Alloderm in Breast Reconstruction
By Brian Kobienia, MD, FACS on July 01, 2011
What? You want to put dead skin in my breast? To reconstruct it? Are you crazy ? Actually it’s not dead skin, but rather a scaffolding of collagen that was harvested from a cadaver then treated to remove all living cells. This collagen scaffolding has many names depending the manufacturer. The most well-known currently is Alloderm. Alloderm is commonly used in breast reconstructioin and other applications in surgery. Just like the use of cadaveric tendons, bones and skin in orthopedic and burn operations we can use portions of cadaver skin (the collagen) to aid in breast reconstruction. I have found this relatively new tool very useful in breast reconstruction.
I have this tool available to my breast reconstruction patients to optimize their reconstructive result. Traditionally, in tissue expander first stage breast reconstruction the expander is placed beneath the pectoralis major muscle medially and under the serratus muscle and fascia laterally. This worked reasonably well but it limited how much expansion could be done at the time the expander was placed (first stage). The serratus muscle and the attached connective tissue is highly prone to tearing and are a big source for post-operative pain.
I use Alloderm for three reasons: pain relief, aesthetics,and rapid expansion. First, the anatomy of the chest and rib cage is mobile by nature to allow for the expansion and contraction we call breathing. In order to breathe the muscles associated with the ribs contract and relax and thereby raise and lower the ribs during the normal breathing cycle. You can simply not rest these muscles – or you fail to breathe. When a tissue expander is placed beneath the pectoralis major and serratus muscles these tissues are immediately under strain and when muscles are under strain they spasm. Limiting arm use is one way of minimizing muscle spasms. By not placing the tissue expander below the the serratus muscle a good portion of the postoperative pain can be avoided. The tissue expander needs to be covered with something, however, and the Alloderm fits the bill.
Because the serratus muscle and it’s surrounding soft tissue (fascia) is not very stretchable this typically with limit the amount of fluid that can be placed in the tissue expander at the initial operation. Sometimes this is a big issue. Occasionally a patient will have a breast cancer that is too big for surgery (mastectomy) first. In this situation chemotherapy is given before surgery in an effort to shrink the tumor. Usually these patients will need to have radiation therapy shortly after they have healed from their surgery. This means there is limited time (usually weeks) to fill the expander. By using the alloderm we don’t have to stretch the serratus muscle and fascia and can thereby can add volume at the first stage operation to accomplish nearly 50-90 % of the expansion before the patient even wakes up from surgery. This can allow a patient who traditionally would have been told to wait and do their reconstruction months or years later to enjoy the benefits of immediate reconstruction. This also makes the technique of tissue expander reconstruction available to the patient who will need radiation therapy as part of their cancer treatment. Remember, we are relying on the stretchability of tissues with the tissue expander technique. Radiation therapy will adversely affect the elasticity of skin much like the effect of sunshine on a rubberband. Because of this tissue expander reconstruction can only be done in someone who has never had radiation therapy. Once radiation therapy had been given tissue expander and implant reconstruction is no longer a breast reconstruction option.
Lastly, I have found that with the use of Alloderm the aesthetic appearance of the breast is much more appealing. Other uses of alloderm in breast reconstruction include nipple augmentation projection and the ability to minimize visible wrinkling, particulary in the cleavage of the reconstructed bust.
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