Meshed Acellular Dermal Matrix for Two-Staged Prepectoral Breast Reconstruction: An Institutional Experience

Abstract

The introduction of acellular dermal matrix (ADM) to breast reconstruction has allowed surgeons to reexplore the prepectoral implant placement technique in postmastectomy breast reconstruction. Our institution adopted a novel approach using meshed ADM to lessen the financial burden of increased ADM utilization with the prepectoral breast reconstruction. This is a retrospective, single-center review of two-stage prepectoral breast reconstruction using meshed human-derived ADM for anterior prosthesis coverage. Patient demographics, oncologic data, perioperative characteristics, and complications were examined and reported as means with standard deviations. Cost-saving with the meshed technique was evaluated. Forty-eight patients (72 breasts) with a mean age of 48.5 ± 15.0 years (range 26–70 years) were included in the study. The mean follow-up time was 13.2 ± 4.4 months (range 4.1–25.8 months). Nineteen breasts (24.6%) experienced complications, with seromas being the most common complication (12.5%, n = 9). Expander removal and reoperation occurred at a rate of 8.3 and 9.7%, respectively. The average time to drain removal was 18.8 ± 6.6 days (range 8–32 days). Meshed ADM provided an average cost savings of $6,601 for unilateral and $13,202 for bilateral reconstructions. Our study found that human-derived meshed ADM can be safely used in two-staged prepectoral tissue expander-based breast reconstruction and can result in significant cost savings.

Full text

Meshed Acellular Dermal Matrix for Two-Staged
Prepectoral Breast Reconstruction: An
Institutional Experience
Jessica Luo, BS1,

Rhett N. Willis Jr, MD1,

Suzanna M. Ohlsen1Meghan Piccinin, BS2
Neal Moores, MD1Alvin C. Kwok, MD, MPH1Jayant P. Agarwal, MD1
1Division of Plastic and Reconstructive Surgery, Department of
Surgery, University of Utah, Salt Lake City, Utah
2Michigan State University College of Osteopathic Medicine, East
Lansing, Michigan
Arch Plast Surg 2022;49:166–173.
Address for correspondence Jayant P. Agarwal, MD, Division of Plastic
and Reconstructive Surgery, University of Utah, 30 North 1900 East,
3B400, Salt Lake City, UT 84132 (e-mail: jay.agarwal@hsc.utah.edu).
Breast prostheses can be placed in either the prepectoral or
subpectoral planes for breast reconstruction. The prepec-
toral technique places the prosthesis above the pectoralis
major muscle. This technique dates back to the early use of
implants in the 1960s but fell out of favor because of the
increased rates of infection, excessive scar tissue formation
causing capsular contracture, and occasional implant expo-
sure.1These complications were attributed to inadequate
soft tissue coverage.2Subsequently, surgeons placed the
implants subpectorally, which provided more vascularized
Keywords
►acellular dermal
matrix
►prepectoral
►breast reconstruction
►meshed
►case reports
Abstract The introduction of acellular dermal matrix (ADM) to breast reconstruction has allowed
surgeons to reexplore the prepectoral implant placement technique in postmastecto-
my breast reconstruction. Our institution adopted a novel approach using meshed
ADM to lessen the financial burden of increased ADM utilization with the prepectoral
breast reconstruction. This is a retrospective, single-center review of two-stage
prepectoral breast reconstruction using meshed human-derived ADM for anterior
prosthesis coverage. Patient demographics, oncologic data, perioperative character-
istics, and complications were examined and reported as means with standard
deviations. Cost-saving with the meshed technique was evaluated. Forty-eight patients
(72 breasts) with a mean age of 48.5 15.0 years (range 26–70 years) were included in
the study. The mean follow-up time was 13.2 4.4 months (range 4.1–25.8 months).
Nineteen breasts (24.6%) experienced complications, with seromas being the most
common complication (12.5%, n¼9). Expander removal and reoperation occurred at a
rate of 8.3 and 9.7%, respectively. The average time to drain removal was 18.86.6
days (range 8–32 days). Meshed ADM provided an average cost savings of $6,601 for
unilateral and $13,202 for bilateral reconstructions. Our study found that human-
derivedmeshedADMcanbesafelyusedintwo-stagedprepectoraltissueexpander-
basedbreastreconstructionandcanresultinsignificant cost savings.

