Does the use of Acellular Dermal Matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review

Does the use of Acellular Dermal Matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? 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A systematic review Hannah Cook, Sevasti P Glynou, Sara Sousi, David Zargaran, Stephen Hamilton, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4523994/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jun, 2024 Read the published version in Systematic Reviews → Version 1 posted You are reading this latest preprint version Abstract Background Breast cancer is the most common malignancy among women in the UK. Reconstruction – of which implant-based breast reconstruction (IBBR) is the most common – forms a core part of surgical management of breast cancer. More recently, pre-pectoral IBBR has become common as technology and operative techniques have evolved. Many surgeons use acellular dermal matrix (ADM) in reconstruction however there is little evidence in literature that this improves surgical outcomes. This review will assess available evidence for surgical outcomes for breast reconstructions using ADM versus non-use of ADM. Methods A database search was performed of Ovid Medline, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (2012-2022). Studies were screened using inclusion and exclusion criteria. Risk of Bias was assessed using the Newcastle Ottawa scale and ROBIS tools. Analysis and meta-analysis were performed. Results This review included 25 studies (4045 breast reconstructions). No significant difference between overall complications and failure rates between ADM and non-ADM use was demonstrated. Capsular contracture, wound dehiscence and implant rippling had significant differences however these results demonstrated high heterogeneity thus wider generalisation may be inaccurate. Patient quality of life scores were not recorded consistently or comparably between papers. Conclusions This review suggests a lack of significant differences in most complications between ADM use and non-use for pre-pectoral IBBR. If no increase in complications exists between groups, this has significant implications for surgical and legislative decision-making. There is, however, inadequate evidence available on the topic and further research is required. Figures Figure 1 Figure 2 Introduction Breast cancer is the most common malignancy diagnosed among women in the UK, accounting for 30% of female cancers in 2019 [ 1 ]. Despite a 25% increase in incidence since 1995, the overall mortality rate has fallen by 40% in the same period [ 1 ]. These changes have been, in part, attributed to the introduction of the UK breast cancer screening programme at the end of last century [ 2 ]. The surgical management of breast cancer has significantly evolved since the original mastectomy technique devised by Halstead in the 1890s [ 3 ]. Increasing use of neoadjuvant chemotherapy and developments in oncoplastic techniques have led to a rise in breast-conserving surgery with greater preservation of subcutaneous fat after removal of breast parenchyma [ 4 ]. Reconstruction is now integral to the surgical management of breast cancer leading to reduced psychosocial morbidity and greater patient satisfaction [ 5 ]. Following the development of silicone implants in the 1960s by Cronin and Gerow, implant-based breast reconstruction (IBBR) gained popularity [ 6 ]. Immediate IBBR is currently the most prevalent reconstructive procedure performed in the UK [ 7 ]. Initial IBBRs took place in the pre-pectoral plane but were replaced by subpectoral techniques in the 1970s because of increased rates of capsular contracture, skin flap necrosis, infection and implant exposure and poor aesthetic results [ 5 ]. Despite the benefits of muscular coverage leading to reduced implant exposure and improved cosmesis, subpectoral reconstruction has been associated with increased postoperative pain, animation deformity and functional deficits [ 8 ]. Pre-pectoral IBBR has gained renewed interest among surgeons [ 4 ][ 5 ]. This is in part due to evolving techniques in oncoplastic surgery such as operating in the mastectomy plane to preserve thicker skin flaps in skin-sparing and nipple-sparing mastectomies[ 9 ]. Furthermore, new technologies help reduce incidence of complications associated with pre-pectoral IBBR. For example, indocyanide green predicts occurrence of skin flap necrosis intra-operatively thus allowing adaptation of operative technique if required [ 9 ]. Its rise in popularity has also been attributed to the use of Acellular Dermal Matrices (ADM) which are widely used by surgeons [ 10 ]. Despite this, there is limited large-scale evidence in the literature for its safety and complication profile in use. ADM is said to improve the cosmetic appearance of pre-pectoral breast reconstruction and provide more flexibility with reconstructive size [ 11 ]. Nonetheless, it has also been reported to increase the risk of infection, seroma and skin necrosis [ 12 ]. The United States Food and Drug Administration (FDA) issued a statement in 2021 highlighting risks associated with the use of ADM and re-iterating that the FDA has not approved or cleared ADM for use in IBBR[ 13 ]. Further safety concerns have been raised recently with Surgimend, an ADM produced by Integra, being recalled due to higher levels of endotoxin in the product causing post-operative fever[ 14 ]. Current evidence in literature regarding pre-pectoral ADM use for IBBR is limited and there is scant comparison with non-ADM use in the same setting. Reporting of complications and patient quality of life is inconsistent. A systematic review was performed to explore surgical outcomes and quality of life for patients undergoing pre-pectoral IBBR with or without ADM. Methodology This review was registered with the International prospective register of systematic reviews (PROSPERO), part of the National Institute for Health Research (NIHR). Registration is as follows: PROSPERO 2023 CRD42023389072 [ 15 ]. Study Question This study aims to investigate surgical outcomes for patients undergoing pre-pectoral IBBR, defined by post-operative complications, implant failure (defined by loss of implant) and patient reported quality of life. Literature Search A systematic literature search was conducted with the assistance of the Royal College of Surgeons of England. Databases searched were Ovid Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR). The search timeframe was 10 years and included the following terms in various combinations and forms: Acellular dermal matrix (ADM) Mammaplasty, breast implantation, breast reconstruction Mastectomy Breast cancer Post-operative complications, treatment outcomes Quality of life A total of 147 studies were identified after removal of 81 duplicates. References of included studies were also screened for inclusion suitability. Additionally, eligible papers suggested by reviewers and not included in the initial search string were included. Study Selection and Data Extraction Studies were independently evaluated according to PICO criteria (Table 1 ) and exclusion criteria (Table 2 ) by two review team members. Titles and abstracts were initially screened using exclusion criteria and then read in full (Fig. 1) [ 16 ]. Conflict on difference of opinion between reviewers was resolved in discussion with senior authors. Data from studies that passed initial and full screening were extracted by two reviewers and cross-checked. Data were collected in a standardized spreadsheet according to categories (patient demographics and outcome measures). With regards to patient quality of life, all patient reported outcome measure scores mentioned in