Is single-stage implant-based breast reconstruction (SSBR) with an acellular matrix safe?: Strattice™ or Meso Biomatrix® in SSBR

A comparison of acellular dermal matrices (ADM) efficacy and complication profile in women undergoing implant-based breast reconstruction: a systematic review and network meta-analysis

INTRODUCTION

Breast cancer is the leading cause of cancer amongst women in the United Kingdom, with implant-based reconstruction (IBR) using Acellular Dermal Matrices (ADM) gaining popularity for post-mastectomy procedures. This study compares outcomes of different ADMs that are commonly used in women undergoing IBR, this was short and long-term complications.

METHODS

A systematic search of MEDLINE, Embase, CENTRAL, and CDSR databases was performed according to the PRISMA guidelines, focusing on women undergoing IBR with FlexHD, AlloDerm, Bovine, or Porcine ADMs. A network meta-analysis (NMA) was also conducted.

RESULTS

A total of 51 studies were captured by the search, of which 27 were included in the network meta-analysis. Alloderm was the most used ADM (54%), followed by Porcine (17%), Bovine (11%), DermAcell (11%), and FlexHD (7%). The mean follow-up was 27.8 months. The complication rates varied. Porcine ADMs had the highest rate of seroma formation (10.3%) and of haematoma formation (2.7%). AlloDerm FD had the highest rate of wound dehiscence (3.1%). Implant failure was highest in AlloDerm FD ADMs (11.8%), followed by Porcine ADMs (11.2%). Infections were most common in Porcine (11.2%) and AlloDerm FD ADMs (11.0%). Capsular contracture was rare across all ADM types, with no significant differences observed. In the NMA, AlloDerm FD showed significantly higher risks of infection, explantation, and wound dehiscence compared to AlloDerm RTU.

CONCLUSION

The overall complication profiles of ADMs used in IBR are similar, except for the higher risks associated with AlloDerm FD compared to RTU. These findings suggest that the choice of ADM may not significantly impact overall outcomes, except in specific cases like AlloDerm FD. Further high-quality, long-term, double-arm studies are necessary to confirm comparative profile of specific ADM types and to account for potential confounding variables through multivariable regression analysis.

The Usage of Mesh and Relevant Prognosis in Implant Breast Reconstruction Surgery: A Meta-analysis

BACKGROUND

Although mesh-based implant breast reconstruction surgery is emerging as the primary surgical procedure for breast reconstruction, mesh use remains controversial in implant breast reconstruction surgery, especially in terms of how to select the ideal mesh. Our aim is to elaborate relevant prognosis in the mesh-based implant breast reconstruction surgery.

METHODS

Relevant studies were identified from PubMed, Web of Science, EMBASE, and Cochrane library searches. Extracted data included study type, basic characteristics, mesh information, complications, etc. We analyzed the included cohort studies and randomized controlled trials that reported mesh-related implant breast reconstruction complications and breast quality scale scores.

RESULTS

A total of 32 studies including 7475 subjects were included. The results showed that the overall complication rate was 2.07 times higher in the biological mesh group than in the synthetic mesh group (risk ratio [RR]: 2.07, 95% CI 1.14-3.78). The risk of seroma was 4.50 times higher in the biological mesh group than in the synthetic mesh group (RR: 4.50, 95% CI 2.27-8.95). In terms of comparing breast quality scale scores, the mesh group had scores that were 1.49 (95% CI 0.19-2.78) higher than the non-mesh group for "physical well-being" and 2.05 (95% CI 0.08-4.02) higher for "sexual well-being."

CONCLUSIONS

Our study found that the risk of total complications was higher with biological mesh than with synthetic mesh in implant breast reconstruction surgery. Based on short-term cost, healthcare burden, and healthcare benefits, synthetic meshes are superior to biological meshes.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Decellularisation and Characterisation of Porcine Pleura as Bioscaffolds in Tissue Engineering