The two authors contributed equally to this work.
DOI https://doi.org/
10.1055/s-0042-1744408.
ISSN 2234-6163.
© 2022. The Korean Society of Plastic and Reconstructive Surgeons.
All rights reserved.
This is an open access article published by Thieme under the terms of the
Creative Commons Attribution-NonDerivative-NonCommercial-License,
permitting copying and reproduction so long as the original work is given
appropriate credit. Contents may not be used for commercial purposes, or
adapted, remixed, transformed or built upon. (https://creativecommons.org/
licenses/by-nc-nd/4.0/)
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Breast/Trunk: Case Report
THIEME
166
Published online: 2022-04-06

soft tissue coverage and addressed the aforementioned
problems. This subpectoral approach became the preferred
method for postmastectomy breast reconstruction for the
next 15 years.3
The subpectoral placement of prostheses presented its own
set of difficulties and complications, including functional im-
pairment of the pectoralis muscle, animation deformities, and
an increase in postoperative pain,all of which are consequences
of the elevation and contraction of the pectoralis muscle.3,4
Aesthetically, this technique resulted in decreased projection
and definition of the breast.1The advent of acellular dermal
matrices (ADMs) has led plastic surgeons to reexplore prepec-
toral prosthesis placement for breast reconstruction. ADM
provides an additional layer of soft tissue support for the tissue
expander or implant, and reduces capsular contracture by
serving as a barrier to the host’s foreign body immune
response.5,6 Prepectoral reconstruction using ADM allows for
a softer reconstruction, adequate support to prevent “bottom-
ing out,”and prevention of inframammary fold (IMF) malposi-
tion, rippling/wrinkling, and device exposure.7
There are various ways to use ADM in prepectoral recon-
struction, including in vivo techniques whereby the prosthesis
is coveredanteriorly,either partially or entirely, and the ex vivo
techniques of the “Wonton”wrap and the “Ravioli”wrap.3The
“Wonton”wrap uses a singlelarge sheet (typicallya 16 20 cm
piece) of ADM with the corners and edges sutured together on
the posterior aspect of the prosthesis, and the “Ravioli”wrap
uses two pieces of ADM, cut to the size of the device, and
sutured to each other along the edge to completelyenclose the
prosthesis.Compared with dual-plane subpectoral reconstruc-
tion, where ADM is only used to provide lower breast pole
coverage, prepectoral reconstruction requires one or multiple
larger sheets of ADM. The additional ADM comes at a signifi-
cant expense to the institution and patient.
Zammit et al8described thetechnique of meshing the ADM,
using a skin mesher, to increase the surface area of a single
sheet of ADM to provide adequate coverage and support for
subpectoral implants. Our institution adopted the prepectoral
breast reconstructive technique with anterior coverage of the
tissue expander using a meshed ADM in 2018. Our study is a
retrospective review ofclinical outcomes and costs associated
with the use of meshed ADM for prepectoral breast recon-
struction in patients who underwent two-stage reconstruc-
tion. This is a novel modification to ADM, and there is a paucity
of data on meshed ADM use in breast reconstruction. We will
be comparing our findings to the two published studies on
meshed ADM in breast reconstruction that are available in
literature.
Methods
This study was exempted by the institutional review board
(IRB00081784). A retrospective chart review identified con-
secutive postmastectomy female patients who underwent
the first stage of a two-stage prepectoral tissue expander
breast reconstruction with meshed ADM between May 2018
and January 2020. Procedures were per formed by one of two
senior plastic surgeons at one institution. Exclusion criteria
were single-stage breast reconstructions, delayed recon-
structions, meshed ADM introduced at later stages of recon-
struction, and incomplete chart data.
Parameters recorded were age, body mass index (BMI),
smoking status, comorbidities (e.g., obesity and diabetes),
follow-up time, cancer stage, chemotherapy and radiation
therapy, mastectomy technique, mastectomy specimen
weight, expander size, initial and final expander fill volume,
drain duration, ADM size and mesh ratio, complications (e.g.,
hematoma, seroma, infection, wound dehiscence, flap necro-
sis, expander removal, and reoperation), type of permanent
implant (e.g., silicone or saline), and reconstruction type (e.g.,
none, nonautologous, autologous, or both). Complications
were divided into major (requiring reoperation or tissue
expander removal) and minor (resolved with therapies done
in the clinic or without therapy). Smokers were required to
stop smoking a minimum of 3 weeks before surgery.
Patient selectionfor the prepectoral meshedADM technique
was based on risk factors, body habitus, and preoperative
discussions, including patient desires and activity levels. A
breast oncologic surgeon performed either a skin-sparing or
nipple-sparing mastectomy. After the mastectomy, the skip
flaps were clinically examined to ensure adequate subcutane-
ous adipose layer and skin flap viability. If skin flaps were
determined to be toothin, such that the dermis was exposed on
pocket examination, or if there were concerns for inadequate
skin flap perfusion, then the prepectoral meshed ADM tech-
nique was aborted and either the traditional subpectoral dual-
plane tissue expander placement or delayed reconstruction
was performed.
All of the ADM used were human-derived, rectangular-
shaped, medium thickness, 6 16 cm or 8 16 cm, and from
Alloderm RTU (LifeCell Corp., Branchburg, NJ) or DermACELL
(LifeNet Health, Virginia Beach, VA). A 1:1.5 ratio Zimmer
Biomet Skin Graft Mesher was used to mesh the ADM
(►Fig. 1). Both sized ADM sheets were medium thickness
and easily passed through the mesher without complications.
Tissue expander sizes selected were based on patient
desires and base diameter measured intraoperatively. The
expander was deflated and placed against the chest wall and
secured using the suture tabs. The meshed ADM was then
placed into the mastectomy pocket, overlying the tissue
expander, and the four “corners”were rounded to accom-
modate the pocket outline. The corners were then sutured to
the underlying pectoralis major muscle and IMF fascia with
2.0 Vicryl interrupted suture. The superior, medial, and
inferior borders were then sutured to the pectoralis major
muscle and the IMF fascia with a running 2.0 Vicryl suture.
Lateral overhang or redundant ADM was trimmed, and the
lateral border was then sutured in a similar fashion to the
serratus anterior fascia (►Fig. 2). One or two 15-French
round drains were placed between the meshed ADM and
the skin flaps, depending on surgeon preference. The tissue
expander was then inflated with saline to an appropriate
volume to allow a tension-free skin flap closure. The incision
was then closed in two layers.
Drains were removed when less than 30 mL of fluid was
draining per day for 2 consecutive days, and serial expansion
Archives of Plastic Surgery Vol. 49 No. 2/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved.
Meshed Acellular Dermal Matrix Luo et al. 167