studies were included in the initial phase, for analysis later. Figure 1: PRISMA chart for publication selection [ 16 ] Table 1 Study Population, Intervention, Comparison and Outcomes (PICO) Patient 1) Females undergoing pre-pectoral implant-based breast reconstruction with or without ADM 2) women undergoing reconstruction for cancer treatment or prophylaxis 3) immediate or delayed reconstruction 4) unilateral or bilateral reconstruction Intervention use of acellular dermal matrices (ADM) during breast reconstruction procedures Comparison non-use of ADM during breast reconstruction procedures Outcome operative success, defined by: 1) complications 2) failure (loss of implant) 3) patient quality of life Table 2 Exclusion Criteria Exclusion Criteria - secondary reconstructive procedures such as reconstruction revision - aesthetic or cosmetic procedures - sub-pectoral implant placement - non-implant-based reconstruction, for example, autologous free flaps - non-English language - animal or cadaveric studies - systematic review including papers already present in results Study Quality Study quality and risk of bias was assessed using the Newcastle-Ottawa scale. Studies were independently reviewed by two team members and scores were correlated. Statistical Analysis The statistical analyses were performed on Microsoft Excel and R (version 4.0.3) software[ 17 ]. Provided data for each complication across studies were combined to calculate complication rates and risk ratios (RR) with 95% confidence intervals (CIs). For two-arm studies, forest plots were created comparing the ADM and non-ADM groups for each complication. A random effects model was fitted; heterogeneity and p-value for overall effect are presented on forest plots (appendix 1), with RR, 95% CIs, and weight. A p-value of less than 0.05 was considered statistically significant. Results A total of 25 publications were eligible for analysis after application of inclusion and exclusion criteria. This included 3219 patients and 4045 breasts (3121 with ADM-incorporated reconstructions, 924 without ADM-incorporated reconstructions). Study and Operative Characteristics The majority (n = 23, 92%) of included studies were retrospective in nature; 2 included studies were prospective. 4 studies were two-arm and comparative [ 18 – 21 ]. Other studies reported ADM use alone ([ 22 – 33 ] and non-ADM use alone)[ 10 , 34 , 35 ]. 7 papers compared pre-pectoral to sub-pectoral IBBR, in these data pertaining solely to pre-pectoral reconstruction was extracted [ 12 , 36 – 41 ]. 16 studies reported solely immediate direct-to-implant (DTI) reconstructions, 4 reported immediate tissue expander (TE) reconstruction and the remaining 5 reported a mixture of one and two stage reconstructions. Overall, 2904 out of 3121 ADM breast reconstructions (93%) and 531 out of 924 non-ADM breast reconstructions (57.4%) were direct-to-implant. For the ADM cohort, 214 breasts were reconstructed using tissue expanders (6.8%), compared to 373 (40.4%) of breasts reconstructed without ADM. 0.1% (n = 3) of ADM breast reconstructions and 2% (n = 20) of non-ADM reconstructions were delayed. With regards to the placement of ADM (when used), 10 studies (40%) described anterior coverage and 8 studies (33%) described complete wrapping of implant or tissue expander with ADM. Unfortunately, due to not all studies documenting ADM coverage methods in reconstruction, sub-group analysis could not be performed to assess whether this affected operative outcomes. Study Quality Study quality and risk of bias were assessed for selection, comparability and outcome using the Newcastle-Ottawa scale (Fig. 2). The average score was 6 out of 9. Generally, studies lost points for comparability and selection of representative groups – likely due to being largely retrospective in nature and frequently single-surgeon studies. Safran et al, (2022) [ 19 ] and Franceschini et al., [ 12 ] were scored highest – 9 and 8, respectively. Lee et al., [ 40 ], Woo et al., [ 27 ], Engel et al., [ 35 ] and Wormer et al., [ 41 ] scored 4 due to poor comparability and inadequate documentation of follow-up. Follow-up was reported as mean (with standard deviation) or median (with range). 10 studies had follow-up times of less than 1 year; only 6 studies had follow-up times of more than 2 years. Klinger et al., 2022 [ 18 ] reported assessing pain and aesthetic outcomes at 12 months but did not provide a timeframe for assessment of other complications. Figure 2: Newcastle Ottawa Score – Study Quality and Risk of Bias Assessment Patient Characteristics Table 3 Patient demographics and factors in included studies Number of Studies Number of Patients ADM No ADM p-value Mean SD Mean SD Age 23 2,828 52.4 3.1 47.5 3.7 0.729 BMI 22 2,917 24.8 2.2 24.9 2.1 0.268 Smoking status (%) 18 2,643 8.3 6.2 13.2 6.9 0.922 Diabetes (%) 14 2,403 2.5 2.7 5.5 2.5 0.202 Neo-adjuvant chemotherapy (%) 16 2,661 17.0 12.7 20.9 12.0 0.153 Adjuvant chemotherapy (%) 8 2,104 19.9 18.5 11.7 13.0 0.302 Neo-adjuvant radiotherapy (%) 14 2,571 5.0 22.3 7.3 6.5 0.492 Adjuvant radiotherapy (%) 10 2,223 66.9 9.2 19.1 5.6 0.155 Skin sparing mastectomy (%) 7 1,814 58.3 26.9 29.6 44.7 0.668 Nipple sparing mastectomy (%) 4 1,893 45.9 26.6 62.7 7.4 0.444 Demographic and surgical data were extracted and compared between ADM and non-ADM breast reconstructions. The average age was 52.4 for ADM reconstructions and 47.5 for non-ADM reconstructions. There were no statistically significant differences observed between patient characteristics (Table 3 ), however not all papers provided data for these measurements. Notably, Salibian et al., 2017 [ 34 ] and Humphries et al., 2015 [ 26 ] did not include any data regarding population age, BMI or prevalence of diabetes. Caputo et al., 2016 [ 28 ] did not comment on BMI, smoking or diabetes in their patient characteristics. Complications and Failure Table 4 Comparison of complications for ADM use versus non-ADM use including risk ratio and heterogeneity Complication Number of papers Number of Complications Rate (%) Risk Ratio (95% CI) p-value ADM no ADM ADM no ADM ADM no ADM Overall Complications 10 5 593 89 21.5% 18.9% 1.13 (0.93–1.37) 0.216 Seroma 15 6 203 33 7.5% 6.8% 1.10 (0.77–1.56) 0.626 Haematoma 13 6 64 9 2.4% 1.9% 1.30 (0.65–2.60) 0.450 Minor Infection 18 4 172 16 6.0% 8.9% 0.67 (0.41–1.10) 0.115 Wound Dehiscence 10 5 97 27 3.6% 6.6% 0.60 (0.40–0.91) 0.016 Flap/NAC Necrosis 13 7 99 32 4.1% 4.1% 1.00 (0.68–1.48) 0.988 Capsular Contracture 8 5 78 67 3.1% 9.8% 0.32 (0.23–0.44) < 0.0001 Implant Removal 15 7 159 49 6.7% 6.7% 1.00 (0.74–1.37) 0.978 Rippling 8 5 105 55 5.4% 8.2% 0.66 (0.48–0.90) 0.009 Rotation 3 3 5 2 0.3% 0.4% 0.55 (0.11–2.83) 0.475 Complications are shown in Table 4 . Overall complication rate was defined as presence of at least one complication per reconstruction. Incidence of overall complication was 21.5% in the ADM group versus 18.9% in the non-ADM group. However, this parameter was only measured in 11 studies (4 two-arm); other studies did not comment on the distribution of complications amongst reconstructions. The complication with the greatest total incidence was seroma. The most mentioned complications across all studies were minor infection and implant removal (22 studies each). Complications with significant difference observed between the ADM and non-ADM groups were wound dehiscence, capsular contracture and rippling. Two-Arm Studies Forest plots for each complication assessing heterogeneity are available in appendix 1. Given that only 4 studies were two-arm, heterogeneity was high across all complications and in some instances underpowered. Subgroup Analysis Subgroup analysis was performed for studies comparing DTI and TE based