Implant-based reconstruction is a very attractive option for women undergoing either therapeutic or prophylactic mastectomy. Those who benefit are patients who lack enough tissue required for autogenous reconstruction, those that have concerns related to donor site morbidities, patients concerned with scarring, and those that want to have little down-time postoperatively. Immediate implant-based reconstruction also has the particular benefit of giving the patient an instant positive psychological advantage. Stevens et al.  showed that patients who undergo immediate reconstruction compared to patients who have delayed reconstruction had a lower incidence of psychological morbidity postoperatively.
Immediate breast reconstruction with expanders has been performed using total muscle coverage of the prosthesis to protect the implant from exposure. It became apparent that the rigidity of the muscle often restricted inferior pole expansion resulting in a high-riding implant, an ill-defined inframammary fold, and less than desirable cosmetic results. With skin-sparing and nipple-sparing mastectomy gaining oncologic acceptance [15, 23], immediate implant-based reconstructions of the breast evolved, given the benefit of having a larger skin envelope. Despite the refinement in surgical techniques and the introduction of new prosthetic materials, reconstruction failure and implant dislocation are still common after prosthetic breast reconstruction.
The use of ADM to reinforce the muscle and to provide an increased area of coverage in the inferior pole of the breast led to promising improvements in these reconstructive challenges [9, 33, 35, 38]. Unfortunately, recent literature shows an increased rate of complications associated with the use of ADM in reconstructive breast procedures [10, 13, 17, 19, 21, 24, 40–43]. While this is controversial because there is literature suggesting a low complication profile with the use of ADMs, the experience of the senior author led him to look for alternatives to ADMs secondary to complications seen in his practice. Some of these complications include seromas, infections, and failure of vascularization. Brooke et al.  recently showed a total complication rate in all cases in which ADM was used of 17 % compared to 11 % in patients who did not receive ADM during reconstruction. Infectious complications were 10 % with ADM vs. 2 % without ADM. In a large retrospective analysis by Weichman et al. , of 628 immediate two-stage breast reconstructions, the use of ADM was associated with a significant increase in major complications. Also in question are the relative mechanical properties between individual sheets of allograft harvested from different donors. A study out of Harvard recently showed that there are statistically significant, highly variable elastic properties between sheets of ADM harvested from different donors . This can be problematic when symmetry is crucial in breast reconstruction.
The use of ADM in corrective reconstructive breast surgery has also been reported in the literature [25, 26, 36]. Given the increasing evidence that ADM may be associated with increased complications, we aimed to examine another option that could prove to be a viable alternative to ADMs when used in select breast cases . In this study we used the TIGR® Matrix Surgical Mesh. The goal of the study was not to compare this product with ADMs or like products but to report on its use as temporary tissue reinforcement in a variety of plastic surgery breast cases.
TIGR® Matrix is the first long-term resorbable synthetic mesh product. It is indicated for reinforcement of soft tissue that is weak and is manufactured from two different synthetic resorbable fibers. It has high strength during the first 6 months following implantation and is completely degraded and resorbed after ~3 years. TIGR® Matrix is manufactured from the well-known and proven materials glycolide, lactide, and trimethylene carbonate, which degrade through hydrolysis and are cleared from the host tissue through normal metabolic pathways. We are now using it as an alternative to ADM in order to aid in correction of breast implant complications such as bottoming out, and as an adjunct in mastopexy surgery. The knitted structure of TIGR® Matrix allows for easy handling and fixation while being strong and flexible. As shown in preclinical trials, it is rapidly vascularized, has a transient inflammatory response, and, over time, is replaced by well-organized connective tissue . This was also our observation during this study. In patients who had a take-back procedure and thus whose mesh was biopsied, there was gross and histological evidence that the mesh was incorporating very nicely and being replaced by well-organized connective tissue. Since its market introduction in 2010, TIGR® Matrix has been used in a variety of plastic and general surgical procedures where soft tissue reinforcement is required, and it has shown excellent results and performance with minimal complications .
We were pleased with the results seen in this patient series. The decision to use the matrix was based on the presence or absence of weakness or deficiency of tissue/pectoralis major muscle. In cases in which complete muscle coverage of a prosthesis was the goal, no mesh was used if complete muscle coverage was possible. It is not routine to use mesh in primary aesthetic procedures but it is beneficial at times in mastopexys to hold the tissue in position. The mesh was very easy to work with intraoperatively. The mesh is flexible and has excellent suture-holding ability. We have not encountered any significant restriction to expansion in those cases when the mesh was used. Very good aesthetic results were obtained in a variety of breast cases. Our total complication rate in patients requiring a revision was 15.2 %. The complication profile seems reasonable compared to that of ADMs. Specifically, postoperative seroma was seen in only 1.8 % of the total breasts reconstructed. The incidence of infections/extrusions was 3.6 %. These numbers are lower than those of many published studies referenced in this article. We have also proven (grossly and histologically) that this mesh incorporates very well into the patient’s native tissue. In order for a surgical mesh to be efficacious, it must allow vascular in-growth and incorporation into surrounding tissue. This mesh certainly meets these criteria.
Based on our results, a limitation of the matrix may be its use in severely radiated cases, as the complication rate was 44 % in patients who had radiation therapy. Complications were more common in radiated cases, with two infections/extrusions and two cases of asymmetry out of the nine patients who had radiation therapy. We now do all radiated-patient revisions in two stages, placing a Spectrum adjustable implant initially in reconstructive cases. Prolonged drainage was necessary in immediate reconstruction, often up to 2 weeks.
Infection complications were noted early in this series and led to a new routine when placing the drains, using longer subcutaneous tunnels and a longer draining period. These corrective actions reduced infections in the latter half of the patient series. Other complications seen included loss of inframammary fold and recurrent ptosis. These complications were seen in earlier cases where the mesh was not adequately positioned. Persistent rippling has also been seen in patients with very thin skin flaps. Overall, we were very pleased with the aesthetic results achieved in this patient series. As expected, there was a natural learning curve to using this new product, and as the study period went by the complication rate dropped off due to changes in technique.
In today’s healthcare environment, cost is becoming more important. A 10-cm × 15-cm sheet of TIGR® Matrix costs $900. This is significantly less than the cost of ADMs and may be one potential advantage of using this matrix . In our study, the cost of the mesh in cosmetic cases was absorbed into the total cost of the procedure.
This study is not without its limitations. First, this is a retrospective study. The sample size is relatively small. While our average follow-up is 16.5 months (longest was 26.1 months), we would like to follow these patients much longer to assess the durability of the postoperative results. A few key surgical techniques were also changed during the course of this study. However, we believe the change in techniques in the latter half of the study would likely improve the results. Also, there were no objective cosmetic assessments performed. However, that was not in the scope of this study. This study was not designed to be a comparative study between TIGR® Matrix and ADMs or between patients receiving TIGR® Matrix versus no mesh. Our goal was to prove that the TIGR® Matrix could be an alternative to ADM when extra tissue support is needed in breast surgery cases.
The results of this study show that the synthetic long-term resorbable mesh TIGR® Matrix Surgical Mesh can be used in patients undergoing implant-based breast reconstruction, breast surgery revisions, or cosmetic breast procedures, and the initial data reveal that it may be a viable alternative to acellular dermal matrices. As the product becomes more widely used and more data become available, we believe that the TIGR® Matrix may have significant value for patients undergoing primary and secondary implant-based breast reconstruction as well as primary aesthetic procedures.