Immediate direct-to-implant breast reconstruction with acellular dermal matrix: Evaluation of complications and safety

Postoperative complications of ADM use in previously irradiated patients during stage I of implant-based breast reconstruction: A national database propensity score-matched analysis

INTRODUCTION

Acellular dermal matrix (ADM) is widely used in implant-based reconstruction to prevent capsular contracture, but its safety in irradiated patients is underexplored. We aimed to evaluate postoperative complications associated with ADM use in stage I of implant-based breast reconstruction in patients with premastectomy radiation.

METHODS

Using the Merative MarketScan Research Databases, 2012-2020, previously irradiated patients undergoing outpatient stage I implant breast reconstruction (prepectoral and submuscular) were stratified by ADM use and propensity score-matched. Postoperative complications and additional surgical interventions within 90 days were analyzed using multivariate logistic regression.

RESULTS

Among 1234 matched patients (617 ADM and 617 non-ADM), ADM use was first recorded in 2012, and its frequency showed a positive correlation over the study (r = 0.214, p <.001). Patients with ADM experienced higher rates of wound (8.5% vs. 7.8%) and tissue necrosis (5.5% vs. 4.0%) than non-ADM patients, but these differences were not statistically significant. Additionally, no significant differences were observed between ADM and non-ADM groups in the rates of seroma formation, hematoma, fat necrosis, or postoperative infections. ADM use was associated with significantly lower odds of requiring image-guided fluid drainage for hematomas or seromas (OR 0.11, 95% CI 0.01-0.89, p =.039).

CONCLUSION

No significant difference in complication rates was found between previously irradiated breast cancer patients with and without ADM on a large scale, even with ADM usage increasing over time. Its adoption should balance cost, surgeon preferences, and esthetic outcomes, with further research needed on its role in various reconstruction planes and cost impacts.

Does the Omission of Cefazolin in Irrigation Solution Affect Outcomes in Prepectoral Direct-to-Implant Breast Reconstruction?

PURPOSE

The widely used triple-antibiotics irrigation solution, comprising cefazolin, gentamycin, and povidone-iodine solution, has been employed for preventing infection and capsular contracture in implant-based breast reconstruction. However, potential overlapping in the coverage of such antimicrobial effects and the recent emergence of cefazolin-resistant gram-positive bacteria has prompted concerns regarding the efficacy of routine use of cefazolin in irrigation solutions. This study aims to evaluate clinical safety of omitting cefazolin from the traditional triple-antibiotic irrigation solution.

METHODS

Patients who underwent immediate prepectoral direct-to-implant breast reconstruction between September 2020 and April 2022 were reviewed. They were divided into two groups: cases using the traditional triple-antibiotics for the former third and those using dual-antibiotics (omitting cefazolin) for the latter. Development of postoperative complications were compared by the type of irrigation solution and its independent associations with the adverse outcomes were evaluated.

RESULTS

In total, 445 cases (126 using triple- and 319 using dual-regimen solution) were analyzed with a mean follow-up period of 12 months. The two groups had generally similar baseline characteristics. Overall complications developed in 126 cases (28.3%), including 12 (2.7%) of infection and 32 (7.2%) of capsular contracture. The complication profiles did not differ between the groups. Multivariable analyses exhibited that the type of irrigation solution was not associated with the development of overall and any kind of complication including infection and capsular contracture.

CONCLUSION

Omission of cefazolin from the irrigation solution may not elevate the risks of infection and capsular contracture in prepectoral direct-to-implant reconstruction. Further long-term studies would be warranted.

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 .

Direct-to-implant and tissue expander-based immediate breast reconstruction in Chinese women: A comparison of surgical complications and patient-reported outcomes

BACKGROUND

Direct-to-implant (DTI) breast reconstruction restores patient body image immediately after mastectomy but may increase postoperative complications compared to tissue expander (TE)-based breast reconstruction. Few studies have compared the surgical complications and patient-reported outcomes (PROs) of DTI and TE breast reconstructions in Asian women.

