Dermal Autograft Using Donor Breast as Alternative to Acellular Dermal Matrices in Tissue Expander Breast Reconstruction: A Comparative Review

The SAEORA Flap for Prosthetic Breast Reconstruction: A Novel Flap Design without the Use of Acellular Dermal Matrices

Background

The gold standard for implant-based breast reconstruction uses acellular dermal matrices (ADMs). They provide improved inferolateral pole coverage, reduced capsular contracture rates, and increased primary expander fill volumes. However, ADMs are costly and have been associated with increased rates of postoperative infection, seroma, hematoma, implant malposition, and mastectomy flap necrosis (MFN). This study describes a novel autologous flap without the need of ADM, the serratus anterior external oblique rectus abdominis (SAEORA) flap, as an alternative in prosthetic-based breast reconstruction.

Methods

A retrospective study was conducted on all patients who underwent SAEORA flap breast reconstruction by a single surgeon between January 1, 2013 and May 31, 2020 at a single institution. Patient demographics, diagnosis, treatment, tissue expander (TE) volume, implant size, complications, and results were assessed.

Results

Forty-seven patients underwent 78 SAEORA flaps. Sixty-two had TEs placed, and 14 were direct-to-implant. Mean body mass index was 23.1 kg per m². Median primary TE fill volume was 150 mL, and final implant volume average was 450 mL. Mean follow-up was 14.5 months. Complications included infection/cellulitis (7.9%), seroma (6.6%), hematoma (5.2%), and MFN (7.9%).

Conclusions

The SAEORA flap is a novel autologous flap and is a viable option for prosthetic-based breast reconstruction, with an acceptable complication profile relative to ADM-based reconstructions. Additionally, SAEORA is MFN-resistant and has been used effectively in salvage of exposed implants or ADM, and in double-bubble deformity correction.

Do Corporate Payments Influence Research Related to the Use of Acellular Dermal Matrices in Breast Surgery?

BACKGROUND

No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs.

METHODS

The PubMed database was used to identify articles that reported on the use of ADM in breast surgery in four leading plastic surgery journals from January of 2014 to December of 2019. Financial COIs for authors were determined using the open payments database.

RESULTS

Fifty-five articles were included. Twenty-four articles (43.6%) supported use of ADM, 12 (21.8%) did not promote ADM use, and 19 (34.5%) were neutral. Fifty-one studies (92.7%) had either a first or senior author with a COI, and authors with a COI more commonly reported positive outcomes ( P = 0.02). Studies with positive outcomes featured first authors who received significantly larger financial payments ($95,955 versus $15,642; P = 0.029) compared with studies with negative or neutral outcomes. Receiver operating characteristic curve demonstrated that studies with first authors receiving over $376.28 were more likely to report positive results. Eight senior authors and three first authors received greater than $500 from ADM producers yet did not report any financial disclosure.

CONCLUSIONS

Financial COI is associated with higher likelihood of studies reporting benefit of using ADM in breast surgery. There remains inconsistent reporting of COIs, and better oversight is needed to ensure unbiased publication on the use of ADM in breast surgery.

A Pure Autologous Dermal Graft and Dermal Flap Pocket in Prepectoral Implant Reconstruction After Skin-Reducing Mastectomy: A One-Stage Autologous Reconstruction Alternative to Acellular Dermal Matrices

Skin-reducing mastectomy (SRM) with subpectoral implant positioning represents a consolidated, oncologically safe and cosmetically effective method for the immediate reconstruction of large and ptotic breasts. Acellular dermal matrix (ADM) has been proposed as a substitute for the pectoralis major muscle in this surgical approach; this technique led to a progressive evolution toward prepectoral reconstructions even in skin-reducing mastectomies. Obese patients with macromastia who are typical candidates for SRM with ADM are at increased risk of complications associated with ADMs. Therefore, we avoided ADMs and developed a novel autologous technique for immediate breast reconstruction in large and ptotic breasts eligible for SRM. Specifically, an autologous dermal graft is harvested from contralateral healthy breast reduction to cover the upper pole of the prepectoral implant.Level of Evidence IV 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 .

Use of dCELL (Decellularized Human Dermis) in Repair of Urethrocutaneous Fistulas or Glans Dehiscence

Background

In hypospadias repairs, there is some evidence to suggest that a "waterproofing" layer can be helpful in reducing the risk of urethrocutaneous fistula formation. The most likely role of this layer is to prevent the creation of overlapping suture lines. Many hypospadias surgeons use a dartos fascia interposition flap for this purpose. However, raising a dartos fascia flap adds time to the procedure, can result in devascularization of the overlying skin, and can create unsightly torsion of the penis, which may be hard to correct. To avoid these problems, the senior author has started to use dCELL (decellularized human dermis) as an alternative to dartos fascia to separate the suture lines.

