Acellular dermal matrix in tissue expander-based breast

reconstruction predicts increased infection and seroma in a

multivariate regression model Eric D Wang BS, Steven T Lanier BA, BS, Taygan Yilmaz MPH, Brett T Phillips MD, Balvant P Arora MD, Steven M Katz MD, Sami U Khan MD, Alexander B

Dagum MD, Duc T Bui, MD

Stony Brook University Medical Center Division of Plastic and Reconstructive Surgery

American Society of Plastic Surgeons: Plastic Surgery 2010Toronto, ON

Disclosures: nothing to disclose

Breast reconstruction with tissue expanders

Acellular Dermal Matrix (ADM) is a relatively recent adjunct to implant-based breast reconstruction

Suggested benefits include:Prevention of implant exposureImproved control of the inframammary

foldImproved aesthetics, with a more natural

ptosisImproved expansion dynamics

Reported complication rates with ADM

Non-ADM complications

ADM complications

P-value(2-tail)

Antony et al. 2010 12.4% 23.6% <0.05*

Lanier et al. 2010 12.0% 28.9% 0.02*

Chun et al. 2010 2.1% 8.9% 0.03*

Nahabedian 2009 5.85% 5% ★

Sbitany et al. 2009 14% 18% 0.79

Preminger et al. 2008

6.7% 15.6% 0.18

Non-comparative case series

(20 publications, n= 5 – 67)Range (0-20%) ★

* Denotes statistical significance★ No statistical comparison was made

Research question

What are the complication risks associated with acellular dermal matrix use?

MethodsDesign: retrospective database review

Setting: postmastectomy TE/I breast reconstructions at a single center between 2004 and 2009

Sample sizeADM: 105 breasts (77 patients)non-ADM: 161 breasts (105 patients)

Statistical analysisDescriptive statistics, Student’s t-, and Fisher’s

ExactMultivariate logistic regression

Model parameters: predictor variables

AgeBMITobaccoNeoadjuvant

chemotherapy and radiation

Postop chemotherapy and radiation

ADM useIndication for

mastectomyTime between

stagesJP drain durationMastectomy

specimen weightTissue expander

sizeIntraoperative fill

volume

Model parameters: outcome variables

InfectionMastectomy skin necrosisSeromaHematomaCapsular contractureExpander explantation due to

infectionReoperation due to complications

Results: baseline patient characteristics

Non-ADM (n = 161)

ADM (n = 105)

P value(2-tailed)

mean age at time of stage I 48.6 51.2 0.04*

mean BMI 24.1 28.1<

0.001*

mean breast tissue removed 601g 891g

< 0.001*

tobacco use 34 (21.1%) 16 (15.2%) 0.26

pre-stage I chemotherapy 31 (19.3%) 18 (17.1%) 0.75

post-stage I chemotherapy 56 (34.8%) 38 (36.2%) 0.90

pre-stage I radiation 7 (4.4%) 4 (3.8%) 1

post-stage I radiation 11 (6.6%) 4 (3.8%) 0.42

number risk-reducing 44 (27.3%) 29 (27.6%) 1

* Denotes statistical significance

Results: univariate analysis

* Denotes statistical significance

0%10%20%30%40%50%

Non-ADM ADM

Results: multivariate regression model

Significant independent predictors of infection:

Odds Ratio

p - value 95% CI

ADM use 12.86 0.044 1.067 – 155.1

decreased age 0.86 0.024 0.756 – 0.981

pre-op radiation 312 0.0391.331 – 73723

time to exchange

1.013 0.007 1.003 – 1.023

Results: multivariate regression model

Significant independent predictors of seroma formation:

Odds Ratio

p - value 95% CI

ADM use 7.377 0.008 1.700 – 32.02

total fill volume 1.006 0.030 1.001 – 1.012

ConclusionsAcellular dermal matrix is associated

with increased risk of infection and seroma, independent of other factors influencing operative outcome

Proposed benefits of ADM must be weighed against the risk of increased complications

Minimizing future complicationsUnderstanding the etiology of

complications

Refinement of surgical and postoperative care protocols to avoid complications with ADM

Utilizing risk factors to guide patient selection and preoperative planning for breast reconstruction

References and Contact1. Preminger BA, McCarthy CM, Hu QY, Mehrara BJ, Disa JJ. The influence of AlloDerm on

expander dynamics and complications in the setting of immediate tissue expander/implant reconstruction: a matched-cohort study. Ann Plast Surg 60; 510-513; 2008.

2. Chun YS, Verma K, Rosen H, Lipsitz S, Morris D, Kenney P, Eriksson E. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative

complications. Plast Reconstr Surg 125; 429-436; 2010.

3. Lanier ST, Wang ED, Chen JJ, Arora BP, Katz SM, Khan SU, Dagum AB, Bui DT. The effect of acellular dermal matrix use on complication rates in tissue expander/implant breast reconstruction. Ann Plast Surg 64; 674-678; 2010.

4. Antony AK, McCarthy CM, Cordeiro PG, Mehrara BJ, Teo EH, Arriaga AF, Disa JJ. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg 125; 1606-1614; 2010.

5. Nahabedian MY. AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation. Plast Reconstr Surg 124: 1743; 2009.

6. Sbitany H, Sandeen SN, Amalfi AN, Davenport MS, Langstein HN. Acellular dermis-assisted prosthetic breast reconstruction vs complete submuscular coverage: a head-to-head comparison of outcomes. Plast Reconstr Surg 124: 1735, 2009.

Contact:Duc T. Bui, MDStony Brook University Medical CenterDivision of Plastic and Reconstructive SurgeryHSC T19-060Stony Brook, NY 11794