METHOD

This study compared postoperative complications and PROs between DTI and TE breast reconstruction in Chinese women and explores the risk factors of postoperative complications and the influencing factors of PROs. A retrospective chart review of patients undergoing immediate breast reconstruction between 2008 and 2022 was conducted, and BREAST-Q questionnaires of the breast reconstruction module were distributed to eligible patients. Multivariate regression models were used to explore risk factors for postoperative complications and factors that influence BREAST-Q scores.

RESULTS

DTI was associated with lower rates of major complications and implant loss but had no significant influence on patient satisfaction or quality of life. Age and axillary lymph node dissection were important complication risk factors for both DTI and TE. The application of acellular dermal matrix significantly increased the risk of seroma or hematoma. In the DTI group, capsular contracture significantly reduced patient satisfaction with breast scores.

CONCLUSION

DTI dual-plane breast reconstruction does not increase complication rates in appropriately selected Chinese patients. In DTI patients, the management of capsular contracture is crucial for improving patient satisfaction.

Single stage direct -to- implant breast reconstruction following mastectomy (The use of Ultrapro® Mesh)

BACKGROUND

Immediate breast reconstruction (IBR) with direct to implant (DTI) is the preferred method of reconstruction by many surgeons and patients, however, acellular dermal matrix (ADM) and other synthetic meshes are expensive especially in low- and middle-income countries. AIM OF THE WORK: To evaluate the technique, indications, aesthetic outcomes, and short and long-term complications of DTI breast reconstruction performed with Ultrapro®, a low-cost alternative mesh to ADM and other synthetic meshes.

METHODS

Our study is a prospective cohort study that was conducted on 133 patients who experienced IBR following nipple-sparing mastectomy (NSM) or skin sparing mastectomy (SSM) using silicone implants and Ultrapro® mesh between December 2020 and December 2023. Techniques used were either sub-pectoral or pre-pectoral, evaluating aesthetic outcome, complication rate and patient satisfaction using breast Q questionnaire.

RESULTS

We included 133 patients (141 breasts) with a median age of 39 years. Mean duration of follow up: 20.364 ± 5.39 months. The sub-pectoral and the pre pectoral techniques were used for 80 breasts and 61 breasts respectively. We used the Ultrapro® mesh in all our patients. Smooth round silicone implants were used. The overall Major complications rate was 16.3%. 8 implants (5.7%) were lost within 6 months post-operatively while 2 implants were removed in the late post-operative period (after 6 months) one due to rupture and the other due to local recurrence. Capsular contracture Baker 3 and 4 was observed in 36 breasts (25%), 31 of them had post mastectomy radiotherapy treatment. 11 (7.8%) were managed by capsulotomies and re-insertion of the same implant. Radiotherapy was a significant risk factors for major complications and capsular contracture with p value of (0.01) and (0.0001) respectively.

CONCLUSION

DTI in properly selected patients offers excellent outcomes and patient satisfaction. The complication rate is low and improves with the experience of the surgeon. The Ultrapro® mesh is a safe, low-cost alternative to ADM or other synthetic meshes especially in low socioeconomic countries. Radiotherapy is a significant risk factor for major complications and capsular contractures.

A Systematic Review and Meta-Analysis of Synthetic Mesh Outcomes in Alloplastic Breast Reconstruction

Background

Mesh implants are frequently employed in alloplastic breast reconstruction. Notably, no mesh to date has FDA approval for this indication. Several synthetic meshes have been introduced with heterogeneous properties and outcomes.

Objectives

This study aims to systematically review synthetic mesh use in alloplastic breast reconstruction, describe rates of short-term complications, and analyze these outcomes in reports comparing synthetic and biologic meshes. The authors hypothesized data from comparative and noncomparative studies would show no significant differences between synthetic and biological meshes.

