Clinical outcomes of thick acellular dermal matrix for partial volume correction in breast conserving and reconstructive surgery: a single-center prospective study

Introduction

Background

Breast cancer is the most common cancer in women and has a high survival rate when diagnosed early (1,2). Depending on the diagnosis and extent of invasion, patients are treated with mastectomy, and an appropriate breast reconstruction technique may be applied to improve quality of life. Among Asians in particular, many women have small to moderate-sized breasts. Therefore, even a small excision volume often comprises a significant portion of the total breast volume. In such cases, various patient-matched autologous volume replacement techniques can be used, depending on the size and location of the defect, ranging from oncoplastic breast surgery to partial breast reconstruction. Oncoplastic breast-conserving surgery (BCS) has been established as oncologically safe, with various volume displacement and replacement techniques reported to minimize postoperative breast deformity (3-11). Within this evolving framework, there remains a need for practical methods to correct small‑to‑moderate volume deficits without resorting to major flap surgery. In many cases, although volume displacement techniques provide partial coverage, more extensive volume replacement procedures are required when the defect exceeds initial expectations. Residual deficiencies may sometimes be filled via revisional fat grafting performed intraoperatively or at a later postoperative stage. Conditionally, flap surgery may also be used to satisfy the volume requirements; however, owing to the risk of morbidity and complications at the donor site, this option will only be considered by reconstructive surgeons after careful consideration.

Rationale and knowledge gap

Several studies have compared different planes and techniques in patients who have undergone mastectomy and prosthetic reconstruction. In these cases, it is essential to perform direct-to-implant breast reconstruction (DTIBR) using acellular dermal matrix (ADM) to create implant neo-pockets of varying sizes and designs, allowing direct placement of the implant into the pocket. ADM is a biological scaffold derived from decellularized dermis, widely used in breast reconstruction for its biocompatibility and ability to support tissue integration and reduce scar formation (12-15). Recently, ADM has been one of the most widely used materials in breast reconstruction involving silicone implants or tissue expanders (16,17). The overall breast reconstruction approach is determined based on the expected defect size after breast surgery (both BCS and total mastectomy) and thorough preoperative discussions with the patient, and ADM is applied intraoperatively using various methods. In the intraoperative field, a defect area arises due to the difference between the round implant and the actual breast parenchyma (usually the lateral part of the breast in the axillary area). Even when an autologous flap is used, a concave, depressed deformity may appear immediately after surgery in the distal part of the flap (usually the medial part of the breast).

Objective

This study aimed to evaluate the safety and clinical outcomes of thick ADM used for intraoperative partial volume correction following BCS or total mastectomy, across multiple oncoplastic and reconstructive settings. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0131/rc).

Methods

Patients

This single-center prospective study was conducted at Kyungpook National University Chilgok Hospital and included 20 patients who underwent concurrent (i.e., performed during the same operative session as mastectomy) total or partial breast reconstruction using thick ADM via the Department of Plastic and Reconstructive Surgery. These cases were selected from 124 patients who underwent total or partial mastectomy for breast cancer between July 2022 and June 2023. Patient age, body mass index (BMI), breast cancer location, defect size, mastectomy weight, ADM size, and diagnosis were recorded. Photometry images were taken preoperatively, intraoperatively, and at 1, 3, and 6 months postoperatively. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This prospective study was approved by the Institutional Review Board of Kyungpook National University Chilgok Hospital (No. 2022-05-004-001), and all patients provided informed consent to have their data (including de-identified photographs) recorded, analyzed, and published for research purposes.

