10
Immediate Two-Stage Implant-Based
Breast Reconstruction With
Acellular Dermal Matrix
PING SONG AND LEE L.Q. PU
Introduction
There continues to be a steady annual growth in breast
reconstruction within the United States, with over 100 000
procedures performed in 2016 and a 39% increase in recon-
structive breast procedures since the year 2000.1,2
Immediate two-stage prosthetic breast reconstruction is
well accepted in breast cancer reconstruction due to its
impact on post-mastectomy body image and quality of life,
as well as its safety and high patient satisfaction.3–5 Fur-
thermore, in 2010, a national survey found half of all US-
based plastic surgeons who perform implant-based breast
reconstruction use acellular dermal matrix (ADM).6 As
prosthetic breast reconstructions continue to increase, all
plastic surgeons should be well versed in delivering a safe,
consistent, and aesthetically pleasing result in this kind of
reconstruction.
In the following chapter, the authors will focus on tissue
expander–based immediate breast reconstruction with acel-
lular dermal matrix as a first-stage implant-based breast
reconstruction. Emphasis will be placed on surgical tech-
nique, as well as highlighting key concepts and pearls in
tissue expander/ADM-based reconstruction.
Indications and Contraindications
Treatment planning for post-mastectomy breast reconstruc-
tion depends on several issues. Key indications for imme-
diate breast reconstruction include the patient’s oncologic
disease burden as well as the need for adjuvant therapy.
Immediate two-stage implant-based reconstruction is
optimal in cases where adjuvant radiation therapy is not
Disclosure: The authors have no financial interest to declare in relation
to the drugs, devices, and products mentioned in this article.
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required. Ideal candidates include relatively thin patients
and patients requiring bilateral reconstruction (Fig. 10.1).
However, the success and outcome of immediate implant-
based reconstruction depends heavily on a reliable native
soft tissue envelope. This can be achieved through a col-
laborative effort between the surgical oncologist and recon-
structive surgeon. The two-stage approach also allows for
precise recreation of the breast mound in terms of Infra-
mammary fold (IMF) positioning, natural shape and final
symmetry and is more flexible than one-stage implant-based
reconstruction with fewer complications.
One absolute contraindication is ischemic or damaged
mastectomy skin flaps. In this case a delayed reconstruction
may be in the patient’s best interest. Other contraindica-
tions include poor quality of the pectoralis major muscle,
obesity, and tobacco use.
Benefits of ADM
Acellular dermal matrices have become ubiquitous in breast
reconstruction. The benefits of ADM include improved
inframammary fold control, better support and control of
the pocket, greater intraoperative expansion with fewer sub-
sequent clinic visits, and decreased risk of capsular contrac-
ture.7 There is also evidence to suggest a clinical benefit for
patients who undergo subsequent radiation therapy,8 but
the literature remains inconclusive and will benefit from
further studies.
Additionally, by utilizing ADM as a tissue supplement
over the inferior pole, further muscle dissection is spared,
which leads to less postoperative pain, and a more anatomi-
cally precise pocket can be defined (Fig. 10.2). The higher-
intra operative fill volume also addresses the retained skin
in skin-sparing mastectomies. These benefits ultimately
result in increased control by the surgeon over the recon-
struction as well as final aesthetic outcome for the patient.9
117
118 C HA P T E R 1 0 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix

Pectoralis
major

• Fig. 10.1 A typical good candidate for immediate breast reconstruc-

tion. In general, patients should be healthy and not obese with moder-
ate breast size and good breast skin condition.
Acellular dermal
Serratus matrix (ADM)
anterior
Preoperative Evaluation and External
A
Special Considerations oblique

During the preoperative visit, the overall quality of breast

skin in each patient should be evaluated carefully. In addi-
tion, the presence of breast ptosis should also be evaluated.
One important discussion to highlight in the preoperative Pectoralis minor
setting with the surgical oncologist is mastectomy flap
thickness. It is imperative to adhere to good oncologic prin- Pectoralis major
ciples during the ablation. However, it must be emphasized
that immediate prosthesis-based reconstruction relies on Tissue Expander
healthy and viable tissue flaps, which are to be respected in
order to optimize the reconstructive outcome.
Skin-sparing or nipple-sparing mastectomy can usually
be decided by the breast surgeon. The patient should be
informed of the possibility of delayed reconstruction if the
plastic surgeon deems the flaps are compromised. Addi-
tional considerations involve the impact of possible adju-
vant chemotherapy and radiation therapy.

