Despite in the recent decade, the free tissue transfer has been the gold standard for breast reconstruction and evolving of DIEP, TUG flaps toe the most common used breast reconstruction approach at present time, however the complexity of the procedure, long operative time, donor site comorbidities, long learning curve and subsequently increased cost were always present as downside of this approach (Table 1).
Table 1: 3 Part questions. View Table 1
More recently with the advances in tissue engineering, the development of Acellular Dermal Matrix variants provided better implant coverage, more aesthetically pleasant lower pole outcome and, alleged, less post-radiotherapy complications. With addressing these previously notorious concerns resulted in shifting away from implant-based breast reconstruction in the past, now the implant-based reconstruction is back in the race. In this review, we are trying to highlight the evidence supporting using either the Free tissue transfer vs. ADM-assisted implant based approaches for breast reconstruction in terms of patient satisfaction, risk-effectiveness ratio and cost.
A 56-years-old female is undergoing a skin sparing mastectomy for breast cancer with expected postoperative radiotherapy, will a free tissue transfer e.g., DIEP breast reconstruction or Implant based + ADM breast reconstruction yield a better outcome in terms of patient satisfaction, cost effectiveness and risks?
Medline 2008-April 2018 using the pubmed interface [(exp Breast reconstruction) AND ADM AND Implant LIMIT to English.
141 papers were found. Of which 121 publications in the last 5 years, only 61 were relative to humans. of these were excluded as they were non relevant to the reconstructive approach. Remaining 19 publications were included (Table 2).
Table 2: Relevant Papers. View Table 2
Breast reconstruction has been evolving fast for the past few decades. Recently the free tissue transfer has been the gold standard in Breast reconstruction replacing the Implant based breast reconstruction (IBBR) in most of the world, providing reliable, autologous, safe and, most importantly, durable tissue that handles the common peri-operative radiotherapy reliably.
However, with the recent advances in tissue engineering and the wide spread of the Acellular Dermal Matrix (ADM) has revolutionized the breast reconstruction and put the IBBR back to the race side by side with the free tissue transfer.
Where some units have adopted the ADM-assisted IBBR either one stage or two staged approaches, other units raised relevant questions with regards to the ADM-assisted IBBR.
Despite having shorter theatre time, hence less cost, the ADM added cost was a concern. The notorious ADM related early post-operative complications e.g., infection, seroma, implant loss and theatre revisits were concerns to be investigated. The claimed evidence of reducing the capsule contracture is another question to be answered. The cosmetic benefit especially in lower pole, implant coverage and contour enhancing are other factors to be highlighted.
In this systematic review, we try to collect the available evidence to address these concerns to try to find a clear answer whether the ADM-assisted IBBR is a safe and reliable breast approach the validated above-mentioned benefits which top the more complicated, lengthy, costly and demanding free tissue transfer or still the downsides of the ADM-assisted IBBR outweighs its merits.
In 2013 Martin L, et al. at Aintree published ADM guidelines in BAPRAS trying to regulate the new wild horse emerging widely in the breast reconstruction [1]. Clear and relative indications plus precautions based on the limited data available that time, gave the green light for the ADM to be used in a more systematic way and resulted in more data available at present time enables us to have more guidance when considering using the ADM.
The Safety of using ADM has been always a concern due to the claimed increased risk of complications e.g., seroma, infection, skin necrosis, theatre revisits and implant loss. In 2016 Lee KT, et al. performed a meta-analysis concluding 6199 cases comparing the traditional submuscular implant reconstruction with ADM-assisted approach [11]. They reported higher risk of early post-operative morbidities including seroma and infection. However, they did not find remarkable difference compared to the traditional ADM-free approach. Krishnan NM, et al. [6], in 2014, when performed a comprehensive literature review comparing the 2 staged IBBR with and without ADM in terms of post-operative complications and found that ADM-assisted IBBR had 30% complications rate compared to 34.5% in IBBR without ADM.
