Breast Implants vs Tissue Fillers for Breast Reconstruction

I have breast cancer, and will undergo mastectomy, but my insurance will not approve the use of Alloderm for the reconstruction because they say its investigational. If this is the case, what are my other options?

Doctor Answers (19)

Breast Reconstruction can be done without AlloDerm

+2

If you haven't done so already, talk about this with your plastic surgeon. Breast reconstruction can be done without AlloDerm. AlloDerm is a product made by LifeCell. It is a "regenerative tissue matrix" produced by removing the living cells from harvested cadaveric epidermis and dermis. "The cells responsible for immune response and graft rejection are removed. What remains is a matrix or framework of the natural biological components, which allows the body to mount its own tissue regeneration process."

These quotes are from the AlloDerm website. In breast reconstruction, this is often used to help to line the pocket in which an expander and subsequently an implant will sit. Prior to the widespread use of AlloDerm, plastic surgeons created this pocket using your own muscle and tissues in the area, i.e. your pectoralis and serratus muscles that make up your chest wall. This "total submuscular" pocket provided good results for many years prior to the advent of AlloDerm. The AlloDerm makes it easier and possibly more reliable for the surgeon. There are also many other options including autologous tissue reconstruction and combined autologous and alloplastic reconstruction. You should discuss all of these options with your plastic surgeon prior to proceeding.

Good luck with your reconstruction and I hope you have a speedy recovery.


Englewood Plastic Surgeon

Breast implants vs tissue fillers for breast reconstruction?

+1

Thank you for your question?  The use of the acellular dermal matrix (e.g., FlexHD, AlloMax, AlloDerm, etc.) has grown in its applications and use in plastic & reconstructive procedures, and growing. It has truly been a remarkable addition for breast reconstruction.  It is not a necessary tool for implant-based breast reconstruction, but certainly has its advantages.  I have come across this situation in the past - discuss this with your surgeon, if you have not already.  Sometimes it is just a matter of which product is requested.  for whatever reason, if AlloDerm is not approved, FlexHD or AlloMax may be approved. 

The acellular dermal matrix is a tissue that is specially-prepared, which comes from cadaveric skin. It is placed on the inside, not on your 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. Packages 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.  Best wishes!

Lewis Albert Andres, MD
Scottsdale Plastic Surgeon
5.0 out of 5 stars 10 reviews

Alloderm Use in Breast Reconstruction Post Mastectomy - Insurance Issues

+1

Alloderm (acellular dermal matrix) has been used more than a decade for breast reconstruction and should not be considered investigational. I would appeal the decision and have your plastic surgeon be your advocate and write a letter of necessity regarding its usage in your particular case. Finally, even if you loose the appeal you should only have to pay the cost of the material (cheaper if the surgeon purchase it for you than the hospital which typically doubles (or more !) the price.

Here is the basics of the federal law:

Women's Rights for Breast Reconstruction  Following Mastectomy

The Federal Women's Health and Cancer Rights Act of 1998 is still the law today

Under the federal Women's Health and Cancer Rights Act of 1998, a yearly notification
of your benefits pertaining to breast reconstruction must be sent to you by your insurance company.
The Women's Health Care Act states that benefits must be provided for:
Reconstruction of a surgically removed breast
Surgery and reconstrcution of the other breast to produce a symmetrical appearance
Prostheses and treatment for physical complications from all stages of a mastectomy, including lymphedema

These benefits are subject to the conditions and terms of your plan, including maximum benefit amounts, deductibles,
copayments, and coinsurance provisions. The benefits are subject to your plan's exclusions and limitations.

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 38 reviews

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Alloderm is not Investigational

+1

Use of an acellular dermal matrix such as Alloderm has become widely utilized in breast reconstruction. If your surgeon feel that it will provide you with an improved outcome then it should be utilized. It may take a few phone calls and letters, but your insurance company should be able to be educated.

Leo Keegan, MD
Manhattan Plastic Surgeon
4.5 out of 5 stars 2 reviews

Use of Alloderm in implant-based reconstruction

+1

Alloderm has been used for many years with a proven record.  It is not investigational nor experimental.  There are many articles that testify for benefits of Alloderm and other dermal matrix.  I would have your plastic surgeon be your advocate and contact your insurance company again.  Best of luck to you.

