The surgical treatment for breast cancer has evolved considerably since the era of Halsted’s radical mastectomy. For many women today, the innovation of the modified radical mastectomy has given way to breast conservation techniques utilizing oncoplastic principles. The ultimate manifestation of this advance can be seen in skin-sparing and nipple-sparing mastectomies. These innovations have now provided plastic surgeons with the opportunity to perform breast reconstruction with the advantage of an intact skin envelope.

Acellular dermal matrix (ADM) is a biotechnological tissue prepared from either human or porcine skin in which the cellular components that cause rejection and inflammation have been removed. The resulting structurally intact tissue matrix provides the biologic scaffold necessary for normal tissue in growth and cellular repopulation as well as the biochemical components needed to initiate angiogenesis and revascularization, thus inducing intrinsic tissue regeneration. Acellular dermal matrix has been used extensively for soft tissue augmentation, including lip augmentation, depressed scar tissue repair, malar and submalar augmentation, and rhinoplasty. In all of these settings, this graft tissue has proven to become well integrated, with excellent postoperative healing, little resorption, and minimal risk for infection, extrusion, hematoma, or seroma. In addition, because this tissue has no cellular components, it may have a greater tolerance for ischemia, as it appears the graft is capable of remaining in place without breakdown until vascular ingrowth and cellular incorporation develops. This process can be demonstrated by a biopsy of the ADM (Fig. 34.1).

Since 2001, we have utilized these unique properties of ADM to provide coverage for either an implant or an expander. Our choice of which prosthesis to use has relied on two important conditions: the vascularity of the overlying postmastectomy skin envelope and whether or not additional skin surface area is required to create a natural breast shape.

Significantly, skin-sparing mastectomy combined with minimal incisional scarring allows the reconstructive surgeon to focus on how best to replace the glandular volume without the restraint of providing donor skin of similar color and texture. The question of which surgical technique to employ has also become more complex, and the challenge that now exists is how to choose the appropriate procedure for each patient. The current surgical repertoire comprises numerous autologous tissue flaps, including pedicled flaps, free tissue transfers, and perforator flaps. In addition, prosthetic techniques utilizing tissue expanders and implants remain popular choices. The advantage of using a prosthetic approach continues to be the relative simplicity of the procedure as well as the avoidance of distant donor-site morbidity. The disadvantage has been the need for tissue expansion with the inconvenience of serial office visits, whose number can vary considerably depending on the patient’s comfort level and the total fill volume.

With the discovery of genetic markers of breast cancer risk, the demand and indications for prophylactic mastectomy have increased. Furthermore, patients are adamant that their choices include procedures with reduced operative time and postoperative recovery. These issues naturally led to the development of a technique that would provide a combined, single-stage approach for both the mastectomy and the reconstruction. The advantages of a single direct-to-implant operation, particularly in the prophylactic mastectomy patient, are obvious, and the direct-to-implant technique with ADM attempts to make available a viable alternative to the other, better-established reconstructive techniques. The indications for this approach, however, are quite specific and should be thoroughly familiar to both the surgeon and patient prior to selecting this option.