Acellular human dermis (AHD) Implantation in 153 Consecutive Immediate Tissue Expander Breast Reconstructions: What is the rate of seroma and infection?
Anuja K. Antony, MD, Ester Teo, B.S., Colleen McCarthy, MD, Beth Aviva Preminger, M.D., Andrea Pusic, M.D., Babak J. Mehrara, M.D., Joseph J. Disa, M.D..
Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
The use of acellular human dermis (AHD) has become increasingly popular in prosthetic breast reconstruction. Acellular human dermis has been shown to become revascularized in the implant pocket and eliminate the need for elevation of the serratus anterior muscle and/or anterior rectus sheath to cover the lower pole of the implant/tissue expander. Concerns with the use of AHD include an increased risk of seroma and infection. Based on previous studies at our institution, we have demonstrated a 0.9-4.4% rate of seroma, 0.9-3.1% rate of infection and 0.2-1.8% rate of premature explantation in our non-alloderm tissue expander reconstructions. The purpose of this study is to evaluate the incidence of postoperative seroma and infection in the largest reported series of AHD and tissue expander breast reconstruction to date.
This study is a retrospective review of all patients undergoing AHD/expander immediate breast reconstruction over a four year period. Patient demographic, reconstructive and complication data were obtained from a prospectively maintained database. Seroma was defined as a clinically appreciated fluid collection (not hematoma) around the expander or in the mastectomy space. Medical records were then retrospectively reviewed to further delineate seroma management, post-operative drain use and tissue expansion characteristics.
This study accrued all patients from 2004-2008 undergoing immediate breast reconstruction with tissue expanders and AHD. Ninety-six women underwent stage one reconstruction. A total of 153 tissue expanders were implanted; of which 39 were unilateral and 57 were bilateral TE reconstructions. Of the 153 reconstructed breasts, 16(10.5%) had prior radiation treatment and 14(9.2%) had radiation treatment after expansion. 27.1% of patients had chemotherapy prior to immediate TE placement reconstruction and 45.8% had chemotherapy post-mastectomy.
Mean initial and final TE volumes were 250cc(range 60-660cc) and 531cc(range 210-980cc). Sentinel lymph node biopsy was carried out in 80% of patients (n=99 of 153 breasts). Twenty(13.1%) of 153 reconstructed breasts required axillary lymph node dissection. Drains were used in all reconstructions and continued for a mean duration of 9.1 days(range 5-31 days). Seroma was identified in 11 reconstructed breasts (7.2% of all reconstructions). Of these, 9 underwent seroma aspiration. Mean aspirated volume was 154cc and mean number of aspirations was 2. Seroma was not statistically associated with sentinel lymph node biopsy or axillary dissection (Fisher’s exact, 2-tail,p=0.10,p =0.16).
Eleven(7.2%) of the 153 tissue expanders were removed; this was due to infection (n=5,3.3%), exposure (n=4,2.6%), and patient preference (n=2,1.3%). Other complications included cellulitis resolved by antibiotics(3.9%), hematoma(2.0%), mastectomy flap necrosis(4.6%). 92.8% of TE reconstructions were successfully expanded and exchanged for a permanent implant. None of the confirmed or suspected seromas went on to develop infection or required implant removal.
Acellular human dermis is a useful adjunct for pocket development in immediate tissue expander reconstruction, as it obviates the need for elevation of the serratus anterior and anterior rectus sheath. The seroma and infection rate compare favorably with previously published data. The results of this study support the use of AHD in tissue expander breast reconstruction when indicated. Minor seroma formation may be managed with limited aspiration.