Methods

The authors conducted a systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty-one studies reporting the use of synthetic mesh and clinical outcomes were included. Eight studies directly comparing synthetic mesh and biological mesh were meta-analyzed for relative risk (RR). Nineteen noncomparative studies were analyzed for meta-rates. Outcomes, including seroma, infection, reoperation, and explant, were assessed on a per-breast basis. Resultant models were challenged for sensitivity and bias.

Results

Meta-analysis of comparative studies demonstrated no difference in the risk of infection with synthetic mesh (RR = 0.53; 95% CI [0.26-1.10]), but a reduced risk of reoperation (RR = 0.54; 95% CI [0.33-0.89]) or explant (RR = 0.43; 95% CI [0.21-0.87]). Meta-analysis of noncomparative studies demonstrated rates of seroma = 3%; 95% CI [1%-6%], infection = 4%; 95% CI [3%-6%], reoperation = 10%; 95% CI [7%-13%], and explant = 3%; 95% CI [2%-5%]).

Conclusions

Studies comparing synthetic and biologic meshes demonstrated noninferiority of synthetic in all outcomes assessed. Noncomparative studies demonstrated rates of seroma, infection, reoperation, and explant similar to literature values for biological mesh.

Level of Evidence 2 Risk

Breast cancer patients' postoperative outcomes in nipple-sparing mastectomy and reconstruction with subpectoral implant placement: a single center experience

Background

The continuous increase in the rate of nipple sparing mastectomy (NSM), the development of several reconstructive techniques and the following introduction of acellular derma matrix (ADM) has revolutionized implant-based breast reconstruction. This study aimed to investigate postoperative complications, health-related quality of life (HRQoL) and patients' satisfaction in patients undergoing NSM and breast reconstruction with or without ADM.

Methods

Enrolled patients were divided into three groups: immediate breast reconstruction (IBR) with definitive implant and ADM (Group A), IBR only with definitive prosthesis (Group B), and two-stage breast reconstruction (Group C). The postoperative complications, BREAST-Q outcomes and reoperations were compared.

Results

A total of 105 BC patients were enrolled and a total of 139 post-mastectomy breast reconstructions were performed. Seroma was the most prevalent complication observed: 8.3% in Group A, 2.9% in Group B and 5.7% in Group C. Postoperative infection occurred in two patients of Group A (5.6%), one patient of Group B (2.9%) and one of Group C (2.9%). Group A reported larger drain volume (1,125±243.5 cc), longer drain period (13.2±2.8 days), and the lowest incidence of capsular contracture (5.6%). The BREAST-Q patient-reported outcome measures document that all patients aged ≥50 years presented a higher score in "Satisfaction with breast" (P<0.001) and "Satisfaction with outcome" domains (P<0.05). Performing a bilateral breast reconstruction was associated to higher scores in "Physical wellbeing chest domain" (P<0.05). In addition, patients in Group A and Group B reported higher score in "Satisfaction with the breast" domain (P<0.001) but only in Group B we reported a higher score in "Satisfaction with outcome" (P<0.001).

Conclusions

Subpectoral IBR results in manageable complications and greater personal satisfaction. The ADM could improve breast reconstruction reducing the rate of capsular contracture. The prepectoral placement of ADM could minimize complications and optimize aesthetic results.

Meta-Analysis of Immediate Implant-Based Breast Reconstruction Versus Autologous Breast Reconstruction in the Setting of PMRT

BACKGROUND

It is still a controversial debate that which type of immediate breast reconstruction should be operated on breast cancer patients in the setting of postmastectomy radiotherapy. This meta-analysis compared incidence of complications requiring reoperation (CRR), reconstruction failure (RF) and patient-reported outcome between immediate autologous breast reconstruction (ABR) and immediate implant-based breast reconstruction (IBBR), tissue expander/implant reconstruction mostly, in the setting of postmastectomy radiotherapy.

METHODS

Systematic and thorough research was conducted to search for studies published before August 1, 2022, by using three online databases. Studies that covered complications or reconstruction failure between two cohorts were included. To evaluate the possible bias in the included studies, the Newcastle-Ottawa Scale was applied.

