Acellular Dermal Matrices in Breast Reconstruction: Tran Nguyen Nhat Khanh, MD., MSC

ACELLULAR DERMAL MATRICES
IN BREAST RECONSTRUCTION
TRAN NGUYEN NHAT KHANH, MD., MSC

 ADM – Acellular Dermal Matrices
 Variety sources included human (HADM), porcine (PADM), bovine (BADM)
WHAT FDA SAYS?
 Acellular Dermal Matrix (ADM), a type of surgical mesh, is developed from human skin (such as
FlexHD, AlloMax, AlloDerm) or animal skin (such as SurgiMend), in which the cells are removed and
the support structure is left in place.
 The FDA has not cleared or approved ADM or mesh for use in breast reconstruction. Over the past
several years, the use of ADM has increased and is now commonly used off-label in implant-based
breast reconstruction.
U. S. Food and Drug Administration. Center for Drug Evaluation and Research. (2021).
Acellular Dermal Matrix (ADM) Products Used in Implant-Based Breast Reconstruction Differ in Complication Rates: FDA Safety Communication
Common commercially available ADMs.
Product Description
AlloDerm® (LifeCell Corp., Bridgewater, NJ, USA) Human, non-cross-linked
AlloMax® (CR Bard/Davol Inc., Cranston, RI, USA) Human, non-cross-linked
DermACELL® (Life Net Health Inc., Virginia Beach, VA, USA) Human, non-cross-linked
FlexHD® (Ethicon, Inc., Somerville, NJ, USA) Human, non-cross-linked

Cortiva® (RTI Surgical, Alachua, FL, USA) Human, non-cross-linked
Integra™ (Integra Life Sciences, Princeton, NJ, USA) Bovine, cross-linked
MatriDerm® (Dr Suwelack AG, Billerbeck, Germany) Bovine, non-cross-linked
SurgiMend® (Integra Life Sciences, Princeton, NJ, USA) Bovine, non-cross-linked
Strattice® (Allergan, Madison, NJ, USA) Porcine, non-cross-linked
Permacol™ (Medtronic, Minneapolis, MN, USA) Porcine, cross-linked
CollaMend™ (CR Bard/Davol Inc., Cranston, RI, USA) Porcine, cross-linked
BURN RECONSTRUCTION
 Intergra
 1996 FDA approval for patients with extensive burn +
insufficient donor tissue for coverage
 2002, approval for use in reconstruction of burn scars
 2016, approval for diabetic foot ulcers
 Matriderm:
 Collagen
 Elastin
Matriderm (BADM)
(A) Defect
(B) The dermal substitute was applied on the donor elevation site.
(C) After six months, the graft area was stable without any
complications and demonstrated a good cosmetic outcome.
Min Jang et al. (2014).

The Use of Matriderm
and Autologous Skin
Graft in the Treatment of
Full Thickness Skin
Defects. Archives of
plastic surgery. 41. 330-
6.
BREAST RECONSTRUCTION
 2020
 137,808 Breast Reconstruction
 103,485 Implant Reconstruction (75%)
 33,323 Flaps
 14% direct to implant, no expander (19,998 )  increase 8%

 51% subpectoral
 38% prepectoral
 ADMs have been applied to revision augmentations, as they adequately reinforce the soft tissue and implant
pocket, thereby decreasing rates of capsular contracture.
ADM IN BREAST RECONSTRUCTION
 2005, Breuing and Warren, first report on the use of ADMs in reconstructive breast surgery.
 10 patients, bilateral mastectomies and direct-to-implant (single-stage) alloplastic reconstruction
 With a sling of Alloderm (LifeCell Corporation, USA) inferiorly
 2007, Bindingnavele et al, first described the use of ADM in two-stage approach with a tissue expander
 Ads: decrease post-op care, faster expansion, elimination of the need for evaluation of the serratus anterior muscle for the
coverage of the prothesis, improved lower pole projection, better aesthetic shape
Current techniques pre-pectoral reconstruction
CURRENT TECHNIQUES PRE-PECTORAL RECONSTRUCTION
Subcutaneous plane
• Problem? -> capsular contracture
over the muscle
Under the • Hard to achieve a natural appearance with ptosis

muscle
• lack secure coverage of the inferior pole of implant

Dual • less control over IMF
plane • superior migration of pectoralis major m. & TE
Prepecto + ADM
Tissue expander is placed in submuscular and subgraft space,
and opposing muscle and graft are secured with suture. Drains
are placed in space between graft and mastectomy flaps.
Lateral view of expander

beneath muscle and graft.
ADVANTAGES OF ADM
 Provide lower pole soft-tissue support

 Create a slightly ptotic
 Natural appearing breast
 Produce a well-defined IMF
 Prevent superior migration of pectoralis major muscle by anchoring it in place
 Reduce the incidence of clinically significant capsular contracture
Nahabedian, 2012; Spear et al., 2012

CURRENT TECHNIQUES PRE-PECTORAL RECONSTRUCTION
Prepectoral reconstruction: a viable option, with the topic gaining significant attention in the literature and
discussion forums
Marks, Jacob M et al. “Current Trends in Prepectoral Breast Reconstruction: A Survey of American Society of Plastic Surgeons Members.” Plastic and reconstructive
surgery. Global open vol. 8,8 e3060.
DISADVANTAGES
 Price
 Complication
Early: seroma, infection, mastectomy skin flap necrosis, and need for explantation
Late: asymmetry, implant wrinkling or displacement, capsular contracture, and late infection
 Other studies have reported no significant difference among different ADMs and between prepectorally
and subpectorally pockets.
Overall infection, flap necrosis, and
seroma are significantly higher in ADM
IBBR compared to non- ADM IBBR
Conversely, ADMs were associated

with lower risks of capsular
contracture and implant
displacement.
 What should be using in reconstruction?
 Nothing
 ADM
 Mesh
 Non-human dermal substitutes
Methods: A retrospective review was performed
of the first 50 consecutive patients (76
reconstructions) who underwent implant-based
breast reconstruction with Vicryl mesh.
Conclusion: low complication rate (6.6 percent)

and excellent aesthetic results. The technique has
resulted in $172,112 in direct material cost savings
over 10 months.
Tessler, Oren et al. “Beyond biologics: absorbable mesh as

a low-cost, low-complication sling for implant-based
breast reconstruction.” Plastic and reconstructive
surgery vol. 133,2 (2014)
 PDO mesh (Durasorb, Surgical Innovation Associates, Inc)
 Stiffer than ADM, cut to size different
 Dissolves by 3-4 months, leaving native expander capsular
CONCLUSION
 Probably represents the greatest advance in breast reconstruction in the last decade.
 Effect against capsular contracture or some implant-related complications + reduces the
number procedure  Improve patient’s overall satisfaction and quality of life.
 Still, there’s no right or wrong
THANK YOU

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ACELLULAR DERMAL MATRICES

TRAN NGUYEN NHAT KHANH, MD., MSC

FlexHD® (Ethicon, Inc., Somerville, NJ, USA) Human, non-cross-linked

Min Jang et al. (2014).

 14% direct to implant, no expander (19,998 )  increase 8%

Under the • Hard to achieve a natural appearance with ptosis

• lack secure coverage of the inferior pole of implant

Lateral view of expander

 Provide lower pole soft-tissue support

Nahabedian, 2012; Spear et al., 2012

Conversely, ADMs were associated

Conclusion: low complication rate (6.6 percent)

Tessler, Oren et al. “Beyond biologics: absorbable mesh as

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