The Use of Acellular Dermal Matrices in Breast Reconstruction

Abstract

Introduction The use of the Acellular Dermal matrix (ADM) has become widespread in implant based breast reconstruction, with new methods and applications being found each year. Evaluation of complications, cost and outcomes often contrast and are not always applicable to the UK based population. The aim of this thesis is to investigate the safety and cost impact of ADM in patients undergoing breast reconstruction compared to alternate surgical methods. Methods A combined retrospective and prospective sample of 337 patients undergoing breast reconstruction was gathered from a single centre from 2010 to 2015. Patient and surgical variables, clinical outcomes and complications were compared between the 126 unilateral ADM-implant, 72 bilateral ADM-implant, 56 Lower Pole Sling (LPS) and 83 Latissimus Dorsi (LD) breast reconstructions. Statistical methods included regression analysis, Poisson regression, and logistic and multinomial logistic regression. Cost of initial surgery and total cost of surgical treatment were compared between the unilateral ADM-implant and LD reconstruction groups using regression analysis. Results There was no association of increased complications in patients that received ADM and no significant difference in health economic analysis between the unilateral and LD groups. While patients who received an LD were at increased of donor site complications, these had little downstream impact on further surgery and no impact on cost. The LD reconstruction group was more robust in situations of radiotherapy, smoking and use of Aromatase inhibitors (AI), which were associated with increased complications in patients receiving implant based reconstructions. The use of implants over 600cc was an independent risk factor for complication. Conclusions This single centre study adds to evidence that there is no increased risk of complication when using ADM in breast reconstruction. It also demonstrates that implant based breast reconstructions may be less robust than the LD method in certain situations, with no difference in cost. These findings have an important implication for decisions regarding treatment pathways and have been used to produce a decision making aid for the patient and surgeon which considers a variety of variables and odds ratios. It indicates that in the situation of smoking, AI use, radiotherapy, and large volume breasts, the LD reconstruction is a more suitable form of reconstruction in the eligible patient.