Late Breakers Break Thursday, September 26 Thu, Sep 26 4:00-5:00 p.m. PDT

Purpose: Implant malposition is one of the leading causes for revision surgery after prosthetic breast reconstruction. Many techniques have been described for the correction of malposition, including the use of biologic acellular dermal matrix (ADM) and synthetic mesh.(1) Although both biologic and synthetic mesh have been shown to be effective, very limited data has been published directly comparing them for the correction of implant malposition.(2) The goal of this study is to compare the rate of implant malposition failure between biologic and synthetic mesh capsulorraphy.

Methods: A retrospective review was performed for a series of implant-based breast reconstructions performed by a single surgeon between 2008 and 2023. Variables of interest included patient age, BMI, radiation history, implant size, biologic or synthetic mesh, and need for secondary capsulorraphy revision. Data was analyzed using RStudio and significance was set to p<0.05. Demographics and outcomes were compared and a multivariate regression assessed other risks for implant malposition.

Results: Fifty-seven breasts underwent capsulorraphy with either biologic (n=29) or synthetic mesh (n=28). Average age was 50.5 years (SD=11.3), average BMI was 27.3 (SD=6.7). Five (8.8%) breasts underwent post-mastectomy radiation. The average implant size was 530.1cc (SD=177.2) and twelve (21.1%) breasts had textured implants inserted. Average follow-up was 79.9 months (range 20 – 185, SD=40.3). Biologic mesh breasts had longer follow-up than synthetic mesh breasts (98.4 months versus 60.6 months, p<0.001). Patients with biologic mesh were also more likely to have a higher BMI (p=0.011) and have had chemotherapy (p=0.005). There were no significant differences in any other demographics between biologic and synthetic mesh breasts.

Twenty-one breasts (36.8%) required re-do capsulorraphy, 15 of which originally had biologic mesh and 6 of which originally had synthetic mesh. Average time to implant malposition failure was 21.7 months (range 8-74 months, SD=16.5). There was no significant difference in time to failure between biologic and synthetic mesh (19.1 months versus 28.0 months, p=0.411). This implant malposition failure was more common in biologic mesh repairs at 51.7% as compared to synthetic mesh repairs at 21.4% (p=0.028). Multivariate regression showed that biologic mesh as compared to synthetic mesh was a risk factor for malposition (OR 1.39, 95% CI 1.06-1.83, p=0.024). Larger implant volume was also a risk for malposition (OR 0.999, 95% CI 0.998-0.999, p=0.006).

Conclusion: Synthetic mesh provides superior outcomes as compared to biologic mesh for preventing implant malposition over time. Synthetic mesh has lower failure rates and lower need for secondary capsulorraphy revision. It also provided more long-term support, as it had an appreciably longer time to implant malposition failure than biologic mesh. Further investigation is still needed to compare the efficacy of different types of biologic and synthetic meshes.

References: 1. Spear SL, Sher SR, Al-Attar A, Pittman T. Applications of acellular dermal matrix in revision breast reconstruction surgery. Plast Reconstr Surg. 2014 Jan;133(1):1-10. doi: 10.1097/01.prs.0000436810.88659.36.

2. Choi YS, You HJ, Lee TY, Kim DW. Comparing complications of biologic and synthetic mesh in breast reconstruction: A systematic review and network meta-analysis. Arch Plast Surg. 2023 Feb;50(1):3-9. doi: 10.1055/a-1964-8181.

Background: Capsular contracture has been shown to occur in 15-30% of implant-based breast reconstruction patients and is one of the most common reasons for re-operation in this patient population.(1) Prior investigations have found that biologic mesh may result in a lower incidence of capsular contracture, and recent research has suggested that synthetic mesh may provide the same benefit.(2) The goal of this study is to assess our own reconstruction patient population to directly compare capsular contracture rates between biologic and synthetic mesh cohorts, as well as to assess for other potential risks that may increase the rate of capsular contracture in these patients.

Methods: A retrospective review was conducted of implant-based breast reconstructions performed by the senior author between 2008 and 2023 in a hospital setting. Patient demographics were assessed including age, BMI, implant size, radiation history, and use of either biologic or synthetic mesh. Incidences of post-operative capsular contracture were recorded. Patients who had documented capsular contracture prior to scaffold insertion were excluded from the study. Wilcoxon signed rank test, 2-sided t-test, and Fischer's Exact test were used to compare demographics and capsular contracture rates between the two groups. Statical analysis was performed in RStudio and significance was set at p<0.05.

Results: Fifty-two breasts had mesh inserted, of which 25 (48.1%) used biologic mesh and 27 (51.9%) used synthetic mesh. The average patient age was 50.6 years (SD=10.9), the average BMI was 27.7 (SD=6.7), the average implant size was 541.8 cc (SD=167.3), and eight breasts (15.4%) had been irradiated. Average follow-up was 85.4 months (range 22–149 months, SD=35.9). Breasts with biologic mesh did have a longer average follow-up than synthetic mesh breasts (99.2 months versus 72.6 months, p=0.006). There were no significant differences between the biologic and synthetic mesh groups for any demographic including age, BMI, hypertension, diabetes, history of tobacco use, radiation, chemotherapy, implant volume, or implant surface texture. Forty-four breasts (84.6%) were undergoing revision reconstruction, and eight breasts (15.4%) were undergoing primary reconstruction. Capsular contracture occurred in 2 biologic mesh breasts (8.0%) and 4 synthetic mesh breasts (14.8%) with no significant difference between the two groups (p=0.670). Five of these capsular contractures had documented Baker grades with three having grade II, one grade III, and one grade IV.

Conclusion: Biologic and synthetic mesh have shown increased utility in implant-based breast reconstruction surgery. Our study shows a lower incidence of capsular contracture with mesh as compared to historical controls without mesh. There was no significant difference in the rate of capsular contracture between biologic and synthetic mesh reconstructions, suggesting that they are similarly efficacious materials with respect to the incidence of capsular contracture.

References: 1. Cunningham B, McCue J. Safety and effectiveness of Mentor's MemoryGel implants at 6 years. Aesthetic Plast Surg. 2009 May;33(3):440-4. doi: 10.1007/s00266-009-9364-6.

2. Vardanian AJ, Clayton JL, Roostaeian J, et al. Comparison of implant-based immediate breast reconstruction with and without acellular dermal matrix. Plast Reconstr Surg. 2011 Nov;128(5):403e-10e. doi: 10.1097/PRS.0b013e31822b6637.