Surgical methods

The surgical approach is determined by the Department of Breast Surgery based on the estimated volume of breast tissue to be excised relative to total breast volume, following a standardized three-tier institutional protocol. When excision involves less than approximately 20% of the total breast volume, BCS is performed by the breast surgery team as a standalone procedure without immediate reconstruction. When excision involves approximately 20–40% of the total breast volume, partial mastectomy is performed; after intraoperative confirmation of clear resection margins by frozen section biopsy, partial breast reconstruction is subsequently performed by the plastic surgery team during the same operative session. When excision exceeds approximately 40% of the total breast volume, total mastectomy is performed, as partial mastectomy would not provide adequate oncological or aesthetic benefit at this extent of resection. Accordingly, patients undergoing partial mastectomy (resection of approximately 20–40% of the total breast volume) who underwent partial breast reconstruction with oncoplastic techniques (glandular reshaping or rotation flap), and patients who underwent nipple-sparing mastectomy (NSM; resection of >40% of the total breast volume) followed by breast reconstruction with an LD flap, areas requiring partial volume correction intraoperatively were treated by manually preparing and applying small, thick ADMs (3–5 mm thickness) at an appropriate size for the defect. After a partial or total mastectomy by the Department of Breast Surgery and confirmation of a clear margin in frozen biopsy, the patient was placed in a seated position on the operating table, and a surgical approach was selected to achieve maximal bilateral breast symmetry with minimal additional surgical morbidity. The ADM used in this study was procured in commercially available standardized dimensions (ordered per case from MegaDerm, L&C BIO, Seongnam, Korea) to a size of 3 cm × 4 cm to 8 cm × 10 cm and the maximum possible thickness (3–5 mm). The procedural techniques are broadly divided into three types, as described below.

Glandular reshaping with small, thick ADM (Figure 1)

Figure 1 An illustration of glandular reshaping methods. (A) The tumor was excised with a safety margin by the Department of Breast Surgery. The defect was covered using a bilateral advancement flap from the adjacent glandular tissue, and the immediate shape and volume were checked. (B) If partial volume correction was judged to be necessary, a small, thick ADM was applied to fit the size of the defect (always positioned deep to the flap). (C) The small, thick ADM was placed such that the dermal side was deepest, and the patch was fixed with at least three 2-0 Vicryl stitches to prevent malposition of the ADM, before closing layer-by-layer. This figure is an original illustration commissioned exclusively for this manuscript from CGMEDI (Gimpo, Republic of Korea; Business Registration No. 188-37-00378), a professional design agency. The authors retain all rights required for publication. ADM, acellular dermal matrix.

For small defects (10–20% of total breast volume) with a slim or thin profile, the healthy breast parenchyma on either side of the defect was undermined and advanced bilaterally toward the midline. The reconstructed breast was then assessed visually and by palpation. If a depression slightly deeper than the tissue surrounding the defect was detected by gross inspection, palpation, or a shadow in photographs, oncoplastic breast surgery was performed by making a small, thick ADM patch suited to the defect size and applying the patch below to the advancement flap, followed by glandular reshaping superficial to the patch. Here, horizontal and vertical slit incisions were made in the ADM patch to minimize seroma formation, and the dermal side of the patch was oriented towards the flap to promote integration with the glandular tissue. Two negative-pressure drain tubes were positioned in the most inferior part of the defect, with one superior to and one inferior to the ADM. This dual-drain strategy was adopted specifically in thick ADM cases to minimize dead space and seroma risk around the graft.

Rotation flap (subcutaneous) with small, thick ADM (Figure 2)

Figure 2 An illustration of a subcutaneous rotation flap. (A) When the defect is in the upper medial part of the breast, a curved flap is designed extending to the axilla. (B) A rotation flap is used at the subcutaneous level, and a sheet-type thick ADM is applied deep to the flap to fit the size of the defect. The ADM is secured with at least three stitches of 2-0 Vicryl to prevent malposition. (C) The skin incision does not extend beyond the defect site. This figure is an original illustration commissioned exclusively for this manuscript from CGMEDI (Gimpo, Republic of Korea; Business Registration No. 188-37-00378), a professional design agency. The authors retain all rights required for publication. ADM, acellular dermal matrix.