was initiated at 3 weeks postoperatively. Oral antibiotics
were prescribed postoperatively until all drains were
removed in clinic.
Patients then underwent a second-stage reconstruction
with tissue expander removal and either implant placement
or autologous tissue. This was performed after the patient
had reached their desired tissue expansion size and a mini-
mum of 3 months after expander placement or after all
adjuvant treatments were completed. The existing mastec-
tomy scar was reopened and the meshed ADM was incised
transversely, enough to extract the t issue expander and place
the permanent implant (►Fig. 3) or perform autologous
reconstruction. For implant-based reconstructions, the
meshed ADM was then closed with interrupted 2.0 Vicryl
sutures and the skin was closed in two layers. Superior
pocket capsulotomies and fat grafting were performed in a
select few patients for better contou r and aesthetic outcomes
(►Fig. 4).
Results
Forty-eight patients (72 breasts) underwent the first of a two-
staged prepectoraltissue expander breast reconstruction with
meshed ADM between May 2018 and January 2020. The mean
follow-up time was 13.2 4.4 months (range 4.1–25.8
months). The average patient age was 48.515.0 years (range
26–70 years).The mean BMI was 26.2 5.3 kg/m
2
(range 19.6–
42.5 kg/m
2
). Eleven patients (22.9%) were obese, 1 (2.1%) was
diabetic, 11 (22.9%) were former smokers, and 1 (2.1%) was an
active smoker (►Table 1).
Of the 72 breasts that underwent a mastectomy, the
number of breasts with cancer and their stages were as
follows: 8 (11.1%) were stage 0, 14 (19.4%) were stage I, 16
(22.2%) were stage II, 5 (6.9%) were stage III, and 29 (40.3%)
breasts were prophylactic. Fifty-seven breasts (79.2%) had no
radiation therapy, and 15 (20.8%) had adjuvant radiation
therapy. As for chemotherapy, 26 patients (54.2%) had none,
12 (25.0%) had neoadjuvant, 9 (18.8%) had adjuvant, and 1
(2.1%) had both neoadjuvant and adjuvant chemotherapy
(►Table 2).
Of the 48 patients, 24 of the cases (50%) were bilateral, and
24 (50%) were unilateral mastectomies. Fifteen mastecto-
mies (20.8%) were nipple-sparing and 57 mastectomies
(79.2%) were skin-sparing. The mean mastectomy specimen
weight was 487 .7 195.9 g (range 132–1,056 g). The mean
expander size used was 466.0 93.5 mL (range 30 0–700 mL),
Fig. 1 Technique in meshing the acellular dermal matrix (ADM). (A) Process of meshing the ADM at 1:1.5 ratio. (B)A616 cm ADM 100%
meshed.
Fig. 2 Meshed acellular dermal matrix (ADM) used in breast reconstruction. (A)MeshedADMsuturedintobreastpocket.(B) Tissue expander
inflated under meshed ADM.
Archives of Plastic Surgery Vol. 49 No. 2/2022 © 2022 . The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved.
Meshed Acellular Dermal Matrix Luo et al.168