Persistent air leaks caused by thoracic surgery, physical trauma, or spontaneous pneumothoraces are a cause of patient morbidity with need for extended chest tube durations and surgical interventions. Current treatment measures involve mechanical closure of air leaks in the compromised pleura. Organ and membrane decellularisation offers a broad range of biomimetic scaffolds of allogeneic and xenogeneic origins, exhibiting innate tissue-specific characteristics. We explored a physicochemical method for decellularising porcine pleural membranes (PPM) as potential tissue-engineered surrogates for lung tissue repair. Decellularised PPM (dPPM) was characterised with histology, quantitative assays, mechanical testing, and sterility evaluation. Cytotoxicity and recellularisation assays assessed biocompatibility of decellularised PPM (dPPM). Haematoxylin and Eosin (H&E) staining showed an evident reduction in stained nuclei in the dPPM, confirmed with nuclear staining and analysis ( ∗∗∗∗ p < 0.0001). Sulphated glycosaminoglycans (sGAG) and collagen histology demonstrated minimal disruption to the gross structural assembly of core extracellular matrix (ECM) in dPPM. Confocal imaging demonstrated realignment of ECM fibres in dPPM against native control. Quantitative analysis defined a significant change in the angular distribution ( ∗∗∗∗ p < 0.0001) and coherence ( ∗∗∗ p < 0.001) of fibre orientations in dPPM versus native ECM. DNA quantification indicated ≥85% reduction in native nuclear dsDNA in dPPM ( ∗∗ p < 0.01). Collagen and sGAG quantification indicated reductions of both ( ∗∗ p < 0.01). dPPM displayed increased membrane thickness ( ∗∗∗ p < 0.001). However, Young's modulus (459.67 ± 10.36 kPa) and ultimate tensile strength (4036.22 ± 155.1 kPa) of dPPM were comparable with those of native controls at (465.82 ± 10.51 kPa) and (3912.9 ± 247.42 kPa), respectively. In vitro cytotoxicity and scaffold biocompatibility assays demonstrated robust human mesothelial cell line (MeT-5A) attachment and viability. DNA quantification in reseeded dPPM with MeT-5A cells exhibited significant increase in DNA content at day 7 ( ∗∗ p < 0.01) and day 15 ( ∗∗∗∗ p < 0.0001) against unseeded dPPM. Here, we define a decellularisation protocol for porcine pleura that represents a step forward in their potential tissue engineering applications as bioscaffolds.

Review: Implant-Based Breast Reconstruction After Mastectomy for Breast Cancer: A Meta-analysis of Randomized Controlled Trials and Prospective Studies Comparing Use of Acellular Dermal Matrix (ADM) Versus Without ADM

BACKGROUND

Breast cancer is the world's most prevalent cancer, and many breast cancer patients undergo mastectomy as the choice of treatment, often with post-mastectomy breast reconstruction. Acellular dermal matrix (ADM) use has become a method to improve outcomes of reconstruction for these patients. We aimed to compare postoperative complications and patient-reported outcomes, which are still poorly characterized, between groups utilizing acellular dermal matrix during reconstruction and those without.

MATERIALS AND METHODS

We searched electronic databases from inception to 16 June 2022 for randomized controlled trials and prospective cohort studies comparing the outcomes of patients who have and have not received acellular dermal matrix in implant-based breast reconstruction. The results were quantitatively combined and analyzed using random-effects models.

RESULTS

A total of nine studies were included, representing 3161 breasts. There was no significant difference in postoperative outcomes, such as seroma formation (p = 0.51), hematomas (p = 0.20), infections (p = 0.21), wound dehiscence (p = 0.09), reoperations (p = 0.70), implant loss (p = 0.27), or skin necrosis (p = 0.21). Only two of the studies included evaluated patient-reported outcomes between the use and non-use of ADM in implant-based breast reconstruction using BREAST-Q questionnaire, as well as self-reported pain. There was no reported significant difference in BREAST-Q or pain scores.

CONCLUSIONS

This meta-analysis shows comparable short- and long-term outcomes between ADM and non-ADM breast reconstruction, suggesting that the use of ADM may not be necessary in all cases given their additional cost. However, there is a paucity of data for patient-reported outcomes, and further research is required to determine whether ADM use affects patient-reported outcomes.

[Update and Trends in Breast Reconstruction After Mastectomy]

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

Risk of major postoperative complications in breast reconstructive surgery with and without an acellular dermal matrix; Development of a prognostic prediction model

Introduction

Acellular dermal matrices (ADM) have been suggested to allow for different approaches and reduce the risk of postoperative complications in implant-based breast surgery. Surgeons seem to embrace ADMs around the world, although a lack of consistent evidence regarding the factors that increase the risk of major postoperative complications remains.

Purpose

To develop and internally validate a model to predict the risk of a major postoperative complication in breast reconstructive surgery with and without an ADM.

Methodology

The DBIR is an opt-out registry that holds characteristics of all breast implant surgeries in the Netherlands since 2015. Using a literature-driven preselection of predictors, multivariable mixed-effects logistic regression modelling was used to develop the prediction model.

