Use of Partial Acellular Dermal Matrix in Prepectoral Nipple-Sparing Mastectomy

Use of Partial Acellular Dermal Matrix in Prepectoral Nipple-Sparing Mastectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Use of Partial Acellular Dermal Matrix in Prepectoral Nipple-Sparing Mastectomy Mallory Rowley, Evan Chernov, Anca Dogaroiu, Prashant Upadhyaya This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4797552/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Feb, 2025 Read the published version in European Journal of Plastic Surgery → Version 1 posted 7 You are reading this latest preprint version Abstract PURPOSE The nipple-sparing mastectomy (NSM) offers a reconstruction option to patients who wish for a more subtle scar pattern and to retain their native nipple-areolar complex. Traditionally used acellular dermal matrix (ADM) has been linked to potential complications including seroma, hematoma, and infection, as well as increased operative costs. Our study examines whether using partial ADM to cover the lower pole of the breast implant during NSM prepectoral reconstruction offers comparable, or even better, rates of postoperative complications while minimizing operative costs. METHODS A retrospective chart review of patients who underwent prepectoral nipple-sparing implant-based reconstruction (IBR) using partial ADM (June 2019 – October 2020) was performed. Demographic, perioperative, and post-operative complication information was collected and described using means, standard deviations, and frequencies. RESULTS Ninety-eight patients (183 breasts) met inclusion criteria, with smoking history (36.73%), prior breast surgery (18.58%), and obesity (18.37%) cited as the most common comorbidities. 12.57% of patients experienced a complication following stage one of reconstruction, with infection as the most common complication (5.46%). Complication rate following stage two was 7.10%, with dehiscence cited as the most common complication (4.92%). CONCLUSION The average cost of ADM for breast reconstruction is upwards of $ 5,000. While our institution does not utilize full ADM coverage in NSMs, historical trends in the literature demonstrate overall complication rates of 5.9% to as high as 35%. Our study demonstrates that utilizing partial ADM coverage in the setting of NSM offers comparable, if not lower, complication rates at a fraction of the cost. INTRODUCTION Breast cancer accounts for 30% of cancer incidence and 15% of cancer-related mortality among women. 1 Surgical resection remains a mainstay of treatment for early-stage breast cancer as 35.5% of early-stage patients opt for total mastectomy, a proportion that has been steadily increasing since the early 2000s. 2 This rise can, at least in part, be attributed to the increase in breast reconstruction options over the same time period. 2 As more women undergo reconstruction, it is critical to identify techniques that minimize complications and achieve favorable cosmetic results. For decades, subpectoral implant placement was the preferred reconstructive technique. However, recent advances including the use of Acellular Dermal Matrices (ADMs) have made prepectoral implant placement feasible by alleviating concerns over implant migration. 3 Modern ADM-assisted prepectoral and subpectoral methods have similar complication rates, however, prepectoral placement has the advantage of a superior cosmetic result and the preservation of the pectoralis muscle leading to less postoperative pain. 4 Therefore, the prepectoral method has rapidly become the preferred approach to post-mastectomy reconstruction. The use of ADM in staged breast reconstruction has also become increasingly popular since it was first described in 2007. 5 Due to improved aesthetic outcomes by bolstering the mastectomy flaps, ADM has been incorporated into more than 60% of alloplastic breast reconstructions since its introduction. 6 Although many surgeons find ADM to be an adjunct in creating a favorable aesthetic breast contour, there is controversy over its use due to concerns over the complication profile and increased surgical costs. In meta-analysis, the use of ADM in reconstruction was shown to have an overall higher rate of complications for seroma, infection, and reconstructive failure, as compared to reconstructions without the use of ADM. 7 Further, several comparative cost analyses have shown that ADM increases cost of surgery as compared to alternative surgical interventions. Even after adjustment for complications, the cost of staged reconstruction with ADM was more expensive than more invasive reconstruction options including the deep inferior epigastric perforator (DIEP) flap. 8 Additionally, the cost of staged reconstruction with ADM was higher as compared to both staged without ADM and direct-to-implant with ADM procedures. 9 In order for ADM-assisted breast reconstruction to remain a feasible method, techniques must be developed to address the increased complications and cost. The use of a reduced quantity of ADM in reconstruction may address some of these concerns. In direct-to-implant surgery, the use of half of a standard sheet of ADM was shown to be successful at lowering procedural costs and may have the benefit of reducing complications such as seroma and infection due to the reduced integration time. 10 Additionally, the use of ADM is thought to reduce the likelihood of capsular contraction perhaps by reducing myofibroblast presence in the capsule. 11 To our knowledge, this is the first time the complication profile of partial ADM in staged prepectoral breast reconstruction has been investigated. METHODS This study retrospectively evaluated the outcomes of 98 female patients (183 breasts) who underwent nipple-sparing, implant-based staged reconstruction between June 2019 and October 2020. All reconstructions were performed by the senior author (PKU) at a tertiary care center. The study was approved by the SUNY Upstate Medical University Institutional Review Board (IRB # 1618419). Charts were accessed using Epic (Epic Systems Corporation, Verona, WI) and data was collected in a deidentified manner. Using Current Procedural Terminology (CPT) codes and excluding patients with less than 6 months of postoperative care following stage two of reconstruction, 98 patients (183 reconstructed breasts) met the criteria for inclusion. Demographic and comorbidity information was collected at the time of stage one. Variables collected included ethnicity, age, body mass index (BMI), smoking history, and diagnosis of hypertension, dyslipidemia, diabetes, and coronary artery disease. Oncologic data collection consisted of history of prior breast surgery, chemotherapy, neoadjuvant chemotherapy, chest wall radiation history, and post-mastectomy radiation therapy. Perioperative information was also collected. Variables included indication for mastectomy, mastectomy incision pattern, mass of the resected breast specimen, use of acellular dermal matrix (ADM), tissue expander (TE) size, initial TE fill, TE and implant plane (pre- or subpectoral), implant size, and whether an axillary lymph node dissection (ALND) was performed. Charts were also monitored for postoperative complications up to six months following stage two of reconstruction. Complications included infection, seroma, hematoma, dehiscence, and malposition of the implant. Infections were subclassified as major or minor. Minor infections were defined as requiring only oral antibiotics or conservative wound care, whereas major infections required surgical intervention including as washout and possible removal of TE or implant. Total follow-up time was calculated as the difference between date of stage one of surgery and the final follow-up visit in days. Statistical Analysis Data was de-identified during and formatted into tables using Microsoft Excel (Microsoft Inc., Seattle, WA). Categorial data was reported using frequencies and continuous data was described using means and standard deviations. Operative Technique The surgery was done in a standard two-stage standard manner. The patient is positioned supine. The breast surgeon performed a unilateral or bilateral simple mastectomy with an inframammary incision pattern. Stage 1 The procedure begins with antibiotic irrigation before and after the placement of drains above the pectoralis major muscle. ADM, which has been soaking in antibiotic solution, is placed with the rough surface facing the inside surface of the mastectomy flaps to create a neopocket. The ADM is fixed to the inferomedial corner and the suture runs along the inframammary fold till the midpoint. Another suture then secures the ADM's lateral border at the supero lateral border of the pectoralis major muscle. The suture runs down to the midpoint of the lateral mammary fold of the neopocket. The third suture starts at the inferomedial corner and the ADM is secured to the Pectoralis major muscle and superior pocket edge with a running suture running towards the superolateral corner to which it is tied. Thus, an opening along the inferolateral border of the neopocket through which the expander can slide in is formed. Now, the air is evacuated from the expander, placed in the pocket, and covered by