mean intraoperative initial fill volume was 248.9 105 .0 mL
(52.7% 18.0%), and the mean final tissue expander fill
volume was 42 4.6 145.9 mL (range 150–700 mL). The aver-
age time for drain removal was postoperative day 18.8 6.6
(range 8–32 days). ADM s 6 16 cm (n¼46, 62.2%) and
816 cm (n¼28, 37.8%) were used, respectively (►Table 3).
Complications occurred in 14 (29.2%) patients and 19
(26.4%) breasts; they are listed as follows (seven breasts
have a sequence of complications that contributed to the
counts of multiple complications): 1 (1.4%) hematoma,
9 (12.5%) seromas, 5 (6.9%) infections, 4 (5.6%) wound
dehiscences, 3 (4.2%) flap necroses, 6 (8.3%) expander
removals, and 7 (9.7%) reoperations. Eight of the nine
seromas resolved with aspiration or on their own. Out of
the 15 (20.8%) breasts that received radiotherapy, 3 (4.2%)
resulted in complications with 1 (1.4%) tissue expander
removal. Additionally, one expander was removed due to
flap necrosis and four expanders were removed due to
infection that did not resolve with antibiotic therapy. Out
of the seven (9.7%) reoperations, six (8.3%) were to remove
the tissue expanders and one (1.4%) was to evacuate a
hematoma (►Table 4).
At the time of manuscript submission, 40 out of the 48
patients (83.3%) had completed second-stage reconstruc-
tion. Fifty-nine breasts (93.3%) had undergone second-stage
reconstruction: 42 (58.3%) had implant-based reconstruc-
tions, 8 (11.1%) had autologous reconstructions, and 7 (9.7%)
had both. Of those with implant-based reconstructions, 44
(89.8%) were with silicone, and 5 (10.2%) were with saline
permanent implants (►Table 5).
At our institution, using a single-meshed 6 16 cm sheet of
ADM instead of a 16 20 cm unmeshed sheet resulted in a
saving of $6,601 for a unilateral, and $13,202 for a bilateral
tissue expander reconstructive procedure. For bigger expand-
ers with larger surface area and width, where a meshed
816 cm sheet was needed, the cost savings was $5,659
and $11,318 in unilateral and bilateral breast reconstructions,
Fig. 3 100% meshed acellular dermal matrix incorporation at implant
exchange.
Fig. 4 Postoperative pictures of breast reconstructive patients using meshed ADM. (A) Patient 1 intraoperative image at implant exchange.
(B) Patient 2 at 5 months status postimplant exchange. (C) Patient 3 at 4 months status postimplant exchange.
Table 1 Demographic data
Characteristics Patients (n¼48)
No. of patients 48
No. of breasts 72
Mean follow-up, mo
Mean SD 13.2 4.4
Range 4.1–25.8
Age, y
Mean SD 48.5 15.0
Range 26–70
Body mass index, kg/m
2
Mean SD 26.2 5.3
Range 19.6–42.5
Obesity, no. (%) 11 (22.9)
Diabetes, no. (%) 1 (2.1)
Smoking, no. (%)
Former 11 (22.9)
Current 1 (2.1)
Abbreviation: SD, standard deviation.
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Meshed Acellular Dermal Matrix Luo et al. 169