Methods

Between March and July 2018, a pilot study was performed in 8 patients undergoing closure of a urethrocutaneous fistula or glans dehiscence combined with dCELL. Data on infections, wound breakdown, length of stay and catheterization, surgical time, and hospital stay were collected.

Results

All patients had a successful reconstruction. One patient developed a urinary tract infection, possibly related to prolonged catheterization following his repair.

Conclusion

Our results suggest that dCELL may be useful in the repair of urethrocutaneous fistulas and glans dehiscence after hypospadias surgery.

Intraoperative Autoderm Decontamination for Use in Immediate Single-stage Direct-to-implant Breast Reconstruction

Acellular dermal matrix (ADM) in direct-to-implant breast cancer reconstruction is the standard of care due to superior cosmetic results and decreased capsular contracture, but can be cost prohibitive. Although more economical, using patient’s own dermis (“Autoderm”) instead of ADM has undescribed sterility. Sterility is essential, as bacterial contamination may cause infection and capsular contraction. This study aimed to determine the sterility and optimal decontamination protocol of Autoderm.

Comparison of breast cancer patients who underwent partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (M + I) regarding quality of life (QOL), cosmetic outcome and survival rates

PURPOSE

The latissimus dorsi muscle has long been used in breast cancer (BC) patients for reconstruction. This study aimed to compare early stage BC patients who had partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (MI) with respect to quality of life (QoL), cosmetic outcome (CO), and survival rates.

PATIENTS AND METHODS

The data of patients who underwent PM + MLDF (Group 1) and M + I (Group 2) between January 2010 and January 2018 were evaluated. Both groups were compared in terms of demographics, clinical and pathological characteristics, surgical morbidity, survival, quality of life, and cosmetic results. The EORTC-QLQ C30 and EORTC-QLO BR23 questionnaires and the Japanese Breast Cancer Society (JBCS) Cosmetic Evaluation Scale were used to assess the quality of life and the cosmetic outcome, respectively.

RESULTS

A total of 317 patients were included in the study, 242 (76.3%) of them in group 1 and 75 (23.6%) of them in group 2. Median follow-up time was 56 (14-116) months. There were no differences identified between the groups in terms of tumor histology, hormonal receptors and HER-2 positivity, surgical morbidity, and 5-year overall and disease-free survival. Group 2 patients were significantly younger than group 1 (p = 0.003). The multifocality/multicentricity rate was higher in group 2 (p ≤ 0.001), whereas tumor size (p = 0.009), body mass index (BMI, p = 0.006), histological grade (p ≤ 0.001), lymph node positivity (p = 0.002), axillary lymph node dissection (ALND) rate (p = 0.005), and presence of lympho-vascular invasion (LVI, p = 0.013) were significantly higher in group 1. When the quality of life was assessed by using the EORTC QLQ C30 and BR23 questionnaires, it was seen that the body image perception (p < 0.001) and nausea/vomiting score (p = 0.024) were significantly better in PM + MLDF group whereas physical function score was significantly better in M + I group (p = 0.012). When both groups were examined in terms of cosmesis with JBCS Cosmetic Evaluation Scale, good cosmetic evaluation score was significantly higher in patients in MLDF group (p = 0.01).

DISCUSSION

The results of this study indicate that in comparison to M + I procedure, the PM + MLDF procedure provides significantly superior results in terms of body image and cosmetic result with similar morbidity and oncologic outcomes. In selected patients with small breasts and a high tumor/breast ratio, PM + MLDF may be an alternative to subcutaneous mastectomy and implant.

Tissue expanders; review of indications, results and outcome during 15 years' experience

BACKGROUND

Tissue expanders (TE) are frequently used worldwide. In this study we surveyed outcome of our patients retrospectively during 15 years.

MATERIALS AND METHODS

We had 1105 patients for whom 3059 TEs have been used. Demographic data, age, sex, indications, type of tissue expander devices, volume of devices, site of scar and site TE insertion, our technique for tissue expander insertion and flap design, complications and outcome were gathered. A complete and through technical points and tips will be discussed.

RESULTS

In 91% of patients overexpansion was done. (Expansion ratio=2.1-4.5). Re-expansion has been done in about 12% of patients. Complications were perforation of skin of pocket (11%) or exposure, infection (6%), dehiscence of the wound (1.5%), perforation of the port or disconnection of the tubes (2.1%), expansion of the scar itself (1%), saggy flap (3%), dog ear (5%), lack of adhesions of flap to its new site (4%).

OUTCOME

In 93% of the patients we could totally remove the scar. Around 9.1% of our patients had two sessions of expansion in the same area and 2.9% had three sessions of expansion. 51% of our patients were highly satisfied and 42% were satisfied of the results of expansion.

CONCLUSION

Our patients were satisfied with the results. In 12% cases we have done re-expansion. Re-expansion is possible as long as you have enough thickness of dermis in the skin. More than 50% of our patients were optimistic for 2nd or 3rd session of re-expansion.