the ADM. The expander is filled with air and the wound is closed in layers. The procedure is repeated on the other breast assuming a bilateral mastectomy. Patients typically stay overnight in the hospital and are discharged the following day on appropriate antibiotics. In subsequent postoperative appointments, the air in the tissue expander is replaced with increasing amounts of saline until the desired size is achieved prior to exchange for implants. Stage 2 The patient is positioned supine with arms kept outstretched on arm boards. The incision is made on the mastectomy scar and deepened down to the capsule. An inferior flap is raised and the Alloderm/capsule is incised in a transverse manner parallel to and below the skin incision. The expander is then deflated and removed. After feeling contracted borders in the pocket, a superior border incision is made and the capsule lifted up. The sharp edge of the capsule is divided in many areas to smoothen out the upper pole profile. Similarly, the inframammary fold and medial pole are divided to smoothen out the inferior and medial pole, respectively. Multiple capsulotomies are also performed along the inferior pole due to the ADM fully incorporating into the breast flap. Next, a sizer is placed and the patient is sat up to assess breast symmetry. The sizer is replaced with the implant. The wound is closed in layers. RESULTS A total of 183 implant-based breast reconstructions using partial ADM in 98 female patients were performed ( Table 1 ). The mean age was 47.41 + 11.13 years. Nearly a fifth of these patients were classified as obese based on a body-mass index (BMI) of 30 or more (mean BMI 25.67 ± 4.58), and the most common comorbidities included hypertension (14.29%) and dyslipidemia (7.14%). Over a third of the cohort had a history of smoking (36.73%), but all patients had stopped within 30 days smoking prior to mastectomy. Over half of the patients received prophylactic mastectomy (53.59%). 18.58% of the breasts had a history of prior breast surgery. A limited number of patients received post-mastectomy radiation therapy (5.46%), while around a sixth of the cohort received neoadjuvant chemotherapy (13.27%) or adjuvant chemotherapy (16.33%). Perioperative information is outlined in Table 2 . Most of the mastectomies were bilateral (85.71%). All of the procedures performed used nipple-sparing incisions and partial ADM (100%) with an average resected breast mass of 352.20 ± 185.88 grams. A minimal constituent of the cohort (6.63%) had an axillary lymph node dissection performed at the time of mastectomy. All tissue expanders were placed in the prepectoral plane (100%). The average tissue expander size was 422.84 ± 91.17 milliliters (mL) and the average fill of the tissue expander prior to stage two was 385.87 ± 110.59 mL with a range of 60 to 600 mL. The average size of the implant placed after stage two was 572.95 ± 153.73 cubic centimeters (cc). Overall complication rate following stage one of reconstruction was 12.6% ( Table 3 ) with infection cited as the most common complication (5.46%). Additional complications in order of decreasing frequency included seroma (4.9%), dehiscence (3.3%), breast pocket washout with TE salvage (2.73%), hematoma (1.6%), malposition of the TE (1.1%), and breast pocket washout with TE removal (1.09%). Overall complication rate following stage two of reconstruction was 7.1% ( Table 4 ) with dehiscence cited as the most common complication (4.9%). Additional complications in order of decreasing frequency included infection (3.8%), capsular contracture (2.19%) breast pocket washout with implant removal (1.6%), and breast pocket washout with implant salvage (0.5%). There were no recorded complications of seroma, hematoma, or malposition of the implant following stage two of reconstruction. The revision rate following stage two of reconstruction was 20.99%. DISCUSSION The nipple-sparing mastectomy (NSM) technique offers a reconstruction option to patients undergoing mastectomy who wish for a more subtle scar pattern and to retain their native nipple-areolar complex. Retaining the native nipple-areolar complex has been demonstrated to positively impact post-operative self-perception and quality of life. 12 As subpectoral reconstruction can cause substantial postoperative pain, animation deformities, and poor cosmetic results due to widened cleavage, prepectoral reconstruction has become increasingly popular in the setting of NSM. 13 As prepectoral reconstruction becomes the predominant technique, it is worth re-examining the necessity of full implant coverage with acellular dermal matrices (ADMs). 4 ADM has been linked to potential complications including increased risk of seroma, hematoma, infection, and failure rates. 7 , 14 Additionally, previous studies have demonstrated that the average cost of ADM for breast reconstruction is upwards of $ 5,000. 14 Our study examines whether using partial ADM to cover the lower pole of the breast implant during NSM prepectoral reconstruction offers comparable, or even better, rates of postoperative complications while minimizing operative costs. The traditional standard approach to NSM reconstruction consisted of a partial subpectoral implant placement with the upper pole of the implant below the pectoralis muscle and ADM covering the lower pole. 15 However, research demonstrates the recent gain in popularity of prepectoral reconstruction given its preservation of the pectoralis muscle, less postoperative pain, reduction of upward migration of the implant, and more pronounced projection of the breast. 16 , 17 Complete ADM coverage is often used in prepectoral implant placement with the belief that this will increase implant stability and reduce capsular contracture. 18 – 20 However, given that the cost of ADM is upwards of $ 5,000 for a standard breast reconstruction procedure, we aim to elucidate whether less ADM could be utilized with similar complication rates as full-coverage ADM reconstructions in the NSM population. Our study demonstrated overall complication rates of 12.6% following stage one of reconstruction and 7.1% following stage two of reconstruction. While the plastic surgeon at our institution does not utilize full ADM coverage in nipple-sparing mastectomies, historical trends in the literature demonstrate overall complication rates of 5.9% to as high as 35%. 21–23 Following stage one of reconstruction, the largest proportion of complications were due to infection (5.46%). The literature surrounding infection rates in the setting of reconstruction with ADM has variable conclusions. In some cases, ADM has been cited as reducing inflammation that may lead to reduced rates of infection. 24 Previous studies, however, cite up to a five-fold increase in the rate of infection when using ADM and reference that concept of introducing a foreign material to the chest wall. 25 – 29 Regardless, the rate of infection using partial ADM was approximately equivalent or lower than that cited in the literature in cases in which the prepectoral implant was completely enmeshed in ADM. These studies were mostly limited to direct-to-implant cases and cited complication rates from 2–26.8%. 30–36 One staged prepectoral study cited a complication rate of 7.5% and a previous meta-analysis demonstrated that using larger proportions of ADM significantly increases the odds of infection, seroma, and necrosis. 7 , 37 ADM has also been cited as a seromatogenic substance, possibly secondary to its introduction as a foreign material to the postoperative wound bed. 7 This may contribute, at least in part, to the 4.92% seroma complication rate following stage one of reconstruction. However, the rate of seroma occurrence in cases with full ADM coverage has been noted as ranging from 0–23% in direct-to-implant studies and 10% in staged prepectoral studies. 32 – 37 As noted above, a meta-analysis concluded that increasing amounts of ADM was significantly associated with seroma formation. 7 Following stage two of surgery, dehiscence (4.92%) was noted as the major contributing factor to complication rates (7.10%). As previous studies have aptly noted, however, dehiscence may be due more to thin mastectomy skin flaps and the increased risk of necrosis that is inherent in the NSM technique. While ADM has been utilized to bolster skin flap thickness without compromising safe oncologic margins, studies suggest it is feasible to utilize skin flaps without ADM in NSM and prevent ischemic complications via adequate measurement of skin flap thickness. 38 Thus, upper pole rippling and ischemic complications can be mitigated by careful measurement of the mastectomy flaps and use of ADM to cover the lower pole. Utilizing ADM in the lower pole may be useful in securing the implant to prevent migration and to better define the inframammary fold and improve breast contour. 39 Additionally, a number of studies have suggested that the use of ADM mitigates capsular contracture. 11 , 40 The capsular contracture in our study was relatively low at 2.19% following stage two. In this study, the number of breasts undergoing revision for an exchange in implant size, usually due to rippling, was 20.99%. In the literature, this rate is up to 35.4%. 