RESULTS

Eight studies presenting 1261 patients were enrolled. The relative risk associated with reconstructive failure favored IBBR (RR = 8.61; 95% CI, 2.84-26.08; P = 0.0001). While the risk for complications requiring reoperation was not significantly different between two groups, either include reconstruction failure (RR = 1.45 95% CI, 0.82-2.55; P = 0.20) or not (RR = 0.63 95% CI, 0.28-1.43; P = 0.27). However, because statistical definitions and methodologies vary, the synthesized result should be taken critically.

CONCLUSION

Patients with IBBR have more possibility experiencing RF compared that with ABR, while the chance for CRR is not that different between two groups. For the purpose of clinical practice refinement, more high-quality studies are needed.

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 .

Application of TiLOOP bra in implant-based breast reconstruction is associated with decreased complication risk compared with other meshes: A systematic review and meta-analysis

BACKGROUND

TiLOOP bra has been used for over 15 years, however, evidence regarding its safety in implant-based breast reconstruction (IBBR) for patients with breast cancer after mastectomy is still limited. We performed this meta-analysis to evaluate its risks and benefits in IBBR comparing with other meshes.

METHODS

Electronic databases were searched to identify relevant studies comparing postoperative complications between TiLOOP bra and other reconstruction techniques in IBBR with or without meshes. We also compared patient satisfaction in physical well-being between two groups. Risk ratios (RRs) and mean differences with 95% confidence interval (CI) were calculated.

RESULTS

Seven studies representing 1203 cases were analyzed. Compared with other meshes, the use of TiLOOP bra significantly reduced the risk of infection (RR = 0.53, 95% CI, 0.32-0.86), seroma (RR = 0.21, 95% CI, 0.07-0.61), red breast syndrome (RR = 0.10, 95% CI, 0.02-0.45), and capsular contracture (RR = 0.20, 95% CI, 0.05-0.75). Patient satisfaction in physical well-being was comparable between two groups.

CONCLUSIONS

TiLOOP bra in IBBR has a favored safety profile over other meshes, which significantly reduced postoperative complication risk and did not affect patient satisfaction. Although prospective well-designed controlled studies are still warranted, TiLOOP bra is safe and reliable at present.

National Trends in Acellular Dermal Matrix Utilization in Immediate Breast Reconstruction

BACKGROUND

Implant-based reconstruction is the most common method of immediate breast reconstruction in the United States, with acellular dermal matrices (ADMs) playing a significant role in implant support and coverage. This study evaluated recent national trends in ADM use in immediate breast reconstruction and assessed patient characteristics and 30-day complication rates.

METHODS

The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing immediate breast reconstruction from 2015 to 2020. Primary outcomes were major surgical and medical complications, as well as ADM use per year. Subset analysis was performed to compare patients undergoing immediate breast reconstruction with ADM in 2015 versus 2020.

RESULTS

In 39,800 immediate breast reconstructions, ADMs were used in 55.5% of cases ( n = 22,087). ADM usage increased annually from 2015 through 2020. Direct-to-implant reconstruction was significantly associated with ADM use ( P < 0.001). Compared with the no-ADM cohort, there was a significantly increased rate of return to the operating room for any reason ( P < 0.001). When comparing the 2015 and 2020 ADM cohorts, the 2020 ADM cohort had a significantly higher rate of superficial infections. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wounds in patients receiving ADM.

CONCLUSIONS

ADM use in immediate breast reconstruction increased significantly from 2015 to 2020, likely reflecting national trends in increasing direct-to-implant and prepectoral breast reconstruction. Obesity, smoking history, and insulin-dependent diabetes were independent risk factors for superficial wound infections in the ADM cohort. Patients with ADM had a slight increased incidence of return to the operating room.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Early Seroma Treatment Protocol Based on US-Guided Aspiration in DTI Prepectoral Reconstruction: A Prospective Study

INTRODUCTION

Seroma is a common complication after prepectoral prosthetic breast reconstruction with ADM, leading to wound dehiscencse, infection, and even loss of reconstruction at last. A new ultrasound (US) guided follow-up protocol has been applied to compare primary and secondary complications incidence and their treatment, and evaluate the effect of precocious seroma detection and its evacuation in reducing secondary complications.