immediate reconstruction for all complication outcomes except rotation, as this was reported in studies where reconstruction was solely DTI. The subgroup effect was not statistically significant for any outcome. As only 3 studies reported delayed reconstruction, subgroup analysis was not performed with this cohort[ 26 , 35 , 36 ]. Subgroup analysis was also performed for ADM use and non-ADM use for patient characteristics: age, BMI and smoking status. There was a weak correlation observed between these factors and each complication, demonstrating no overall subgroup effect. Patient Quality of Life A total of 6 studies reported some form of patient reported outcome measure; 2 used BREAST-Q (including satisfaction with breast, operative outcome, psychosocial and sexual wellbeing), 1 used EORT-QLQ and QLQ-BR23 (European Organisation for research and treatment of cancer questionnaire for all cancer and breast cancer patients, respectively)[ 31 ], 1 used Hospital Anxiety and Depression Score [ 40 ] and 2 used self-devised patient questionnaires [ 12 , 35 ]. Safran et al., 2021 [ 21 ] were the only study to perform BREAST-Q scores on patients receiving both ADM and non-ADM reconstructions; scores were collected at 6 months and 1 year postoperatively. Only overall satisfaction was reported – 54% for ADM and 55% for non-ADM reconstructions. Hong et al. (ADM use) reported consistently high scores in all parameters (> 80%)[ 22 ]. Among ADM patients, body image was 80% (with higher score representing a greater health outcome), sexual wellbeing 65–73%, emotional health 86% and overall life and quality of health score 77%. Discussion With the renaissance of pre-pectoral IBBR, it is important that surgeons have an adequate evidence base to enable operative planning in the patient’s best interest. Arguably, pre-pectoral IBBR is beneficial both in the short term (reduced operative time and postoperative pain) and the long term (reduced risk of animation deformity and functional loss) [ 8 ]. The use of ADM has significantly contributed to increased pre-pectoral IBBR rates, alongside implant technology improvement and access to intra-operative perfusion assessment [ 4 , 5 ]. Studies have suggested that ADM use improves aesthetic outcomes via improved implant coverage and additional tissue support[ 42 ], however claims of these benefits are not substantiated in randomised clinical trials and are often based on author opinion alone[ 43 ]. It has been suggested that the benefits associated with ADM in pre-pectoral IBBR can be replicated with careful patient selection, operative planning and technique. Comparable aesthetic outcomes and complication rates were demonstrated in a retrospective, single-surgeon study between ADM and non-ADM pre-pectoral IBBR [ 44 ]. ADM is also costly – the same study estimated the institutional cost saving would be $ 3 million – $ 6 million (unilateral – bilateral cases) if ADM were no longer used [ 44 ]. This review has demonstrated no significant difference between complication and failure rates between ADM and non-ADM pre-pectoral IBBR for seroma/haematoma, infection, skin/NAC necrosis and implant rotation. Overall complications (as defined by presence of at least 1 complication per reconstruction) was slightly higher in the ADM group but not significantly so. This parameter was also only included in 11 studies. There is no significant difference in implant failure or explantation between groups. This is consistent with results from Salibian and Safran [ 20 , 21 ]. Capsular contracture, wound dehiscence and implant rippling had significant differences between groups however results demonstrated a high rate of heterogeneity and were from relatively small sample sizes, thus caution should be applied when generalising this finding to the wider population. This study has also highlighted a lack of external validity of existing evidence in the literature on this topic. Limitations include heterogeneity of data (for example the high number of TEs in the non-ADM cohort) and lack of available evidence directly comparing ADM and non-ADM use in pre-pectoral IBBR in a single study setting. Meta-analysis was limited by studies being mainly retrospective and the scarcity of randomised data. Another limitation is an inadequate follow-up time of less than 1 year in 10 of the included studies. Potential confounding factors such as the degree of ADM coverage around implants was not ascertainable from the literature. Severity and grade of capsular contracture was recorded variably among studies – with some documenting all incidences (ungraded) and others documenting only Baker Grade 3 and above. This reduced reliability of extracted data for comparison. The lack of externally valid evidence and significant limitations of data on this topic is significant given the high frequency of pre-pectoral IBBR procedures performed in the UK and worldwide, and the costs associated with ADM use. Further prospective, randomised and large-scale studies are required on this topic, with data captured from more homogenous patient groups. Further research into patient reported outcome measures in these populations is also required. Conclusion In conclusion, there is no correlation between ADM use in pre-pectoral IBBR and decreased complications except for capsular contracture, wound dehiscence and rippling, and these results should be interpreted with caution given significant heterogeneity and small sample sizes. Lack of significant difference between use of ADM versus non-use has significant implications for ongoing clinical practice and healthcare legislature in breast cancer reconstruction given the widespread use of ADM and associated cost. However, limited data exists on this topic and further evidence is required in the form of large-scale, randomised studies to ascertain surgical outcomes accurately and reliably. Declarations Ethics Approval and Consent to Participate As this review analyses papers which are already published and in the public domain, ethics approval is not required Data and Materials Details regarding search strategy are available on the study PROSPERO registration. Details regarding data extraction and analysis should be requested from the corresponding author if required. Competing Interests The authors declare they have no competing interests Funding This research did not receive any grant or funding from organisations in the public, commercial, or not-for-profit sectors. Author Contribution conception - AM, SH, DZliterature search - HC, SGarticle screening - HC, SGdata extraction - HC, SG, SSdata analysis - HC, SG, SSmanuscript writing - HC, SG, SS, DZsupervision - AM, SHreview of manuscript - HC, SG, SS, DZ, AM, SH Acknowledgement With thanks to Janet Clapton, Information Specialist, The Royal College of Surgeons of England Library and Archives Team, for conducting the literature searches. Data Availability Data is provided within the manuscript or supplementary information files References House of Commons Library. Cancer: summary of statistics (England). 2021. Duffy S, Vulkan D, Cuckle H, Parmar D, Sheikh S, Smith R, et al. Annual mammographic screening to reduce breast cancer mortality in women from age 40 years: Long-term follow-up of the uk age rct. Health Technol Assess (Rockv). 2020;24:1–24. https://doi.org/10.3310/hta24550 . Freeman MD, Gopman JM, Salzberg CA. The evolution of mastectomy surgical technique: From mutilation to medicine. 