Occasionally, there are true game changers in all fields. In tissue expander breast reconstruction, acellular dermis use has had a tremendous impact on how we approach the operation.
Acellular dermis ( ACD) is human cadaver dermis that has been washed of all cells such that is basically a dense sheet of collagen which is not rejected by the body. This is a safe (although admittedly a bit gruesome) product; to my knowledge, there has never been any disease transmission with its use. Alloderm by Lifecell is the original product, but there are now many variations out there. I used ACD in fellowship training 10 years ago for various reconstructive purposes. A main indication was for abdominal hernia repairs where synthetic mesh was inappropriate. In this setting, however, it was found that the product stretched and so is no longer used – other improved products have followed, however.
In my training 10 years ago, breast tissue expanders were covered by muscle both on their upper as well as lower halves. This provided good protection, but poor expansion of the overlying skin on the lower half of the breast – right where it was needed. When I got to Boise, my colleagues showed me great results in delayed reconstructions (performed months post mastectomy) where only the top half of the expander was covered with muscle. But what about in immediate (at the time of mastectomy) reconstructions? Someone smart (and then popularized by academic surgeons) thought to place a strip of ACD over the lower half of the expander instead of muscle. In this setting, the ACD provided initial shaping, support, and protection while later stretching. Thus, a property that was bad for hernia repair turned out to be perfect for breast reconstruction.
This technique made immediate breast reconstruction results much more reliable, but certainly not problem free, as I have noted in previous blogs. In controlled settings where residual disease and future radiation therapy are unlikely, such as mastectomy for pre cancerous lesions, very early breast cancer, or prophylaxis (high risk patients such as those with the BRCA genes), I am more enthusiastic about immediate reconstruction. I also may use ACD when I am doing a bilateral reconstruction with a latissimus flap on only one side. ACD also has applications for secondary reconstructive as well as cosmetic breast surgery. There are various problems associated with ACD use, but are mainly related to the reconstructive operation itself. A significant downside, however, is that the product is very expensive (approximately $3500 per piece for this purpose) and there are frequent problems with reimbursement. This factor will become more important as health care reform evolves.