Background: Immediate single-stage direct-to-implant breast reconstruction with acellular dermal matrix optimizes aesthetics by preserving the mastectomy skin envelope. The authors report trends, early complications, and costs.

Methods: A retrospective review of three surgeons' experience was performed for immediate single-stage implant reconstruction with acellular dermal matrix and tissue expander reconstruction without it at Massachusetts General Hospital.

Results: Two hundred eleven patients had 331 direct-to-implant reconstructions using AlloDerm following nipple-sparing (n = 66) or skin-sparing (n = 265) mastectomy for cancer (n = 216) or prophylaxis (n = 115). The number of single-stage implant reconstructions increased from seven in 2006 to 116 in 2009. The percentage performed for prophylaxis increased from 29 percent to 41 percent. Fifty-one patients underwent preoperative (n = 33) or postoperative (n = 18) irradiation. Total complications included 10 infections (3.0 percent), five seromas (1.5 percent), four hematomas (1.2 percent), and 30 reconstructions (9.1 percent), with skin necrosis leading to five implant losses (1.5 percent). Tissue expander reconstruction without AlloDerm had a similar total complication rate (158 reconstructions) (p = 0.18), including nine infections (5.7 percent), three seromas (1.9 percent), three hematomas (1.9 percent), and 16 reconstructions (10.1 percent), with skin necrosis leading to 11 implant losses (7.0 percent). A higher complication rate occurred in the surgeons' combined first year performing single-stage implant reconstruction (21.4 percent) compared with subsequent years (10.9 percent) (p < 0.02) and in one- or two-stage reconstruction patients undergoing irradiation (p = 0.005). There was no significant difference in total overall costs (p = 0.8).

Conclusions: Immediate single-stage implant reconstruction using acellular dermal matrix offers a cost-effective reconstruction with a low complication rate. This may be the procedure of choice in select patients.

Clinical question/level of evidence: Therapeutic, III.