respectively (exact costs vary by institution and ADM manu-
facturer) when compared with a 16 20 cm unmeshed sheet.
Discussion
ADM is composed of extracellular collagenous material
derived from decellularized xenogeneic or human cadaveric
skin that serves as a biologic scaffold for host cellular
integration and revascularization. First adopted in breast
surgery in 2001, ADM is now utilized by 84% of plastic
surgeons as an adjunct in both single- and two-stage breast
reconstructive procedures.9Prior attempts at prepectoral
breast implant placement resulted in serious complications
due to the inadequacy of the thin and ischemic mastectomy
skin envelope in accommodating a device.10 With the addi-
tion of ADM, prepectoral breast implant placement was
again explored, which resulted in improved aesthetic out-
comes and reduced risk of capsular contracture.5,7
The introduction of ADM in prepectoral breast recon-
struction is a relatively new development, and a standard-
ized technique is lacking. Variations in surgeon technique,
ADM placement (e.g., complete coverage vs. anterior
coverage of the device), type of ADM (e.g., bovine-, por-
cine-, vs. human-derived), and ADM modifications (e.g.,
whole sheet, fenestrated, vs. meshed) have resulted in
high degrees of heterogeneity between studies that make
comparisons difficult. Meshing ADM is also a relatively
novel modification, therefore literature on the subject is
also deficient.
Since the introduction of meshing ADM with a skin mesher
by Zammit et al in 2016,8there have been two studies on
meshedADM in breast reconstruction. Hagartyet al4compared
postoperative outcomes of subpectoral breast reconstruction
using a 1:1 and 1:1.5 meshing ratio of human-derived ADM to
unmeshed ADM. Concerned about ADM laxity, she later
changed to a 1:1 mesh ratio for the ADM. This study found
that meshing ADM decreases postoperative drain removal
times, postoperative pain, and length of stay in the hospital.
Complications were collectively reported as overall, major
(resulted in reoperations), and minor complications. Lotan
et al11 compared a ratio of 1:2 meshed bovine-derived ADM
to fenestrated bovine-derived ADM of mostly single-stage
(84.3% direct-to-implant) breast reconstructions, and found
reduced rates of seromas, hematomas, and infections, and
postoperative drain removal times. Both studies have found
meshed ADM in breast reconstruction as effective and safe in
comparison to unmeshed ADM. The literature has reported a
difference in the outcomes of xenogeneic and allogeneic ADMs.
Human-derived ADM has been found to have significantly
fewer complication rates than bovine- and porcine-derived
ADMs.12 Our study found that human-derived meshed ADM
can be safely used in two-staged prepectoral tissue expander-
Table 2 Preoperative data
Characteristics No. (%)
Cancer per breast (n¼72)
Stage 0 8 (11.1)
Stage I 14 (19.4)
StageII 16(22.2)
Stage III 5 (6.9)
Prophylactic 29 (40.3)
Radiation per breast (n¼72)
None 57 (79.2)
Neoadjuvant 0
Adjuvant 15 (20.8)
Neoadjuvant and adjuvant 0
Chemotherapy per patient (n¼48)
None 26 (54.2)
Neoadjuvant 12 (25.0)
Adjuvant 9 (18.8)
Neoadjuvant and adjuvant 1 (2.1)
Table 3 Perioperative data
Characteristics Value
No. of bilateral 24
No. of unilateral 24
Mastectomy incision (n¼72)
Nipple-sparing 15 (20.8)
Skin-sparing 57 (79.2)
Mastectomy weight (g)
Mean SD 487.7 195.9
Range 132–1,056
Expander size (mL)
Mean SD 466.0 93.5
Range 300–700
Intraoperative expander fill (m L), mean SD
Volume 248.9 105.0
Percent 52.7 18.0
Tot a l expan s i on (mL )
Mean SD 424.6 132.7
Range 150–700
Permanent implant size (mL)
Mean SD 442.9 145.9
Range 200–700
Time to last drain removal (d)
Mean SD 18.8 6.6
Range 8–32
Acellular dermal matrix size and mesh ratio (n¼74), no. (%)
616 medium thickness 1:1.5 ratio 46 (62.2)
816 medium thickness 1:1.5 ratio 28 (37.8)
Abbreviation: SD, standard deviation.
Archives of Plastic Surgery Vol. 49 No. 2/2022 © 2022 . The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved.
Meshed Acellular Dermal Matrix Luo et al.170

