Why do we need Acellular Dermal Matrix (ADM)?
After a Nipple sparing mastectomy(NSM) or skin sparing mastectomy(SSM) , when a Direct-to-Implant (DTI) procedure is planned , the implant needs some mechanical support (especially at lower pole) , over and above the skin flap , otherwise the chance of implant extrusion is very high.
1.Synthetic meshes -form a firm scar plate , hence giving inferior cosmetic results.
2.Dermal slings- are an option only in large ptotic breast.
3.Latissimus dorsi muscle- donor site morbidity
4.ADMs- are natural biological material which get incorporated into the tissue giving good support and superior cosmetic results.
What is ADM?
- ADM is a biologically engineered mesh made by a scaffold of dermis taken from human, bovine or porcine dermis.
- It is processed (decellularized) to remove the immunogenic components but keep its structural matrix.
- It stimulates tissue regeneration and angiogenesis .
Various Options
- Cadaveric human (FlexHD®, Alloderm®, Allomax®, DermaCell®)
- Porcine (Strattice®, PermacolTM,
- Porcine (Native®, Braxon®)Bovine (SurgiMend®)
- Bovine pericardium (Veritas®)
A well done mastectomy is half job done!
- Be careful of subcutaneous planes- err on side of thicker flap- you can always revise later.
- If possible, use ICG to check flap vascularity.
- Mark the extent of Breast Preoperatively and avoid raising flaps beyond it.
- Taper at the end of superior flap to avoid a step.
- Do not go beyond IMF.
- NSM:- Inframammary incision > subareolar extended laterally
- – Send Nipple undershave for frozen section.
My tips:-
- Do not raise pectoralis major superiorly beyond the marking.
- Soak the ADM and implant well in antibiotic-saline solution (Gentamycin+ Teicoplanin)- you can use the remaining solution to give a final wash to pocket before closing the skin.
- Use the entire ADM- just cut the corner bits
- While fixing to IMF- create pleates and folds to get a deeper pocket and more lower projection.
- After fixing , cut out the extra bits that is not touching any tissue- it wont get integrated.
- Separate incision for axilla (lesser dead space)
- Tunnel the vacuum suction drain to a distance before taking out of skin- decreases infection chances
- The subcutaneous and skin closure should be water-tight.
- Refresh skin margins if needed.
- Faster procedure means less exposure to environment and lesser infection.
Possible Complications
- Flap Necrosis: Rare- Diabetics, smokers . Debridement and watertight closure is necessary to avoid infection and implant loss.
- Seroma: common. leave it -gets reabsorbed by 4 weeks. If drainage needed- USG guidance and strict asepsis.
- Infection: usually happens by the end of the 3rd week. Common organisms are staphylococci and pseudomonas. Longer course of antibiotics is usually required. May lead to implant loss.
- Red Breast Syndrome: to be differentiated from infection. Onset is early than infection. Make sure infection is ruled out, RBS settles on its own.
- Other complications: capsular contracture, implant deflation (saline leakage), implant migration, implant flip over, pain (capsule contracture is common cause), rupture, nipple sensation changes, rippling (fat grafting can correct rippling), implant extrusion, chronic pain and radiotherapy related severe contracture and scarring.