How do medical products like Alloderm aid in breast reconstruction procedures?
How is Alloderm Used During Breast Reconstruction?
Doctor Answers (30)
Alloderm inBreast Reconstruction
Reconstruction using a breast implant can generally be accomplished in one of two ways:
* Using a tissue matrix such as AlloDerm in conjunction with a breast implant in a single stage procedure
* Using a tissue expander that is subsequently replaced by a breast implant; this process requires two separate procedures, usually months apart
Breast implants used in reconstruction cannot generally be placed directly in the space created by the removal of breast tissue. The reason for this is that an implant placed directly below the skin will generally not produce cosmetically desirable results and has a high risk of eroding through the surgical incision or through the skin itself.
With the use of a tissue matrix such as Alloderm®, some women are able to avoid the tissue-expansion phase of breast reconstruction in what has been termed a “straight-to-implant” procedure. During this kind of surgery, the lower edge of the pectoralis muscle is detached from the chest and lifted up to form the upper part of a “pocket” that will eventually contain a breast implant. The upper portion of the breast implant is placed under the lifted muscle; tissue matrix is then used to span the space between the edge of the detached muscle and the chest, thereby covering the lower portion of the breast implant. The tissue matrix is attached between the muscle edge and the chest wall so that behind the muscle and the implanted tissue matrix a pocket large enough to accommodate an implant can be created without the need for tissue expansion. Typically, small- to medium-sized breasts can be reconstructed in this manner. (Keep in mind that a second surgical procedure is still typically needed for nipple reconstruction, unless nipple-sparing mastectomy has been performed.)
In addition tissue expansion may be combined with the placement of a tissue matrix such as AlloDerm® to effect more complete coverage of the breast implant. Tissue matrix, attached to the lower edge of the pectoralis muscle and the chest wall can be draped over the lower portion of the implant to provide additional coverage of the impant in order to try to provide a somewhat more natural appearance to the reconstructed breast.
Breast Reconstruction with Alloderm and Implants
Alloderm, or other similar products, are frequently used in breast reconstruction with expanders and implants. The expander or implant is placed below the muscle (pectoralis major). Themuscle only covers the top half of the implant. In the past, other muscles were also mobilized to cover the inferior portion of the implant or expander. In the present time, many surgeons use the Alloderm or similar acellular dermal matrix to cover the lower half of the implant. From El Paso, Las Cruces, Mexico.
Alloderm and breast reconstruction
Alloderm, or any of the other biological products, has taken the place of the lower muscles that used to be integral to breast reconstruction with a tissue expander or implant. When undergoing breast reconstruction with a tissue expander, the expander is covered by your pectoralis major muscle. However, this only covers the top portion of the expander.
Ten years ago, the standard was to lift up some of your abdominal muscle and side muscles to cover the expander completely. Howeever, this has three problems. It was very painful after surgery, disrupted more of your natural anatomy, and did not allow the expander to really create a nice inframammary fold.
The Alloderm has taken the place of these muscles. It allows the expander to really sit where it is placed and create a nice fold, while not disrupting any other anatomy, and there is much less pain. The Alloderm gets incorporated into your own tissue by about 6 weeks, and becomes part of your natural tissue. The infection rate is extremely low, and there is no rejection of the material itself.
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Breast reconstruction with Acellular Dermal Matrix
The use of the acellular dermal matrix (such as AlloMax, AlloDerm, FlexHD, etc.) has grown in its applications and use in plastic & reconstructive procedures, and continues to expand. It has truly been a remarkable addition for breast reconstruction.The acellular dermal matrix is a tissue that is specially-prepared, which comes from cadaveric skin. It has been processed in such a way that the basement membrane and cellular matrix remain intact, while removing all other cellular components that may lead to both rejection and infection. Packaged as a sterile tissue product, due to its preparation, the chance of acquiring viruses and such is nearly absent.
Its applications for breast reconstruction alone include its use in tissue expander/implant reconstruction, to act as a "hammock" at the inferior portion of the breast for which the implant lies within. This creates a natural "sling" which mimics the ptosis (sag) of the breast, while supporting it in place. By suturing this matrix to its exact position of the breast margins, the plastic surgeon is able to precisely recreate an excellent contour for your breast, especially at the inferior, medial, and lateral positions. This also minimizes migration of the implant, as sometimes seen with "bottoming out" inferiorly or its displacement into the axilla (armpit). In addition to its increased aesthetic results, the acellular dermal matrix provides additional coverage over your implant. This is especially useful in those instances of dehiscence (your incision opening up), thus protecting the implant from exposure, and threatening its necessity for removal. Furthermore, in cases where the overlying mastectomy flaps are thin or damaged, leading to partial flap necrosis, the tissue matrix again provides a coverage over your implant, which can heal over time or a graft placed over the are or simply closed. Lastly, the additional coverage lessens implant visibility and palpability and is a great adjunct for revisionary breast surgery. The use of this matrix, along with the advantages listed above, has reduced the time of the reconstructive portion of the procedure as well. There is less pectoralis muscle retraction and eliminates the need to raise any other surrounding muscles in order to achieve complete implant coverage.
