Acellular Dermal Matrices in Prepectoral Breast Reconstruction—Do We Need It?

Commentary

The article titled, “Immediate Prepectoral Breast Reconstruction Without Acellular Dermal Matrices: Preliminary Results” by Bounhadana et al ¹ is a single surgeon, retrospective case series of 66 prepectoral breast reconstruction patients (n = 88 breasts) without the use of acellular dermal matrices (ADM). Specifically, the authors demonstrate that the incidence of major and minor complications is comparable to the published ADM-assisted prepectoral breast reconstruction literature.^2–5

While retrospective case series are subject to inherent threats to internal validity, such as an inability to control for known and unknown confounding variables, when considered in the context of the existing literature, this study questions the necessity of ADM to mitigate the risk of prosthetic device exposure in the prepectoral plane. Notably, a retrospective chart review of 84 prepectoral breast reconstruction patients by Safran et al ⁵ demonstrated a comparable incidence of major complications (ADM [14.3%] vs No-ADM [11.4%], P = 1.00), implant exposure (ADM [2.6%] vs No-ADM [2.3%], P = 1.00), and BREAST-Q patient-reported outcome measures within ADM and no-ADM cohorts. Similarly, Manrique et al ⁴ demonstrated a similar complication profile and BREAST-Q outcomes in a retrospective cohort of 40 nipple-sparing mastectomy patients who underwent prepectoral implant-based breast reconstruction with (n = 21) and without ADM (n = 19). At an estimated cost of $9955 USD for a 16 × 20 cm piece of ADM, the authors quoted direct cost savings to their institution of $3,105,960 to $6,211,920 if ADM were not used for unilateral and bilateral cases, respectively. ⁴

Given limited healthcare resources, particularly in single-payer public models such as in the Canadian context, costs associated with the use of ADM may prevent surgeons from attempting prepectoral breast reconstruction in patients they deem to be appropriate candidates. The results published by Bounhadana et al, ¹ Manrique et al, ⁴ and Safran et al ⁵ provide some evidence that ADM may not be required in select patients, particularly in settings where resource limitations prohibit its use.

These results should be interpreted with caution given their retrospective design and potentially underpowered analysis; however, there is sufficient justification to undertake either a prospective observational cohort or randomized control trial design with associated cost-effectiveness analysis. Currently, Dr E. Matros and Dr J. Nelson at Memorial Sloan Kettering Cancer Center have an ongoing randomized controlled trial comparing prepectoral breast reconstruction with and without the use of ADM (NCT05316324). ⁶ Such a study design enables researchers to address current limitations within the literature and control for both known and unknown confounding variables. Ultimately, we encourage authors like Bounhadana et al ¹ to continue their pursuit establishing the safety of ADM-sparing prepectoral breast reconstruction.