The added benefit of cosmetically enhancing the reconstructed breast with ADM especially with lack of breast tissue after mastectomy and lower pole augmentation plus allowing better expansion was validated by the work of Ibrahim AM, et al. in 2015 [12]. They had 5 independent blinded plastic surgeons reviewing the pre- and post-operative photographs of two staged IBBR with and without ADM from cosmetic outcome angle. They have concluded that ADM-assisted IBBR had improved contour, lower pole projection, infra mammary fold definition and implant placement. This great work came in agreement with their successor Forsberg CG, et al. [13] in 2014 who had 18 blinded reviewers scoring 183 breast reconstruction from 1 to 5, being 5 is the most cosmetically appealing reconstruction. They have concluded that the ADM-assisted IBBR group had a better cosmetically appealing outcome in terms of contour, symmetry and implant position. Moreover, Apte, et al. in 2016 [3] reported 93.3% high level of body confidence in 53 cases of ADM-assisted IBBR.
Another major concern was the capsule contracture, especially with common post-operative radiotherapy which enabled the autologous free tissue transfer to claim the golden medal for the most reliable reconstruction approach in such condition and the notorious reputation of capsule contracture in IBBR which has a 4 folds risk increase with radiotherapy. Chopra K, et al. in 2017 [8] had an interesting study when they took two biopsies at the time of replacing the expander with implant from the pectoral adjacent capsule and the ADM adjacent capsule. The results showed, clearly, that the ADM capsule had thinner capsule with less inflammatory response. This confirmed the work of Yu D, et al. in 2016 [10] when they analyzed histologically 24 ADM capsules vs. non-ADM IBBR capsules and found that ADM-assisted IBBR capsules show significantly less vascular proliferation and concluded that it has less risk of capsule contracture.
On the other hand, a key factor in considering recruiting a management approach is cost effectiveness. This particular point was a fierce debate between two teams. The ADM supporters claimed that due to much shorter theatre time, less complicated equipment and quicker learning curve the ADM is more cost effective. Paradoxically the Autologous free tissue transfer team thought the added cost of the ADM plus the alleged risk of theatre revisits could mean that ADM is not a cost-effective option. In 2017, Tran BNN, et al. [5] compared the cost of two staged IBBR to DIEP as the most common autologous free tissue transfer used in breast reconstruction. Using the reimbursement codes, they found that the average cost of DIEP is $10,237.13 compared to $13,304.55, in case of 2 staged IBBR. They added the average complications cost and this demonstrated that two staged IBBR cost is $13,963.46 compared to $12,624.29 for the DIEP. Despite the cost was not significantly different, however the comparison was to a two stage ADM-assisted IBBR approach.
This could be significantly lower in case of adoption of the one stage approach which was found reliable through the work of Hunsicker LM, et al. in 2017 [7] when they reviewed the complications rate of 1584 one stage ADM-assisted IBBR and found that it is comparable to the two-stage approach.
Apte A, et al. in 2016 [3] added more credit to cost effectiveness the one stage ADM-assisted IBBR, when they reviewed the hospital stay and return to activity duration in 53 cases and reported mean hospital stay of 1.7 days post-surgery and 2.5 weeks return to light activity and 5.4 weeks to normal activity. Compared to the longer hospital stay (5-7 days post-surgery) and delayed return to activity mainly due to donor site morbidity and chest wall operative insult. These factors conclude that, in fact, the one stage ADM-assisted IBBR could be cost effective approach of choice.
It was not a surprise that Kankam HKN, et al. in January 2018 [4] reported that in 264 patients over the last 18 months the ADM-assisted IBBR percentage has increased from 16% to 52% of all breast reconstruction procedures, stepping down the DIEP from 49% to 34%. Which can be a sign of a pending shift in the breast reconstruction in the following years.
The available data suggest that ADM-assisted IBBR has unremarkable higher rate of early postoperative complications, however it enhances the cosmetic outcome and patient satisfactions. Moreover, there is some evidence that it could represent a more cost-effective option compared to the autologous free tissue transfer.