The authors document their experience in the use of synthetic 100% bioresorbable surgical mesh (TIGR Matrix, Novus Scientific, Uppsala, Sweden) in breast reconstruction as well as in breast aesthetic surgery. They performed a retrospective review on patients who underwent implant-based breast reconstruction as well as patients who underwent breast reduction mammoplasty procedures with the use of TIGR Matrix Surgical Mesh. When compared with other synthetic but nonresorbable meshes, it appears to show a potentially lower seroma and infection rates, but most importantly, a lower rate of revisional and mesh explantation surgeries.
Key points
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Synthetic mesh is a viable alternative to acellular dermal matrices when used in breast surgery.
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The use of 100% resorbable synthetic mesh in implant-based breast reconstruction significantly lowers the reconstruction cost while maintaining the benefits of tissue enforcement in the lower pole.
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The use of 100% resorbable synthetic mesh in aesthetic surgery might potentially help maintain long-lasting aesthetic results.
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TIGR Matrix exhibits promising preliminary results when used in breast surgery, such as low seroma and infection rates, when compared with other nonresorbable or semiresorbable synthetic meshes.
Introduction
The use of acellular dermal matrices (ADM) and synthetic meshes in breast surgery is gaining popularity in recent years. In implant-based breast reconstruction, complete implant coverage has been the main target of surgeons in order to reduce the risk of implant exposure. The matrices are widely used in order to facilitate the complete coverage of the prosthesis. In aesthetic breast surgery, ADMs and synthetic meshes can be used as a sling to decrease gravitational changes as well as to strengthen weakened inferior pole tissue, so cosmetic benefits such as stable nipple-areola position and adequate breast projection can be achieved. The use of these matrices and meshes in both reconstructive and aesthetic breast surgery is promising, especially because the surgical techniques can be used by almost every experienced surgeon and are characterized with a steep but fast learning curve.
Many options are currently available on the market and vary from human cadaveric ADM to fetal bovine–derived ADM, bovine-derived collagen matrix, porcine-derived ADM, and synthetic meshes. ADMs are produced by decellularization of dermal matrix, a process that leaves the extracellular scaffold intact. It is within this scaffold that patient’s cells repopulate and therefore vascularize the graft. Synthetic meshes are defined as products that are manufactured synthetically. They can be either nonresorbable, partially resorbable, or completely resorbable devices. Concerns regarding the significant cost associated with the biological matrices have been expressed, especially when compared with the synthetic meshes.
It is well documented in the literature that synthetic meshes are viable alternatives to ADMs. This article documents the authors’ experience in the use of a synthetic 100% bioresorbable surgical mesh (TIGR Matrix, Novus Scientific, Uppsala, Sweden) in breast reconstruction as well as in breast aesthetic surgery.
Introduction
The use of acellular dermal matrices (ADM) and synthetic meshes in breast surgery is gaining popularity in recent years. In implant-based breast reconstruction, complete implant coverage has been the main target of surgeons in order to reduce the risk of implant exposure. The matrices are widely used in order to facilitate the complete coverage of the prosthesis. In aesthetic breast surgery, ADMs and synthetic meshes can be used as a sling to decrease gravitational changes as well as to strengthen weakened inferior pole tissue, so cosmetic benefits such as stable nipple-areola position and adequate breast projection can be achieved. The use of these matrices and meshes in both reconstructive and aesthetic breast surgery is promising, especially because the surgical techniques can be used by almost every experienced surgeon and are characterized with a steep but fast learning curve.
Many options are currently available on the market and vary from human cadaveric ADM to fetal bovine–derived ADM, bovine-derived collagen matrix, porcine-derived ADM, and synthetic meshes. ADMs are produced by decellularization of dermal matrix, a process that leaves the extracellular scaffold intact. It is within this scaffold that patient’s cells repopulate and therefore vascularize the graft. Synthetic meshes are defined as products that are manufactured synthetically. They can be either nonresorbable, partially resorbable, or completely resorbable devices. Concerns regarding the significant cost associated with the biological matrices have been expressed, especially when compared with the synthetic meshes.
It is well documented in the literature that synthetic meshes are viable alternatives to ADMs. This article documents the authors’ experience in the use of a synthetic 100% bioresorbable surgical mesh (TIGR Matrix, Novus Scientific, Uppsala, Sweden) in breast reconstruction as well as in breast aesthetic surgery.
Methods
The authors performed a retrospective review of patients who underwent implant-based breast reconstruction as well as patients who underwent breast reduction mammoplasty procedures with the use of the TIGR Matrix Surgical Mesh.