Sugene Kim, MD
Houston Plastic Surgeon
4.5 out of 5 stars 35 reviews

Alternative to Alloderm in Breast Reconstruction

+1

Although insurance coverage for Alloderm (and other similar products, called collectively Acellular Dermal Matrix, aka ADM) is becoming more common, some payers may not cover it due to the high cost of the product. If your surgeon feels that you could benefit from it but cost is an issue, a much less expensive option is using Vicryl mesh (same material from which some sutures are made). While it does not have all the advantages of ADMs, it can accomplish the same result for creating a more natural breast reconstruction and allow for faster tissue expansion. At least one medical paper has been published demonstrating the positive results of this product.

Karol A. Gutowski, MD, FACS
Ohio Plastic Surgeon
5.0 out of 5 stars 17 reviews

Alloderm in Breast Reconstruction

+1

The use of Alloderm in your implant-based reconstruction plan is NOT experimental.  There is ample data to support its use and its is one of the options for breast cancer mastectomy reconstruction.  I would speak with your plastic surgeon and have them serve as your advocate.  In addition, I would recommend that you contact your insurance company to fight this nonsense.  Despite the 1998 federal law mandating mastectomy reconstruction coverage, on occasion, some pesky insurance companies continue to look for ways to reduce or deny covered services.  This is exactly when patients and physicians need to team up and battle this nonsense.

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.5 out of 5 stars 113 reviews

Alloderm and breast reconstruction

+1

While breast reconstruction has been around for a long time before Alloderm, more and more surgeons are using it for their breast reconstructions.  Insurance companies are about saving money.  They like to label things "experimental" so they do not have to pay.  Remember it took an act of Congress to get them to pay for breast reconstruction at all, and another act of Congress to get them to pay for the other side.  Having said that, Alloderm is not experimental.  It is in common usage, and has good studies to back it up.  Enlist your plastic surgeon and appeal the denial.  Often the alternative reconstructive option, (rotational flap or free flap) is more costly and then the insurance company may want to go the Alloderm route.

Jeffrey Roth, MD
Las Vegas Plastic Surgeon
4.5 out of 5 stars 7 reviews

Insurance Coverage for Alloderm Use in Breast Reconstruction

+1

Although AlloDerm certainly has a proven track record for use in breast reconstruction surgery, some insurance companies will try to deny it as experimental in order to avoid coverage.

DO NOT BE DISCOURAGED!

This is when your surgeon needs to be your advocate.

1. The Women's Health Care Act of 1998 requires that any insurance company that covers mastectomy must also cover all stages of reconstruction and matching surgery.

2. Lifecell corporation, who makes AlloDerm, has a reimbursement hotline to help deal with these issues- LifeCell Reimbursement Hotline at 888.543.3656 or reimbursement@lifecell.com.
 

3. If you work for a large company, your Human Resources Representative has significant clout in working with your insurer.

4. Breast reconstruction is a hot political and media issue. Getting your local press involved is a powerful form of ground roots activism for yourself and others.

GOOD LUCK!!!

Karen Vaniver, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 17 reviews

Alloderm not approved by insurance

+1

Insurance companies commonly categorize certain treatments or adjuvants as "investigational" and do not cover the cost of using them. Thankfully, most insurance companies are approving Alloderm usage in breast reconstruction due to the large numbers of positive studies regarding its use. If your insurance company does not cover Alloderm, you have a few options:

  1. Have your Plastic Surgeon contact the insurance company for pre-authorization - this usually requires a letter including copies of studies purporting the use of Alloderm
  2. Contact the insurance company yourself. Sometimes, the coverage policies displayed on the websites are not up to date and they may have recently begun covering Alloderm

Reconstruction with tissue expanders can also be done without the use of Alloderm. This involves covering the lower portion of the implant with other muscles adjacent to the pectoralis muscle (the serratus anterior and the rectus sheath). Have the discussion with your surgeon as to the pros and cons of each and whether the fight to get your insurance company to cover the Alloderm is worth it!

David Bogue, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 8 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.