Alloplastic adjuncts in breast reconstruction

There has been an increasing role of acellular dermal matrices (ADMs) and synthetic meshes in both single- and two-stage implant/expander breast reconstruction. Numerous alloplastic adjuncts exist, and these vary in material type, processing, storage, surgical preparation, level of sterility, available sizes and cost. However, there is little published data on most, posing a significant challenge to the reconstructive surgeon trying to compare and select the most suitable product. The aims of this systematic review were to identify, summarize and evaluate the outcomes of studies describing the use of alloplastic adjuncts for post-mastectomy breast reconstruction. The secondary aims were to determine their cost-effectiveness and analyze outcomes in patients who also underwent radiotherapy.Using the PRSIMA 2009 statement, a systematic review was conducted to find articles reporting on the outcomes on the use of alloplastic adjuncts in post-mastectomy breast reconstruction. Multiple databases were searched independently by three authors (Cabalag MS, Miller GS and Chae MP), including: Ovid MEDLINE (1950 to present), Embase (1980 to 2015), PubMed and Cochrane Database of Systematic Reviews.Current published literature on available alloplastic adjuncts are predominantly centered on ADMs, both allogeneic and xenogeneic, with few outcome studies available for synthetic meshes. Outcomes on the 89 articles, which met the inclusion criteria, were summarized and analyzed. The reported outcomes on alloplastic adjunct-assisted breast reconstruction were varied, with most data available on the use of ADMs, particularly AlloDerm(®) (LifeCell, Branchburg, New Jersey, USA). The use of ADMs in single-stage direct-to-implant breast reconstruction resulted in lower complication rates (infection, seroma, implant loss and late revision), and was more cost effective when compared to non-ADM, two-stage reconstruction. The majority of studies demonstrated inferior outcomes in ADM assisted, two-stage expander-to-implant reconstruction compared to non-ADM use. Multiple studies suggest that the use of ADMs results in a reduction of capsular contracture rates. Additionally, the reported beneficial effects of ADM use in irradiated tissue were varied.ADM assisted two-stage breast reconstruction was associated with inferior outcomes when compared to non-ADM use. However, alloplastic adjuncts may have a role in single stage, direct-to-implant breast reconstruction. Published evidence comparing the long-term outcomes between the different types of adjuncts is lacking, and further level one studies are required to identify the ideal product.