Surgical Techniques
Acellular dermal
Relevant Surgical Anatomy matrix (ADM)

The mastectomy defect can vary with the approach to B

the soft tissue envelope. The most important consid-
eration is the viability of the remaining skin flaps (Fig.
10.3). As the skin relies on the dermal and subdermal
plexus for its perfusion, any injury during the mastectomy
from improper tissue handling or thermal cautery injury
can lead to subsequent delayed wound healing or even
reconstructive failure.
Once the breast parenchyma is removed, the pectoralis
major muscle must be dissected free from its underlying
attachments. This fan-shaped muscle has origins from the
medial half of the clavicle, the sternum, the costal cartilage
from the first to sixth ribs, and from the aponeurosis of the
• Fig. 10.2 Schematic diagrams (A and B) showing the placement
of ADM and created pectoral/ADM pocket in immediate breast
reconstruction.
external oblique muscles. The fibers form two heads that
course towards the insertion into the bicipital groove of the
humerus. It is innervated by the lateral and medial pecto-
ralis nerves and the blood supply is from the pectoral branch
of the thoracoacromial artery. Deep to the pectoralis major
muscle is its vascular pedicle, the pectoralis minor muscle
and the chest wall and fibers from the external oblique. Care
must be taken with dissection underneath the pectoralis

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 CHAPTER 10 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix 119

• Fig. 10.3 A typical good example of the mastectomy skin flap after • Fig. 10.5 Intraoperative view showing the appearance after skin-
immediate skin-sparing mastectomy. sparing mastectomy. The mastectomy skin flap is not compromised.

• Fig. 10.4
A standard preoperative marking for a skin-sparing mas- • Fig. 10.6 Intraoperative view showing the quality of the mastectomy
tectomy patient. skin flap and pectoralis major muscle after skin-spared mastectomy.

major muscle to avoid injury to the above structures as well
as major perforators from the internal mammary arteries.
Finally, it is wise to avoid cautery dissection directly on top
of the ribs, as this will lead to increased postoperative pain.
Preoperative Markings
Prior to surgery, the patient is marked in the standing posi-
tion. The anatomic landmarks include the sternal notch,
midline, clavicle, inframammary fold, and anterior axillary
line. Specific attention must be paid to the inframammary
fold as the inferior border of the mastectomy. The infra-
mammary fold along with the medial, lateral and supe-
rior borders of the breast are marked. The skin-sparing
skin pattern is also marked (Fig. 10.4). Several options of
expanders and acellular dermal matrix sizes are available
but the final decision is made by the plastic surgeon intra-
operatively after the mastectomy is completed. This ensures
that each patient receives a reconstruction tailored to her
individual needs.
Intraoperative Markings
It is routine at our institution to begin reconstruction after
the mastectomy is complete. The entire chest and axilla are
re-prepped with betadine. It is always wise to inspect the
mastectomy flaps for signs of thermal injury or full-thickness
compromise (Fig. 10.5). Often this can be mitigated with
direct excision, but the decision to proceed must be made
at this juncture, as compromised skin flaps may compro-
mise the reconstruction entirely. Skin perfusion imaging
may serve as an adjunct to clinical exam in determining skin
flap viability. In addition, the quality of the pectoralis major
muscle should also be inspected (Fig. 10.6).
Next, the external breast border markings are transposed
inside on top of the chest wall to help to restore the implant
pocket. The two key areas are the inframammary fold and
anterior axillary line, as this will define the dermal matrix
sling and define the borders of the new breast. The trans-
posed markings will also serve to guide suture placement
for securing the ADM.

