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Use Of Acellular Dermal Matrix (ADM) In Breast Reconstruction

May 17th, 2013

Use Of Acellular Dermal Matrix (ADM) In Breast Reconstruction

 Introduction

Acellular Dermal Matrix  (ADM), or biological mesh, was introduced in the UK towards the end of 2009 and has gradually become an important aid to oncoplastic breast surgery. It has been used very successfully in the USA since 2004 in the field of breast reconstruction after mastectomy and in abdominal wall reconstruction for repairs of large incisional hernia and grade IV incisional hernias. Use of acellular dermal matrix (ADM) is on the increase in the UK since its introduction in 2009.

Most often derived from human (e.g. Alloderm) or porcine dermis (e.g. Strattice), these materials have been processed to acellular, porous extracellular matrix scaffolds of collagen and elastin. Some source growth factors remain and attract endothelial cells and subsequent fibroblasts into the mesh. In other words, donor skin is transformed into a strong material – a patch of sorts – that is designed to merge naturally with the patient’s own tissue and encourage new growth.

The host cells release additional chemo-attractants that signal the migration of other structural cells. The multi-dimensional nature of the mesh and porosity allow cells to enter the mesh and adhere. This is followed by a cycle of remodelling consisting of degradation of the biologic mesh and regeneration of the collagen scaffold with host tissue including neoangiogenesis in some instances (formation of new blood vessels). The balance of this degradation and rebuilding process, and the speed with which it occurs, influences the ultimate strength and structural integrity of the biologic mesh reconstruction.

 

Indications and uses of acellular matrix (ADM) in breast reconstruction

Initially biological meshes were exclusively used for hernia repairs, especially large incisional and contaminated hernia, but in the last few years their usefulness in breast reconstruction has been recognised.

Following are the most common indications for the use of ADM in the breast:

  1.          Immediate reconstruction with skin sparing mastectomy
  2.          Delayed reconstruction
  3.          Revision reconstruction
  4.          Implant palpability and rippling
  5.          Re-establishing IMF in implant-based reconstruction
  6.          Immediate reconstruction when adjuvant radiotherapy is anticipated

Oncoplastic surgeons in the UK have not been quick to add this technique to their repertoire, mainly because of the cost: biological mesh is very expensive. However, more and more surgeons are learning and using this technique, because studies show the “downstream cost” of biological mesh is low. In the long run, this mode of reconstruction is actually more economical compared to other forms of reconstruction.

Traditionally, surgeons have avoided doing implant-based reconstructions when radiotherapy is anticipated because of the fear of bad cosmetic results, but new data favours ADM-aided reconstruction with minimal post-radiotherapy damage to implant-based reconstructions.

Revision reconstruction is a difficult surgery, but with ADMs it has become possible to produce better results in both oncoplastic and cosmetic breast surgery. For instance it is invaluable in re-establishing the inframammary crease when definition is lost after implant-aided Latissimus Dorsi reconstruction. It is also very useful in dealing with a symmastia (“uniboob”) deformity.

One-stage delayed reconstruction with variable volume or permanent implant has now become possible with the introduction of biological mesh. Although not many surgeons are aware of this technique, it is easy to learn and produces very good cosmetic outcomes.

The company LifeCell has been running workshops to teach various techniques with ADM for a few years now with lectures on uses of acellular matrix (ADM) in breast reconstruction. I strongly recommend this workshop to anyone who is planning to use Strattice or any other ADM in his or her practice.

 

 

Pre-op ADM

 

 

 

 

 

 

Pre-operative: Cancer upper outer quadrant left breast. Acellular dermal matrix ADM (Strattice) aided reconstruction was opted by the patient after immediate ultra-skin sparing mastectomy.

 

Post-immediate ADM recon copy

Post-op: Left ultra-skin sparing mastectomy and immediate ADM (Strattice by LifeCell) aided reconstruction with implant (Allergan inspire TRX-375)

Filed in Augmentation / Mastopexy, Breast Augmentation, Breast Cancer Articles, Breast Enlargement, Breast Surgery, Cosmetic and Oncoplastic Breast Surgery, Cosmetic breast surgeon, Oncoplastic breast surgery.

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