**4. Mesh versus autologous tissue for lower pole support**

Since its introduction in the late 1990s, the acellular dermal matrix (ADM), derived from various biological sources, has been responsible for the meteoric rise in mastectomy rates with implant and tissue expander reconstruction [21]. There is a substantial global market for ADM or biological meshes currently manufactured from porcine dermis, foetal or neonatal bovine dermis, bovine pericardium and human cadaveric skin.

Parallel to the success of ADM, there has also been an increase in synthetic mesh used for lower pole support in implant and tissue expander reconstruction (**Table 1**). The main driver for synthetic mesh has stemmed from cost associated with ADM, reports of 'red breast syndrome' (RBS) and higher seroma rates [22]. The 'red breast syndrome' (RBS) is a unique delayed hypersensitivity reaction to ADM and presents as erythematous skin overlying the mesh. Despite lack of febrile response and normal laboratory markers which characterises RBS, patients often receive increasing amounts of unnecessary antibiotics, due to concerns for the underlying implant [23].

The absorbable synthetic TIGR mesh produces a stable IMF after 18 months post-reconstruction compared to ADM with lower implant loss rates and half the volume of seroma output in the author's experience (**Figure 22**) [24].

In one of the largest reported series of TIGR mesh since May 2014, a total of 138 cases in 87 consecutive patients undergoing immediate or delayed reconstruction were recently presented in the Annual Scientific Congress of RACS (Royal Australasian College of Surgeons) in Sydney, Australia, in May 2018. There was no 90-day post-operative implant loss reported in the author's series, with three cases of delayed implant loss at 5, 12 and 28 months following radiotherapy. There were no cases of skin flap necrosis or RBS in this series [25]. These results

are similar to a recent publication by Pompei et al., with 49 consecutive patients and 60 TIGR

**Figure 22.** Nipple-sparing mastectomy via inframammary fold incision and retropectoral implant reconstruction and

The following is the example of nipple-sparing mastectomy, axillary node clearance with immediate expander-implant reconstruction in a 54-year-old woman with previous breast

mesh used over a 2-year period with only 1 implant loss due to skin necrosis [26].

**Mesh ADM/synthetic Source Manufacturer** Strattice ADM Porcine LifeCell Corp. Permacol ADM Porcine Covidien

ALLOMAX™ ADM Human cadaveric skin Bard, Inc.

TIGR Synthetic absorbable Novus Scientific

dermis

Alloderm ADM Human cadaveric skin LifeCell Corp. Branchburg. N.J Epiflex ADM Human cadaveric skin Deutsches Institut für Zell-und

DermaMatrix® ADM Human cadaveric skin Synthesis CMF/Johnson & Johnson

SERAGYN BR® Synthetic SERAG-WIESSNER GmbH & Co. KG

**Table 1.** Current list of ADM and synthetic mesh used for implant and tissue expander reconstruction.

VERITAS ADM Bovine pericardium Synovis Surgical innovations, St. Paul,

Integra LifeScience Ltd.

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23

Gewebeersatz [DIZG] gGmbH, Berlin,

pfm medical, Cologne, Germany

MN, USA®

Germany

SurgiMend ADM Foetal/neonatal bovine

TiLoop® Bra Synthetic titanium

TIGR mesh.

coated


**Table 1.** Current list of ADM and synthetic mesh used for implant and tissue expander reconstruction.

**4. Mesh versus autologous tissue for lower pole support**

**Figure 21.** Post-op bilateral skin-sparing mastectomy with immediate Li-CAP flap reconstruction.

bovine dermis, bovine pericardium and human cadaveric skin.

the underlying implant [23].

22 Breast Cancer and Surgery

author's experience (**Figure 22**) [24].

Since its introduction in the late 1990s, the acellular dermal matrix (ADM), derived from various biological sources, has been responsible for the meteoric rise in mastectomy rates with implant and tissue expander reconstruction [21]. There is a substantial global market for ADM or biological meshes currently manufactured from porcine dermis, foetal or neonatal

Parallel to the success of ADM, there has also been an increase in synthetic mesh used for lower pole support in implant and tissue expander reconstruction (**Table 1**). The main driver for synthetic mesh has stemmed from cost associated with ADM, reports of 'red breast syndrome' (RBS) and higher seroma rates [22]. The 'red breast syndrome' (RBS) is a unique delayed hypersensitivity reaction to ADM and presents as erythematous skin overlying the mesh. Despite lack of febrile response and normal laboratory markers which characterises RBS, patients often receive increasing amounts of unnecessary antibiotics, due to concerns for

The absorbable synthetic TIGR mesh produces a stable IMF after 18 months post-reconstruction compared to ADM with lower implant loss rates and half the volume of seroma output in the

In one of the largest reported series of TIGR mesh since May 2014, a total of 138 cases in 87 consecutive patients undergoing immediate or delayed reconstruction were recently presented in the Annual Scientific Congress of RACS (Royal Australasian College of Surgeons) in Sydney, Australia, in May 2018. There was no 90-day post-operative implant loss reported in the author's series, with three cases of delayed implant loss at 5, 12 and 28 months following radiotherapy. There were no cases of skin flap necrosis or RBS in this series [25]. These results

**Figure 22.** Nipple-sparing mastectomy via inframammary fold incision and retropectoral implant reconstruction and TIGR mesh.

are similar to a recent publication by Pompei et al., with 49 consecutive patients and 60 TIGR mesh used over a 2-year period with only 1 implant loss due to skin necrosis [26].

