Research in context
Evidence before this study
The use of acellular dermal matrices (ADMs) in implant-based breast reconstruction (IBBR) has increased substantially over the past decade. Although early reports were overwhelmingly promising, evidence on the safety of ADMs in breast reconstructive surgery has since been ambiguous. We searched MEDLINE and Embase for papers reporting studies done to assess safety outcomes of ADM-assisted breast reconstruction, according to the the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and published before April, 2016. We used the search term (“Acellular Dermis”[Mesh] OR acellular dermis[tiab] OR acellular dermal matri*[tiab] OR acellular tissue matri*[tiab] OR collagen matri*[tiab] OR adm[tiab] OR strattice[tiab] OR alloderm[tiab] OR veritas[tiab]) AND (“Mammaplasty”[Mesh] OR mammaplast*[tiab] OR (breast[tiab] AND reconstruct*[tiab]) OR mammoplast*[tiab] OR (mamma[tiab] AND reconstruct*[tiab])). After screening, we found 99 studies that were suitable to include in a meta-analysis. Most were retrospective. Reported incidences of complications varied substantially between studies. Meta-analyses of the incidences of complications revealed that study heterogeneity was significant for almost all safety outcomes. The overall proportion of events was 18·7% (95% CI 0·159–0.219). Which factors underlie the variation in outcomes, however, was unclear. Additionally, comparison of ADM-assisted techniques with conventional breast reconstructive techniques was lacking. Prospective studies are needed to investigate whether the use of ADM is beneficial in IBBR compared with conventional breast reconstructive surgery.
Added value of this study
The Breast Reconstruction in One Stage (BRIOS) randomised study prospectively assessed conventional two-stage IBBR with the newer one-stage direct-to-implant technique with ADM.
Implications of all the available evidence
The evidence before this study did not show whether the proposed advantages of ADM in breast reconstruction were realised in practice. We found far more early postoperative complications after one-stage IBBR with ADM than after two-stage IBBR, particularly wound healing problems, such as wound dehiscence, skin necrosis, and wound infection, that led to reoperation and, often, removal of the implant. Our results suggest that use of one-stage IBBR with ADM should be considered carefully. This outcome will have direct implications for all women undergoing IBBR, and understanding of selection of patients, risk factors, and surgical and postsurgical procedures will need to be improved.