based breast reconstruction and can result in significant cost
savings.
In our study, 26.4% (n¼19) of breasts experienced com-
plications, with the two other meshed ADM papers repo rting
similar complication rates (21.5% in the human-der ived ADM
subpectoral4and 29.5% in the bovine-derived ADM prepec-
toral11). It has been well repor ted in meta-analyses that ADM
increases overall complication (odds ratio, 1.13–1.33) com-
pared with no ADM use, and some case series reported rates
between 4 and 41%.13,14 Although the rates of complications
within the three meshed studies are within the reported
rates in literature, the major complications requiring reop-
eration were relatively low (9.7% in our study, 4.6% in Hagarty
et al, and 13.0% in Lotan et al).
Our study had an 8.3% and L otan et al had a 5.2% prosthesis
removal rate in the breast reconstructions with meshed
ADM. These proportions are within the literature-reported
rates of implant or tissue expander loss in prepectoral breast
reconstruction using unmeshed ADM (3.5–10.2%).15–18
Seroma formation is the most commonly reported com-
plication in ADM use in breast reconstruction, with rates
ranging widely from 1.5 to 14.1%.13,19,20 In our study, the rate
of seroma occurrences was 12.5% (n¼9), with one major
seroma (1.4%) resulting in a sequence of infection, reopera-
tion, and tissue expander removal. Lotan et al found a
significant difference in major seromas between the meshed
and unmeshed cohorts (0% vs. 8.2%, p<0.01).11 While ADM
meshing is a relatively novel concept in breast reconstruc-
tion, commercially available fenestrated ADM has shown
benefit in reducing the risk of postoperative seroma forma-
tion relative to nonfenestrated ADM.21–23
With the decrease in seroma formation, it is also specu-
lated that meshing the ADM will decrease the time to drain
removal since the two reflect the same process. Our average
time of dr ain removal is 18.8 6.6 days (range 8–32 days).
The other meshed ADM studies found a significant decrease
in drain removal time in their meshed cohorts compared
with the unmeshed cohorts (18.78 vs. 28.81 days, p<0.001
and 8.3 vs. 10.0 days, p<0.01).4,11 The integration of the
ADM to surrounding tissues is associated with the normal
healing process that includes exudation of fluids.2The
meshing and fenestrations in the ADM are hypothesized to
allow the free fluid to more easily egress, enhancing the
effacement between the ADM graft and skin flaps, and
accelerating cellular integration and revascularization via
improved tissue oxygenation and fibroblast and macrophage
lineage host integration.21,22,24
The ADM’s additional enhanced support is theorized to
allow for increased intraoperative inflation of tissue expand-
ers and fewer postoperative fill sessions and, therefore, clinic
visits.25,26 Our study had a 52.7% initial fill volume, but our
study did not follow the number of postoperative fills and
clinic visits. Hagarty el al’s study found a lower initial fill
Table 4 Complications
Variable No. (%)
No. of patients with complications 14 (29.2)
Overall
No complications 53 (73.6)
Minor 12 (16.7)
Major 7 (9.7)
Seroma
No complications 63 (87.5)
Minor 8 (11.1)
Major 1 (1.4)
Hematoma
No complications 71 (98.6)
Minor 0
Major 1 (1.4)
Infection
No complications 67 (93.1)
Minor 1 (1.4)
Major 4 (5.6)
Wound dehiscence
No complications 68 (94.4)
Minor 3 (4.2)
Major 1 (1.4)
Flap necrosis
No complications 69 (95.8)
Minor 3 (4.2)
Major 0
Radiotherapy
No complications 12 (16.7)
Minor 2 (2.8)
Major 1 (1.4)
Expander removal 6 (8.3)
Reoperation 7 (9.7)
Table 5 Postoperative data
Characteristics No. (%)
No. of second-stage reconstruction
completion patients
a
40 (83.3)
Reconstruction t ype (n¼72)
None 2 (2.8)
Nonautologous 42 (58.3)
Autologous 8 (11.1)
Both 7 (9.7)
Pending 13 (18.1)
Implant exchange (n¼49)
Silicone 44 (89.8)
Saline 5 (10.2)
a
Total number of patients ¼48.
Archives of Plastic Surgery Vol. 49 No. 2/2022 © 2022. The Korean Society of Plastic and Reconstructive Surgeons. All rights reserved.
Meshed Acellular Dermal Matrix Luo et al. 171

