A retrospective review of submuscular implant-based breast reconstruction: The influence of dermal matrix (ADM) on complications and aesthetic outcomes

Published:August 23, 2022DOI:



      The use of acellular dermal matrix changed the breast reconstruction algorithm facilitating implant coverage and direct to implant technique. This study aims to evaluate the effect of the ADM surgical complications, breast aesthetics, and patient satisfaction.


      In a tertiary hospital, patients that underwent implant-based breast reconstructions during a three-year period had their charts retrospectively reviewed, received post-operative BreastQ, and had their post-operative photos evaluated by a three-member panel using a multi-parameter breast specific scale (scored 1–5). The complication information was analysed per reconstructed breast while the analysis of aesthetic and patient-reported outcomes was done per patient.


      A total of 501 patients (990 breasts) were evaluated. In the complication analysis group, 20.3% of the breasts had ADM. Overall complications and major complications were more frequent in the ADM group. During the first 30 postoperative days the most frequent complications were: skin necrosis/delayed wound healing and haematoma, after 30 days was infection, and complications after 1 year being less than 1%.
      On the outcome analysis group, ADM was used in 21.5% patients, 44% had post-operative photos, and 29% answered the BreastQ. Factors associated with higher appearance score were bilateral reconstruction, prophylactic surgery, and nipple presence. ADM demonstrated no difference in satisfaction with breasts.


      In implant-based breast reconstructions ADM has been shown to increase rate of complications. The use of acellular dermal matrix did not influence the overall appearance or the patient-reported outcome. A good aesthetic outcome is positively influenced by bilateral reconstructions with preservation of the nipple.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        U.S. Breast Cancer Statistics |
        2019 ([online] Available at) ([Accessed 12 May 2019])
        • American Society of Plastic Surgeons
        Plastic surgery statistics report.
        Am Soc Plast Surg Arlingt Height. 2018;
        • Losken A.
        • Carlson G.W.
        • Bostwick III, J.
        • Jones G.E.
        • Culbertson J.H.
        • Schoemann M.
        Trends in unilateral breast reconstruction and management of the contralateral breast: the Emory experience.
        Plast Reconstr Surg. 2002; 110: 89-97
        • Jeevan R.
        • Cromwell D.
        • Browne J.
        • et al.
        The national mastectomy and breast reconstruction audit. A national audit of provision and outcomes of mastectomy and breast reconstruction surgery for women in England.
        Second Annu Rep. 2009;
        • Salzberg C.
        • Andrew M.D.
        Nonexpansive immediate breast reconstruction using human acellular tissue matrix graft (AlloDerm).
        Ann Plast Surg. 2006; 57: 1-5
        Plastic Surgery Statistics Report. [online].
        2018 (Available at:) ([Accessed 30 May 2019])
        • Rawlani V.
        • Buck 2nd, D.W.
        • Johnson S.A.
        • Heyer K.S.
        • Kim J.Y
        Tissue expander breast reconstruction using prehydrated human acellular dermis.
        Ann Plast Surg. 2012; 129 (Jan): 28-41
        • Chun Y.S.
        • Verma K.
        • Rosen H.
        • Lipsitz S.
        • Morris D.
        • Kenney P.
        Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications.
        Plast Reconstr Surg. 2010; 125 (Feb): 429-436
        • Losken A.
        Early results using sterilized acellular human dermis (neoform) in post-mastectomy tissue expander breast reconstruction.
        Plast Reconstr Surg. 2009; 23 (Mar)
        • Antony A.K.
        • McCarthy C.M.
        • Cordeiro P.G.
        • Mehrara B.J.
        • Pusic A.L.
        • Teo E.H.
        • et al.
        Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications.
        Plast Reconstr Surg. 2010; 125 (Jun): 1606-1614
        • Ho G.
        • Nguyen T.J.
        • Shahabi A.
        • Hwang B.H.
        • Chan L.S.
        • Wong A.K.
        A systemic review and meta-analysis of complications associated with acellular dermal matrix- associated breast reconstruction.
        Ann Plast Surg. 2012; 68: 346-356
        • Cuomo R.
        Submuscular and pre-pectorial ADM assistend immediate breast reconstruction: a literature review.
        Medicina. 2020; 56: 256
        • Duraes E.F.R.
        • Schwarz G.S.
        • Sousa J.B.
        • Duraes L.C.
        • Morisada M.
        • Baker T.
        • Djohan R.
        • Bernard S.
        • Moreira A.A
        Factors influencing the aesthetic outcome and quality of life after breast reconstruction – a cross-sectional study.
        Ann Plast Surg. 2020; ([Epub ahead of print])
        • Zhao X.
        • Wu X.
        • Dong J.
        • et al.
        Aesth Plast Surg. 2015; 39: 892
        • Duraes E.F.R.
        • Durand P.
        • Morisada M.
        • Scomacao I.
        • Duraes L.C.
        • de Sousa J.B.
        • Abedi N.
        • Djohan R.S.
        • Bernard S.
        • Moreira A.
        • Schwarz G.S.
        A Novel Validated Breast Aesthetic Scale.
        Plast Reconstr Surg. 2022; 149 (Epub 2022 Mar 29. PMID: 35349538): 1297-1308
        • Sbitany H.
        • Sandeen S.N.
        • Amalfi A.N.
        • Davenport M.S.
        • Langstein H.N.
        Acellular dermis-assisted prosthetic breast reconstruction versus complete submuscular coverage: a head-to-head comparison of outcomes.
        Plast Reconstr Surg. 2009; 124: 1735-1740
        • Lanier S.T.
        • Wang E.D.
        • Chen J.J.
        • Arora B.P.
        • Katz S.M.
        • Gelfand M.A.
        • et al.
        The effect of acellular dermal matrix use on complication rates in tissue expander/implant breast reconstruction.
        Ann Plast Surg. 2010; 64: 674-678
        • Lohmander F.
        • Lagergren J.
        • Roy P.G.
        • et al.
        Implant based breast reconstruction with acellular dermal matrix.
        Ann. Surg. 2019; 296: 836-841
        • Forsber C.G.
        • Kelly D.A.
        • Wood B.C.
        • et al.
        Aesthetic outcomes of acellular dermal matrix in tissue expander/implant-based breast reconstruction.
        Ann Plast Surg. 2013; 72: 0-4
        • Negenborn V.L.
        • Dikmans R.E.G.
        • Bouman M.B.
        • Wilschut J.A.
        • Mullender M.G.
        • Salzberg C.A.
        Patient-reported outcomes after ADM-assisted implant-based breast reconstruction: a cross-sectional study.
        Plast Reconstr Surg Glob Open. 2018; 6 (Published 2018 Feb 8): e1654