Salvage of Prosthetic Breast Reconstruction with Vascularized Acellular Dermis Flap

Abstract

1 Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Sir, U of acellular dermal matrix (ADM) is well described in implant-based aesthetic and reconstructive breast surgery. ADM is a structured, nonvascularized collagenbased matrix that adds shape, support, and an additional interface within the breast pocket. Initially, ADM is devoid of cells and other immunologic reactants. The intended outcome for ADM is to incorporate into the host, with subsequent revascularization.1 We used a previously placed, now revascularized acellular dermal (VAD) matrix flap to provide repair of implant exposure. The patient was a 41-year-old woman with a personal history of breast cancer who underwent bilateral nipplesparing mastectomy, with direct-to-implant-reconstruction and overlying 8 × 8 cm2 ADM (FlexHD pliable, MTF Biologics, Edison, N.J.) placement. Unfortunately, her postoperative course was complicated by left nipple areola complex necrosis, necessitating several attempts at complex closure. Nine months after a stable closure was accomplished, the patient underwent a revision surgery consisting of fat grafting of the entire breast envelope and skin grafting for reconstruction of the previously debrided left areola. Six weeks after this procedure, she re-presented with a left implant exposure at the previous opening site (Fig. 1). Because there were no signs of infection, salvage of reconstruction was undertaken. The breast pocket was entered using an elliptical incision that included the area of skin breakdown. The pocket showed no abnormal drainage. On inspection of the breast skin undersurface, the previously placed dermal matrix as well as fat graft appeared well taken. Fat graft contributed to enhanced thickness of the breast envelope, which was found suitable to give rise to a VAD flap while still providing adequate coverage of the prosthetic. A 3 × 3.5 cm2 VAD flap was raised in a medial-to-lateral direction, revealing a healthy underbelly of completely vascularized tissue, with adherent fat globules. It provided a layer of healthy tissue under the troublesome breast closure (Fig. 2). A new 400 moderate plus profile smooth round gel implant (Mentor Worldwide LLC, Irvine, Calif.) was placed in the pocket. The VAD flap was secured across the incision to the adjacent dermal matrix and capsule. Closure was performed in layered fashion, including drain placement. Application of dermal matrix coupled with staged fat grafting is a powerful approach to enhance breast skin overlaying an implant.2 Our patient presented with recurrent implant exposure due to paucity and poor quality of overlaying tissues. To address these tissue deficiencies, a well-vascularized flap, derived from previously acellular construct and grafted fat were brought into the compromised area to aid wound closure. The described technique allowed for a successful implant salvage using Salvage of Prosthetic Breast Reconstruction with Vascularized Acellular Dermis Flap