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      Improving Equipment Setup While Preparing Acellular Dermal Matrix during Prepectoral Breast Reconstruction

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      , MD, MS * , , , MD
      Plastic and Reconstructive Surgery Global Open
      Wolters Kluwer Health

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          Abstract

          Prosthetic breast reconstruction remains one of the most frequently performed procedures in plastic surgery. Two-stage and one-stage implant-based reconstruction are both commonly offered with varying amounts of acellular dermal matrix (ADM) use dependent on surgeon preference. Advantages of ADM include potential lower incidence of capsular contracture, improvement in implant coverage particularly in the lower pole, and increased ability to define placement of the inframammary fold and expander/implant position. 1–3 The dual-plane approach continues to be the most commonly performed method of implant-based breast reconstruction. However, recently, there has been increased use of prepectoral techniques in an effort to minimize undesired muscle animation deformity, morbidity related to muscle dissection, and operative time. 1 Commonly, ADM is used to wrap the expander/implant to ensure coverage of the anterior surface of the implant at minimum, usually requiring at least 2 ADM pieces sutured together. In an effort to decrease operating time and increase operating room ergonomics, we developed a safe and effective equipment setup technique for use during ADM preparation. This setup allows suturing of the ADM pieces to one another before wrapping of the expander or implant and placement inside the postmastectomy breast pocket. Two pieces of ADM are opened and prepared in standard fashion on a sterile back table and stacked on top of each other, aligning the edges to ensure the “rough” dermal surface of each piece of ADM oppose one another. This in turn ensures the “smooth” surfaces of each ADM piece remain exposed on the outside surfaces. With 2 small sharp towel clamps, one at each end of the stacked ADM construct, the pieces of ADM are suspended using 2 additional Kelly clamps (or similar) attached to a large sterile plastic basin (Fig. 1). Tension can be adjusted accordingly by moving the towel clamps or Kelly clamps as desired. In this new suspended position, the 2 pieces of ADM can be sutured together quickly with minimal manipulation and handling of the ADM itself (Fig. 2). Once suturing is complete, the construct can be quickly taken down to perform subsequent steps including wrapping of the expander/implant, which we also perform on the sterile back table. Our technique ensures that all suture knots remain on the inner surface, along the implant surface interface, once the expander/implant is wrapped and secured. Fig. 1. Setup using the presented technique to suture 2 pieces of ADM before wrapping of prosthesis during prepectoral breast reconstruction. Two towel clamps are used at each end of the ADM pieces to suspend from a sterile basin. Fig. 2. Intraoperative photograph showing 2 pieces of ADM sutured together while suspended by towel clamps at each end. Prepectoral breast reconstruction provides many clinical advantages. Our technique has allowed surgeons to continue preparing the ADM simultaneously during the mastectomy portion of immediate breast reconstruction cases while decreasing operating time and minimizing traumatic handling of the ADM. In addition, the benefits of surgeon ergonomics increase dramatically. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

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          A systematic review and meta-analysis of complications associated with acellular dermal matrix-assisted breast reconstruction.

          Multiple outcome studies have been published on the use of acellular dermal matrix (ADM) in breast reconstruction with disparate results. The purpose of this study was to conduct a systematic review and meta-analysis to determine an aggregate estimate of risks associated with ADM-assisted breast reconstruction. The MEDLINE, Web of Science, and Cochrane Library databases were queried, and relevant articles published up to September 2010 were analyzed based on specific inclusion criteria. Seven complications were studied including seroma, cellulitis, infection, hematoma, skin flap necrosis, capsular contracture, and reconstructive failure. A pooled random effects estimate for each complication and 95% confidence intervals (CI) were derived. For comparisons of ADM and non-ADM, the pooled random effects odds ratio (OR) and 95% CI were derived. Heterogeneity was measured using the I2 statistic. Sixteen studies met the inclusion criteria. The pooled complication rates were seroma (6.9%; 95% CI, 5.3%-8.8%), cellulitis (2.0%; 95% CI, 1.2%-3.1%), infection (5.7%; 95% CI, 4.3%-7.3%), skin flap necrosis (10.9%; 95% CI, 8.7%-13.5%), hematoma (1.3%; 95% CI, 0.6%-2.4%), capsular contracture (0.6%; 95% CI, 0.1%-1.7%), and reconstructive failure (5.1%; 95% CI, 3.8%-6.7%). Five studies reported findings for both the ADM and non-ADM patients and were used in the meta-analysis to calculate pooled OR. ADM-assisted breast reconstructions had a higher likelihood of seroma (pooled OR, 3.9; 95% CI, 2.4-6.2), infection (pooled OR, 2.7; 95% CI, 1.1-6.4), and reconstructive failure (pooled OR, 3.0; 95% CI, 1.3-6.8) than breast reconstructions without the use of ADM. The relation of ADM use to hematoma (pooled OR, 2.0; 95% CI, 0.8-5.2), cellulitis (pooled OR, 2.0; 95% CI, 0.9-4.3), and skin flap necrosis (pooled OR, 1.9; 95% CI, 0.6-5.4) was inconclusive. In the studies evaluated, ADM-assisted breast reconstructions exhibited a higher likelihood of seroma, infection, and reconstructive failure than prosthetic-based breast reconstructions using traditional musculofascial flaps. ADM is associated with a lower rate of capsular contracture. A careful risk/benefit analysis should be performed when choosing to use ADM in implant-based breast reconstruction.
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            Prepectoral Breast Reconstruction.

            Oncologic and reconstructive advancements in the management of patients with breast cancer and at high risk for breast cancer have led to improved outcomes and decreased patient morbidity. Traditional methods for prosthetic breast reconstructions have utilized total or partial muscle coverage of prosthetic devices. Although effective, placement of devices under the pectoralis major muscle can be associated with increased pain due to muscle spasm and animation deformities. Prepectoral prosthetic breast reconstruction has gained popularity in the plastic surgery community, and long-term outcomes have become available. This article will review the indications, technique, and current literature surrounding prepectoral prosthetic breast reconstruction.
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              Acellular dermal matrix in primary breast reconstruction.

              The use of acellular dermal matrix (ADM) in many plastic surgery procedures, including breast reconstruction, has increased dramatically in recent years. While expander/implant reconstruction can be performed successfully with standard techniques, the introduction of ADM has added a new tool with which to achieve lasting, predictable results. This article is a summary of existing literature on ADM for primary implant reconstruction, to provide a more thorough understanding of the benefits of ADM in single- and to two-stage breast reconstruction and to identify the areas where further investigation is needed.
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                Author and article information

                Journal
                Plast Reconstr Surg Glob Open
                Plast Reconstr Surg Glob Open
                GOX
                Plastic and Reconstructive Surgery Global Open
                Wolters Kluwer Health
                2169-7574
                April 2020
                24 April 2020
                : 8
                : 4
                : e2798
                Affiliations
                From the [* ]Harvard Plastic Surgery Residency Program, Boston, Mass.
                []Mercy Clinic Plastic and Reconstructive Surgery, St. Louis, Mo.
                Author notes
                Arman T. Serebrakian, MD, MS, Harvard Plastic Surgery Residency Program, 75 Francis Street, Boston, MA 02115, E-mail: aserebrakian@ 123456bwh.harvard.edu
                Article
                00071
                10.1097/GOX.0000000000002798
                7209829
                3b34e428-9afc-4ccd-97a7-4e13e8d8c62d
                Copyright © 2020 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.

                History
                : 18 January 2020
                : 2 March 2020
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