Techniques to Reduce Seroma and Infection in Acellular Dermis–Assisted Prosthetic Breast Reconstruction

Sir: It was with great interest that I read the report by Chun et al. on their series of acellular dermal matrix–assisted breast reconstruction.1 The versatility and utility of such techniques have now been well reported.2,3 Dr. Chun and colleagues have taken this one step further in reporting the largest series to date. In their review, they found significantly higher rates of both seroma and infection in the acellular dermis–assisted cohort than had been found in previous reports. Interestingly, this association held true even after adjusting for cases of native mastectomy flap necrosis. Similar to Dr. Chun's group, we perform a large volume of implant-based breast reconstructions in our institution, both with the aid of acellular dermis and without (full submuscular coverage). As such, we use somewhat of an intraoperative “checklist” during each reconstruction. This includes both steps taken to determine whether acellular dermis is appropriate for the given patient, and techniques used to minimize our rates of seroma and infection. Although there is no question that some degree of both seroma and infection are unavoidable, I do feel that such steps help to keep this to a minimum. In addition, although I have no doubt that Dr. Chun et al., with their vast experience, perform such steps routinely, I do feel that it would be beneficial to share these ideas with some of the readers who may be in the beginning stages of using such techniques. As in most procedures, patient selection is key to achieving good results. In most cases, obese patients and those with preoperative macromastia are deemed to be poor candidates for acellular dermis–assisted reconstruction. Even with aggressive flap trimming and large intraoperative implant fill volumes, those with redundant mastectomy flaps will present an increase in dead space over the acellular dermis, thus increasing seroma rates. Similarly, those patients with evidence of excessive vascular insult to the flaps following mastectomy, or extremely thin flaps with significant amounts of exposed dermis on the underside, are offered a fully submuscular reconstruction. These patients will often require aggressive mastectomy flap débridement and will likely not tolerate the excessive filling of the implant afforded by the acellular dermis. For those patients proceeding to acellular dermis–assisted breast reconstruction, maintaining unflappable sterile technique while handling the product is of utmost importance. The dermal matrix is handled by only one surgeon, after either changing or cleansing of the gloves. Furthermore, the product is taken from the saline bath where it is soaking, and placed directly in the wound. As such, it does not contact either the operative field or the patient's skin. This further reduces the potential for contamination. As Dr. Chun has alluded to, I agree that both vigilant antibiotic management and drain management are crucial. Our patients remain on antibiotics to cover Gram-positive skin flora for a 7-day period. In addition, two drains are crucial for each breast. When no portion of the implant pocket is left open, there is no question that a drain placed within the acellular dermis/pectoralis major pocket is of benefit. In addition, every effort should be made to allow the course of at least one drain to traverse the dissected portions of the axilla, as this area tends to drain moderate amounts in most cases. Finally, the acellular dermal matrix has a distinct polarity, and this must be identified intraoperatively. The “dermal side” can be identified by its smooth, shiny appearance. In addition, this side appears to absorb blood that it contacts. It is crucial that this side be placed up, such that it contacts the underside of the mastectomy flap, rather than the implant. This side has been shown to be more likely to revascularize, and is potentially more seromagenic, and is thus kept away from the implant. This is in contrast to the “basement membrane side,” which is dull and rough in appearance, and appears to repel blood that it contacts. This side is placed down, such that it contacts the implant. Although it goes without saying that prevention of all seroma and infection in any technique for breast reconstruction is not possible, it is my belief that following the steps described in this article will reduce such occurrences. Hani Sbitany, M.D. University of Rochester Rochester, N.Y.