Shaping Alloderm to Overcome Contour Deformities in ...



Shaping Alloderm to Overcome Contour Deformities in Autologous Breast Reconstruction

Aldona J. Speigel, M.D., Hector Salazar-Reyes, M.D., Sylvia Martinez, M.D.

Introduction: Autologous breast reconstruction is widely accepted as the ideal option for women seeking a natural aesthetic result after mastectomy. Specifically, the deep inferior epigastric artery perforator (DIEaP) and superficial inferior epigastric artery (SIEA) flaps recreate much of the breast’s original appearance and texture (1-3). The refinement of these and other reconstructive techniques has resulted in a higher aesthetic standard by which surgeons and patients evaluate outcomes of breast reconstruction. Contour deformities are a particular development that can adversely impact the result of autologous breast reconstruction. If present, these irregularities usually affect the superior rim of the flap becoming more obvious several months into the postoperative period. This poses a challenge for plastic surgeons since there are limited options for correcting or minimizing such defects.

Techniques that have been used to overcome similar breast contour deformities include fat injection and capsular flaps (4-5). This article reports on the novel technique of incorporating the use Alloderm to correct superior rim contour irregularities after autologous breast reconstruction.

Methods and Surgical Technique: An observational retrospective review of twenty-nine patients with a total of thirty-four breast sites is the basis for this study. Included patients underwent immediate or delayed breast reconstruction surgery after mastectomy secondary to breast cancer, with the exception of 1 patient who had breast reconstruction following complications related to breast implant surgery.

The surgical material used in all patients was Alloderm (Life Cell Corporation, Branchburg, NJ), an acellular human dermal matrix that has been processed to remove its immunogenic components. Although reports of its utilization in breast surgery are limited to implant-based reconstruction and augmentation mammoplasty, it has been widely used in soft tissue reconstruction of the abdomen and face (6-8). Alloderm has been histologically shown to incorporate into a variety of biological sites through cell repopulation and revascularization. In addition, it has a minimal associated risk of infection and extrusion (9-10).

All surgical procedures were performed by the primary author. The Alloderm (thickness and range of sizes) was rehydrated in sterile saline solution according to manufacturer’s instructions. It was shaped by folding it on itself and secured with absorbable sutures. The contoured Alloderm was then tacked to the defect, using monocryl suture. Proper positioning of the Alloderm was confirmed by placing patient in the upright position before conclusion of procedure.

Results: The shaped Alloderm was placed into thirty-four breast sites in a total of twenty-nine patients. Postoperative follow-up ranged from six months to four years, with only five patients having less than one year of follow-up. Patients included in the study had breast reconstruction with DIEaP, SIEA, TRAM, or SGAP flaps with the majority (sixty-four percent) having a DIEaP flap. Prior to reconstruction, twelve patients underwent radiation therapy and no patients had radiation postoperatively.

From the aesthetic point of view the results were judged to be good to excellent based on preoperative and postoperative pictures. Judgment criteria included symmetry to contralateral breast, diminished appearance of superior rim depression, and desirable fullness of the upper pole of the reconstructed breast.

Overlying skin necrosis, loss or extrusion of material, and infection were considered major complications and were not found in any study patient. However, one patient did report subjective movement of the Alloderm which was partially excised. Minor complications included pruritus (2.9 percent), material migration (3.8 percent), material crumpling (2.9 percent), and subtle overlying skin wrinkling (2.9 percent). None of the patients with minor complications required revision of the shaped Alloderm.

Conclusion: This retrospective study presents encouraging aesthetic results in the use of Alloderm to address contour deformities in breast reconstruction process. As previously reported, Alloderm was found to be a safe and versatile material for tissue reconstruction. Given the limited techniques available to correct contour irregularities and the encouraging results of this study, shaped Alloderm should be considered a reliable option for minimizing contour defects associated with autologous breast reconstruction.

A B

C D

Figure 1. Figure 1 illustrates the autologous breast reconstruction process of this 42 year-old patient. (A) Figure 1A shows the residual post-mastectomy defect, the starting point for breast restoration. (B) The patient underwent a right delayed DIEaP flap. In this 3-month postoperative picture, the residual upper pole contour defect can be recognized as an upper medial shaded depression. (C) Figure 1C demonstrates the preoperative markings for Alloderm placement (D) Improvement can be noted in this picture, taken two months after corrective surgery.

References:

1. Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 114:1077-1083, 2004.

2. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast construction. Ann Plas Surg 32:32-28, 1994.

3. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. J Plast Reconstr Aesth Surg. 59:571-579, 2006.

4. Spear SL. Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the reconstructed breast. Plast Reconstr Surg 116:1300-1305, 2005.

5. Imran D, Javaid M, Lewis D. Attar KH. Capsular flap for correction of contour deformities of the breast. Ann Plast Surg 54:662-663, 2005.

6. Salzberg CA. Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (Alloderm).. Ann Plast Surg. 57:1-5, 2006.

7. Breuing KH, Warren SM. Immediate bilateral breast reconstruction with implants and inferolateral Alloderm slings. Ann Plast Surg 55:232-239 2005.

8. Buinewicz B, Rosen B. Acellular cadaveric dermis (Alloderm): a new alternative for abdominal hernia repair. Ann Plast Surg 52:188-194, 2004.

9. Sclafani A, Romo T, Jacono A, et al. Evaluation of acellular dermal graft (Alloderm) sheet for soft tissue augmentation: 1 year follow-up of clinical observation and histological findings. Arch Facial Plast Surg. 3:101-103, 2001.

10. Eppley BL. Revascularization of acellular human dermis (Alloderm) in subcutaneous implantation. J Aesthetic Surg 21:291, 2000.

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