Results

A total of 2939 breasts were eligible, of which 11% underwent an ADM-assisted procedure (single-stage or two-stage). However, 31% underwent a two-stage procedure (with or without the use of ADM). Of all breasts, 10.2% developed a major postoperative complication. Age (OR 1.01), delayed timing (OR 0.71), and two-stage technique (OR 4.46) were associated with the outcome.

Conclusion

The data suggest that ADM use was not associated with a major postoperative complication, while two-stage reconstructions were strongly associated with an increased risk of major complications. Despite these findings, ADMs are not as popular in the Netherlands as in the USA. The predictive capabilities of the developed model are mediocre to poor, but because of the above findings, we believe that the role of the two-stage technique as a golden standard should be put up for debate.

Decellularized xenografts in regenerative medicine: From processing to clinical application

Decellularized xenografts are an inherent component of regenerative medicine. Their preserved structure, mechanical integrity and biofunctional composition have well established them in reparative medicine for a diverse range of clinical indications. Nonetheless, their performance is highly influenced by their source (ie species, age, tissue) and processing (ie decellularization, crosslinking, sterilization and preservation), which govern their final characteristics and determine their success or failure for a specific clinical target. In this review, we provide an overview of the different sources and processing methods used in decellularized xenografts fabrication and discuss their effect on the clinical performance of commercially available decellularized xenografts.

Extracellular matrix-based biomaterials as adipose-derived stem cell delivery vehicles in wound healing: a comparative study between a collagen scaffold and two xenografts

BACKGROUND

Stem cell therapies represent a promising tool in regenerative medicine. Considering the drawbacks of direct stem cell injections (e.g. poor cell localisation), extracellular matrix-based biomaterials (e.g. scaffolds and tissue grafts), due to their compositional biofunctionality and cytocompatibility, are under investigation as potential stem cell carriers.

METHODS

The present study assessed the potential of three commercially available extracellular matrix-based biomaterials [a collagen/glycosaminoglycan scaffold (Integra™ Matrix Wound Dressing), a decellularised porcine peritoneum (XenoMEM™) and a porcine urinary bladder (MatriStem™)] as human adipose-derived stem cell delivery vehicles.

RESULTS

Both tissue grafts induced significantly (p < 0.01) higher human adipose-derived stem cell proliferation in vitro over the collagen scaffold, especially when the cells were seeded on the basement membrane side. Human adipose-derived stem cell phenotype and trilineage differentiation potential was preserved in all biomaterials. In a splinted wound healing nude mouse model, in comparison to sham, biomaterials alone and cells alone groups, all biomaterials seeded with human adipose-derived stem cells showed a moderate improvement of wound closure, a significantly (p < 0.05) lower wound gap and scar index and a significantly (p < 0.05) higher proportion of mature collagen deposition and angiogenesis (the highest, p < 0.01, was observed for the cell loaded at the basement membrane XenoMEM™ group). All cell-loaded biomaterial groups retained more cells at the implantation side than the direct injection group, even though they were loaded with half of the cells than the cell injection group.

CONCLUSIONS

This study further advocates the use of extracellular matrix-based biomaterials (in particular porcine peritoneum) as human adipose-derived stem cell delivery vehicles. Comparative analysis of a collagen scaffold (Integra™ Matrix Wound Dressing) and two tissue grafts [decellularised porcine peritoneum (XenoMEM™) and porcine urinary bladder (MatriStem™)] as human adipose-derived stem cells carriers.

The modified serratus anterior fascia flap improves satisfaction and long-term results in immediate implant-based breast reconstruction: A retrospective study

After immediate implant-based breast reconstruction (IIBR) following skin-sparing mastectomy, postoperative complications such as implant exposure or badly defined mammary folds can occur. Acellular dermal matrix can provide good esthetic outcomes but remain expensive. This study evaluates a new technique of one-stage IIBR by using a modified serratus anterior fascia flap (MSFF group), providing lower implant coverage, as compared to the classical submuscular technique. In this retrospective study, we included all patients who underwent IIBR using either the MSFF technique or the classic technique between November 2012 and February 2015. We collected data regarding demographics, perioperative factors, postoperative complications, patient satisfaction (Breast-Q score), and esthetic outcomes. One hundred twenty-three patients who underwent IIBR, of which 61 breasts (59 patients) using the MSFF and 67 breasts (64 patients) the classical technique, were included. The size of the implants used were significantly higher in the MSFF group (p = 0.036). There were no statistically significant differences between the two groups with regard to the immediate complications rate. After a mean follow-up of 43.9 months, we observed more capsular contractures in the classic group (p < 0.001). In the classic group, patients required more revision surgeries (p = 0.008), more implant changes (p < 0.001), and higher volume of additional lipofilling (p < 0.001). According to the Breast Q scores, patients' satisfaction was better in the MSFF group regarding their breasts (p = 0.001) and the outcomes (p = 0.009). The MSFF is a simple, safe, effective, and inexpensive autologous technique for IIBR, which improves implant coverage with a vascularized flap and provides satisfying outcomes as compared to classic IIBR, with less complications.