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120 C HA P T E R 1 0 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix
Details of the Procedure
Once the initial intraoperative markings are complete, the
lateral edge of the pectoralis major muscle is identified.
Using electrocautery, the dissection is started from the
lateral extent. After the plane is identified between pecto-
ralis major and the underlying chest wall, blunt finger dis-
section can be used to continue the dissection and elevate
the muscle. It is common to encounter several perforators
during the dissection, which should be cauterized.
Once the pectoralis major is sufficiently elevated (Fig.
10.7), the sizing of the ADM can be approximated.
The senior author uses rectangular ADM measuring
16 cm × 8 cm ultra-thick, and designs the matrix to lay
parallel to the fibers of the pectoralis muscle. The excess
corners of the dermal matrix are then cut to specification
based on the preoperative markings along the IMF and
lateral breast border (Fig. 10.8).
• Fig. 10.7
Intraoperative view showing the elevation of the pectoralis
major muscle and division of its lower attachment for creation of the
muscle/ADM pocket.
• Fig. 10.8 Intraoperative view showing the plan for ADM placement
as a sling for the lower and lateral poles of the muscle/ADM pocket.
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Next, the ADM, with the dermal side facing up, is
sutured in place using two 2-0 PDS sutures on a cutting
needle. The steps of suture placement are key in ensuring
precise pocket design, and are as follows. The first running
suture begins in the inferior medial aspect; here the ADM
is secured to Scarpa’s fascia to recreate the fold as well as to
the pectoralis muscle. The suture is run in a simple inter-
rupted fashion laterally as outlined by the transposed mark-
ings. The suture is then anchored in the superior lateral
aspect. A bite is taken from the ADM to the deep pectoralis
muscle fascia and to the substance of the serratus anterior
fascia. This three-part stitch helps to close the implant
pocket from the axilla. The second suture will be used in
the final step to close the pocket once the tissue expander
is in place. Continued running of the first suture is done to
recreate the lateral border of the pocket, ending where the
second suture is anchored.
The pectoralis and ADM pocket is then thoroughly irri-
gated with triple-antibiotic solution. Next, an appropriately
sized expander is prepared by removing the air, soaking in
triple antibiotic solution, then placing it within the pocket
with a no-touch technique (Fig. 10.9).
A medium high textured tissue expander is routinely
selected in the senior author’s practice for the first-stage
implant-based breast reconstruction. The expander is filled
usually to approximately 120 cc with methylene blue inject-
able saline solution. The second running 2-0 PDS suture is
then run down the ADM–pectoralis interface to close the
pocket. At this point, additional expander fill is performed
to obtain a snug fit within the pectoralis–ADM pocket
without compromising muscle perfusion or overlying skin
perfusion (Fig. 10.10). In general, the expander can be filled
to 50%–80% of its volume as long as mastectomy skin flap
perfusion is not compromised (Fig. 10.11).
Two drains are left under the breast skin but above the
pectoralis and ADM pocket on each side, which drain the
inferior and lateral aspects, respectively. The overlying skin
• Fig. 10.9 Intraoperative view showing the completion of the muscle/
ADM pocket and the placement of a tissue expander for immediate
breast reconstruction.
 CHAPTER 10 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix
• Fig. 10.10 Intraoperative view showing the closure of the muscle/
ADM pocket after the placement of a tissue expander with initial filling
for immediate breast reconstruction.
• Fig. 10.11 Intraoperative view showing the completion of the place-
ment of a tissue expander after additional filling for immediate breast
reconstruction.
incision is closed in two layers with 3-0 Monocryl and 4-0
Monocryl (Fig. 10.12). Dressings involve gauze fluffs and a
surgical bra to provide padding and gentle compression.
Special considerations for immediate breast reconstruction
are summarized in Box 10.1.
Postoperative Care and Expansion
All patients are discharged home with a soft surgical bra and
on oral antibiotic regimen. Drains are removed once output
decreases to less than 30 cc a day.
In the absence of delayed wound healing from ischemic
flap complications, we routinely begin expansion at three
weeks once the incision is healed. This allows for wound
healing as well as initial dermal matrix incorporation and
vascularization. Patients undergo, on average, 120 cc of fill
each clinic visit every three weeks until we reach 20%–25%
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121
• Fig. 10.12 Intraoperative view showing the completion of the place-
ment of a tissue expander for immediate breast reconstruction.
• BOX 10.1 Special Considerations for
Implant-Based Immediate
Breast Reconstruction
• Proper determination of viability for mastectomy skin flap
• Reconstruction of IMF within the breast skin pocket
• Restoration of the same breast pocket size after mastectomy
• Creation of the pectoral/ADM pocket that is large enough
and in proper position
• Adequate fill of a tissue expander as long as the breast skin
is not compromised
over-expansion. Patients can be ready for the second-stage
reconstruction involving permanent breast implant and
tissue expander exchange in 2–3 months after the first-stage
immediate breast reconstruction.
Second-Stage Reconstruction
The subsequent tissue expander to implant exchange occurs
2–3 months after the first stage. Through the initial incision,
but limiting the length, careful dissection is carried down
through the ADM–muscle layer. The expander is deflated
via puncture and aspiration with suction. After removal of
the expander, capsulotomy is usually needed medially or
superiorly for further adjustment of the pectoralis–ADM
pocket. Capsulorrhaphy can be performed using 2-0 PDS
suture to prevent implant from lateral migration. The
pocket is thoroughly irrigated with triple antibiotics and the
new permanent implant is placed via Keller funnel. A high-
profile smooth, round silicone implant is routinely selected
to replace the tissue expander in the senior author’s practice
for the second-stage implant-based breast reconstruction.
The incision is closed in three layers: the muscle–ADM is
closed with 3-0 Vicryl suture, and skin closed with 3-0 and
4-0 Monocryl sutures.
122 C HA P T E R 1 0 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix

Case Examples
CASE 10.1
A 45-year-old white woman with an early stage of right breast
cancer (Case 10.1.1) was offered bilateral skin-sparing
mastectomies and immediate breast reconstructions with
tissue expander (Case 10.1.2). After the mastectomy, she
underwent a tissue expander placement within the pectoral
muscle/ADM pocket for each side. Her tissue expander
(450 cc) was filled to 300 cc initially. Her tissue expander was
fully expanded within 2 months postoperatively and she
underwent the second-stage reconstruction with tissue
expander/implant exchange and medial capsulotomy (Case
10.1.3). After successful placement of a permanent silicone
breast implant (550 cc) (Case 10.1.4), she had nipple–areola
complex reconstruction on both sides. Her entire postoperative
course was uneventful. Results are shown 17 months (Case
10.1.5) and 58 months (Case 10.1.6) after initial breast
reconstruction.

• Case 10.1.1 • Case 10.1.4

• Case 10.1.2 • Case 10.1.5

• Case 10.1.3 • Case 10.1.6

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 CHAPTER 10 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix 123

CASE 10.2
A 39-year-old woman with an early stage of left breast cancer
(Case 10.2.1) was offered bilateral skin-sparing mastectomies
and immediate breast reconstructions with tissue expander
(Case 10.2.2). After the mastectomy, she underwent a tissue
expander placement within the pectoral muscle/ADM pocket
for each side. Her tissue expander (300 cc) was filled to
180 cc initially. Her tissue expander was fully expanded within
3 months postoperatively and she underwent the second-
stage reconstruction with tissue expander/implant exchange,
medial and superior capsulotomy, and lateral caspsulorrhaphy
(Case 10.2.3). After a successful placement of a permanent
silicone breast implant (375 cc) (Case 10.2.4), she had
nipple–areola complex reconstruction on both sides. Her entire
postoperative course was uneventful. Results are shown 10
weeks after nipple reconstruction and 10 months after initial
breast reconstruction (Case 10.2.5), and 10 months after
nipple reconstruction and 16 months after initial breast
reconstruction (Case 10.2.6).

• Case 10.2.1 • Case 10.2.4

• Case 10.2.2 • Case 10.2.5

• Case 10.2.3 • Case 10.2.6

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124 C HA P T E R 1 0 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix

CASE 10.3
A 48-year-old white woman with an early stage of left breast
cancer (Case 10.3.1) was offered bilateral nipple-sparing
mastectomies and immediate breast reconstructions with
tissue expander (Case 10.3.2). After the mastectomy through
an inframammary approach, she underwent a tissue expander
placement within the pectoral muscle/ADM pocket for each
side. Her tissue expander (550 cc) was filled to 450 cc initially.
Her tissue expander was fully expanded within 2 months
postoperatively and she underwent the second-stage
reconstruction with tissue expander/implant exchange and
medial capsulotomy (Case 10.3.3). After successful placement
of a permanent silicone breast implant (600 cc), she underwent
two autologous fat-grafting procedures to improve the contour
over her upper left reconstructed breast. Her entire
postoperative course was uneventful. Results are shown 5
months after the first fat grafting and 12 months after initial
reconstruction (Case 10.3.4), and 2 months after the second
fat grafting and 17 months after initial breast reconstruction
(Case 10.3.5). Case 10.3.6 shows the result 24 months after
initial breast reconstruction (Case 10.3.6).