41,42 ADM has been historically used to reduce the rippling effect in the past by bolstering the native skin flap. However, as previously mentioned, studies have contradicted the necessity of ADM and instead advocate for use of the patient’s native breast flap given sufficient thickness. 43 , 44 Of particular advantage, however, is the cost savings that may be implemented by using less ADM during breast reconstruction. Studies report vastly different costs in the use of ADM during bilateral reconstruction ranging from $ 3,047 to $ 11,255. 9 , 45 Our proposed technique fractionalizes this cost by as much as half. Draping only the lower pole of the implant with ADM substantially reduces operative costs and has the potential to lower complication costs associated with ADM as previously noted. While synthetic mesh was not used in our study, several studies have shown it has low complication rates and can also minimize operative costs. 46 We recognize that complication rates and cost are not the only metrics that provide guidance when choosing a particular reconstruction modality, however complication rates serve as a strong indicator of safety. As a retrospective study, this study may be subject to the biases of record keeping and the sample size is limited to a single tertiary care center without a direct control cohort that utilized full ADM coverage. Follow-up time was limited to six months, therefore studies with longer follow-up windows may strengthen the use of complication rates as an indicator of safety. Additional studies may be useful in determining the cost-savings to both the institution and patient in utilizing partial ADM. Finally, the need for associated patient-reported outcomes is necessary to assess the aesthetic and psychosocial outcomes of this technique. CONCLUSION The NSM technique has the inherent benefit of improved cosmesis and retainment of the patient’s own nipple areolar complex. Many surgeons bolster the mastectomy flap at both the upper and lower pole with ADM for increased flap thickness. However, the cost of ADM coupled with the historical complication rate of up to 35% in patients who receive reconstruction with full-coverage ADM warrants reconsideration. Our study demonstrates that utilizing partial ADM coverage in the setting of NSM offers comparable, if not lower, complication rates with the additional benefit of significantly reduced surgical costs. Declarations Author Contribution MR collected and analyzed data.EV, AD, and MR wrote the main manuscript text and tables. EV and AD reformatted tables.All authors reviewed and edited the manuscript. 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Plast Reconstr Surg Glob Open 4(5):e708. 10.1097/GOX.0000000000000681 PMID: 27579232; PMCID: PMC4995704 Reitsamer R, Peintinger F (2015) Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: a new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg 68(2):162–167. 10.1016/j.bjps.2014.10.012 Epub 2014 Oct 16. PMID: 25455288 Woo A, Harless C, Jacobson SR (2017) Revisiting an Old Place: Single-Surgeon Experience on Post-Mastectomy Subcutaneous Implant-Based Breast Reconstruction. Breast J 23(5):545–553. 10.1111/tbj.12790 Epub 2017 Mar 13. PMID: 28295975 Momeni A, Remington AC, Wan DC, Nguyen D, Gurtner GC (2019) A Matched-Pair Analysis of Prepectoral with Subpectoral Breast Reconstruction: Is There a Difference in Postoperative Complication Rate? Plast Reconstr Surg. ;144(4):801–807. 10.1097/PRS.0000000000006008 . PMID: 31568276 Frey JD, Salibian AA, Choi M, Karp NS (2017) Mastectomy Flap Thickness and Complications in Nipple-Sparing Mastectomy: Objective Evaluation using Magnetic Resonance Imaging. Plast Reconstr Surg Glob Open 5(8):e1439 Published 2017 Aug 8. 10.1097/GOX.0000000000001439 Kalstrup J, Balslev Willert C, Brinch-Møller Weitemeyer M, Hougaard Chakera A, Hölmich LR (2021) Immediate direct-to-implant breast reconstruction with acellular dermal matrix: Evaluation of complications and safety. Breast 60:192–198. 10.1016/j.breast.2021.10.006 Liu J, Hou J, Li Z, Wang B, Sun J (2020) Efficacy of Acellular Dermal Matrix in Capsular Contracture of Implant-Based Breast Reconstruction: A Single-Arm Meta-analysis. Aesthetic Plast Surg 44(3):735–742. 10.1007/s00266-019-01603-2 Epub 2020 Jan 9. PMID: 31919627 Downs RK, Hedges K (2016) An Alternative Technique for Immediate Direct-to-Implant Breast Reconstruction-A Case Series. Plast Reconstr Surg Glob Open 4(7):e821 Published 2016 Jul 22. 10.1097/GOX.0000000000000839 Vidya R, Iqbal FM, Becker H, Zhadan O (2019) Rippling Associated with Pre-Pectoral Implant Based Breast Reconstruction: A New Grading System. World J Plast Surg 8(3):311–315. 10.29252/wjps.8.3.311 Hon HH, Mubang RN, Wernick BD et al (2017) Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost. Plast Reconstr Surg Glob Open 5(6):e1382 Published 2017 Jun 28. 10.1097/GOX.0000000000001382 Torstenson T, Boughey JC, Saint-Cyr M (2013) Inferior dermal flap in immediate breast reconstruction. Ann Surg Oncol 20(10):3349. 10.1245/s10434-013-3109-0 Epub 2013 Aug 22. PMID: 23975284 Bank J, Phillips NA, Park JE, Song DH (2013) Economic analysis and review of the literature on implant-based breast reconstruction with and without the use of the acellular dermal matrix. Aesthetic Plast Surg. ;37(6):1194 – 201. 10.1007/s00266-013-0213-2 . Epub 2013 Oct 3. PMID: 24091489 Choi YS, You HJ, Lee TY, Kim DW (2023) Comparing Complications of Biologic and Synthetic Mesh in Breast Reconstruction: A Systematic Review and Network Meta-Analysis. Arch Plast Surg 50(1):3–9. 10.1055/a-1964-8181 PMID: 36755646; PMCID: PMC9902089 Tables Table 1. Patient Demographics Demographic N % or ± SD Patients 98 Average Age (Years) 47.41 ± 11.13 Ethnicity Asian 3 3.06% Black 3 3.06% Other, Hispanic/Latino 1 1.02% Other, Non-Hispanic 0 0.00% Pacific Islander, Non-Hispanic 0 0.00% White 91 92.86% Mean BMI 25.67 4.58 Obese (BMI > 30) 18 18.37% Diabetes 1 1.02% Hypertension 14 14.29% Dyslipidemia 7 7.14% Coronary Artery Disease (CAD) 1 1.02% Smoking History Yes 36 36.73% No 62 63.27% History of Chest Wall Radiation 15 8.20% Chemotherapy 16 16.33% Neoadjuvant Chemotherapy 13 13.27% Breasts Receiving PMRT 10 5.46% History of Breast Surgery 34 18.58% Final Follow-Up Time (in days) 337.63 138.00 *Abbreviations: BMI – body-mass index, XRT – chest wall radiation history, PMRT – Post mastectomy radiation therapy (by breast, rather than by patient) Table 2. Perioperative Information Factor N % or + SD Breasts Reconstructed 183 Indication for Mastectomy Breast cancer 86 46.99% Prophylactic 97 53.01% Mastectomy Type Nipple-Sparing 183 100.00% Mean Mass of Resected Specimen (in grams) 352.20 + 185.88 Tissue Expander Plane Prepectoral 183 100.00% Mean TE Size (in mL) 422.84 + 91.17 Mean TE Fill (in mL) 385.87 + 110.59 Reconstruction Laterality Unilateral 14 14.29% Bilateral 84 85.71% Axillary Lymph Node Dissection Yes 12 6.56% No 171 93.44% ADM Use Yes 183 100.00% Mean Implant Size (in CC) 572.95 + 153.73 Table 3. Stage 1 Postoperative Outcomes (by breast) Complication N % Any complication 23 12.57% Infection 10 5.46% Major Infection 7 3.83% Minor Infection 3 1.64% Washout + Salvage (Tissue Expander) 5 2.73% Washout + Tissue Expander removal 2 1.09% Dehiscence 6 3.28% Seroma 9 4.92% Hematoma 3 1.64% Malposition 2 1.09% Table 4. Stage 2 Postoperative Outcomes (by breast) Complication N % Any complication 13 7.10% Infection 7 3.83% Major Infection 4 2.19% Minor Infection 3 1.64% Washout + Salvage (Implant) 1 0.55% Washout + Implant removal 3 1.64% Dehiscence 9 4.92% Seroma 0 0.00% Hematoma 0 0.00% Malposition 0 0.00% Capsular Contracture 4 2.19% Revision 38 20.99% Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Feb, 2025 Read the published version in European Journal of Plastic Surgery → Version 1 posted Editorial decision: Revision requested 28 Nov, 2024 Reviews received at journal 15 Nov, 2024 Reviewers agreed at journal 07 Nov, 2024 Reviewers invited by journal 30 Jul, 2024 Editor assigned by journal 26 Jul, 2024 Submission checks completed at journal 26 Jul, 2024 First submitted to journal 24 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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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-4797552","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":335729511,"identity":"fb925069-5a67-40b7-a8f0-9a05d7337b1d","order_by":0,"name":"Mallory Rowley","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYFAC5sYDcPYDBgY5EH3gAV4tjA0ILQkMDMZgLQmkaElsgDJwAt32gw0HPu45LM8gffiYRELF4fT5YYcfAm2xk9NtwK7F7Exiw8EZzw4bNvClpUkknDmcu/F2mgFQS7Kx2QEcWg4kNhzmOXCYsYGHx+xGYhtQy+wEkJYDidtwaTn/EKzFHqLl3+F0w9npH/BruQGxJRGipeFwgrx0DgFbbjwE+uVAenIbD1v6j4Rj6YYbpHMKDiQY4PHL+eSDDz4csLbt52E+bPChxlpefnb65g8fKuzkcGmBgmYGNhjDAKzSAK9yEKhDMOQbCKoeBaNgFIyCEQYAcoxt2bdhqaYAAAAASUVORK5CYII=","orcid":"","institution":"SUNY Upstate Medical University","correspondingAuthor":true,"prefix":"","firstName":"Mallory","middleName":"","lastName":"Rowley","suffix":""},{"id":335729512,"identity":"9d4858b4-1b55-4c5f-8464-1e84af516efd","order_by":1,"name":"Evan Chernov","email":"","orcid":"","institution":"SUNY Upstate Medical University","correspondingAuthor":false,"prefix":"","firstName":"Evan","middleName":"","lastName":"Chernov","suffix":""},{"id":335729513,"identity":"995333aa-35dd-4464-8672-9efc93ed4c4c","order_by":2,"name":"Anca Dogaroiu","email":"","orcid":"","institution":"SUNY Upstate Medical University","correspondingAuthor":false,"prefix":"","firstName":"Anca","middleName":"","lastName":"Dogaroiu","suffix":""},{"id":335729514,"identity":"aaf1c5e0-6460-47d2-ab44-9fec5e07ba28","order_by":3,"name":"Prashant Upadhyaya","email":"","orcid":"","institution":"SUNY Upstate Medical University","correspondingAuthor":false,"prefix":"","firstName":"Prashant","middleName":"","lastName":"Upadhyaya","suffix":""}],"badges":[],"createdAt":"2024-07-24 19:35:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4797552/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4797552/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00238-025-02285-7","type":"published","date":"2025-02-17T15:57:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77053772,"identity":"5219bb13-2551-41d6-9aa3-9ced94285250","added_by":"auto","created_at":"2025-02-24 16:30:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":621718,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4797552/v1/2a11088f-1a3a-4155-b831-241225cf8060.