Aesthetic outcomes of acellular dermal matrix in tissue expander/implant-based breast reconstruction.

INTRODUCTION: Tissue expander and implant-based breast reconstruction after mastectomy is the most common method of breast reconstruction. Modifications of the traditional total submuscular reconstruction (TSR) have been made using acellular dermal matrix (ADM) to create an inferolateral sling and a more natural implant pocket for superior aesthetic results. The objective of this study was to assess aesthetic outcomes when using ADM in breast reconstruction. METHODS: A retrospective chart review identified all patients who underwent implant-based breast reconstruction from 2005 to 2009 at our institution. Demographic information, complications, reoperations, and aesthetic outcome data were collected for all patients meeting inclusion criteria related to adequate follow-up and postoperative photographs. Five aesthetic outcomes were evaluated for all study patients by 18 blinded evaluators using postoperative photographs. Outcomes were scored on a scale of 1 to 5, with 5 representing the best possible aesthetic score. RESULTS: A total of 122 patients underwent 183 tissue expander-based reconstructions (ADM, n = 58; TSR, n = 125). The infection rate in patients with ADM was 16.2% compared to 5.9% in TSR patients, but this was not statistically significant (P = 0.09). Capsular contracture was more common in TSR patients (23.5%), compared to those with ADM (8.1%), P = 0.048. Aesthetic scores from the attending plastic surgeons were as follows: natural contour (ADM, 3.36; TSR, 3.02; P = 0.0001), symmetry of shape (ADM, 3.57; TSR, 3.27; P = 0.005), symmetry of size (ADM, 3.68; TSR, 3.42; P = 0.002), position on chest wall (ADM, 3.75; TSR, 3.45; P = 0.004), and overall aesthetic appearance (ADM, 3.56; TSR, 3.20; P = 0.0001). CONCLUSIONS: For all 5 aesthetic parameters evaluated, the ADM group scored significantly higher than the TSR group by 18 blinded evaluators. These consistent findings suggest that the use of ADM in breast reconstruction does confer a significant advantage in aesthetic outcomes for breast reconstruction. This is likely at the cost of a higher infection rate when using ADM; however, that may be offset by the advantage of a lower rate of capsular contracture in patients with ADM.

Breast cancer reconstruction in the elderly.

Mastectomy is a surgical choice for breast cancer, yet breast reconstruction is underused in women older than age 60 years. Because of a paucity of information examining breast cancer reconstruction in the elderly, we sought to review our experience. By retrospective chart review, we evaluated 89 women older than 60 years having mastectomy and reconstruction from January 1998 to June 2008. Mean patient age was 65 years (range, 60 to 74 years). The majority (41%) had Stage 1 disease or Stage 2 (30%). Ductal carcinoma in situ comprised 25 per cent and Stage 3 totaled 2 per cent. Mastectomy for ipsilateral breast tumor recurrence after radiation therapy and lumpectomy comprised 11 per cent. Most underwent immediate breast reconstruction (89%). Reconstructive techniques included two-stage implant (58%), transverse rectus abdominus musculocutaneous (TRAM) flap (10%), latissimus dorsi musculocutaneous flap with implant (2%), or deep inferior epigastric perforator flap (1%). Complications included a 12 per cent infection rate, removal of two expanders resulting from exposure, one TRAM failure, and one TRAM required débriding. Four patients undergoing mastectomy with tissue expander had radiation resulting in one expander being removed. One local skin recurrence was treated with removal of implant and skin resection. Two patients have died from metastatic disease. Age should not be a contraindication for breast reconstruction in elderly women.

Efficacy of preoperative autologous blood donation in free TRAM flap breast reconstruction.

BACKGROUND: The authors critically evaluated the use of autologous blood donation in patients who had surgical breast reconstruction using the free transverse rectus abdominis musculocutaneous (fTRAM) flap technique following mastectomy. METHODS: A retrospective chart review of 201 patients was performed. Patients were operated on at one community hospital and one university hospital. Cohorts of 101 blood donors and 100 control nondonors were established. Demographic and premorbid factors and primary outcome variables were evaluated. RESULTS: The autologous donor and nondonor groups were not statistically different in any demographic categories, and there were no significant differences in premorbid factors between the two groups. Total surgical complications were more common in the autologous donor group (48 percent versus 28 percent; p < 0.004). The autologous donor group was also more likely to receive a transfusion intraoperatively (13 percent versus 0 percent, p < 0.001) or postoperatively (28 percent versus 5 percent, p < 0.001) compared with the nondonor group. CONCLUSIONS: Few patients in the nondonor group required perioperative transfusion, and fewer than half of the donors received their blood back. There was a statistically significant higher rate of surgical complications associated with autologous blood donation, most likely due to relative preoperative anemia. Autologous donation was associated with a significantly higher rate of transfusion intraoperatively and postoperatively. The authors do not recommend autologous blood donation before free TRAM flap autogenous breast reconstruction.