Forty-nine consecutive patients, who were operated between 2014 and 2016, were included in the study. There were no exclusion criteria. Complications and surgical revision rate data were collected and documented. Retrospective review approval was obtained by the ethical board of the hospital.
All patients received perioperative care from the senior author and members of his team at Sandro Pertini Hospital. They received prophylactic antibiotic on anesthesia induction, followed by mastectomy for breast reconstruction patients performed by the general surgeon. Subsequently, tissue expander (TE) with mesh or direct to implant (DTI) with mesh breast reconstruction was performed immediately after mastectomy. Polyurethane foam–covered implants (Polytech, Dieburg, Germany) were used in DTI reconstruction, and textured tissue expanders (Mentor, Allergan, Silimed) were used for the first stage of the 2-stage reconstruction.
The implant or tissue expander pocket was prepared by elevation of the pectoralis major muscle superiorly, and TIGR mesh was sutured to the muscle’s lower border inferiorly. The mesh was subsequently sutured to the chest wall at the desired level of the newly created inframammary fold (IMF; Fig. 1 ). The pocket and the implant or TE were irrigated with cefazolin solution, and the surgical team routinely changed their gloves before implant placement. Complete implant coverage was therefore achieved by pectoralis muscle superomedial and the mesh inferolateral. In order to maximize the contact surface between the implant and the pocket walls, suction drains were placed in every patient (one subcutaneously and one in the pocket). The TE was filled intraoperatively according to the volume capacity of the pocket.
Reduction mastopexy operations were performed under general anesthesia. Inferior pedicle technique was performed as first described by Ribeiro and colleagues. TIGR matrix was used to stabilize the flap and to secure it on the pectoral fascia ( Fig. 2 ).
All patients received intravenous antibiotics for the first postoperative day, and drains were removed when fluid collection was less than 30 mL/d. The first follow-up visit was routinely at the second postoperative week and thereafter at 1, 3, 6, and 12 months. For the 2-staged reconstruction procedures, the TEs were filled every week by adding 10% of the total TE volume capacity or as tolerated by the patient.
All the statistical analyses were performed with Stata 13 statistical software (StataCorp LP, College Station, TX, USA). Descriptive statistics were reported as mean and percentages. Associations between categorical variables were evaluated by the use of the χ 2 test, and the P value <.05 was considered statistically significant. Mesh-complication rate was estimated by means of the Kaplan-Meier method for cumulative incidence. Time of complication onset was defined as the time from the initial breast surgery to the diagnosis of the mesh complication (in months). Patients who did not experience mesh complications were reviewed after the final follow-up session.
Results
Forty-nine patients underwent breast surgery with the use of the TIGR Matrix mesh. The mean patient age was 51 years (range, 25–73 years), and the mean follow-up period was 12 months (range 0–43 months) shown in Table 1 . There was no patient lost to follow-up.
| No. of Patients | 49 |
| Mean age, y (range) | 51 (25–73) |
| Body mass index > 30 | 8 (16.3%) |
| Smokers | 7 (14.3%) |
| Diabetes | 1 (2%) |
| Bilateral | 11 (22.4%) |
| Radiotherapy | 5 (10.2%) |
| Chemotherapy | 22 (44.9%) |
| Neoadjuvant chemotherapy | 6 (12.2%) |
Eleven patients underwent bilateral interventions, whereas the remaining 38 patients were unilateral. Therefore, a total of 60 meshes were used in 60 breast surgeries (54 breast reconstructions and 2 mastopexies and 4 breast reductions). Twenty-three patients had a history of chemotherapy; 7 patients had a history of neoadjuvant chemotherapy, and 5 patients received radiation therapy.
One device was lost because of prosthesis removal due to skin necrosis.
For 54 breast reconstructions performed using mesh (52 for cancer and 2 for fibroadenoma removal) ( Table 2 ), 35 were after skin-sparing mastectomy, 13 were after nipple-sparing mastectomy, and 4 were after skin-reducing mastectomy. Two meshes were used to treat contour deformities in secondary reconstruction attempts.
| Nipple-Sparing Mastectomy | Skin-Sparing Mastectomy | Skin-Reducing Mastectomy | Secondary Reconstruction | Reduction Mammaplasty | Total | |
|---|---|---|---|---|---|---|
| Cancer | 11 | 4 | 35 | 2 a | — | 52 |
| Fibroadenoma | 2 | 0 | 0 | 0 | — | 2 |
| Weight loss | — | — | — | — | 2 | 2 |
| Breast ptosis | — | — | — | — | 4 | 4 |
| Total | — | — | — | — | — | 60 |
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