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Skin-Reduction Breast Reconstructions with Prepectoral Implant. Plast Reconstr Surg. 2016;137:1702–5. https://doi.org/10.1097/PRS.0000000000002227 . Downs RK, Hedges K. An alternative technique for immediate direct-to-implant breast reconstruction—a case series. Plast Reconstr Surg Glob Open. 2016;4. https://doi.org/10.1097/GOX.0000000000000839 . Fin A, De Biasio F, Mura S, Massarut S, Zaccaria G, Parodi PC. Prepectoral Implant-Based Breast Reconstruction Using Meshed ADM. Plast Surg. 2021;29:81–7. https://doi.org/10.1177/2292550320933687 . Onesti MG, Maruccia M, Di Taranto G, Albano A, Soda G, Ballesio L, et al. Clinical, histological, and ultrasound follow-up of breast reconstruction with one-stage muscle-sparing wrap technique: A single-center experience. J Plast Reconstr Aesthetic Surg. 2017;70:1527–36. https://doi.org/10.1016/j.bjps.2017.06.023 . Masià J, Salgarello M, Cattelani L, Parodi PC, Ribuffo D, Onesti MG, et al. The largest multicentre data collection on prepectoral breast reconstruction: The iBAG study. J Surg Oncol. 2020;122:848–60. https://doi.org/10.1002/JSO.26073 . Chandarana M, Group on behalf of the NBAS, Harries S, Group on behalf of the NBAS, Tenovici A, Group on behalf of the NBAS. Multicentre study of prepectoral breast reconstruction using acellular dermal matrix. BJS Open. 2020;4:71–7. https://doi.org/10.1002/BJS5.50236 . Salibian AH, Harness JK, Mowlds DS. Staged Suprapectoral Expander/Implant Reconstruction without Acellular Dermal Matrix following Nipple-Sparing Mastectomy. Plast Reconstr Surg. 2017;139:30–9. https://doi.org/https://dx.doi.org/10.1097/PRS.0000000000002845 . Engel H, Huang JJ, Lin CY, Lam WL, Gazyakan E, Cheng MH. Subcutaneous tissue expansion and subsequent subpectoral implantation for breast reconstruction in Asian patients: Safety and outcome. Ann Plast Surg. 2013;70:135–43. https://doi.org/10.1097/SAP.0b013e3182367bbe . Soni SE, Le NK, Buller M, Modica AD, Kumar A, Smith PD, et al. Complication Profile of Total Submuscular Versus Prepectoral Tissue Expander Placement: A Retrospective Cohort Study. Ann Plast Surg. 2022;88:S439–42. https://doi.org/https://dx.doi.org/10.1097/SAP.0000000000003165 . Suh YC, Kim JK, Kim NR, Choi JS, Kim YJ, Lee JH, et al. A comparative study of pre- or subpectoral expander position with the fenestrated Acellular dermal matrix anterior coverage, on drainage volume and Seroma Formation after Non-Nipple-Sparing Mastectomy: Expander position and drainage volume. J Plast Reconstr Aesthetic Surg. 2021;74(9):2237–43. https://doi.org/https://dx.doi.org/10.1016/j.bjps.2021.01.015 . Patel R, Somogyi RB. Comparing post-surgical outcomes of pre-pectoral versus dual-plane direct-to-implant breast reconstruction without increasing the use of acellular dermal matrix. J Plast Reconstr Aesthet Surg. 2022;75:1123–9. https://doi.org/https://dx.doi.org/10.1016/j.bjps.2021.11.017 . Ribuffo D, Berna G, de Vita R, di Benedetto G, Cigna E, Greco M, et al. Dual-Plane Retro-pectoral Versus Pre-pectoral DTI Breast Reconstruction: An Italian Multicenter Experience. Aesthetic Plast Surg. 2021;45:51–60. https://doi.org/https://dx.doi.org/10.1007/s00266-020-01892-y . Lee JS, Park E, Lee JH, Lee J, Park HY, Yang JD, et al. A prospective comparison study of early functional outcomes after implant-based breast reconstruction: subpectoral versus prepectoral technique. Ann Palliat Med. 2021;10:2520–9. https://doi.org/https://dx.doi.org/10.21037/apm-20-1550 . Wormer BA, Valmadrid AC, Ganesh Kumar N, Al Kassis S, Rankin TM, Kaoutzanis C, et al. Reducing Expansion Visits in Immediate Implant-Based Breast Reconstruction: A Comparative Study of Prepectoral and Subpectoral Expander Placement. Plast Reconstr Surg. 2019;144:276–86. https://doi.org/https://dx.doi.org/10.1097/PRS.0000000000005791 . Bindingnavele V, Gaon M, Ota KS, Kulber DA, Lee DJ. Use of acellular cadaveric dermis and tissue expansion in postmastectomy breast reconstruction. J Plast Reconstr Aesthetic Surg. 2007;60:1214–8. https://doi.org/10.1016/J.BJPS.2007.03.015 . JoAnna Nguyen T, Carey JN, Wong AK. Use of human acellular dermal matrix in implant- based breast reconstruction: Evaluating the evidence. J Plast Reconstr Aesthetic Surg. 2011;64:1553–61. https://doi.org/10.1016/j.bjps.2011.02.001 . Manrique OJ, Huang TCT, Martinez-Jorge J, Ciudad P, Forte AJ, Bustos SS, et al. Prepectoral Two-Stage Implant-Based Breast Reconstruction with and without Acellular Dermal Matrix: Do We See a Difference? Plast Reconstr Surg. 2020;145:e263–72. https://doi.org/10.1097/PRS.0000000000006442 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4523994","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":310812391,"identity":"19134873-9031-4878-ac04-6d19bbd370d2","order_by":0,"name":"Hannah Cook","email":"","orcid":"","institution":"Royal Free Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hannah","middleName":"","lastName":"Cook","suffix":""},{"id":310812393,"identity":"217c75cd-ab93-488c-af20-37058e905189","order_by":1,"name":"Sevasti P Glynou","email":"data:image/png;base64,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","orcid":"","institution":"Imperial College London","correspondingAuthor":true,"prefix":"","firstName":"Sevasti","middleName":"P","lastName":"Glynou","suffix":""},{"id":310812394,"identity":"4687fe6d-f389-477d-b61b-30e2e0e927a3","order_by":2,"name":"Sara Sousi","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Sousi","suffix":""},{"id":310812398,"identity":"77a84813-7998-44ec-837d-14678c16c4af","order_by":3,"name":"David Zargaran","email":"","orcid":"","institution":"Royal Free Hospital","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Zargaran","suffix":""},{"id":310812399,"identity":"0016ade2-783b-45a0-8766-c8cdf0988d41","order_by":4,"name":"Stephen Hamilton","email":"","orcid":"","institution":"Royal Free Hospital","correspondingAuthor":false,"prefix":"","firstName":"Stephen","middleName":"","lastName":"Hamilton","suffix":""},{"id":310812402,"identity":"762c11d9-f7b2-46fd-ab9a-cbc4464f5697","order_by":5,"name":"Afshin Mosahebi","email":"","orcid":"","institution":"University College London","correspondingAuthor":false,"prefix":"","firstName":"Afshin","middleName":"","lastName":"Mosahebi","suffix":""}],"badges":[],"createdAt":"2024-06-03 21:01:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4523994/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4523994/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13643-024-02564-7","type":"published","date":"2024-06-07T20:38:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59052690,"identity":"a0dc2a75-c0c5-45f4-a525-27c19e6115fe","added_by":"auto","created_at":"2024-06-25 20:20:57","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":358127,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA chart for publication selection \u003c/strong\u003e[16]\u003c/p\u003e","description":"","filename":"Figure1BreastCancerResearch.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4523994/v1/dcea42cb8157e02fb781575a.jpg"},{"id":59052691,"identity":"7b4c5014-c0db-4e95-b686-a5b102192e4c","added_by":"auto","created_at":"2024-06-25 20:20:57","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":361415,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNewcastle Ottawa Score – Study Quality and Risk of Bias Assessment\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure2BreastCancerResarch.