volume of tissue expanders in the meshed ADM compare with
the unmeshed ADM cohort (52.89% vs. 73.51%, p<0.001).4In
contrast, Lotan et al11 had an increase in initial fill volume in
the meshed ADM in comparison to the fenestrated ADM
cohort, although the finding was insignificant (94.9% vs.
74.9%, p¼0.125). The variations in meshing ratios likely
explain the differences found in the initial fill volumes of the
different studies.
In our study, 3 (4.1%) of the 15 breasts (20.8%) that had
adjuvant radiotherapy resulted in complications: one infec-
tion that resolved with antibiotic treatment, one flap necro-
sis and infection that resulted in tissue expander removal,
and one hematoma that resulted in reoperation for evacua-
tion, but the tissue expander was retained. Of the six (8.3%)
tissue expander l osses, only one breast had radiotherapy. The
literature is overall conflicted on the long-term impact of
radiotherapy when ADM is used in breast reconstruction,
and there is no data on the impact of radiotherapy on ADM
that is meshed.27
Anterior coverage of the breast prosthesis often requires
one 16 20 cm or two 6 16 cm s heets o f ADM per breast,
and complete wrapping (anterior and posterior coverage)
can require two 16 20 cm s heets of ADM per b reast. Given
the significant expense of ADM, many surgeons have ques-
tioned whether it is a worthwhile adjunct in breast recon-
struction procedures. Bank et al determined that ADM
placement reduced the number of expansion visits for fill
volumes greater t han 350 mL, although these economic
savings failed to offset the cost of the graft.28 By increasing
the surface area of ADM up to 50% t hrough meshing, we were
able to obviate the need for larger, 16 20 cm sheets of ADM,
resulting in an average cost reduction of $6,601 for unilateral
and $13,202 for bilateral reconstructions with a single sheet
of 6 16 cm meshed ADM per s ide.
The anterior coverage technique of ADM must span the
length and width of the implant or expander.29 Sheets that
are too short to cover the implant fully may cause compres-
sion of the inferior pole, superior migration, and limited
projection.29 In the case of two-staged reconstruction, the
ADM should be sutured into place with some laxity to
accommodate eventual inflation of the tissue expander.30
Our use of meshed ADM increases the sheet’s surface area to
allow for full anterior coverage of a tissue expander by a
single piece of ADM, while maintaining structural integrity.
This study’s goal was a n early assessment of the sa fety and
efficacy of meshed ADM in two-staged prepectoral breast
reconstruction; however, it is not without limitations. The
prepectoral technique was first adopted along with ADM
meshing at our institution, so there is no unmeshed ADM
prepectoral cohort for comparison. Due to the relatively new
introduction and modification in ADM use in breast recon-
struction, more long-term and high-quality studies are
needed to understand the incidence and causality of com-
plications associated with meshing ADM. We hope to con-
tinue patient accrual and follow-up to ensure adequate long-
term aesthetic and patient-reported outcomes with prepec-
toral meshed ADM. Meanwhile, we believe that a single sheet
of meshed ADM for anterior prosthesis coverage is a safe and
effective option for women who desire prepectoral breast
reconstruction.
Author Contributions
Conceptualization: R.N.W.-Jr, N.M., A.C.K., J.P.A. Data cura-
tion: J.L., R.N.W.-Jr, S.M.O., M.P. Investigation: J.L., R.N.W.-
Jr, A.C.K., J.P.A. Methodology: J.L., R.N.W.-Jr, A.C.K., J.P.A.
Project administration: J.L., R.N.W.-Jr, A.C.K., J.P.A. Super-
vision, validation, visualization: A.C.K., J.P.A. Writing -
original draft: J.L., R.N.W.-Jr, S.M.O. Writing - review and
editing: J.L., A.C.K., J.P.A.
Ethical Approval
This study was exempted by the Institutional Review
Board of University of Utah Hospital (IRB00081784) and
performed in accordance with the principles of the Dec-
laration of Helsinki. The informed consent was waived
because this study design is a retrospective chart review.
Patient Consent
The patients provided written informed consent for the
publication and the use of their images.
Prior Presentation
This article was presented at the Mountain West Society
of Plastic Surgeons, Squaw Valley, Lake Tahoe, March 7–
10, 2019.
Conflict of Interest
J.P.A. is a consultant for DonJoy Orthopedics. The rest of
the authors have nothing to disclose.
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