Acellular dermal matrices in breast reconstruction: a narrative review and institutional perspective

Breast reconstruction after mastectomy is commonly undertaken in patients inappropriate for breast conserving surgery, women who are at high genetic risk for breast cancer or otherwise based on patient preference. Current breast reconstruction techniques are diverse and may involve the use of an autologous tissue flap, tissue expanders or definitive implants. Regardless of the technique used, the use of acellular dermal matrices (ADMs) has become increasingly prevalent. The increased uptake of ADMs has led to a paradigm shift in breast reconstruction. This has led to a proliferation of new products and materially contributed to increased rates of pre-pectoral reconstruction. Single-stage and two-stage breast reconstruction remain a contentious issue with increasing evidence justifying direct-to-implant reconstruction in well selected patients with ADMs. ADMs are able to provide solutions to a multitude of issues surrounding inadequate tissue coverage and support, such as implant rippling, implant migration and capsular contracture. This review outlines an overview of the history of ADMs, commonly used ADMs and addresses the evidence with respect to known complications of ADMs. A number of product alternatives to ADMs are explored and an analysis of materials and characteristics are also provided. Notwithstanding cheaper costs of manufacturing these products may offer comparable outcomes. Ultimately this narrative review provides an institutional insight into breast reconstruction in a high volume Australian centre routinely employing ADMs. Important adjuncts such as indocyanine green angiography (ICGA) and negative pressure wound therapy (NPWT) have enhanced outcomes in our practice facilitating the identification of patients likely to benefit from staged expander based reconstruction.