Prepectoral reconstruction with acellular dermal matrix (ADM) strattice

Abstract

The conventional mastectomies (modified radical mastectomy, simple mastectomy) are more and more replaced by conservative mastectomies (nipple-sparing mastectomy (NSM), skin-sparing mastectomy) without compromising the oncologic safety. Conservative mastectomies entail immediate autologous or heterologous breast reconstruction. For the implant-based breast reconstruction generally the subpectoral implant placement with a partial detachment of the pectoralis major muscle (PMM) is recommended. The advantage of a potentially better cosmetic result faces the disadvantages, such as partial dissection of the PMM with subsequent muscular deficit, breast animation deformity, and postoperative pain. Prepectoral implant placement and complete coverage of the implant with an acellular dermal matrix (ADM) could be an alternative and is described in this chapter. In a total of 70 breasts in 49 patients (21 bilateral, 28 unilateral) NSM and immediate direct-to-implant breast reconstruction was performed with prepectoral implant placement. The PMM was not dissected or detached at all. The implant was completely covered by a porcine ADM, which was sutured to the fascia of the PMM and the inframammary fold to keep the implant in place. Complications comprised minimal nipple necrosis without further intervention in four patients and hematoma with evacuation in four patients. Implant removal had to be performed in one patient after radiotherapy and massive edema and pain. Cosmetic results were excellent and patients were fully satisfied at a median follow-up of 16 months. Breast animation and implant displacement could not be observed. Implant rims were visible or palpable in the upper poles of the breasts in three very skinny patients and rippling was observed in two very skinny patients. Capsular contractures could not be observed, not even in patients treated with radiotherapy. Prepectoral implant placement and the complete coverage with a porcine ADM is a novel approach and may provide an alternative to the subpectoral implant placement with an excellent cosmetic result avoiding the disadvantages of the subpectoral implant placement.