The following is the example of nipple-sparing mastectomy, axillary node clearance with immediate expander-implant reconstruction in a 54-year-old woman with previous breast implants and multifocal triple negative breast cancer with nodal involvement (**Figures 23**–**25**). Patient developed significant lymphangitis and cellulitis of the breast skin envelope 28 months after radiotherapy with explantation and request for contralateral symmetrising mastectomy.

The two-stage tissue expander (TE) reconstruction with limited mobilisation of the serratus muscle and pectoralis major was the standard procedure prior to ADM or synthetic mesh for lower pole support. The results were often inconsistent with high-riding TE and need for revision surgery. The nipple-areolar complex (NAC) and most of the redundant mastectomy skin envelope in medium to large breasted women had to be sacrificed due to limited capacity of the muscle pocket. Stable inframammary fold (IMF), preservation of the native mastectomy skin flap, retropectoral direct to implant reconstruction with predictable aesthetic results and relatively short learning curve; are some of the reasons for the exponential global uptake of biological and synthetic mesh. Shorter operative time and hospital stay, earlier recovery and return to normal function with less donor site morbidity and high patient satisfaction rates have also contributed to its popularity.

More recently, use of prepectoral implant with complete ADM coverage appears to have good outcomes with high levels of patient satisfaction [27]. 'Animation' or variable movement of the reconstructed breast when tensing the pectoral muscles is a recognised issue with retropectoral implant reconstruction (Video: https://mts.intechopen.com/download/index/process/270/ authkey/a5ea41ce666a3344dd2e459c34b3d46a). The prepectoral technique circumvents the 'animation' problem and patients are able to return to physical activity without the usual restrictions of retropectoral surgery.

Any contour defect due to capsular contracture or tethering of skin to the pectoral fascia above the implant, can be addressed with fat grafting; either at the index operation or as

a delayed procedure. In very slim patients without significant subcutaneous body fat, prepectoral approach may be challenging with 'ghosting' effect from the underlying implant. Braxon ADM (designed and patented by DECOmed s.r.l.) is a specially designed biological mesh, which offers complete coverage of the implant for prepectoral placement with the

Oncoplastic Breast Surgery in the Treatment of Breast Cancer

http://dx.doi.org/10.5772/intechopen.77955

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added convenience of suturing the mesh directly onto the chest wall.

**Figure 25.** Bilateral mastectomy post explantation and request for delayed reconstruction.

**Figure 24.** Cellulitis 28 months after radiotherapy.

**Figure 23.** Left nipple-sparing mastectomy with immediate expander-implant reconstruction.

Oncoplastic Breast Surgery in the Treatment of Breast Cancer http://dx.doi.org/10.5772/intechopen.77955 25

**Figure 24.** Cellulitis 28 months after radiotherapy.

implants and multifocal triple negative breast cancer with nodal involvement (**Figures 23**–**25**). Patient developed significant lymphangitis and cellulitis of the breast skin envelope 28 months after radiotherapy with explantation and request for contralateral symmetrising mastectomy. The two-stage tissue expander (TE) reconstruction with limited mobilisation of the serratus muscle and pectoralis major was the standard procedure prior to ADM or synthetic mesh for lower pole support. The results were often inconsistent with high-riding TE and need for revision surgery. The nipple-areolar complex (NAC) and most of the redundant mastectomy skin envelope in medium to large breasted women had to be sacrificed due to limited capacity of the muscle pocket. Stable inframammary fold (IMF), preservation of the native mastectomy skin flap, retropectoral direct to implant reconstruction with predictable aesthetic results and relatively short learning curve; are some of the reasons for the exponential global uptake of biological and synthetic mesh. Shorter operative time and hospital stay, earlier recovery and return to normal function with less donor site morbidity and high patient satisfaction rates

More recently, use of prepectoral implant with complete ADM coverage appears to have good outcomes with high levels of patient satisfaction [27]. 'Animation' or variable movement of the reconstructed breast when tensing the pectoral muscles is a recognised issue with retropectoral implant reconstruction (Video: https://mts.intechopen.com/download/index/process/270/ authkey/a5ea41ce666a3344dd2e459c34b3d46a). The prepectoral technique circumvents the 'animation' problem and patients are able to return to physical activity without the usual

Any contour defect due to capsular contracture or tethering of skin to the pectoral fascia above the implant, can be addressed with fat grafting; either at the index operation or as

**Figure 23.** Left nipple-sparing mastectomy with immediate expander-implant reconstruction.

have also contributed to its popularity.

24 Breast Cancer and Surgery

restrictions of retropectoral surgery.

**Figure 25.** Bilateral mastectomy post explantation and request for delayed reconstruction.

a delayed procedure. In very slim patients without significant subcutaneous body fat, prepectoral approach may be challenging with 'ghosting' effect from the underlying implant. Braxon ADM (designed and patented by DECOmed s.r.l.) is a specially designed biological mesh, which offers complete coverage of the implant for prepectoral placement with the added convenience of suturing the mesh directly onto the chest wall.

Despite the significant global trend towards ADM and synthetic mesh-assisted implant reconstruction, recent years have also witnessed a resurgence in autologous tissue for inferior pole support, such as scar-less mini-LD flap and T-DAP flap. ADM associated 'red breast syndrome RBS', less than anticipated reduction in capsular contracture, higher seroma rates and secondary infection with implant loss; may account for this parallel rise in autologous tissue support. Some permanent synthetic meshes can result in higher rates of capsular contracture with firm tissue in the lower pole, resulting in long-term discomfort. Continued technological advances in lightweight synthetic mesh which integrate better with the host tissue, could help improve cosmetic outcomes for patients.