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4523994/v1/2597cdd057516132eb4beebd.jpg"},{"id":59054568,"identity":"45a9b11c-1e88-4837-9719-8582790a20b4","added_by":"auto","created_at":"2024-06-25 20:38:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1373254,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4523994/v1/67d25564-e5ef-4037-846c-c9ed238152f4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does the use of Acellular Dermal Matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBreast cancer is the most common malignancy diagnosed among women in the UK, accounting for 30% of female cancers in 2019 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite a 25% increase in incidence since 1995, the overall mortality rate has fallen by 40% in the same period [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These changes have been, in part, attributed to the introduction of the UK breast cancer screening programme at the end of last century [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe surgical management of breast cancer has significantly evolved since the original mastectomy technique devised by Halstead in the 1890s [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Increasing use of neoadjuvant chemotherapy and developments in oncoplastic techniques have led to a rise in breast-conserving surgery with greater preservation of subcutaneous fat after removal of breast parenchyma [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Reconstruction is now integral to the surgical management of breast cancer leading to reduced psychosocial morbidity and greater patient satisfaction [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Following the development of silicone implants in the 1960s by Cronin and Gerow, implant-based breast reconstruction (IBBR) gained popularity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Immediate IBBR is currently the most prevalent reconstructive procedure performed in the UK [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInitial IBBRs took place in the pre-pectoral plane but were replaced by subpectoral techniques in the 1970s because of increased rates of capsular contracture, skin flap necrosis, infection and implant exposure and poor aesthetic results [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Despite the benefits of muscular coverage leading to reduced implant exposure and improved cosmesis, subpectoral reconstruction has been associated with increased postoperative pain, animation deformity and functional deficits [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePre-pectoral IBBR has gained renewed interest among surgeons [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This is in part due to evolving techniques in oncoplastic surgery such as operating in the mastectomy plane to preserve thicker skin flaps in skin-sparing and nipple-sparing mastectomies[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, new technologies help reduce incidence of complications associated with pre-pectoral IBBR. For example, indocyanide green predicts occurrence of skin flap necrosis intra-operatively thus allowing adaptation of operative technique if required [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIts rise in popularity has also been attributed to the use of Acellular Dermal Matrices (ADM) which are widely used by surgeons [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Despite this, there is limited large-scale evidence in the literature for its safety and complication profile in use. ADM is said to improve the cosmetic appearance of pre-pectoral breast reconstruction and provide more flexibility with reconstructive size [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nonetheless, it has also been reported to increase the risk of infection, seroma and skin necrosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The United States Food and Drug Administration (FDA) issued a statement in 2021 highlighting risks associated with the use of ADM and re-iterating that the FDA has not approved or cleared ADM for use in IBBR[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Further safety concerns have been raised recently with Surgimend, an ADM produced by Integra, being recalled due to higher levels of endotoxin in the product causing post-operative fever[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrent evidence in literature regarding pre-pectoral ADM use for IBBR is limited and there is scant comparison with non-ADM use in the same setting. Reporting of complications and patient quality of life is inconsistent. A systematic review was performed to explore surgical outcomes and quality of life for patients undergoing pre-pectoral IBBR with or without ADM.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eThis review was registered with the International prospective register of systematic reviews (PROSPERO), part of the National Institute for Health Research (NIHR). Registration is as follows: PROSPERO 2023 CRD42023389072 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudy Question\u003c/p\u003e\u003cp\u003eThis study aims to investigate surgical outcomes for patients undergoing pre-pectoral IBBR, defined by post-operative complications, implant failure (defined by loss of implant) and patient reported quality of life.\u003c/p\u003e\u003cp\u003eLiterature Search\u003c/p\u003e\u003cp\u003eA systematic literature search was conducted with the assistance of the Royal College of Surgeons of England. Databases searched were Ovid Medline, Embase and Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR). The search timeframe was 10 years and included the following terms in various combinations and forms:\u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eAcellular dermal matrix (ADM)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMammaplasty, breast implantation, breast reconstruction\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMastectomy\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBreast cancer\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePost-operative complications, treatment outcomes\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e\u003cp\u003eA total of 147 studies were identified after removal of 81 duplicates. References of included studies were also screened for inclusion suitability. Additionally, eligible papers suggested by reviewers and not included in the initial search string were included.\u003c/p\u003e\u003cp\u003eStudy Selection and Data Extraction\u003c/p\u003e\u003cp\u003eStudies were independently evaluated according to PICO criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and exclusion criteria (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) by two review team members. Titles and abstracts were initially screened using exclusion criteria and then read in full (Fig.\u0026nbsp;1) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e Conflict on difference of opinion between reviewers was resolved in discussion with senior authors. Data from studies that passed initial and full screening were extracted by two reviewers and cross-checked. Data were collected in a standardized spreadsheet according to categories (patient demographics and outcome measures). With regards to patient quality of life, all patient reported outcome measure scores mentioned in studies were included in the initial phase, for analysis later.