From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction

Powers, Jeremy M.; Muñoz, Katherine D. Reuter; Parkerson, Jamie; Nigro, Lauren C.; Blanchet, Nadia P.

doi:10.1097/prs.0000000000008519

Cited by 14 publications

(11 citation statements)

References 64 publications

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“…The management of periprosthetic infection in implant-based breast reconstructions following mastectomy remains complex, ranging from oral antibiotic therapy to prosthesis explantation and washout. 5,6,16,17 Algorithmic approaches to implant salvage have been suggested, often relying on subjective criteria to stratify by infection severity. [15][16][17][18] However, variability in surgeon assessment of potential periprosthetic infection limits generalizability, resulting in a salient need for objective parameters.…”

Section: Discussionmentioning

confidence: 99%

“…4 This may result in prolonged antibiotic therapy duration, multiple operations, and implant loss. [5][6][7] The current paradigm for implant salvage relies on stratification of infection severity, primarily based on clinical assessment, which may be inherently subjective or variable among providers. 5,8 Furthermore, bacterial culture, which represents the gold standard for diagnosis, is dichotomous, where the extent of colonization rarely correlates with infection severity, especially in the setting of empirical antibiotic administration.…”

Section: Introductionmentioning

confidence: 99%

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Alpha Defensin-1 Level Correlates with Periprosthetic Infection Severity following Implant-based Breast Reconstruction

Sobti,

Vishwanath,

Stead

et al. 2024

Plastic and Reconstructive Surgery - Global Open

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Background: Accurate diagnosis of periprosthetic infections following breast reconstructions is paramount to reduce morbidity. Alpha defensin-1 (AD-1) is an antimicrobial peptide released by neutrophils. This study evaluates the relationship between quantitative AD-1 levels and infection severity in patients with suspected periprosthetic infection. Methods: Retrospective review was conducted of patients with prior breast implant reconstruction undergoing surgery for either suspected infection or prosthesis exchange and revision. The AD-1 level in periprosthetic fluid was sent for quantitative analysis. Association between AD-1 levels with outcomes, management, systemic markers of infection, and overall infection severity was evaluated. Results: Thirty-eight breasts were included. Infected breasts had higher AD-1 levels (3.91 versus 0.14, P < 0.01), greater odds of erythema [odds ratio (OR) 2.98 (1.53–5.82), P = 0.01], purulence [OR 2.84 (1.51–5.35), P = 0.01], fever [OR 1.84 (1.15–2.93), P = 0.01], threatened implant exposure [OR 2.97 (1.48–5.95), P < 0.01], and true implant exposure [OR 1.79 (1.04–3.08), P = 0.04]. Increasing AD-1 was an independent risk factor for washout (P < 0.01), and explant [OR 2.48 (1.47–4.2), P < 0.01]. AD-1 positively correlated with white blood cell count (β = 1.81 cells/µL, P < 0.01), and serum lactate (β = 0.19 meq/L, P < 0.04). Increasing AD-1 level was an independent predictor of infection severity (χ² = 22.77, P < 0.01). Conclusions: AD-1 levels correlate with infection severity, highlighting its potential both when clinical examination is ambiguous and when treatment response is being monitored. Although further evaluation is warranted, AD-1 may demonstrate utility in novel breast implant salvage algorithms.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Alpha Defensin-1 Level Correlates with Periprosthetic Infection Severity following Implant-based Breast Reconstruction

Sobti,

Vishwanath,

Stead

et al. 2024

Plastic and Reconstructive Surgery - Global Open

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“…The effect of ADM on infection could also be explored by using a more sterile or antibiotic-impregnated ADM. Powers et al 44 reported a lower rate of infection when switching from AlloDerm to DermACELL, a potentially more sterile ADM. AlloDerm and FlexHD, the two ADMs used in this study and the ones available at this institution, do not have any sterile processing, and other ADMs that do have sterile processing should be explored for implant-based reconstruction. 45,46 These changes in surgical and perioperative management may help ameliorate the infection rate associated with prepectoral implants in the current study.…”

Section: Discussionmentioning

confidence: 99%

Prepectoral vs. Submuscular Implant-based Breast Reconstruction: A Matched-Pair Comparison of Outcomes

Talwar

Lanni

Ryan

et al. 2023

Plastic &Amp; Reconstructive Surgery

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Background: Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center. Methods: Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions. Results: A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months. Conclusions: Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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“…These studies suggest clinical equivalence concerning seroma and implant loss rates, but offer contradictory evidence regarding rates of infection, red breast syndrome, and time to drain removal across the 2 hADMs. 3,[14][15][16] More recently, fbADMs have emerged as a cost-effective competitor to hADM. Yet, only 3 studies to date directly compare AlloDerm hADM to fbADMs such as SurgiMend PRS (Integra Lifesciences, Princeton, NJ).…”

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confidence: 99%

Acellular Dermal Matrix–Assisted, Prosthesis-Based Breast Reconstruction

Berger,

Spoer,

Huffman

et al. 2024

Ann Plast Surg

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Background Acellular dermal matrices (ADMs) are frequently employed in immediate prosthesis-based breast reconstruction (iPBR) to provide structural support. Despite differences in ADM derivatives, few studies directly compare their outcomes in the setting of iPBR. We sought to conduct a large head-to-head study comparing 3 ADMs used across our institution. Methods A multicenter retrospective review of patients undergoing iPBR with SurgiMend PRS (fetal bovine–derived; Integra Lifesciences, Princeton, NJ), AlloDerm (human-derived; LifeCell Corp, Bridgewater, NJ), or DermACELL (human-derived; Stryker Corp, Kalamazoo, MI) between January 2014 to July 2022 was performed. Primary outcomes included rates of unplanned explantation and total reconstructive failure. Secondary outcomes included 90-day postoperative complications and long-term rates of capsular contracture development. Results A total of 738 patients (1228 breasts) underwent iPBR during the study period; 405 patients received DermACELL (54.9%), 231 received AlloDerm (31.3%), and 102 received SurgiMend PRS (13.8%). Rates of short-term complications, total reconstruction failure, reoperation within 90 days, capsular contracture, and unplanned explantation were comparable. These findings remained true upon multivariate analysis accounting for baseline differences between cohorts, whereby ADM type was not an independent predictor of any outcome of interest. Conversely, factors such as body mass index, diabetes mellitus, smoking history, neoadjuvant and adjuvant chemotherapy, adjuvant radiation, skin-sparing mastectomy, Wise pattern and periareolar incisions, use of tissue expanders, and a subpectoral plane of insertion were significant predictors of postoperative complications. Conclusion Low rates of complications support the equivalency of fetal bovine and human-derived ADMs in iPBR. Patient characteristics and operative approach are likely more predictive of postoperative outcomes than ADM derivative alone.

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From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction

Cited by 14 publications

References 64 publications

Alpha Defensin-1 Level Correlates with Periprosthetic Infection Severity following Implant-based Breast Reconstruction

Alpha Defensin-1 Level Correlates with Periprosthetic Infection Severity following Implant-based Breast Reconstruction

Prepectoral vs. Submuscular Implant-based Breast Reconstruction: A Matched-Pair Comparison of Outcomes

Acellular Dermal Matrix–Assisted, Prosthesis-Based Breast Reconstruction

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