METHODS

We enrolled 406 patients from January 1st, 2021 to July 1st, 2023 who underwent mastectomy and 1-stage prepectoral reconstruction with ADM. Experimental group counted 96 patients, whom have been treated as protocol fashion, therefore with multiple US-guided evaluations and eventual evacuations along with postoperative period; control group (310 patients) has exclusively been clinically evaluated.

RESULTS

Seroma incidence detected rate among experimental group, after 1-year follow-up, was 32.2%, compared to 16.8% in control cohort, additionally no other secondary complications were detected in the first group. Referring to the wound dehiscence incidence, a statistically significant higher frequency was observed in control group compared with treatment 1 (21.2% vs. 0%; P = .0027).

CONCLUSIONS

Seroma and correlated secondary complications may lead to additional surgeries, higher sanitary costs and even reconstructive failure. With a seriated US follow-up protocol application, the surgeon could promptly manage and treat seroma, decreasing additional complications rate, particularly wound dehiscence.

LEVEL OF EVIDENCE

III.

Safety of Augmenting Breast Volume in Direct-to-Implant Breast Reconstruction With Contralateral Breast Augmentation: Comparison With 2-Stage Reconstruction

BACKGROUND

Direct-to-implant breast reconstruction is a standard method of implant-based reconstruction; however, the risk of skin necrosis and implant failure exists. During simultaneous contralateral augmentation, an implant larger than the resected tissue must be inserted to balance both sides, which may increase the risk of complications. This study examined the differences in the incidence of complications between the single-stage direct-to-implant reconstruction and 2-stage reconstruction when contralateral augmentation was performed simultaneously.

METHODS

This study included 99 patients who underwent implant-based breast reconstruction with contralateral augmentation between 2012 and 2020. A retrospective chart review was conducted and the patients were divided into 2 groups: the single-stage reconstruction (n = 61) and 2-stage reconstruction (TSR, n = 38) groups. Demographic data and surgical and oncological information were collected. Complications including skin necrosis and reconstruction failure were investigated as the primary outcome.

RESULTS

Implant volume and contralateral implant volume were significantly greater in TSR group than in the single-stage reconstruction group. There were no significant differences in the incidence of complications and reconstruction failure rates between both groups. The nipple-sparing mastectomy was the risk factor for complications. Furthermore, the risk factors for mastectomy skin necrosis were implant volume and differences in the volume of both implants.

CONCLUSIONS

Single-stage reconstruction did not increase the risk of complications compared with TSR when implants that were larger than the resected tissue were inserted after mastectomy. Proper patient selection and selection of implants that are not excessively large could satisfy patients' cosmetic needs in a single operation.

Optimizing Acellular Dermal Matrix Integration in Heterologous Breast Reconstructive Surgery: Surgical Tips and Post-Operative Management