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Use of Partial Acellular Dermal Matrix in Prepectoral Nipple-Sparing Mastectomy","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBreast cancer accounts for 30% of cancer incidence and 15% of cancer-related mortality among women.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Surgical resection remains a mainstay of treatment for early-stage breast cancer as 35.5% of early-stage patients opt for total mastectomy, a proportion that has been steadily increasing since the early 2000s.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e This rise can, at least in part, be attributed to the increase in breast reconstruction options over the same time period.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e As more women undergo reconstruction, it is critical to identify techniques that minimize complications and achieve favorable cosmetic results.\u003c/p\u003e \u003cp\u003eFor decades, subpectoral implant placement was the preferred reconstructive technique. However, recent advances including the use of Acellular Dermal Matrices (ADMs) have made prepectoral implant placement feasible by alleviating concerns over implant migration.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Modern ADM-assisted prepectoral and subpectoral methods have similar complication rates, however, prepectoral placement has the advantage of a superior cosmetic result and the preservation of the pectoralis muscle leading to less postoperative pain.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Therefore, the prepectoral method has rapidly become the preferred approach to post-mastectomy reconstruction. The use of ADM in staged breast reconstruction has also become increasingly popular since it was first described in 2007.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Due to improved aesthetic outcomes by bolstering the mastectomy flaps, ADM has been incorporated into more than 60% of alloplastic breast reconstructions since its introduction.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough many surgeons find ADM to be an adjunct in creating a favorable aesthetic breast contour, there is controversy over its use due to concerns over the complication profile and increased surgical costs. In meta-analysis, the use of ADM in reconstruction was shown to have an overall higher rate of complications for seroma, infection, and reconstructive failure, as compared to reconstructions without the use of ADM.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Further, several comparative cost analyses have shown that ADM increases cost of surgery as compared to alternative surgical interventions. Even after adjustment for complications, the cost of staged reconstruction with ADM was more expensive than more invasive reconstruction options including the deep inferior epigastric perforator (DIEP) flap.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Additionally, the cost of staged reconstruction with ADM was higher as compared to both staged without ADM and direct-to-implant with ADM procedures.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In order for ADM-assisted breast reconstruction to remain a feasible method, techniques must be developed to address the increased complications and cost.\u003c/p\u003e \u003cp\u003eThe use of a reduced quantity of ADM in reconstruction may address some of these concerns. In direct-to-implant surgery, the use of half of a standard sheet of ADM was shown to be successful at lowering procedural costs and may have the benefit of reducing complications such as seroma and infection due to the reduced integration time.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Additionally, the use of ADM is thought to reduce the likelihood of capsular contraction perhaps by reducing myofibroblast presence in the capsule.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e To our knowledge, this is the first time the complication profile of partial ADM in staged prepectoral breast reconstruction has been investigated.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study retrospectively evaluated the outcomes of 98 female patients (183 breasts) who underwent nipple-sparing, implant-based staged reconstruction between June 2019 and October 2020. All reconstructions were performed by the senior author (PKU) at a tertiary care center. The study was approved by the SUNY Upstate Medical University Institutional Review Board (IRB # 1618419). Charts were accessed using Epic (Epic Systems Corporation, Verona, WI) and data was collected in a deidentified manner. Using Current Procedural Terminology (CPT) codes and excluding patients with less than 6 months of postoperative care following stage two of reconstruction, 98 patients (183 reconstructed breasts) met the criteria for inclusion.\u003c/p\u003e \u003cp\u003eDemographic and comorbidity information was collected at the time of stage one. Variables collected included ethnicity, age, body mass index (BMI), smoking history, and diagnosis of hypertension, dyslipidemia, diabetes, and coronary artery disease. Oncologic data collection consisted of history of prior breast surgery, chemotherapy, neoadjuvant chemotherapy, chest wall radiation history, and post-mastectomy radiation therapy.\u003c/p\u003e \u003cp\u003ePerioperative information was also collected. Variables included indication for mastectomy, mastectomy incision pattern, mass of the resected breast specimen, use of acellular dermal matrix (ADM), tissue expander (TE) size, initial TE fill, TE and implant plane (pre- or subpectoral), implant size, and whether an axillary lymph node dissection (ALND) was performed.\u003c/p\u003e \u003cp\u003eCharts were also monitored for postoperative complications up to six months following stage two of reconstruction. Complications included infection, seroma, hematoma, dehiscence, and malposition of the implant. Infections were subclassified as major or minor. Minor infections were defined as requiring only oral antibiotics or conservative wound care, whereas major infections required surgical intervention including as washout and possible removal of TE or implant. Total follow-up time was calculated as the difference between date of stage one of surgery and the final follow-up visit in days.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData was de-identified during and formatted into tables using Microsoft Excel (Microsoft Inc., Seattle, WA). Categorial data was reported using frequencies and continuous data was described using means and standard deviations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eOperative Technique\u003c/h2\u003e \u003cp\u003eThe surgery was done in a standard two-stage standard manner. The patient is positioned supine. The breast surgeon performed a unilateral or bilateral simple mastectomy with an inframammary incision pattern.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eStage 1\u003c/h2\u003e \u003cp\u003eThe procedure begins with antibiotic irrigation before and after the placement of drains above the pectoralis major muscle. ADM, which has been soaking in antibiotic solution, is placed with the rough surface facing the inside surface of the mastectomy flaps to create a neopocket. The ADM is fixed to the inferomedial corner and the suture runs along the inframammary fold till the midpoint. Another suture then secures the ADM's lateral border at the supero lateral border of the pectoralis major muscle. The suture runs down to the midpoint of the lateral mammary fold of the neopocket. The third suture starts at the inferomedial corner and the ADM is secured to the Pectoralis major muscle and superior pocket edge with a running suture running towards the superolateral corner to which it is tied. Thus, an opening along the inferolateral border of the neopocket through which the expander can slide in is formed. Now, the air is evacuated from the expander, placed in the pocket, and covered by the ADM. The expander is filled with air and the wound is closed in layers. The procedure is repeated on the other breast assuming a bilateral mastectomy. Patients typically stay overnight in the hospital and are discharged the following day on appropriate antibiotics. In subsequent postoperative appointments, the air in the tissue expander is replaced with increasing amounts of saline until the desired size is achieved prior to exchange for implants.