This technique is most suitable for defects that are not too large (20–30% of the total breast volume) but are positioned in the upper medial part of the breast, particularly in the upper mid-to-medial region where glandular reshaping alone is insufficient to adequately cover the defect. When the defect size exceeds what can be reliably addressed by glandular reshaping—typically around 20–30% of total breast volume—this rotation flap approach offers a reliable alternative. Traditionally, a skin incision is made from the medial part of the defect to the axillary area, resulting in a long, curved scar. However, when the subcutaneous flap thickness is sufficient (generally 1 cm or greater), a dual-plane dissection can be performed along both the subdermal plane and the plane superficial to the pectoralis major muscle, allowing the entire procedure to be carried out internally without any additional skin incision. This approach significantly reduces scar formation, which represents a key advantage of this technique. In this study, undermining was performed at the subcutaneous level; hence, the skin incision was limited to the defect site, and surgery proceeded internally. A dual-plane subcutaneous rotation flap was created and advanced at both the subcutaneous and deeper planes beneath the breast parenchyma to cover the defect. Outcomes were assessed by gross inspection, palpation, and shadows in photographs, and a small, thick ADM was placed deep to the flap in areas with a volume deficit. A single negative-pressure drain was placed at the inferior aspect of the defect and maintained until drainage was minimal.

Partial volume correction in total breast reconstruction with an LD flap (Figure 3)

Figure 3 An illustration of the LD flap. (A) A small, thick ADM is applied for correction at the site of a triangular depression superficial to the axillary tunnel that the LD flap pedicle has passed through. (B,C) When the volume or area of the LD muscle is smaller than expected, a thick ADM is applied in a sheet shape deep to the muscle. In cases with a triangular depression superficial to the axillary tunnel, the thick ADM is tailored to the defect, placed superficial to the LD pedicle without compressing it, and anchored to the surrounding muscle with interrupted sutures to maintain stable volume correction. Importantly, this technique is specifically applied to cases where the LD pedicle has descended inferiorly, creating a focal concave depression in the axillary area. The axillary skin flap is generally thicker than the breast skin flap, and the ADM is covered by the adjacent LD muscle margin rather than lying directly beneath a thin skin envelope, thereby reducing the risk of visibility or palpability. This figure is an original illustration commissioned exclusively for this manuscript from CGMEDI (Gimpo, Republic of Korea; Business Registration No. 188-37-00378), a professional design agency. The authors retain all rights required for publication. ADM, acellular dermal matrix; LD, latissimus dorsi.

In patients who underwent skin-sparing or NSM followed by LD flap reconstruction (in all LD flap cases in this cohort, reconstruction was performed without a prosthetic implant), ADM was used to augment areas where the LD muscle was thinner or smaller than anticipated. This technique is specifically applied to cases where the LD pedicle has descended significantly inferiorly, creating a localized triangular concave depression in the axillary area that cannot be fully corrected by the LD muscle alone. In such cases, the superior margin of the flap is first secured with absorbable sutures to establish the overall contour, after which the LD pedicle—including the surrounding muscle—naturally settles into the defect area. Because precise intraoperative prediction of the exact volume deficit is difficult, ADM is placed beneath the anticipated depression zone to achieve partial correction of the residual concavity rather than complete filling of the entire defect. Notably, the skin flap in the axillary area is generally thicker than the breast skin flap, and the region itself is naturally concave toward the axilla, reducing the risk of the ADM being directly palpable beneath a thin skin envelope. After LD flap insertion, the course of the pedicle along the axillary tunnel was carefully palpated and visualized. A small, thick ADM was then trimmed to match the footprint of the triangular depression and inserted superficial to the pedicle and deep to the skin flap, ensuring that the pedicle was not directly compressed. The dermal surface of the ADM was oriented toward the LD muscle, and the patch was fixed with at least three interrupted 2‑0 Vicryl sutures to the surrounding muscle to prevent migration, while maintaining a loose pocket around the pedicle to avoid kinking or torsion. Any potential dead space around the ADM was minimized, and the suction drain was positioned away from the pedicle trajectory to reduce the risk of mechanical irritation.