Background and Objective: Prepectoral implant placement in breast reconstruction is currently a must-have in the portfolios of breast surgeons. The introduction of new tools and conservative mastectomies is a game changer in this field. The prepectoral plane usually goes hand-in-hand with the ADM wrapping of the implant. It is a cell-free dermal matrix comprising a structurally integrated basement membrane complex and an extracellular matrix. The literature reports that ADMs may be useful, but proper patient selection, surgical placement, and post-operative management are essential to unlock the potential of this tool, as these factors contribute to the proper integration of the matrix with surrounding tissues. Materials and Methods: A total of 245 prepectoral breast reconstructions with prostheses or expanders and ADMs were performed in our institution between 2016 and 2022. A retrospective study was carried out to record patient characteristics, risk factors, surgical procedures, reconstructive processes, and complications. Based on our experience, we developed a meticulous reconstruction protocol in order to optimize surgical practice and lower complication rates. The DTI and two-stage reconstruction were compared. Results: Seroma formation was the most frequent early complication (less than 90 days after surgery) that we observed; however, the majority were drained in outpatient settings and healed rapidly. Secondary healing of wounds, which required a few more weeks of dressing, represented the second most frequent early complication (10.61%). Rippling was the most common late complication, particularly in DTI patients. After comparing the DTI and two-stage reconstruction, no statistically significant increase in complications was found. Conclusions: The weakness of prepectoral breast reconstruction is poor matrix integration, which leads to seroma and other complications. ADM acts like a graft; it requires firm and healthy tissues to set in. In order to do so, there are three key steps to follow: (1) adequate patient selection; (2) preservative and gentle handling of intra-operative technique; and (3) meticulous post-operative management.

Assessment, Complications, and Surveillance of Breast Implants: Making Sense of 2022 FDA Breast Implant Guidance

As more information about the potential risks and complications related to breast implants has become available, the United States Food and Drug Administration (FDA) has responded by implementing changes to improve patient education, recalling certain devices and updating the recommendations for screening for silicone implant rupture. In addition to staying up-to-date with FDA actions and guidance, radiologists need to maintain awareness about the types of implants they may see, breast reconstruction techniques including the use of acellular dermal matrix, and the multimodality imaging of implants and their complications. Radiologists should also be familiar with some key differences between the updated FDA guidelines for implant screening and the imaging recommendations from the American College of Radiology Appropriateness Criteria. The addition of US as an acceptable screening exam for silicone implant rupture by the FDA is one of the most notable changes that has potentially significant implications.

Converting Acellular Dermal Matrix into On-Demand Versatile Skin Scaffolds by a Balanceable Crosslinking Approach for Integrated Infected Wounds Therapy

Ideal tissue-engineered skin scaffolds should possess integrated therapeutic effects and multifunctionality, such as broad-spectrum antibacterial properties, adjustable mechanical properties, and bionic structure. Acellular dermal matrix (ADM) has been broadly used in many surgical applications as an alternative treatment to the "gold standard" tissue transplantation. However, insufficient broad-spectrum antibacterial and mechanical properties for therapeutic efficacy limit the practical clinical applications of ADM. Herein, a balanceable crosslinking approach based on oxidized 2-hydroxypropyltrimethyl ammonium chloride chitosan (OHTCC) was developed for converting ADM into on-demand versatile skin scaffolds for integrated infected wounds therapy. Comprehensive experiments show that different oxidation degrees of OHTCC have significative influences on the specific origins of OHTCC-crosslinked ADM scaffolds (OHTCC-ADM). OHTCC with an oxidation degree of about 13% could prosperously balance the physiochemical properties, antibacterial functionality, and cytocompatibility of the OHTCC-ADM scaffolds. Owing to the natural features and comprehensive crosslinking effects, the proposed OHTCC-ADM scaffolds possessed the desirable multifunctional properties, including adjustable mechanical, degradable characteristics, and thermal stability. In vitro/in vivo biostudies indicated that OHTCC-ADM scaffolds own well-pleasing broad-spectrum antibacterial performances and play effectively therapeutic roles in treating infection, inhibiting inflammation, promoting angiogenesis, and promoting collagen deposition to enhance the infected wound healing. This study proposes a facile balanceable crosslinking approach for the design of ADM-based versatile skin scaffolds for integrated infected wounds therapy.