\u003c/p\u003e\u003cp\u003e \u003cb\u003eFigure 1: PRISMA chart for publication selection\u003c/b\u003e [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy Population, Intervention, Comparison and Outcomes (PICO)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1) Females undergoing pre-pectoral implant-based breast reconstruction with or without ADM\u003c/p\u003e \u003cp\u003e2) women undergoing reconstruction for cancer treatment or prophylaxis\u003c/p\u003e \u003cp\u003e3) immediate or delayed reconstruction\u003c/p\u003e \u003cp\u003e4) unilateral or bilateral reconstruction\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003euse of acellular dermal matrices (ADM) during breast reconstruction procedures\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComparison\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enon-use of ADM during breast reconstruction procedures\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eoperative success, defined by:\u003c/p\u003e \u003cp\u003e1) complications\u003c/p\u003e \u003cp\u003e2) failure (loss of implant)\u003c/p\u003e \u003cp\u003e3) patient quality of life\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eExclusion Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExclusion Criteria\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e- secondary reconstructive procedures such as reconstruction revision\u003c/p\u003e \u003cp\u003e- aesthetic or cosmetic procedures\u003c/p\u003e \u003cp\u003e- sub-pectoral implant placement\u003c/p\u003e \u003cp\u003e- non-implant-based reconstruction, for example, autologous free flaps\u003c/p\u003e \u003cp\u003e- non-English language\u003c/p\u003e \u003cp\u003e- animal or cadaveric studies\u003c/p\u003e \u003cp\u003e- systematic review including papers already present in results\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003eStudy Quality\u003c/p\u003e\u003cp\u003eStudy quality and risk of bias was assessed using the Newcastle-Ottawa scale. Studies were independently reviewed by two team members and scores were correlated.\u003c/p\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe statistical analyses were performed on Microsoft Excel and R (version 4.0.3) software[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Provided data for each complication across studies were combined to calculate complication rates and risk ratios (RR) with 95% confidence intervals (CIs). For two-arm studies, forest plots were created comparing the ADM and non-ADM groups for each complication. A random effects model was fitted; heterogeneity and p-value for overall effect are presented on forest plots (appendix 1), with RR, 95% CIs, and weight. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 25 publications were eligible for analysis after application of inclusion and exclusion criteria. This included 3219 patients and 4045 breasts (3121 with ADM-incorporated reconstructions, 924 without ADM-incorporated reconstructions).\u003c/p\u003e \u003cp\u003eStudy and Operative Characteristics\u003c/p\u003e \u003cp\u003eThe majority (n\u0026thinsp;=\u0026thinsp;23, 92%) of included studies were retrospective in nature; 2 included studies were prospective. 4 studies were two-arm and comparative [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Other studies reported ADM use alone ([\u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] and non-ADM use alone)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. 7 papers compared pre-pectoral to sub-pectoral IBBR, in these data pertaining solely to pre-pectoral reconstruction was extracted [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR37 CR38 CR39 CR40\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e16 studies reported solely immediate direct-to-implant (DTI) reconstructions, 4 reported immediate tissue expander (TE) reconstruction and the remaining 5 reported a mixture of one and two stage reconstructions. Overall, 2904 out of 3121 ADM breast reconstructions (93%) and 531 out of 924 non-ADM breast reconstructions (57.4%) were direct-to-implant. For the ADM cohort, 214 breasts were reconstructed using tissue expanders (6.8%), compared to 373 (40.4%) of breasts reconstructed without ADM. 0.1% (n\u0026thinsp;=\u0026thinsp;3) of ADM breast reconstructions and 2% (n\u0026thinsp;=\u0026thinsp;20) of non-ADM reconstructions were delayed.\u003c/p\u003e \u003cp\u003eWith regards to the placement of ADM (when used), 10 studies (40%) described anterior coverage and 8 studies (33%) described complete wrapping of implant or tissue expander with ADM. Unfortunately, due to not all studies documenting ADM coverage methods in reconstruction, sub-group analysis could not be performed to assess whether this affected operative outcomes.\u003c/p\u003e \u003cp\u003eStudy Quality\u003c/p\u003e \u003cp\u003eStudy quality and risk of bias were assessed for selection, comparability and outcome using the Newcastle-Ottawa scale (Fig.\u0026nbsp;2). The average score was 6 out of 9. Generally, studies lost points for comparability and selection of representative groups \u0026ndash; likely due to being largely retrospective in nature and frequently single-surgeon studies. Safran et al, (2022) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Franceschini et al., [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] were scored highest \u0026ndash; 9 and 8, respectively. Lee et al., [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], Woo et al., [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], Engel et al., [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] and Wormer et al., [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] scored 4 due to poor comparability and inadequate documentation of follow-up.\u003c/p\u003e \u003cp\u003eFollow-up was reported as mean (with standard deviation) or median (with range). 10 studies had follow-up times of less than 1 year; only 6 studies had follow-up times of more than 2 years. Klinger et al., 2022 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported assessing pain and aesthetic outcomes at 12 months but did not provide a timeframe for assessment of other complications.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 2: Newcastle Ottawa Score \u0026ndash; Study Quality and Risk of Bias Assessment\u003c/b\u003e \u003c/p\u003e \u003cp\u003ePatient Characteristics\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics and factors in included studies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of Studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of Patients\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eADM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eNo ADM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.729\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,917\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e24.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking status (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.922\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeo-adjuvant chemotherapy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,661\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant chemotherapy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeo-adjuvant radiotherapy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.492\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant radiotherapy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2,223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSkin sparing mastectomy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e29.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e44.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNipple sparing mastectomy (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1,893\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e45.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDemographic and surgical data were extracted and compared between ADM and non-ADM breast reconstructions. The average age was 52.4 for ADM reconstructions and 47.5 for non-ADM reconstructions. There were no statistically significant differences observed between patient characteristics (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), however not all papers provided data for these measurements. Notably, Salibian et al., 2017 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] and Humphries et al., 2015 [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] did not include any data regarding population age, BMI or prevalence of diabetes. Caputo et al., 2016 [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] did not comment on BMI, smoking or diabetes in their patient characteristics.