Comment on the First Use of Human-Derived ADM in Prepectoral Direct-to-Implant Breast Reconstruction After Skin-Reducing Mastectomy

Abstract

In early breast cancer patients, conservative oncologically safe nipple-sparing (NSM), skin-sparing (SSM), and skin-reducing mastectomy (SRM) preserving most of the native skin together with the infra-mammary fold architecture have precipitated a major shift in breast reconstruction techniques and allowed safe implant-based breast reconstruction, that still represents the most widespread reconstructive strategy, achieving highly gratifying aesthetic outcome. Direct-to-implant single-stage immediate (DISSI) has emerged as an appealing reconstructive option; this requires, however, proper coverage of the implant to avoid implant extrusion and subsequent loss of the reconstruction [1]. Key to success of this approach has been traditionally coverage of the implant with well-vascularized tissues of adequate thickness achieved with the pectoralis major, the serratus anterior, and the anterior rectus fascia in addition to well-designed and dissected mastectomy skin flaps that are not excessively long. A major disadvantage of this approach has been the implantation pocket size that prevents insertion of large implants together with post-operative animation deformity. Realizing that total muscle coverage of the implant is not necessary, a shift toward dual plane implantation circumvented some of the drawbacks of the original approach provided the implant is separated from the suture line, nevertheless animation deformity remained a serious concern [1]. Nowadays, prepectoral implantation is gaining in popularity and several devices have been described to improve implant coverage and maintain it in position. Acellular dermal matrix (ADM) is mainstream in breast reconstruction and has been widely used to supplement the muscle deficit at the lower breast pole in traditional subpectoral alloplastic breast reconstruction. ADM is sutured superiorly to the detached inferior edge of the pectoralis major muscle and inferiorly anchored to the chest wall at the level of the infra-mammary fold creating a distensible pocket that is large enough to place a fully inflated implant and provide proper coverage should mastectomy flap necrosis occur particularly at the most vulnerable T-junction of a wise skin incision pattern. Currently, ADM is being used to completely cover the implant in prepectoral reconstruction. More recently, synthetic meshes associated with significant cost savings are being considered as a viable alternative to ADM [2]. Marongiu et al. [3] described what they have called ‘‘the first use of human-derived ADM in prepectoral direct-toimplant breast reconstruction after skin-reducing mastectomy’’. In fact, their title is somewhat misleading. They should have specified that what they are describing is the first use of a novel ADM device ‘‘MODA’’ (matrice omologa dermica acellulata) since ADM produced outside Europe cannot be used and commercialized in their country. The authors have performed skin-reducing mastectomy with a standard Wise pattern approach (Carlson type IV [4]) and free nipple-areola complex graft. Lower pole skin is de-epithelialized constituting an inferiorly based dermal & Fadl Chahine [email protected]