An Algorithmic Approach for Selective Acellular Dermal Matrix Use in Immediate Two-Stage Breast Reconstruction: Indications and Outcomes

Background: Acellular dermal matrix use has gained widespread acceptance despite higher material costs because of its ease of use and potential for enhanced cosmesis. The authors developed a resource-sensitive algorithm for selective acellular dermal matrix use with indications and contraindications based on body mass index, breast size, radiation therapy, flap vascularity, and pectoralis anatomy. Methods: The algorithm incorporates preoperative and intraoperative decision points. Complication rates and aesthetic scores were compared for procedures performed before and after adoption of the algorithm. Multiple logistic regression was used to determine the independent influence of the algorithm on postoperative outcomes. Results: One hundred ninety-three breasts underwent reconstruction before and 179 underwent reconstruction after implementation of the algorithm. Overall complication rates did not differ between the cohorts (22.8 percent versus 20.7 percent; p = 0.138). After adjusting for potential confounders, the algorithm did not significantly affect the incidence of infection, seroma, flap necrosis, explantation, or overall complications (all p > 0.05). Aesthetic scores were not affected (2.75 of 4 versus 3.03 of 4; p = 0.138). Acellular dermal matrix use decreased from 84 percent to 36 percent, resulting in a materials cost savings of $270,000 over the study period. Conclusions: This algorithm obviated placement of acellular dermal matrix in an estimated 48 percent of immediate tissue-expander reconstructions. Patients treated after adoption of this algorithm experienced similar complication rates and aesthetic outcomes as those who underwent reconstruction before. The authors' preliminary outcomes demonstrate that evidence-based measures can be taken to selectively use acellular dermal matrix without a concomitant worsening of patient outcomes.