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStage 2\u003c/h2\u003e \u003cp\u003eThe patient is positioned supine with arms kept outstretched on arm boards. The incision is made on the mastectomy scar and deepened down to the capsule. An inferior flap is raised and the Alloderm/capsule is incised in a transverse manner parallel to and below the skin incision. The expander is then deflated and removed. After feeling contracted borders in the pocket, a superior border incision is made and the capsule lifted up. The sharp edge of the capsule is divided in many areas to smoothen out the upper pole profile. Similarly, the inframammary fold and medial pole are divided to smoothen out the inferior and medial pole, respectively. Multiple capsulotomies are also performed along the inferior pole due to the ADM fully incorporating into the breast flap. Next, a sizer is placed and the patient is sat up to assess breast symmetry. The sizer is replaced with the implant. The wound is closed in layers.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 183 implant-based breast reconstructions using partial ADM in 98 female patients were performed (\u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e). The mean age was 47.41\u0026thinsp;+\u0026thinsp;11.13 years. Nearly a fifth of these patients were classified as obese based on a body-mass index (BMI) of 30 or more (mean BMI 25.67\u0026thinsp;\u0026plusmn;\u0026thinsp;4.58), and the most common comorbidities included hypertension (14.29%) and dyslipidemia (7.14%). Over a third of the cohort had a history of smoking (36.73%), but all patients had stopped within 30 days smoking prior to mastectomy. Over half of the patients received prophylactic mastectomy (53.59%). 18.58% of the breasts had a history of prior breast surgery. A limited number of patients received post-mastectomy radiation therapy (5.46%), while around a sixth of the cohort received neoadjuvant chemotherapy (13.27%) or adjuvant chemotherapy (16.33%).\u003c/p\u003e \u003cp\u003ePerioperative information is outlined in \u003cb\u003eTable\u0026nbsp;2\u003c/b\u003e. Most of the mastectomies were bilateral (85.71%). All of the procedures performed used nipple-sparing incisions and partial ADM (100%) with an average resected breast mass of 352.20\u0026thinsp;\u0026plusmn;\u0026thinsp;185.88 grams. A minimal constituent of the cohort (6.63%) had an axillary lymph node dissection performed at the time of mastectomy. All tissue expanders were placed in the prepectoral plane (100%). The average tissue expander size was 422.84\u0026thinsp;\u0026plusmn;\u0026thinsp;91.17 milliliters (mL) and the average fill of the tissue expander prior to stage two was 385.87\u0026thinsp;\u0026plusmn;\u0026thinsp;110.59 mL with a range of 60 to 600 mL. The average size of the implant placed after stage two was 572.95\u0026thinsp;\u0026plusmn;\u0026thinsp;153.73 cubic centimeters (cc).\u003c/p\u003e \u003cp\u003eOverall complication rate following stage one of reconstruction was 12.6% (\u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e) with infection cited as the most common complication (5.46%). Additional complications in order of decreasing frequency included seroma (4.9%), dehiscence (3.3%), breast pocket washout with TE salvage (2.73%), hematoma (1.6%), malposition of the TE (1.1%), and breast pocket washout with TE removal (1.09%).\u003c/p\u003e \u003cp\u003eOverall complication rate following stage two of reconstruction was 7.1% (\u003cb\u003eTable\u0026nbsp;4\u003c/b\u003e) with dehiscence cited as the most common complication (4.9%). Additional complications in order of decreasing frequency included infection (3.8%), capsular contracture (2.19%) breast pocket washout with implant removal (1.6%), and breast pocket washout with implant salvage (0.5%). There were no recorded complications of seroma, hematoma, or malposition of the implant following stage two of reconstruction.\u003c/p\u003e \u003cp\u003eThe revision rate following stage two of reconstruction was 20.99%.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe nipple-sparing mastectomy (NSM) technique offers a reconstruction option to patients undergoing mastectomy who wish for a more subtle scar pattern and to retain their native nipple-areolar complex. Retaining the native nipple-areolar complex has been demonstrated to positively impact post-operative self-perception and quality of life.\u003csup\u003e \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e \u003c/sup\u003e As subpectoral reconstruction can cause substantial postoperative pain, animation deformities, and poor cosmetic results due to widened cleavage, prepectoral reconstruction has become increasingly popular in the setting of NSM.\u003csup\u003e \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e \u003c/sup\u003e As prepectoral reconstruction becomes the predominant technique, it is worth re-examining the necessity of full implant coverage with acellular dermal matrices (ADMs).\u003csup\u003e \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e \u003c/sup\u003e ADM has been linked to potential complications including increased risk of seroma, hematoma, infection, and failure rates.\u003csup\u003e \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e \u003c/sup\u003e Additionally, previous studies have demonstrated that the average cost of ADM for breast reconstruction is upwards of \u003cspan\u003e$\u003c/span\u003e5,000.\u003csup\u003e \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e \u003c/sup\u003e Our study examines whether using partial ADM to cover the lower pole of the breast implant during NSM prepectoral reconstruction offers comparable, or even better, rates of postoperative complications while minimizing operative costs.\u003c/p\u003e \u003cp\u003eThe traditional standard approach to NSM reconstruction consisted of a partial subpectoral implant placement with the upper pole of the implant below the pectoralis muscle and ADM covering the lower pole.\u003csup\u003e \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e \u003c/sup\u003e However, research demonstrates the recent gain in popularity of prepectoral reconstruction given its preservation of the pectoralis muscle, less postoperative pain, reduction of upward migration of the implant, and more pronounced projection of the breast.\u003csup\u003e \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e \u003c/sup\u003e Complete ADM coverage is often used in prepectoral implant placement with the belief that this will increase implant stability and reduce capsular contracture.\u003csup\u003e \u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e \u003c/sup\u003e However, given that the cost of ADM is upwards of \u003cspan\u003e$\u003c/span\u003e5,000 for a standard breast reconstruction procedure, we aim to elucidate whether less ADM could be utilized with similar complication rates as full-coverage ADM reconstructions in the NSM population.\u003c/p\u003e \u003cp\u003eOur study demonstrated overall complication rates of 12.6% following stage one of reconstruction and 7.1% following stage two of reconstruction. While the plastic surgeon at our institution does not utilize full ADM coverage in nipple-sparing mastectomies, historical trends in the literature demonstrate overall complication rates of 5.9% to as high as 35%.\u003csup\u003e21\u0026ndash;23\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFollowing stage one of reconstruction, the largest proportion of complications were due to infection (5.46%). The literature surrounding infection rates in the setting of reconstruction with ADM has variable conclusions. In some cases, ADM has been cited as reducing inflammation that may lead to reduced rates of infection.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Previous studies, however, cite up to a five-fold increase in the rate of infection when using ADM and reference that concept of introducing a foreign material to the chest wall.\u003csup\u003e\u003cspan additionalcitationids=\"CR26 CR27 CR28\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Regardless, the rate of infection using partial ADM was approximately equivalent or lower than that cited in the literature in cases in which the prepectoral implant was completely enmeshed in ADM. These studies were mostly limited to direct-to-implant cases and cited complication rates from 2\u0026ndash;26.8%.\u003csup\u003e30\u0026ndash;36\u003c/sup\u003e One staged prepectoral study cited a complication rate of 7.5% and a previous meta-analysis demonstrated that using larger proportions of ADM significantly increases the odds of infection, seroma, and necrosis.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eADM has also been cited as a seromatogenic substance, possibly secondary to its introduction as a foreign material to the postoperative wound bed.