Additional benefits seen with the acellular dermal matrix are numerous. There has been a significantly decreased incidence of capsular contracture around the implant at the area of the tissue matrix. Reasons are unknown as of yet, but contracture has been a huge problem in cases of implants used for reconstruction and augmentation. Also, there are tissue regeneration properties of the matrix in which rather than inciting a scarring response, the dermal matrix begins a regenerative process in which it acts as a biologic scaffold and unbelievably, vessels incorporate into matrix and the surrounding cells differentiate into surrounding tissue that it is incorporated into (an amazing concept).
Overall, the use of the acellular dermal matrix in breast reconstruction has been revolutionary. Its applications for tissue expander reconstruction, possibility to use in immediate implant reconstruction (going directly to implants rather than the use of a tissue expander first), revisionary breast surgery, capsular contracture complications, and nipple reconstruction have been great.
Acellular dermal matrix (alloderm)
acellular dermal matrices are products that may be used as part tissue expander or implant-based breast reconstruction. These products are sutured in place over the breast expander or implant and beneath the skin. They may aid in maintaing the inframammary crease of the breast and providing additional coverage over the implant
Role of Alloderm in Breast Reconstruction
Alloderm is a materai dervied from processed human dermis, which the strong layer of the skin. Alloderm is used to supplement the strength and thickness of the mastectomy skin flaps to allow for use of implants in cases where the breast implant might extrude, or displace by stretching out the mastectomy flap, or be more likely to form a capsular contracture particularly after radiation therapy.
While Alloderm may help to reduce the chance of those problems, I prefer to use the patients own tissues for breast reconstruction.
These techniques include TRAM flaps, TRAM free flaps, and DIEP perforator flaps. For more information on these and other breast reconstruction options see nybreastreconstruction.com
"The first use of alloderm in the breast"
This procedure of using Alloderm for breast surgery was first utilized by me in 2010.The idea was to extend the pectoralis muscle and avoid expanders. Since that time we have performed this procedure on more than 800 breasts with only a small incidence of complications and the procedure has now become the "gold standard " for breast reconstruction.
How Alloderm has helped in reconstruction
As you have read from other plastic surgeons, Alloderm is processed human tissue devoid of cells including immune markers which has greatly improved the quality, predictabilty and options in breast reconstruction. It can provide for a more predictable placement of an implant or expander in am immediate reconstruction as well as increased tissue thickness. It also allows for more precision in the creation/preservation of the fold at the lower part of the breast.
Studies have also shown that it can lower the risk/extent of capsular contracture around the implant even in irradiated tissue which is great news for many.
Alloderm is cadavaric skin that is treated and used as a biologic to reinforce the soft tissue coverage of the lower pole and protect the expander from exposure.
Dermal matrix in breast reconstruction
Alloderm(TM) and other dermal matrix products have increasingly become the norm in tissue expander/implant reconstruction. The basic concept is that dermal matrices have no living cells anymore, but have a scaffolding, template of collagen and other structural molecules that allow your own tissue to grow along the scaffold.
Historically, when expanders/implants were used in breast reconstruction for mastectomy patients, the surgeon would lift up portions of other muscles, like the serratus anterior muscle along the outer aspect of the lower breast, to help provide complete muscle coverage over the device, since the pectorlais major muscle would typically only cover the upper 2/3 to 3/4 of the device. Remember that when a mastectomy is done, the patient no longer has as much tissue to cover the lower pole of the implant compared to a patient undergoing straightforward breast augmentation.
Now, with the advent of matrix materials, the matrix can be sewn to the lower edge of the pectoralis major muscle and the other chest wall muscles do not need to be violated. This may result in less pain, and may allow the expander/implant to sit more naturally in the lower pole of the breast. It may also allow more rapid expansion. Think of the matrix as extending the reach of the muscle, although it does not actually turn into muscle. Some products, like Alloderm (TM), are fairly "stretchy", allowing them to facilitate expansion of the breast without tightening up too much.
Dermal matrices of a less stretchy nature can also be used in the abdominal wall during TRAM flaps to reconstruct the defect in the strength layer (fascia) of the abdomen, to avoid a synthetic mesh.
There are many sources of dermal matrix, including human-, porcine- and bovine-derived products. Surgeons vary in their adoption and preferences of these products.