Chicago, Ill.From the Division of Plastic and Reconstructive Surgery, Department of Surgery, and the School of Medicine, University of Illinois at Chicago.
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Immediate two-stage breast reconstruction using a tissue expander and implant has evolved in sophistication to become the procedure of choice for many reconstructive surgeons treating postmastectomy patients. The modification of the immediate two-stage reconstruction using AlloDerm (Lifecell, Branchburg, N.J.) to create complete coverage of the tissue expander further enhanced this already reliable and effective approach. When used in this fashion, AlloDerm provides inferior pole coverage of a subpectorally placed tissue expander, allows higher initial fill volume, improves definition of inframammary fold, and results in less postoperative pain.1AlloDerm has also been used in nipple reconstruction to tackle the challenge of projection loss over time. Although experience on nipple reconstruction with AlloDerm is limited, preliminary results are encouraging.2,3The cost of AlloDerm can be prohibitive, especially when it is used in both breast and nipple reconstruction. For breast reconstruction, it costs $2100 to $3400 per breast, depending on the size selected. For nipple reconstruction, an additional $480 to $1500 is needed. Despite the Women's Health and Cancer Rights Act of 1998, U.S. health insurance companies do not provide consistent coverage for the cost of AlloDerm in breast reconstruction, and at the time of writing of this article, none covers the cost of AlloDerm in nipple reconstruction. We describe a novel cost-saving approach that obviates the cost of AlloDerm in nipple reconstruction when the AlloDerm has already been used in the breast reconstruction.TECHNIQUESAfter completion of mastectomy and creation of a subpectoral pocket, a 16 × 6-cm-thick piece of AlloDerm is tailored to provide proper contour of inframammary fold and lateral border of the breast (Fig. 1). The AlloDerm is secured to chest wall with interrupted 3-0 Vicryl. After introduction of an appropriately sized tissue expander, the remote port is brought into an inframammary location via a separate incision. The excess AlloDerm is implanted subcutaneously with the remote port. The procedure is completed by inflating the tissue expander to the maximal volume allowed by the subpectoral/skin pocket.At the time of exchange to a permanent implant, the excess AlloDerm “banked” at the remote port site is retrieved (Fig. 2). It is rolled lengthwise into cylindrical shapes and secured with 3-0 Vicryl (Fig. 3). No attempt is made to orient the AlloDerm with the dermal side or the basement membrane side out, as no difference in vascular ingrowth has been shown.4 Tissue expander removal and implant placement proceed in standard fashion. We use a modified C-V flap technique for nipple reconstruction. The fabricated AlloDerm cylinder is inserted into the core of the reconstructed nipple. Closure with 6-0 nylon completes the nipple reconstruction.PATIENTS AND METHODSA retrospective chart review was performed on 23 breast reconstructions (13 patients) that were performed by the senior author (R.K.) between July of 2008 to February of 2009. Of these, 19 nipple reconstructions (11 patients) were performed with retrieved AlloDerm (Table 1).The primary outcomes assessed were (1) whether the AlloDerm maintained structural integrity to allow easy retrieval, (2) whether the retrieved AlloDerm provided sufficient material for nipple reconstruction, and (3) complications. As secondary outcomes, we also assessed the initial fill volume, the time to exchange to implant, and patient satisfaction. Patient satisfaction was measured by survey (scale of 1 to 10) upon completion of reconstruction. Patients with a satisfaction score of 7 or higher were considered satisfied patients.