Postoperative complications and patient satisfaction

Postoperative complications were assessed prospectively using electronic medical records and follow-up monitoring data. Complications were defined as events occurring within 6 months postoperatively, with additional events confirmed during outpatient visits also recorded. The complication categories investigated were seroma, hematoma, skin flap necrosis, dehiscence, partial firmness (suggesting fat necrosis), surgical site infection, and re-surgery directly related to complications. Seroma and hematoma were classified only in cases where water retention was confirmed by clinical examination or ultrasound, and aspiration or drainage was required. Skin flap necrosis and dehiscence were defined as cases where local treatment or additional sutures were required due to partial or full-thickness skin necrosis or suture loosening at the surgical site.

Partial firmness suggestive of fat necrosis was assessed by palpation and recorded in cases when fat necrosis was suspected. Surgical site infection was defined as redness, warmth, or discharge at the surgical site that required antibiotics. Complication-related re-surgery included all additional surgeries performed with the aim of correcting the above complications, but these were mostly categorized as small-scale revisional procedures under local anesthesia.

Patient satisfaction was assessed after 6 postoperative months using the modified Kyungpook National University (KNU) Breast-Q, adapted from the Breast-Q questionnaire. The modified KNU Breast-Q used here is a postoperative instrument; no preoperative baseline version was administered, which is acknowledged as a limitation. Patient satisfaction was assessed across the following five domains based on the modified KNU Breast-Q: overall satisfaction, aesthetic outcome, physical symptoms, psychosocial impact, and decision satisfaction. A visual analog scale was used, with 5 indicating very satisfied and 1 indicating very dissatisfied (9,18).

All enrolled patients completed the 6‑month clinical and questionnaire follow-up; thus, there were no missing outcome data, and all analyses were performed on complete cases.

Statistical analysis

Depending on the results of a normality test, continuous variables were presented in terms of the mean ± standard deviation or the median (quartile). For between-group comparisons, an independent samples t-test or a non-parametric test (Mann-Whitney U test) was used. Categorical variables were presented in terms of frequency and percentage, and their distributions were analyzed using a Chi-squared test or Fisher’s exact test if the expected frequency was low. All statistical analyses were performed using IBM SPSS Statistics Version 30.0 (IBM Corp., Armonk, NY, USA; released in 2024), and a P value less than 0.05 was considered statistically significant. All P values were reported without corrections for multiple comparisons.

Results

In accordance with the prospective study design, oncoplastic or breast reconstruction surgery was performed using thick ADM in 20 of 144 cases. Patient demographics, including age and BMI, were generally similar between the two groups; however, differences were observed in the extent of the excision and the distribution of reconstruction methods (Table 1).

In this prospective cohort, the thick ADM group more frequently underwent oncoplastic volume displacement or replacement procedures and postoperative radiotherapy and tended to present with earlier tumor, node, metastasis (TNM) stages and specific pathological subtypes compared with the reference cohort. These baseline imbalances should be considered when interpreting between-group comparisons of complications and patient-reported outcomes. In particular, the 50 DTIBR cases in the reference cohort represent a fundamentally different reconstructive approach for which thick ADM was not indicated; their inclusion provides broad safety context but precludes matched comparison. Comparison of patient characteristics and surgery-related variables revealed some statistically significant between-group differences. Among breast reconstruction methods, the percentages of patients undergoing glandular reshaping, rotation flap, LD flap, and DTIBR were significantly different, with the investigational group being more likely to undergo oncoplastic volume displacement/replacement procedures (Table 1). There were clear differences in the distribution of radiotherapy (RTx) between the two groups. Specifically, the investigation group was more likely to receive postoperative RTx, whereas the ratio of patients not receiving RTx was higher in the control group (Table 1). Significant differences were also observed in some items for TNM staging and pathological diagnosis, with the investigational group tending to show an earlier disease stage and a higher ratio of certain pathological subtypes (Table 1). In clinical photographs of partial breast reconstruction using small, thick ADM for a superolateral defect, the local depression that had been expected is not present, and the bilateral breast outline and symmetry are relatively well preserved (Figure 4).