• Case 10.3.1 • Case 10.3.4

• Case 10.3.2 • Case 10.3.5

• Case 10.3.3 • Case 10.3.6

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 CHAPTER 10 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix 125

CASE 10.4
A 43-year-old white woman with an early stage of left breast
cancer (Case 10.4.1) was offered bilateral skin-sparing
mastectomies and immediate breast reconstructions with
tissue expanders (Case 10.4.2). After the mastectomy, she
underwent a tissue expander placement within the pectoral
muscle/ADM pocket for each side. Her tissue expander
(650 cc) was filled to 480 cc initially. Her tissue expander was
fully expanded within 2 months postoperatively (Case 10.4.3)
and she underwent the second-stage reconstruction with
tissue expander/implant exchange and medial and superior
capsulotomy. After a successful placement of a permanent
silicone breast implant (700 cc), she had her first fat grafting
procedure to improve her upper breast contour on both sides
and the result is shown at 17 months after the first fat grafting
(Case 10.4.4). She then underwent nipple–areolar complex
reconstruction on both sides and additional fat grafting to
improve her upper breast contour (Case 10.4.5). Her entire
postoperative course was uneventful. Results are shown 5
months after the second fat grafting and 60 months after initial
breast reconstruction (Case 10.4.6).

• Case 10.4.1 • Case 10.4.4

• Case 10.4.2 • Case 10.4.5

• Case 10.4.3 • Case 10.4.6

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126 C HA P T E R 1 0 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix

Management of Complications
In the senior author’s experience, the majority of postopera-
tive complications involve compromised skin perfusion.
Partial skin flap necrosis and other threatened wound
healing issues are often due to aggressive thinning and
thermal trauma of mastectomy flaps and result in infection
or expander extrusion. If skin edge necrosis occurs (Fig.
10.13A), the tissue expander can be deflated further and the
necrotic portion of the skin can be excised (Fig. 10.13B)
and the open area can be closed (Fig. 10.13C).10
Another relatively common complication from immedi-
ate two-stage prosthetic breast reconstruction with acellular
dermal matrix is seroma, which can be treated with needle
aspiration. Infection is less common and is usually following A
skin flap necrosis or seroma. Treatment of infection includes
intravenous antibiotics or removal of the tissue expander.
In addition, red breast syndrome has been described in the
literature and its management includes observation or oral
antibiotics.11 It is important to note that the use of acellular
dermal matrices has been shown to increase certain compli-
cations (i.e., seroma). Evidence is inconclusive as to whether
ADM increases overall complication rates after breast recon-
struction,12,13 however with a judicious approach to flap
viability, intraoperative fill, and postoperative expansion, it
is our experience that many of these complications can be
effectively managed.

Secondary Procedures
B
After the second-stage implant-based breast reconstruction,
patients may present with several problems related to shape,
size, contour, even symmetry of their reconstructed breasts.
Implant malposition can be managed with reposition of
the “old” breast implant after adjustment of the pectoral/
ADM pocket and IMF position. A smaller size of recon-
structed breast can be improved by an implant exchange
with a larger size or different shape. Contour depression in
the upper pole of the reconstructed breast can be treated
with a series of fat grafting procedures. Excess skin or tissue
over or around the reconstructed breast can be treated with
direct excision or liposuction. Composite breast reconstruc-
tion can be performed with the same concept as composite
breast augmentation by adding fat to an implant-based
reconstructed breast so that the overall cosmetic result after
C
implant-based breast reconstruction can be significantly
improved in selected patients.14 • Fig. 10.13 Intraoperative view showing (A) the outline of the necrotic
mastectomy skin edges for possible excision, (B) the appearance
after excision of necrotic mastectomy skin edges, and (C) the re-
Conclusion approximation for closure of the wound after excision of necrotic
mastectomy skin edges.
Immediate two-stage implant-based breast reconstruction
is a technique that every plastic surgeon should master.
The advantages of incorporating acellular dermal matrix
have allowed for more precise and consistently better recon-
structive results. This chapter highlights the principles of a
two-stage immediate breast reconstruction and describes a
method for obtaining reliable and successful outcomes in
appropriately selected patients.

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 CHAPTER 10 Immediate Two-Stage Implant-Based Breast Reconstruction With Acellular Dermal Matrix
PEARLS FOR SUCCESS
• Appropriate patient selection for implant-based
reconstruction.
• Preoperative counseling regarding the postoperative
course, including expansion and any potential adjuvant
therapy.
• Attention to post-mastectomy skin flaps and the
importance of healthy flaps.
• Design the subpectoral/ADM breast pocket correctly
based on patient preoperative dimensions.
• Adequate intraoperative fill of the tissue expander should
allow for a “hand-in-glove” fit within the new breast
pocket and skin envelope.
• Tissue expander fill should be adjusted according to skin
flap viability; do not compromise flap perfusion for greater
expansion.
• In revision cases, common areas to address include
capsulotomy for inadequate medial pocket and
capsulorrhaphy for lateral pocket excess.
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