Comparing the benefits and risks of immediate breast cancer reconstruction with or without acellular dermal matrix (ADM) or synthetic mesh support- A Systematic Review and Network Meta-analysis.

INTRODUCTION AND AIMS: The use of acellular dermal matrices (ADM) and synthetic mesh as part of implant-based breast reconstruction (IBBR) has been widely adopted. Our aims were to investigate the clinical efficacy and safety of the use of human/allograft (HADM), xenograft (XADM) and synthetic mesh as part of IBBR in post-mastectomy patients as compared to previous standard implant reconstruction techniques using only a submuscular pocket for coverage.

METHODS: A systematic search for randomised control trials and observational studies was performed. A frequentist network meta-analysis was conducted using the R packages netmeta and Shiny.

RESULTS: A total of 31 studies of 2375 identified met the predefined inclusion criteria. Traditional submuscular placement (no ADM/mesh) had fewer overall complications compared to HADM (odds ratio [OR] 0.51; Credible interval [CrI]: 0.34 - 0.74), however there was no significant difference between no ADM/mesh and XADM (OR 0.63; CrI: 0.29-1.32) or synthetic mesh (OR 0.77; CrI: 0.44 - 1.30). No one treatment was superior with regards to implant loss. No ADM/mesh was associated with less infectious complications than HADM (OR 0.6; CrI 0.39 - 0.89). Both no ADM/mesh (OR 0.45; CrI 0.27 - 0.75) and XADM (OR 0.46; CrI 0.23 - 0.88) had reduced seroma compared with HADM.

CONCLUSION: Selecting the appropriate IBBR should evaluate effectiveness, adverse events, and cost. While 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 has shown to be significantly predisposed to complications of infection and seroma. Randomised data is required comparing XADM versus synthetic meshes given the similar risk profiles but significant cost discrepancy between the techniques.