Development of an Evidence-Based Approach to the Use of Acellular Dermal Matrix in Immediate Expander-Implant-based Breast Reconstruction

SUMMARY Background Although acellular dermal matrix (ADM) is widely used in expander-implant-based breast reconstructions, previous analyses have been unable to demonstrate improvements in patient-reported outcomes (PROs) with this approach over non-ADM procedures. This study aims to develop a more selective, evidence-based approach to the use of ADM in expander-implant-based breast reconstruction by identifying patient subgroups in which ADM improved clinical and patient-reported outcomes. Study Design The Mastectomy Reconstruction Outcomes Consortium (MROC) Study prospectively evaluated immediate expander-implant reconstructions at 11 centers from 2012 to 2015. Complications (any/overall and major), and PROs (satisfaction, physical, psychosocial and sexual well-being) were assessed two years postoperatively using medical records and the BREAST-Q, respectively. Using mixed-models accounting for centers and with interaction terms, we analyzed for differential ADM effects across various clinical subgroups, including age, body-mass-index, radiation timing, and chemotherapy. Results Expander-implant-based reconstruction was performed in 1451 patients, 738 with and 713 without ADM. Major complication risk was higher in ADM users vs. non-users (22.9% vs. 16.4%, p=0.04). Major complication risk with ADM increased with higher BMI (BMI=30, OR=1.70; BMI=35, OR=2.29, interaction p=0.02). No significant ADM effects were observed on breast satisfaction, psychosocial, sexual and physical well-being within any subgroups. Conclusion In immediate expander-implant-based reconstruction, ADM was associated with greater risk of major complications, particularly in high-BMI patients. We were unable to identify patient subgroups where ADM was associated with significant improvements in PROs. Given these findings and the financial costs of ADM, a more critical approach to the use of ADM in expander-implant reconstruction may be warranted.