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e This may contribute, at least in part, to the 4.92% seroma complication rate following stage one of reconstruction. However, the rate of seroma occurrence in cases with full ADM coverage has been noted as ranging from 0\u0026ndash;23% in direct-to-implant studies and 10% in staged prepectoral studies.\u003csup\u003e\u003cspan additionalcitationids=\"CR33 CR34 CR35 CR36\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e As noted above, a meta-analysis concluded that increasing amounts of ADM was significantly associated with seroma formation.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFollowing stage two of surgery, dehiscence (4.92%) was noted as the major contributing factor to complication rates (7.10%). As previous studies have aptly noted, however, dehiscence may be due more to thin mastectomy skin flaps and the increased risk of necrosis that is inherent in the NSM technique. While ADM has been utilized to bolster skin flap thickness without compromising safe oncologic margins, studies suggest it is feasible to utilize skin flaps without ADM in NSM and prevent ischemic complications via adequate measurement of skin flap thickness.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Thus, upper pole rippling and ischemic complications can be mitigated by careful measurement of the mastectomy flaps and use of ADM to cover the lower pole. Utilizing ADM in the lower pole may be useful in securing the implant to prevent migration and to better define the inframammary fold and improve breast contour.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Additionally, a number of studies have suggested that the use of ADM mitigates capsular contracture.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e The capsular contracture in our study was relatively low at 2.19% following stage two.\u003c/p\u003e \u003cp\u003eIn this study, the number of breasts undergoing revision for an exchange in implant size, usually due to rippling, was 20.99%. In the literature, this rate is up to 35.4%.\u003csup\u003e41,42\u003c/sup\u003e ADM has been historically used to reduce the rippling effect in the past by bolstering the native skin flap. However, as previously mentioned, studies have contradicted the necessity of ADM and instead advocate for use of the patient\u0026rsquo;s native breast flap given sufficient thickness.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOf particular advantage, however, is the cost savings that may be implemented by using less ADM during breast reconstruction. Studies report vastly different costs in the use of ADM during bilateral reconstruction ranging from \u003cspan\u003e$\u003c/span\u003e3,047 to \u003cspan\u003e$\u003c/span\u003e11,255.\u003csup\u003e \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e \u003c/sup\u003e Our proposed technique fractionalizes this cost by as much as half. Draping only the lower pole of the implant with ADM substantially reduces operative costs and has the potential to lower complication costs associated with ADM as previously noted. While synthetic mesh was not used in our study, several studies have shown it has low complication rates and can also minimize operative costs.\u003csup\u003e \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e \u003c/sup\u003e \u003c/p\u003e \u003cp\u003eWe recognize that complication rates and cost are not the only metrics that provide guidance when choosing a particular reconstruction modality, however complication rates serve as a strong indicator of safety. As a retrospective study, this study may be subject to the biases of record keeping and the sample size is limited to a single tertiary care center without a direct control cohort that utilized full ADM coverage. Follow-up time was limited to six months, therefore studies with longer follow-up windows may strengthen the use of complication rates as an indicator of safety. Additional studies may be useful in determining the cost-savings to both the institution and patient in utilizing partial ADM. Finally, the need for associated patient-reported outcomes is necessary to assess the aesthetic and psychosocial outcomes of this technique.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe NSM technique has the inherent benefit of improved cosmesis and retainment of the patient\u0026rsquo;s own nipple areolar complex. Many surgeons bolster the mastectomy flap at both the upper and lower pole with ADM for increased flap thickness. However, the cost of ADM coupled with the historical complication rate of up to 35% in patients who receive reconstruction with full-coverage ADM warrants reconsideration. Our study demonstrates that utilizing partial ADM coverage in the setting of NSM offers comparable, if not lower, complication rates with the additional benefit of significantly reduced surgical costs.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMR collected and analyzed data.EV, AD, and MR wrote the main manuscript text and tables. 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Plast Reconstr Surg. ;125(2):429\u0026ndash;436. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PRS.0b013e3181c82d90\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0b013e3181c82d90\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 20124828\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JYS, Davila AA, Persing S, Connor CM, Jovanovic B, Khan SA, Fine N, Rawlani V (2012) A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. ;129(1):28\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PRS.0b013e3182361fd6\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0b013e3182361fd6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 22186498\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee KT, Mun GH (2016) Updated Evidence of Acellular Dermal Matrix Use for Implant-Based Breast Reconstruction: A Meta-analysis. Ann Surg Oncol 23(2):600\u0026ndash;610. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1245/s10434-015-4873-9\u003c/span\u003e\u003cspan address=\"10.1245/s10434-015-4873-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2015 Oct 5. PMID: 26438439\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheflan M, Allweis TM, Ben Yehuda D, Maisel Lotan A (2020) Meshed Acellular Dermal Matrix in Immediate Prepectoral Implant-based Breast Reconstruction. Plast Reconstr Surg Glob Open 8(11):e3265. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/GOX.0000000000003265\u003c/span\u003e\u003cspan address=\"10.1097/GOX.0000000000003265\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 33299724; PMCID: PMC7722619\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowers JM, Reuter Mu\u0026ntilde;oz KD, Parkerson J, Nigro LC, Blanchet NP (2021) From Salvage to Prevention: A Single-Surgeon Experience with Acellular Dermal Matrix and Infection in Prepectoral Breast Reconstruction. Plast Reconstr Surg. ;148(6):1201\u0026ndash;1208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PRS.0000000000008519\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0000000000008519\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 34644266\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNahabedian MY (2018) Current Approaches to Prepectoral Breast Reconstruction. Plast Reconstr Surg. ;142(4):871\u0026ndash;880. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PRS.0000000000004802\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0000000000004802\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30252807\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerna G, Cawthorn SJ, Papaccio G, Balestrieri N (2017) Evaluation of a novel breast reconstruction technique using the Braxon\u003csup\u003e\u0026reg;\u003c/sup\u003e acellular dermal matrix: a new muscle-sparing breast reconstruction. ANZ J Surg 87(6):493\u0026ndash;498. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/ans.12849\u003c/span\u003e\u003cspan address=\"10.1111/ans.12849\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2014 Sep 29. PMID: 25266930\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKobraei EM, Cauley R, Gadd M, Austen WG Jr, Liao EC (2016) Avoiding Breast Animation Deformity with Pectoralis-Sparing Subcutaneous Direct-to-Implant Breast Reconstruction. Plast Reconstr Surg Glob Open 4(5):e708. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/GOX.0000000000000681\u003c/span\u003e\u003cspan address=\"10.1097/GOX.0000000000000681\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 27579232; PMCID: PMC4995704\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReitsamer R, Peintinger F (2015) Prepectoral implant placement and complete coverage with porcine acellular dermal matrix: a new technique for direct-to-implant breast reconstruction after nipple-sparing mastectomy. J Plast Reconstr Aesthet Surg 68(2):162\u0026ndash;167. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bjps.2014.10.012\u003c/span\u003e\u003cspan address=\"10.1016/j.bjps.2014.10.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2014 Oct 16. PMID: 25455288\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWoo A, Harless C, Jacobson SR (2017) Revisiting an Old Place: Single-Surgeon Experience on Post-Mastectomy Subcutaneous Implant-Based Breast Reconstruction. Breast J 23(5):545\u0026ndash;553. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/tbj.12790\u003c/span\u003e\u003cspan address=\"10.1111/tbj.12790\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2017 Mar 13. PMID: 28295975\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMomeni A, Remington AC, Wan DC, Nguyen D, Gurtner GC (2019) A Matched-Pair Analysis of Prepectoral with Subpectoral Breast Reconstruction: Is There a Difference in Postoperative Complication Rate? Plast Reconstr Surg. ;144(4):801\u0026ndash;807. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PRS.0000000000006008\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0000000000006008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 31568276\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrey JD, Salibian AA, Choi M, Karp NS (2017) Mastectomy Flap Thickness and Complications in Nipple-Sparing Mastectomy: Objective Evaluation using Magnetic Resonance Imaging. Plast Reconstr Surg Glob Open 5(8):e1439 Published 2017 Aug 8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/GOX.0000000000001439\u003c/span\u003e\u003cspan address=\"10.1097/GOX.0000000000001439\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalstrup J, Balslev Willert C, Brinch-M\u0026oslash;ller Weitemeyer M, Hougaard Chakera A, H\u0026ouml;lmich LR (2021) Immediate direct-to-implant breast reconstruction with acellular dermal matrix: Evaluation of complications and safety. Breast 60:192\u0026ndash;198. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.breast.2021.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.breast.2021.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu J, Hou J, Li Z, Wang B, Sun J (2020) Efficacy of Acellular Dermal Matrix in Capsular Contracture of Implant-Based Breast Reconstruction: A Single-Arm Meta-analysis. Aesthetic Plast Surg 44(3):735\u0026ndash;742. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00266-019-01603-2\u003c/span\u003e\u003cspan address=\"10.1007/s00266-019-01603-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2020 Jan 9. PMID: 31919627\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowns RK, Hedges K (2016) An Alternative Technique for Immediate Direct-to-Implant Breast Reconstruction-A Case Series. Plast Reconstr Surg Glob Open 4(7):e821 Published 2016 Jul 22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/GOX.0000000000000839\u003c/span\u003e\u003cspan address=\"10.1097/GOX.0000000000000839\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVidya R, Iqbal FM, Becker H, Zhadan O (2019) Rippling Associated with Pre-Pectoral Implant Based Breast Reconstruction: A New Grading System. World J Plast Surg 8(3):311\u0026ndash;315. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.29252/wjps.8.3.311\u003c/span\u003e\u003cspan address=\"10.29252/wjps.8.3.311\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHon HH, Mubang RN, Wernick BD et al (2017) Acellular Dermal Matrix Versus Inferior Deepithelialized Flap Breast Reconstruction: Equivalent Outcomes, with Increased Cost. Plast Reconstr Surg Glob Open 5(6):e1382 Published 2017 Jun 28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/GOX.0000000000001382\u003c/span\u003e\u003cspan address=\"10.1097/GOX.0000000000001382\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorstenson T, Boughey JC, Saint-Cyr M (2013) Inferior dermal flap in immediate breast reconstruction. Ann Surg Oncol 20(10):3349. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1245/s10434-013-3109-0\u003c/span\u003e\u003cspan address=\"10.1245/s10434-013-3109-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2013 Aug 22. PMID: 23975284\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBank J, Phillips NA, Park JE, Song DH (2013) Economic analysis and review of the literature on implant-based breast reconstruction with and without the use of the acellular dermal matrix. Aesthetic Plast Surg. ;37(6):1194\u0026thinsp;\u0026ndash;\u0026thinsp;201. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00266-013-0213-2\u003c/span\u003e\u003cspan address=\"10.1007/s00266-013-0213-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2013 Oct 3. PMID: 24091489\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi YS, You HJ, Lee TY, Kim DW (2023) Comparing Complications of Biologic and Synthetic Mesh in Breast Reconstruction: A Systematic Review and Network Meta-Analysis. Arch Plast Surg 50(1):3\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/a-1964-8181\u003c/span\u003e\u003cspan address=\"10.1055/a-1964-8181\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 36755646; PMCID: PMC9902089\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"},{"header":"Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTable\u0026nbsp;1. Patient Demographics\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDemographic\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e% or \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;SD\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatients\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e98\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAverage Age (Years)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e47.41\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;11.13\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEthnicity\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eAsian\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.06%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eBlack\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.06%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eOther, Hispanic/Latino\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.02%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eOther, Non-Hispanic\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.00%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003ePacific Islander, Non-Hispanic\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.00%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eWhite\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e91\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e92.86%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMean BMI\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e25.67\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.58\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eObese (BMI\u0026thinsp;\u0026gt;\u0026thinsp;30)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e18\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e18.37%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDiabetes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.02%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHypertension\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e14.29%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDyslipidemia\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7.14%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCoronary Artery Disease (CAD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.02%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSmoking History\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e36\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e36.73%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e62\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e63.27%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHistory of Chest Wall Radiation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e8.20%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eChemotherapy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e16\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e16.33%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNeoadjuvant Chemotherapy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e13.27%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBreasts Receiving PMRT\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e5.46%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHistory of Breast Surgery\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e34\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e18.58%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFinal Follow-Up Time (in days)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e337.63\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e138.00\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e\u003cp\u003e*Abbreviations: BMI \u0026ndash; body-mass index, XRT \u0026ndash; chest wall radiation history, PMRT \u0026ndash; Post mastectomy radiation therapy (by breast, rather than by patient)\u003c/p\u003e\u003cbr/\u003e \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Perioperative Information\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e% or \u003cu\u003e+\u003c/u\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eBreasts Reconstructed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eIndication for Mastectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;Breast cancer\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e46.99%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eProphylactic\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e53.01%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMastectomy Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eNipple-Sparing\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMean Mass of Resected Specimen (in grams)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e352.