Advantages & Disadvantages to Alloderm Put in During Implant Exchange?

Question

I currently have tissue expanders. My surgeon will use alloderm to make a hammock during implant exchange. What are advantages & disadvantages of using Alloderm at this final stage? What effect will it have on my pectoral muscles? Will I see or feel a ridge along suture line once stitches have dissolved? Thank you

Lewis Albert Andres, MD · Answer

The use of the acellular dermal matrix has grown in its applications and use in plastic & reconstructive procedures, and growing. 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 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!

Adam Schaffner, MD, FACS · Answer

In my New York City plastic surgery practice, I have observed that if AlloDerm is used in breast reconstruction, it is usually placed immediately before tissue expanders are inserted. AlloDerm has more elasticity than Strattice which is advantageous when stretching the skin. It is available in a sterile manner (which was not always the case) and minimizes the amount of dissection that needs to be performed during surgery. Over time, AlloDerm and the sutures which secure it dissolve. No ridge should be apparent along the suture line once the sutures (stitches) have dissolved.

Richard Baxter, MD · Answer

Alloderm is an acellular dermal matrix that is tranformed into living tissue over time to form a sort of internal bra. This helps to support implants and allow for a better shape to the breast. There is evidence that it also helps to prevent capsular contracture, which is more common in reconstruction than in augmentation. The Alloderm is sewn to the pectoral muscle, so the muscle covers the upper part of the implant and the Alloderm the bottom part. You should not feel much of a ridge but it depends.

David Mathes, MD · Answer

Generally, Alloderm is used during the first stage of a two stage breast reconstruction. The use of it in the second stage to make a sling is useful if the lower mastectomy flaps are very thin and there is concern about rippling. The suture line in either use of alloderm will dissolve but depending on the suture it can take time. The major downside of putting alloderm at the second stage would be an increased risk of seroma. This can lead to infection and other problems. Many surgeons recommend the use of drains with the placement of alloderm. I usually don't use drains for the implant exchange but would be more likely to do so if I was going to place alloderm. The question to ask your surgeon is why the think you need an alloderm sling and how if would improve your results. I am sure they have a good indication and should be able to explain the rationale to you in the office. Good luck.

Paul Gill, MD · Answer

Most surgeons will use the alloderm during the first stage when the tissue expanders are placed to help add shape to the lower pole of the breast.  It also results in less pain and easy expansion.

	A new technique that some surgeons are now trying is to place a small sheet of strattice or alloderm during the tissue expander to implant exchange along the upper pole of the breast to reduce the risk of capsular contracture.  I do not feel the benefits outweigh the risks on this.    I have not seen issue s with ridging of the suture line with alloderm and find it has little effect on the pectoralis muscles.    
	
	I wish you a safe recovery and fantastic result.

	Dr. Gill

Sugene Kim, MD, FACS · Answer

Alloderm is acellular dermal matrix that is usually used at the time of tissue expander placement. I routinely use Strattice (xenograft, another option); I think a dermal matrix allows a faster expansion and better shape. You should not feel any ridge or sutures. The dermal matrix will incorporate with your body. I don't know why Alloderm is being used for implant exchange stage...

W. Thomas McClellan, MD, FACS · Answer

Alloderm is an acellular dermal matrix that is used for breast reconstruction most commonly but also revision breast augmentation to hide ripples or abdominal hernia repair. All allografts, as there are many, are human cadaveric skin which has been sterilized. Our bodies use the allograft as a scaffold in which to incorporate (grow into) new tissue. You can think of the allograft as a type of "skin graft". Allograft has been very well studied in breast cancer reconstruction and a few negatives are that its known to have a higher infection rate(~15% higher) and seroma rate (~10% higher) than traditional breast recon. (Seroma = collection of fluid) However the infection and seroma rates can be effectively lowered by good patient selection (non smoker, no diabetes, no obesity), and good surgical technique (good hydration of the allograft prior to placement, strict hemostasis, proper drain placement and time (typically 5-7 days), securing the allograft to the underside of the skin, and proper orientation of the allograft (there's an up and a down side)).

	Even with the higher rate of inection and seroma I think the allograft is a valuable tool in the plastic surgeons ability to achieve a beautiful result.

	You should not feel the suture line as long as the surgeon uses vicryl suture. Occationally surgeons use PDS which is like fishing line. Its possible to feel the knots if that type of suture is used.  Allograft should have no lasting effect on your muscle. I believe that the cosmetic results of breast caner reconstruction using allografts in conjunction with a skin sparing mastectomy are superior.

	Talk with your surgeon more about the risks and benefits that he/she perceives and how to mitigate them. I hope this helps.

	Check out my page on breast reconstruction at mtpsaDOTcom I think it will help explain the process I use.

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