Acellular dermal matrix (ADM) has been increasingly accepted as a useful tool in primary prosthetic breast reconstruction (1,2,3,4,5,6,7,8,9,10,11,12). Observed benefits include better control of implant position, better implant support and coverage, and the suggestion of a decreased frequency of capsular contracture (1,2,3,4,5,6,8,9,10,11,13,14,15). In a series of 11 mastectomy patients with poor pectoralis major muscle coverage, Gamboa-Bobadilla placed human acellular dermis matrix (HADM) alongside 13 breast prostheses and found that 92% of patients had a successful reconstruction and 73% had an “excellent” aesthetic outcome (2). Salzberg performed single-stage immediate implant-based reconstruction of 76 breasts in 49 patients using HADM and reported a 0% contracture rate and a 0% “serious” complication rate over a 52-month follow-up period (3). Zienowicz and Karacaoglu observed a 0% rate of contracture, rippling, synmastia, or bottoming out in a study of 30 immediate implant-breast reconstructions with HADM over an 18-month mean folow-up time (6). In a study of 44 primary prosthetic breast reconstructions with HADM, Breuing and Colwell identified a 0% contracture rate, 2.3% extrusion rate, and 4.5% infection rate over a 6-month to 3-year surveillance period (5).

In addition to the growing literature on the applications of ADM for primary prosthetic breast reconstruction, a handful of studies have explored the use of ADM in the treatment of breast implant–associated deformities (5,16,17,18). Following prosthetic breast surgery, capsular attenuation may develop and manifest as implant malposition or rippling, while capsular contracture may occur in a subset of patients and present as implant firmness or distortion. Duncan described the use of HADM in the correction of 34 patients with implant rippling and observed an improvement in palpable rippling, an average patient satisfaction rate of 85%, a 2.9% rate of capsular contracture, and a 2.9% rate of infection (16). In a case series of 10 patients with breast implant–related problems, including rippling, bottoming out, synmastia, and contracture, Baxter found that 80% of revisions were stable with the use of HADM (17). Finally, Breuing and Colwell reported a 0% recurrence of contracture in 23 breasts treated with capsulectomy and HADM for implant-related contracture (5).

Given the low frequency of complications in cases of primary prosthetic breast reconstruction with ADM (1,2,3,4,5,6,9,10,11), as well as the encouraging preliminary data on the use of ADM in select cases of secondary prosthetic breast surgery (5,16,17,18), we believe that ADM may be a useful adjunct in the treatment and prevention of some implant-associated deformities. This is especially significant because many of these problems have proven extraordinarily difficult to consistently correct in the past (19,20,21,22,23,24,25,26,27). In secondary prosthetic breast surgery, it is hypothesized that ADM may do one or more of the following: offload tension on a capsulorrhaphy suture line to help restore the normal breast boundaries, recreate the implant space to better match an implant’s dimensions, interrupt scar formation, and reinforce and essentially thicken thin skin flaps. These properties make ADM a useful adjunct in the correction of recurrent implant malposition, rippling, capsular contracture, and skin flap deficiency, respectively. Furthermore, in primary aesthetic breast implant surgery in the massive-weight-loss population, one could hypothesize that ADM might define the natural breast shape and landmarks by providing inferior pole support. These properties may help prevent loss of inframammary fold definition and implant bottoming out in postbariatric surgery patients.