Goals/Purpose:
Acellular Dermal Matrices (ADM) have been available to plastic surgeons for over ten years making their way from burn and breast reconstructions and now breast augmentation revision procedures. ADM's are now used daily for complex breast revisions where soft tissue support, reinforcement is required including patients with: malposition, rippling, stretch deformity, hyperanimation and also replacement of capsular tissue in the treatment of capsular contraction. A compelling case may be made for the reduction in capsular contraction recurrence historically in breast reconstruction studies, the lack of capsule formation deep to the ADM, experimentally in animal studies, and clinically in breast augmentation studies. The purpose of this research is to determine if the use of two ADM's currently available may reduce the incidence of recurrent, or multiple recurrent capsular contracture clinically in post augmentation patients and their usefulness in patients having revision for other post-augmentation complications.
Methods/Technique:
A retrospective review of seventy-six (76) consecutive breast augmentation revision patients with surgeries performed over a four year period and receiving StratticeTM or Alloderm® for their aesthetic revision were reviewed. Capsular contraction was the primary reason for breast implant revision, although some patients had a combination of complications, including lateral or fold malpositions, symmastia, stretch deformity of the lower pole and hyperanimation. StratticeTM was utilized in fifty-eight (58) patients and Alloderm® in eighteen (18) patients. Four patients had unilateral revisions, two in each tissue group and all other patients, 72 patients had bilateral revisions, for a total of 148 breasts revised. Breast reconstruction and radiated patients were excluded. A minimum of 6 cm of total vertical height of Acellular Dermal Matrix was utilized as a pectoral extension when used for treating the fifty-six (56) capsular contraction patients, the reconstruction model using the ADM as a pectoral extension was utilized in all these repairs. ADM gutter onlays over neo-subpectoral pockets or capsular flaps were used in the majority of other repairs.
Results/Complications:
The Acellular Dermal Matrix was successful in the treatment of all patients for its designated use. Overall complications by patient were 5.3% including one patient with a delayed seroma and ADM exposure necessitating short term implant removal in one patient, or 1.3% of patients, and delayed implant replacement. Three patients, 4%, have had an additional fold malposition repair, so it is very important not to create a new complication when correcting another. Overall complications were 2.7% by implant. The patient requiring temporary implant removal but was successfully re-augmented at 6 months, and 3 patients required (5.3%) fold revisions. Most significantly, recurrent capsular contraction rate was zero in all patients including 56 patients presenting primarily with capsular contracture as their main complication, many patients with two or more recurrences. All patients felt their result was significantly improved from their preoperative result and even the four patients with a new complication stated they would undergo the ADM revision again. All 4 patients with new complications were successfully treated following one additional operation.
Conclusion:
Breast revision surgery is common with a 20-30% revision rate reported following primary augmentation and up to a 35-50% revision rate following a second operation. ADM are now used extensively in breast reconstructions and are now becoming more commonly utilized in complex aesthetic revision. Along with a high degree of success in aesthetic revisions in patients undergoing stretch and malposition repairs with ADM support, they have been reported in published reconstruction and cosmetic literature to be associated with low capsular contraction rates. In addition, experimentally ADM's have been shown to decrease or eliminate capsule formation around silicone devices, and histologically shown to inhibit capsule formation on the underside of the ADM adjacent to implants and expanders. This study confirms with a minimum 18 month follow-up, a zero percent capsular recurrence rate even when used in patients with multiple recurrent capsular contractures. Overall complication rate was 5.3% with one patient requiring temporary implant removal successfully re-implanted, and three patients have required fold revisions, so care must be taken not to create a new complication while fixing another. Capsular contraction is the most common complication in both aesthetic and reconstructive breast implant related surgeries. In many patients, recurrence occurs even with total capsulectomy, antibiotic irrigation, textured devices and implant exchange. The utilization of StratticeTM and Alloderm® in first time and recurrent capsular contracture has successfully resulted in soft breasts thus far in all seventy-six augmentation revision patients with up to a four-year follow-up, and all patients were successfully revised although four patients required one additional operation to have a stable successful outcome.
The Capsule extends down to the ADM junction and stops with no continuation on the underside of the ADM.
A patient with four times recurrent capsular contracture, fold malposition, Hyperanimation and asymmetry.
Patient one year following total capsulectomy, and StratticeTM utilized as a pectoral extension bilaterally with soft breasts and improved symmetry.
