Immediate Breast Cancer Reconstruction with or without Dermal Matrix or Synthetic Mesh Support: A Review and Network Meta-Analysis

Abstract

Background: The use of acellular dermal matrices (ADMs) and synthetic mesh as part of implant-based breast reconstruction (IBBR) has been widely adopted. The authors investigated the clinical efficacy and safety of human ADM (HADM), xenograft ADM (XADM), and synthetic mesh as part of IBBR in postmastectomy patients as compared with previous standard implant reconstruction techniques using only a submuscular pocket for coverage. Methods: A systematic search for randomized controlled trials and observational studies was performed. A frequentist network meta-analysis was conducted using the R packages netmeta and Shiny. Results: Thirty-one of 2375 studies identified met the predefined inclusion criteria. Traditional submuscular placement (no ADM or mesh) had fewer overall complications compared with HADM [OR, 0.51; credible interval (CrI), 0.34 to 0.74], but there was no significant difference between no ADM or mesh and XADM (OR, 0.63; CrI, 0.29 to 1.32) or synthetic mesh (OR, 0.77; CrI, 0.44 to 1.30). No one treatment was superior with regards to implant loss. No ADM or mesh was associated with fewer infectious complications than HADM (OR, 0.6; CrI, 0.39 to 0.89). Both no ADM or mesh (OR, 0.45; CrI, 0.27 to 0.75) and XADM (OR, 0.46; CrI, 0.23 to 0.88) had reduced seroma compared with HADM. Conclusions: Selecting the appropriate IBBR should evaluate effectiveness, adverse events, and cost. Although it is difficult to select a universal ideal IBBR, evaluation using this network analysis may help guide both physicians and patients in their choice of procedure, especially in the case of HADM, which in this study was shown to be significantly predisposed to complications of infection and seroma. Randomized data are required comparing XADM versus synthetic meshes, given the similar risk profiles but significant cost discrepancy between the techniques.