\u003c/p\u003e \u003cp\u003eComplications and Failure\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of complications for ADM use versus non-ADM use including risk ratio and heterogeneity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eNumber of papers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eNumber of Complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eRate (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRisk Ratio (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eADM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno ADM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eADM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eno ADM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eADM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eno ADM\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Complications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e18.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003cp\u003e(0.93\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.216\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeroma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.10\u003c/p\u003e \u003cp\u003e(0.77\u0026ndash;1.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaematoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.30\u003c/p\u003e \u003cp\u003e(0.65\u0026ndash;2.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.450\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor Infection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e172\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003cp\u003e(0.41\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWound Dehiscence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003cp\u003e(0.40\u0026ndash;0.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.016\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlap/NAC Necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003cp\u003e(0.68\u0026ndash;1.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.988\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapsular Contracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003cp\u003e(0.23\u0026ndash;0.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.0001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant Removal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003cp\u003e(0.74\u0026ndash;1.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.978\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRippling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003cp\u003e(0.48\u0026ndash;0.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRotation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003cp\u003e(0.11\u0026ndash;2.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComplications are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Overall complication rate was defined as presence of at least one complication per reconstruction. Incidence of overall complication was 21.5% in the ADM group versus 18.9% in the non-ADM group. However, this parameter was only measured in 11 studies (4 two-arm); other studies did not comment on the distribution of complications amongst reconstructions. The complication with the greatest total incidence was seroma. The most mentioned complications across all studies were minor infection and implant removal (22 studies each). Complications with significant difference observed between the ADM and non-ADM groups were wound dehiscence, capsular contracture and rippling.\u003c/p\u003e \u003cp\u003eTwo-Arm Studies\u003c/p\u003e \u003cp\u003eForest plots for each complication assessing heterogeneity are available in appendix 1. Given that only 4 studies were two-arm, heterogeneity was high across all complications and in some instances underpowered.\u003c/p\u003e \u003cp\u003eSubgroup Analysis\u003c/p\u003e \u003cp\u003eSubgroup analysis was performed for studies comparing DTI and TE based immediate reconstruction for all complication outcomes except rotation, as this was reported in studies where reconstruction was solely DTI. The subgroup effect was not statistically significant for any outcome. As only 3 studies reported delayed reconstruction, subgroup analysis was not performed with this cohort[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSubgroup analysis was also performed for ADM use and non-ADM use for patient characteristics: age, BMI and smoking status. There was a weak correlation observed between these factors and each complication, demonstrating no overall subgroup effect.\u003c/p\u003e \u003cp\u003ePatient Quality of Life\u003c/p\u003e \u003cp\u003eA total of 6 studies reported some form of patient reported outcome measure; 2 used BREAST-Q (including satisfaction with breast, operative outcome, psychosocial and sexual wellbeing), 1 used EORT-QLQ and QLQ-BR23 (European Organisation for research and treatment of cancer questionnaire for all cancer and breast cancer patients, respectively)[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], 1 used Hospital Anxiety and Depression Score [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and 2 used self-devised patient questionnaires [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSafran et al., 2021 [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] were the only study to perform BREAST-Q scores on patients receiving both ADM and non-ADM reconstructions; scores were collected at 6 months and 1 year postoperatively. Only overall satisfaction was reported \u0026ndash; 54% for ADM and 55% for non-ADM reconstructions. Hong et al. (ADM use) reported consistently high scores in all parameters (\u0026gt;\u0026thinsp;80%)[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Among ADM patients, body image was 80% (with higher score representing a greater health outcome), sexual wellbeing 65\u0026ndash;73%, emotional health 86% and overall life and quality of health score 77%.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWith the renaissance of pre-pectoral IBBR, it is important that surgeons have an adequate evidence base to enable operative planning in the patient\u0026rsquo;s best interest.\u003c/p\u003e \u003cp\u003eArguably, pre-pectoral IBBR is beneficial both in the short term (reduced operative time and postoperative pain) and the long term (reduced risk of animation deformity and functional loss) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The use of ADM has significantly contributed to increased pre-pectoral IBBR rates, alongside implant technology improvement and access to intra-operative perfusion assessment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Studies have suggested that ADM use improves aesthetic outcomes via improved implant coverage and additional tissue support[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], however claims of these benefits are not substantiated in randomised clinical trials and are often based on author opinion alone[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt has been suggested that the benefits associated with ADM in pre-pectoral IBBR can be replicated with careful patient selection, operative planning and technique. Comparable aesthetic outcomes and complication rates were demonstrated in a retrospective, single-surgeon study between ADM and non-ADM pre-pectoral IBBR [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. ADM is also costly \u0026ndash; the same study estimated the institutional cost saving would be \u003cspan\u003e$\u003c/span\u003e3\u0026nbsp;million \u0026ndash; \u003cspan\u003e$\u003c/span\u003e6\u0026nbsp;million (unilateral \u0026ndash; bilateral cases) if ADM were no longer used [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis review has demonstrated no significant difference between complication and failure rates between ADM and non-ADM pre-pectoral IBBR for seroma/haematoma, infection, skin/NAC necrosis and implant rotation. Overall complications (as defined by presence of at least 1 complication per reconstruction) was slightly higher in the ADM group but not significantly so. This parameter was also only included in 11 studies. There is no significant difference in implant failure or explantation between groups. This is consistent with results from Salibian and Safran [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Capsular contracture, wound dehiscence and implant rippling had significant differences between groups however results demonstrated a high rate of heterogeneity and were from relatively small sample sizes, thus caution should be applied when generalising this finding to the wider population.