Porcine mesothelium matrix as a biomaterial for wound healing applications

The increasing economic burden of wound healing in healthcare systems requires the development of functional therapies. Xenografts with preserved extracellular matrix (ECM) structure and biofunctional components overcome major limitations of autografts and allografts (e.g. availability) and artificial biomaterials (e.g. foreign body response). Although porcine mesothelium is extensively used in clinical practice, it is under-investigated for wound healing applications. Herein, we compared the biochemical and biological properties of the only two commercially available porcine mesothelium grafts (Meso Biomatrix® and Puracol® Ultra ECM) to traditionally used wound healing grafts (Endoform™, ovine forestomach and MatriStem®, porcine urinary bladder) and biomaterials (Promogran™, collagen/oxidized regenerated cellulose). The Endoform™ and the Puracol® Ultra ECM showed the highest (p<0.05) soluble collagen and elastin content. The MatriStem® had the highest (p<0.05) basic fibroblast growth factor (FGFb) content, whereas the Meso Biomatrix® had the highest (p<0.05) transforming growth factor beta-1 (TGF-β1) and vascular endothelial growth factor (VEGF) content. All materials showed tissue-specific structure and composition. The Endoform™ and the Meso Biomatrix® had some nuclei residual matter. All tissue grafts showed similar (p>0.05) response to enzymatic degradation, whereas the Promogran™ was not completely degraded by matrix metalloproteinase (MMP)-8 and was completely degraded by elastase. The Promogran™ showed the highest (p<0.05) permeability to bacterial infiltration. The Promogran™ showed by far the lowest dermal fibroblast and THP-1 attachment and growth. All tested materials showed significantly lower (p<0.05) tumor necrosis factor-alpha (TNF-α) expression than the lipopolysaccharides group. The MatriStem® and the Puracol® Ultra ECM promoted the highest (p<0.05) number of micro-vessel formation, whereas the Promogran™ the lowest (p<0.05). Collectively, these data confer that porcine mesothelium has the potential to be used as a wound healing material, considering its composition, resistance to enzymatic degradation, cytocompatibility, and angiogenic potential.

Acellular dermal matrices as an adjunct to implant breast reconstruction: Analysis of outcomes and complications

PURPOSE

Acellular dermal matrices (ADM) are increasingly used in implant-based breast reconstruction (IBR). Uncertainty remains with regard to their efficacy and complications. The aim of this study was to evaluate the outcomes and complication rates associated with the use of ADMs in IBR.

METHODS

Retrospective cohort study of patients undergoing ADM-assisted IBR between 2008 and 2013. Cases were identified from a prospectively collected database. Simple descriptive statistics and logistic regression analysis were performed.

RESULTS

A total of 110 patients (175 mastectomies) were included in the analysis. The median age was 46 (19-75) years and the median BMI was 22.2 (16.2-41.5). Seventy nine mastectomies were performed for therapeutic purposes. The median mastectomy weight was 244 (185-335) gr. The majority of reconstructions were performed with fixed volume (n = 115, 66%) or permanent expandable implants (n = 53, 30%) as one-stage procedures. Forty mastectomies were associated with at least one complication. The infection rate was 2.3% (n = 4). Post-operative haematoma developed in 5 cases (2.9%), but only 2 required surgical interventions. Three mastectomies were complicated by nipple necrosis (3.6%), 3 with skin necrosis (1.7%) and 9 with wound dehiscence (5.1%). The capsule formation rate was 2.3% (n = 4). Reconstruction failure with implant loss occurred in 3 cases (1.7%).

CONCLUSIONS

The complication rates following ADM-assisted IBR can be very low with appropriate patient selection and meticulous surgical technique. This supports the safety of using ADM in carefully selected patients. Further research is warranted to assess the health economics of ADM use in IBR.