Acellular dermal matrix in reconstructive surgery: Applications, benefits, and cost

Modern tissue engineering has made substantial advancements that have revolutionized plastic surgery. Acellular dermal matrix (ADM) is an example that has gained considerable attention recently. ADM can be made from humans, bovines, or porcine tissues. ADM acts as a scaffold that incorporates into the recipient tissue. It is gradually infiltrated by fibroblasts and vascularized. Fortunately, many techniques have been used to remove cellular and antigenic components from ADM to minimize immune system rejection. ADM is made of collagen, fibronectin, elastin, laminin, glycosaminoglycans, and hyaluronic acid. It is used in critical wounds (e.g., diabetic wounds) to protect soft tissue and accelerate wound healing. It is also used in implant-based breast reconstruction surgery to improve aesthetic outcomes and reduce capsule contracture risk. ADM has also gained attention in abdominal and chest wall defects. Some studies have shown that ADM is associated with less erosion and infection in abdominal hernias than synthetic meshes. However, its higher cost prevents it from being commonly used in hernia repair. Also, using ADM in tendon repair (e.g., Achilles tendon) has been associated with increased stability and reduced rejection rate. Despite its advantages, ADM might result in complications such as hematoma, seroma, necrosis, and infection. Moreover, ADM is expensive, making it an unsuitable option for many patients. Finally, the literature on ADM is insufficient, and more research on the results of ADM usage in surgeries is needed. This article aims to review the literature regarding the application, Benefits, and costs of ADM in reconstructive surgery.

Prophylactic treatment of breast implants with a solution of gentamicin, vancomycin and cefazolin antibiotics for women undergoing breast reconstructive surgery: protocol for a randomised, double-blind, placebo-controlled trial (The BREAST-AB trial)

INTRODUCTION

Periprosthetic infection is one of the most severe complications following implant-based breast reconstruction affecting 5%-10% of the women. Currently, many surgeons apply antibiotics locally on the breast implant to reduce the risk of postoperative infection, but no randomised, placebo-controlled trials have tested the treatment's efficacy.

METHODS AND ANALYSIS

The BREAST-AB trial (BREAST-AntiBiotics) is an investigator-initiated, multicentre, randomised, placebo-controlled, double-blind trial of local treatment with gentamicin, vancomycin and cefazolin on breast implants in women undergoing implant-based breast reconstruction. The trial drug consists of 80 mg gentamicin, 1 g vancomycin and 1 g cefazolin dissolved in 500 mL of isotonic saline. The placebo solution consists of 500 mL isotonic saline. The trial drug is used to wash the dissected tissue pocket and the breast implant prior to insertion. The primary outcome is all-cause explantation of the breast implant within 180 days after the breast reconstruction surgery. This excludes cases where the implant is replaced with a new permanent implant, for example, for cosmetic reasons. Key long-term outcomes include capsular contracture and quality of life. The trial started on 26 January 2021 and is currently recruiting.

ETHICS AND DISSEMINATION

The trial was approved by the Regional Ethics Committee of the Capital Region (H-20056592) on 1 January 2021 and the Danish Medicines Agency (2020070016) on 2 August 2020. The main paper will include the primary and secondary outcomes and will be submitted to an international peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT04731025.

Advances on the modification and biomedical applications of acellular dermal matrices

Acellular dermal matrix (ADM) is derived from natural skin by removing the entire epidermis and the cell components of dermis, but retaining the collagen components of dermis. It can be used as a therapeutic alternative to “gold standard” tissue grafts and has been widely used in many surgical fields, since it possesses affluent predominant physicochemical and biological characteristics that have attracted the attention of researchers. Herein, the basic science of biologics with a focus on ADMs is comprehensively described, the modification principles and technologies of ADM are discussed, and the characteristics of ADMs and the evidence behind their use for a variety of reconstructive and prosthetic purposes are reviewed. In addition, the advances in biomedical applications of ADMs and the common indications for use in reconstructing and repairing wounds, maintaining homeostasis in the filling of a tissue defect, guiding tissue regeneration, and delivering cells via grafts in surgical applications are thoroughly analyzed. This review expectedly promotes and inspires the emergence of natural raw collagen-based materials as an advanced substitute biomaterial to autologous tissue transplantation.

Graphical Abstract