\u003c/p\u003e \u003cp\u003eThis study has also highlighted a lack of external validity of existing evidence in the literature on this topic. Limitations include heterogeneity of data (for example the high number of TEs in the non-ADM cohort) and lack of available evidence directly comparing ADM and non-ADM use in pre-pectoral IBBR in a single study setting. Meta-analysis was limited by studies being mainly retrospective and the scarcity of randomised data. Another limitation is an inadequate follow-up time of less than 1 year in 10 of the included studies. Potential confounding factors such as the degree of ADM coverage around implants was not ascertainable from the literature. Severity and grade of capsular contracture was recorded variably among studies \u0026ndash; with some documenting all incidences (ungraded) and others documenting only Baker Grade 3 and above. This reduced reliability of extracted data for comparison.\u003c/p\u003e \u003cp\u003eThe lack of externally valid evidence and significant limitations of data on this topic is significant given the high frequency of pre-pectoral IBBR procedures performed in the UK and worldwide, and the costs associated with ADM use. Further prospective, randomised and large-scale studies are required on this topic, with data captured from more homogenous patient groups. Further research into patient reported outcome measures in these populations is also required.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, there is no correlation between ADM use in pre-pectoral IBBR and decreased complications except for capsular contracture, wound dehiscence and rippling, and these results should be interpreted with caution given significant heterogeneity and small sample sizes.\u003c/p\u003e \u003cp\u003eLack of significant difference between use of ADM versus non-use has significant implications for ongoing clinical practice and healthcare legislature in breast cancer reconstruction given the widespread use of ADM and associated cost. However, limited data exists on this topic and further evidence is required in the form of large-scale, randomised studies to ascertain surgical outcomes accurately and reliably.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate\u003c/p\u003e\n\u003cp\u003eAs this review analyses papers which are already published and in the public domain, ethics approval is not required\u003c/p\u003e\n\u003cp\u003eData and Materials\u003c/p\u003e\n\u003cp\u003eDetails regarding search strategy are available on the study PROSPERO registration. Details regarding data extraction and analysis should be requested from the corresponding author if required.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research did not receive any grant or funding from organisations in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003econception - AM, SH, DZliterature search - HC, SGarticle screening - HC, SGdata extraction - HC, SG, SSdata analysis - HC, SG, SSmanuscript writing - HC, SG, SS, DZsupervision - AM, SHreview of manuscript - HC, SG, SS, DZ, AM, SH\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWith thanks to Janet Clapton, Information Specialist, The Royal College of Surgeons of England Library and Archives Team, for conducting the literature searches.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information files\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHouse of Commons Library. 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Plast Reconstr Surg. 2020;145:e263\u0026ndash;72. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/PRS.0000000000006442\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0000000000006442\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4523994/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4523994/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eBreast cancer is the most common malignancy among women in the UK. Reconstruction – of which implant-based breast reconstruction (IBBR) is the most common – forms a core part of surgical management of breast cancer. More recently, pre-pectoral IBBR has become common as technology and operative techniques have evolved.\u003c/p\u003e\n\u003cp\u003eMany surgeons use acellular dermal matrix (ADM) in reconstruction however there is little evidence in literature that this improves surgical outcomes. This review will assess available evidence for surgical outcomes for breast reconstructions using ADM versus non-use of ADM.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eA database search was performed of Ovid Medline, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (2012-2022). Studies were screened using inclusion and exclusion criteria. Risk of Bias was assessed using the Newcastle Ottawa scale and ROBIS tools. Analysis and meta-analysis were performed.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eThis review included 25 studies (4045 breast reconstructions). No significant difference between overall complications and failure rates between ADM and non-ADM use was demonstrated. Capsular contracture, wound dehiscence and implant rippling had significant differences however these results demonstrated high heterogeneity thus wider generalisation may be inaccurate. Patient quality of life scores were not recorded consistently or comparably between papers.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThis review suggests a lack of significant differences in most complications between ADM use and non-use for pre-pectoral IBBR. If no increase in complications exists between groups, this has significant implications for surgical and legislative decision-making. There is, however, inadequate evidence available on the topic and further research is required.\u003c/p\u003e","manuscriptTitle":"Does the use of Acellular Dermal Matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-25 20:20:52","doi":"10.21203/rs.3.rs-4523994/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"02cc7cde-9516-46db-b545-0c76c6016d83","owner":[],"postedDate":"June 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-19T07:01:36+00:00","versionOfRecord":{"articleIdentity":"rs-4523994","link":"https://doi.org/10.1186/s13643-024-02564-7","journal":{"identity":"systematic-reviews","isVorOnly":false,"title":"Systematic Reviews"},"publishedOn":"2024-06-07 20:38:15","publishedOnDateReadable":"June 7th, 2024"},"versionCreatedAt":"2024-06-25 20:20:52","video":"","vorDoi":"10.1186/s13643-024-02564-7","vorDoiUrl":"https://doi.org/10.1186/s13643-024-02564-7","workflowStages":[]},"version":"v1","identity":"rs-4523994","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4523994","identity":"rs-4523994","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}