Figure 4 Clinical outcomes in glandular reshaping. (A) Excised mass and small, thick acellular dermal matrix. (B) After a partial mastectomy, the ADM is placed in the deepest layer (immediately superficial to pectoralis major) to match the footprint of the defect. (C) In the layer superficial to the ADM, the glandular flap is undermined bilaterally, and coverage is confirmed. (D) Preoperative findings. (E) Postoperative 3-month findings. (F) Postoperative 6-month findings. After completing RTx and thoroughly maintaining skin hydration, a good outcome can be observed, with the patient recovering close to their preoperative appearance. ADM, acellular dermal matrix; RTx, radiotherapy.

In a patient with a superomedial defect treated using a subcutaneous rotation flap with small, thick ADM, no superomedial volume imbalance or skin depression was observed, and the patient maintained a natural upper breast contour (Figure 5). There was no obvious asymmetry compared to the contralateral breast, suggesting satisfactory maintenance of breast contour in this case. In a case of total breast reconstruction using an LD flap, where a distal volume deficit was anticipated, a small, thick ADM was used to reinforce this area, and the patient maintained a clean superolateral outline on the reconstructed breast (Figure 6). In long term follow-up, there was no obvious flap contracture or local depression, and so this case was thought to show the potential of thick ADM as a material for partial volume correction (Figure 6).

Figure 5 Clinical outcomes in rotation flap (subcutaneous plane). (A) Excised mass and defect on the left breast upper pole area. (B,C) After a partial mastectomy, ADM matched to the defect footprint was inserted at the deepest level (immediately superior to pectoralis major), the rotation flap was elevated to the subcutaneous plane, the layer superior to the ADM, as far as the axillary area, and coverage was confirmed. In this case, the subcutaneous flap thickness was sufficient (≥1 cm), allowing a dual-plane dissection to be performed along both the subdermal plane and the plane superficial to the pectoralis major without any additional skin incision beyond the defect site, thereby minimizing scar formation. (D) Preoperative findings. (E) Postoperative 3-month findings. (F) Postoperative 6-month findings. After completing RTx, a good outcome can be observed, with the patient recovering close to their preoperative appearance. ADM, acellular dermal matrix; RTx, radiotherapy.

Figure 6 Clinical outcomes in the extended LD flap after nipple sparing mastectomy. (A) Robot-assisted nipple sparing mastectomy design. (B) Excised mass. (C) Breast reconstruction was performed using an LD flap, and a small, thick ADM was applied to the triangle-shaped defect where the LD pedicle passed through the axillary area. (D) Preoperative findings. (E) Postoperative 3-month findings. (F) Postoperative 6-month findings. A relatively favorable course could be observed. ADM, acellular dermal matrix; LD, latissimus dorsi.

Regarding postoperative complications, there was 1 case (5.0%) each of seroma and hematoma in the thick ADM group and 10 cases (8.1%) and 4 cases (3.2%), respectively, in the non-thick ADM group, indicating no significant difference in the incidence rates between the two groups (Table 2).

Skin flap necrosis occurred in four cases (3.2%) in the non-thick ADM group only, but this difference was not statistically significant due to the low frequency. Dehiscence was similar between the two groups, with one case (5.0%) in the thick ADM group and nine cases (7.3%) in the control group. Partial firmness suggestive of fat necrosis was observed rarely in the two groups, with one case (5.0%) in the thick ADM group and eight cases (6.5%) in the non-thick ADM group. These patients complained of slight discomfort, but it did not result in clinically serious sequelae overall.