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cu\u003e+\u003c/u\u003e185.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTissue Expander Plane\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003ePrepectoral\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMean TE Size (in mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e422.84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cu\u003e+\u003c/u\u003e91.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMean TE Fill (in mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e385.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cu\u003e+\u003c/u\u003e110.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eReconstruction Laterality\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eUnilateral\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e14.29%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eBilateral\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e85.71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAxillary Lymph Node Dissection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6.56%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e93.44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eADM Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100.00%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMean Implant Size (in CC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e572.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cu\u003e+\u003c/u\u003e153.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"83.33333333333333%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Stage 1 Postoperative Outcomes (by breast)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.666666666666668%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eAny complication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e12.57%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eInfection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e5.46%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eMajor Infection\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cem\u003eMinor Infection\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.64%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eWashout + Salvage (Tissue Expander)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.73%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eWashout + Tissue Expander removal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eDehiscence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.28%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eSeroma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e4.92%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eHematoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.64%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"66.99801192842942%\" valign=\"bottom\"\u003e\n \u003cp\u003eMalposition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.302186878727635%\" valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"16.69980119284294%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.09%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTable\u0026nbsp;4. Stage 2 Postoperative Outcomes (by breast)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eComplication\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eN\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e%\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAny complication\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7.10%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eInfection\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.83%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eMajor Infection\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.19%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eMinor Infection\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.64%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWashout\u0026thinsp;+\u0026thinsp;Salvage (Implant)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.55%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWashout\u0026thinsp;+\u0026thinsp;Implant removal\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.64%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDehiscence\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4.92%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSeroma\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.00%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHematoma\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.00%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMalposition\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0.00%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCapsular Contracture\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.19%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eRevision\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e38\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e20.99%\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\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":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4797552/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4797552/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePURPOSE\u003c/h2\u003e \u003cp\u003eThe nipple-sparing mastectomy (NSM) offers a reconstruction option to patients who wish for a more subtle scar pattern and to retain their native nipple-areolar complex. Traditionally used acellular dermal matrix (ADM) has been linked to potential complications including seroma, hematoma, and infection, as well as increased operative costs. Our study examines whether using partial ADM to cover the lower pole of the breast implant during NSM prepectoral reconstruction offers comparable, or even better, rates of postoperative complications while minimizing operative costs.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003e A retrospective chart review of patients who underwent prepectoral nipple-sparing implant-based reconstruction (IBR) using partial ADM (June 2019 \u0026ndash; October 2020) was performed. Demographic, perioperative, and post-operative complication information was collected and described using means, standard deviations, and frequencies.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eNinety-eight patients (183 breasts) met inclusion criteria, with smoking history (36.73%), prior breast surgery (18.58%), and obesity (18.37%) cited as the most common comorbidities. 12.57% of patients experienced a complication following stage one of reconstruction, with infection as the most common complication (5.46%). Complication rate following stage two was 7.10%, with dehiscence cited as the most common complication (4.92%).\u003c/p\u003e\u003ch2\u003eCONCLUSION\u003c/h2\u003e \u003cp\u003eThe average cost of ADM for breast reconstruction is upwards of \u003cspan\u003e$\u003c/span\u003e5,000. While our institution does not utilize full ADM coverage in NSMs, historical trends in the literature demonstrate overall complication rates of 5.9% to as high as 35%. Our study demonstrates that utilizing partial ADM coverage in the setting of NSM offers comparable, if not lower, complication rates at a fraction of the cost.\u003c/p\u003e","manuscriptTitle":"Use of Partial Acellular Dermal Matrix in Prepectoral Nipple-Sparing Mastectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-22 16:21:14","doi":"10.21203/rs.3.rs-4797552/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-28T13:12:41+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-15T17:18:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120976785063051966402310609845027902514","date":"2024-11-07T11:42:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-30T10:24:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-26T10:12:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-26T10:10:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Plastic Surgery","date":"2024-07-24T19:33:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"fb14aefd-2537-496b-8586-024e54fc28ad","owner":[],"postedDate":"August 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-24T16:24:13+00:00","versionOfRecord":{"articleIdentity":"rs-4797552","link":"https://doi.org/10.1007/s00238-025-02285-7","journal":{"identity":"european-journal-of-plastic-surgery","isVorOnly":false,"title":"European Journal of Plastic Surgery"},"publishedOn":"2025-02-17 15:57:23","publishedOnDateReadable":"February 17th, 2025"},"versionCreatedAt":"2024-08-22 16:21:14","video":"","vorDoi":"10.1007/s00238-025-02285-7","vorDoiUrl":"https://doi.org/10.1007/s00238-025-02285-7","workflowStages":[]},"version":"v1","identity":"rs-4797552","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4797552","identity":"rs-4797552","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}