Prepectoral Breast Reconstruction with Fenestrated Acellular Dermal Matrix: A Novel Design

Summary: Fenestrated acellular dermal matrix (ADM) has improved patient outcomes in both direct-to-implant and 2-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap to enhance the breast reconstruction experience. We present a novel, surgeon-designed shaped fenestrated ADM, placed in the recently repopularized prepectoral pocket for anterior coverage of implants in direct-to-implant and 2-stage breast reconstruction. A retrospective review of 10 patients (18 breasts) who underwent direct-to-implant or 2-stage breast reconstruction utilizing fenestrated shaped ADM in the prepectoral plane at a major academic institution in 2016 was conducted. Sixteen breasts (88.9%) underwent direct-to-implant reconstruction, and 2 breasts (11.1%) received tissue expanders. All reconstructions were performed using FlexHD Pliable ADM with surgeon-designed shape and fenestrations. The average implant size was 544.4 cc (±137.2 cc). The average intraoperative tissue expander fill volume measured 450 cc (90% of tissue expander size). The single expander case utilized 1 office fill (day 21) for full expansion. Major complications requiring reoperation within 90 days postoperatively were observed in 22.2% (4 breasts) of reconstructions. Three breasts (16.7%) due to partial mastectomy flap necrosis, 1 breast (5.5%) explantation due to infection. There was no seroma or capsular contracture. Prepectoral reconstruction with shaped fenestrated ADM is safe with high intraoperative fill volumes and facilitates more direct-to-implant reconstructions. Patients undergo fewer postoperative expansions, experience less time to full expansion, and subjectively report less pain. Patients benefit from improved cosmetic outcomes with better shape and no functional loss or animation deformity. 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. Published online 4 April 2018. Received for publication December 12, 2017; accepted December 19, 2017. Drs. Paydar, Wirth, and Mowlds have a royalty and consultancy agreement with the Musculoskeletal Transplant Foundation Biologics (Edison, N.J.). No financial support or funding was provided in the preparation of this article. Disclosure: Drs. Paydar, Wirth, and Mowlds have a royalty and consultancy agreement with the Musculoskeletal Transplant Foundation Biologics (Edison, N.J.). The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. Supplemental digital content is available for this ­article. Clickable URL citations appear in the text. Keyianoosh Z. Paydar, MD, FACS, Department of Plastic Surgery, University of California, Irvine, 200 S. Manchester Avenue, Suite 650, Orange, CA 92868–3298, E-mail: kpaydar@uci.edu Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.

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