastic Surgery Residency Program, Boston, MA, USA, 2Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Vanderbilt University Medical Center, Nashville, TN, USA, 4Brigham and Women's Hospital, Boston, MA, USA.

PURPOSE: Acellular dermal matrix (ADM) is a common adjunct to tissue expander (TE) and implant-based breast reconstruction. While ADM can enhance aesthetic outcome, its use has been associated with higher rates of post-operative seroma and infection. Specific procedural modifications have been made to reduce seroma and minimize complications when using ADM, including changes in drain position, drainage duration, and addition of post-operative soft compression. This follow-up study was performed to determine whether these modifications are associated with a reduction in the rate of complications associated with ADM-assisted implant-based reconstruction.
METHODS: The authors performed a retrospective analysis of consecutive immediate ADM-assisted TE/implant-based breast reconstructions performed by a single surgeon over an eighteen-month period following institution of specific modifications to prevent seroma. These measures included draining both the sub-mastectomy and sub-ADM planes (vs. sub-mastectomy plane only), lowering the threshold for drain removal to <20cc/24hrs (vs. <30cc/24hrs), and addition of post-operative soft compression dressings and surgical bras to optimize ADM apposition and reduce dead space. A total of 179 TE/implant-based reconstructions were evaluated for rates of complications, including seroma, infection, hematoma, and skin flap necrosis. These were compared to results of a consecutive series of 150 similar procedures performed by the same surgeon prior to institution of the procedural modifications described.
RESULTS: A total of 329 TE/implant-based breast reconstructions by a single surgeon were evaluated. Among these, 192 reconstructions were immediate ADM-assisted TE/implant-based reconstructions. 106 reconstructions were performed after implementation of the drain and post-operative management modifications and 86 reconstructions were performed prior to the modifications. Significant reduction in post-operative complication rates were noted. Seroma rate decreased from 18.6 to 4.7 percent (p=0.0022), and major infection rate decreased from 7 to 1.9 percent (p=0.0250). There was no significant difference in the rate of complications between the ADM-assisted TE/implant-based reconstructions compared to TE/implant-only reconstructions after the procedural modifications were employed.
CONCLUSION: While implant-based breast reconstruction using ADM has previously been associated with increased seroma and possible infection rates, specific clinical measures to prevent seroma can minimize the rate of these post-operative complications. Drainage of both the sub-mastectomy and sub-ADM pocket, drain removal threshold of <20cc/24hrs, as well as the use of soft compression dressings and bras post-operatively, can reduce seroma and infection rates. Careful patient selection and seroma reducing measures should be implemented to optimize overall reconstructive outcome when using ADM in immediate prosthetic breast reconstruction.


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