Breast Reconstruction Postmastectomy. Using DermaMatrix Acellular Dermis in breast reconstruction with tissue expander.

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1 Breast Reconstruction Postmastectomy. Using DermaMatrix Acellular Dermis in breast reconstruction with tissue expander. Strong and flexible Bacterially inactivated Provides implant support

2 Breast Reconstruction Postmastectomy Patient profile A 39-year-old woman with a one centimeter invasive lobular carcinoma and several additional areas of ductal carcinoma in situ (DCIS) in the left breast elected to have a total skin sparing mastectomy and sentinel node biopsy. Due to the multifocal nature of her carcinoma, lumpectomy was not an option. The small size of the primary lesion and its distance from the nipple enabled the patient to be considered as an appropriate candidate for nipple-areola sparing mastectomy. Surgical treatment Preoperatively, the patient s inframammary folds (IMF) and chest meridian were marked in the upright position. Once the patient was anesthetized and prepped, the IMF line was fixed by skin staples. The surgical oncologist then performed a left-sided nipple sparing mastectomy and sentinel node dissection. The pectoralis major muscle was then elevated from the chest wall inferiorly and disinserted medially off the sternum to the level of the contralateral nipple. The base diameter of the IMF was measured and a piece of 4 cm x 16 cm, thick (0.8 mm to 1.7 mm) DermaMatrix tissue was selected. The DermaMatrix tissue was hydrated in normal saline for three minutes prior to implantation. The inframammary fold of the breast was recreated using the hydrated DermaMatrix tissue with the dermal side up toward the vascularized mastectomy flaps to promote ingrowth. Using the skin staples as a positioning guide, the inferior aspect of the DermaMatrix tissue was sutured to the chest wall using a running 3-0 Monycryl suture at the level of the previously marked IMF. Surgeon s notes: The IMF was translated to the mastectomy cavity by temporarily inserting 25 gauge needles externally. This step ensures that the IMF is not displaced superiorly, as may occur if a large amount of skin has been resected from the chest. This technique allows for precise fixation of the IMF and secure fixation of the expander in the appropriate position.

3 Breast Reconstruction Postmastectomy continued The DermaMatrix tissue was then trimmed to create a comfortable pocket at the inferior border and lateral edge of the elevated pectoralis muscle. 3-0 Monocryl sutures were placed in an interrupted horizontal mattress fashion. The two edges were approximated and clamped. The pocket was then irrigated with antibiotic solution and inspected for hemostasis. A 400 cc Inamed medium-profile tissue expander was inserted and filled to a total volume of 200 cc. Horizontal mattress sutures were then tied down to approximate the pectoralis muscle to the DermaMatrix tissue after proper positioning of the expander was accomplished. The mastectomy flaps were closed in layers: 4-0 Vicryl interrupted for the deep dermal layer and 4-0 running Moncryl in a subcuticular fashion. No compressive dressings other then steri-strips were applied. A drain was placed exiting through a separate axillary stab incision and attached to a bulb suction. The patient was sent home the next day on oral antibiotics. Immediately postoperative, the patient had excellent replacement of the breast volume. Expansion was performed over the next four weeks to bring the total expanded volume to 450 cc. Two months after initial surgery, the patient was taken back to the operating room for tissue expander removal and permanent implant placement. In addition to the left-sided implant exchange, a right-sided augmentation and circumareolar mastopexy was performed to achieve breast symmetry. The left side was re-created with a 425 ml implant and the right with a 200 ml implant (Inamed Silicone style 20). Breast Reconstruction Postmastectomy

4 Gross examination of DermaMatrix tissue The DermaMatrix tissue is seen inferiorly and the pectoralis major muscle superiorly at the time of permanent implant placement illustrating incorporation into the surrounding tissues at two months. Histology slide of normal breast capsule Note the abundant collagen and extracellular matrix with a few blood vessels two months after the tissue expander placement. There is also a strong inflammatory reaction with a ridge of eosinophils and macrophages against the implant surface. Histology slide of DermaMatrix breast capsule DermaMatrix breast capsule two months after the tissue expander placement demonstrating vascular ingrowth, modest extracellular matrix, and less inflammatory reaction against the implant surface.

5 Breast Reconstruction Postmastectomy Postoperative management Oral antibiotics were continued until the drain was removed at one week postoperative. Results The patient did not experience any complications and was satisfied with the result at 10 months follow-up. She subsequently underwent 8 cycles of chemotherapy without radiation. Breast Reconstruction Postmastectomy

6 Benefit of DermaMatrix Acellular Dermis The DermaMatrix tissue allows for rapid initial tissue expansion without displacement of the expander or compromise of the mastectomy flaps. The revascularized DermaMatrix tissue provides an additional layer of protection which masks the inferior pole of the implant. This strong, durable, non-reactive graft material promotes vascular ingrowth to firmly reestablish the inframammary fold. It is cost-effective and cosmetically beneficial. Using DermaMatrix tissue at the lower breast pole is a safe and feasible option for breast reconstruction with implants. We use DermaMatrix tissue in all of our expander/implant breast cancer reconstructions for several reasons. As with all other products, it allows precise placement of the IMF, which is especially crucial for bilateral reconstructions. Contrary to popular belief, we do not intend nor expect for the matrix to expand. We believe it acts as a shelf to create a space beneath the pectoralis in the lower pole that facilitates robust lower pole expansion. Using this technique we have not had any difficulties with lower pole expansion. In addition, the thickness of DermaMatrix decreases the palpability of the implant long term. Geoffrey C. Gurtner, MD Results from this case study are not predictive of results in other cases. Results may vary.

7 Breast Reconstruction Postmastectomy Commonly used sizes for breast reconstruction DermaMatrix Acellular Dermis Size (cm) Thickness (mm) X X X X X X Breast Kits* 2 Units, Thick 0B X B X B X B X Breast Kits* 2 Units, Ultra Thick 0B X B X B X B X * Breast Kits contain two units from the same donor. Additional sizes are available; please contact your Synthes Sales Consultant for details. To order, call Synthes Customer Relations at (800) or fax to (877) Surgeon profile Geoffrey C. Gurtner, MD Reconstructive Surgery Department of Surgery, Division of Plastic Surgery Stanford University Medical Center Stanford, California Geoffrey C. Gurtner, MD Available through 1302 Wrights Lane East West Chester, PA Telephone: (610) To order call: (800) Fax: (877) Processed by Musculoskeletal Transplant Foundation 125 May Street Edison, NJ Telephone: (732) Fax: (732) Synthes, Inc. or its affiliates. All rights reserved. DermaMatrix and Synthes are trademarks of Synthes, Inc. or its affiliates. MTF is a registered trademark of the Musculoskeletal Transplant Foundation. Printed in U.S.A. 4/12 J7731-C