Surgical side infection was observed in five cases (4.0%) in the non-thick ADM group and resolved with an appropriate antibiotic regimen without requiring additional surgery. Complication-related re-surgery was required in one case (5.0%) in the thick ADM group and seven cases (5.6%) in the control group. All complications were resolved with small-scale revisional surgery under local anesthesia, with no severe incidents leading to reconstruction failure or prosthesis removal.

Patient satisfaction was evaluated across five categories: overall, aesthetic, physical symptoms, psychosocial, and decisional. Overall satisfaction was high in both groups (4.30±0.60 vs. 4.25±0.55); although the difference was not statistically significant (4.30 vs. 4.25, P=0.64); this small numerical difference should not be interpreted as a trend. In the item related to breast symmetry (Q2), both groups showed high scores (4.45±0.55 vs. 4.40±0.50), with no significant difference between the groups (P=0.71). For aesthetic satisfaction, the mean scores were generally good, and satisfaction in breast shape (Q4) was slightly higher in the thick ADM group (4.40±0.60 vs. 4.35±0.55), but there was no statistically significant difference (P=0.77). Satisfaction in breast size (Q3) and scars (Q5) also showed no significant differences between the two groups. Among physical symptoms, breast tactile sensation (Q6) and pain level (Q7) scores were both approximately 4.0 points, showing overall low physical discomfort after reconstruction, with no significant differences between the two groups. For psychosocial satisfaction, the item on self-confidence and self-esteem (Q8) was scored highly in both groups, and the difference between the two groups was minimal. Satisfaction in sexual attractiveness (Q9) showed slightly higher scores in the thick ADM group (4.35±0.65 vs. 4.30±0.60), but this was not statistically significant (P=0.76). The total score, reflecting the final satisfaction in the decision, was excellent in both groups (4.23±0.50 vs. 4.22±0.48), and no significant differences were observed depending on the reconstruction method (Table 3).

Discussion

Breast cancer has a high survival rate when diagnosed and treated early. Therefore, immediate reconstruction is now actively performed as part of a total or partial mastectomy. With sufficient interdisciplinary consultation and preoperative discussions with the patient, reconstructive breast surgery is even considered to improve postoperative breast shape and volume after BCS. Breast reconstruction is performed with the aim of maintaining symmetry with the contralateral healthy breast and restoring the patient’s preoperative appearance. The reconstructive surgeon’s clinical training and experience are crucial because total reconstruction, partial reconstruction, and even simple wound revision can result in partial deficits, even if the procedure is broadly performed according to the planned procedure. In such cases, the patient’s course is monitored, and secondary surgery can be considered for further correction. However, from the patient’s perspective, completing the treatment with a single procedure is preferred. Surgeons face limitations in performing larger surgeries due to mild deficits in volume or aesthetics. The potential for complications associated with larger surgeries also needs to be considered. In addition, patients’ living conditions usually necessitate a rapid return to daily living. When patients are satisfied with their preoperative breast shape or volume and wish to preserve their preoperative appearance with minimal intervention, even if the scope of surgery is relatively small, mild volume deficits may become apparent during postoperative follow-up and treatment in parallel (Figure 7). A thick ADM can be a very useful material in such cases.

Figure 7 Indications for the use of thick ADMs. (A) Preoperative findings. A depression is predicted even though the excision volume is relatively small due to small breasts. (B) Six-month postoperative findings after glandular reshaping. The patient was observed to need further recovery for postoperative RTx, and a concave depression was observed around the incision. ADM, acellular dermal matrix; RTx, radiotherapy.

Key findings

In this study, the investigational group encompassed patients who underwent partial mastectomy with subsequent partial breast reconstruction, resulting in clear differences in the distribution of adjuvant RTx between the groups. As expected, patients in the investigational group were more likely to undergo postoperative adjuvant RTx, whereas a higher proportion of patients in the control group did not receive RTx (Table 1). TNM stage and pathological diagnosis showed trends for an earlier disease stage and higher frequency of certain pathological subtypes in the investigational group, reflecting the possibility that clinical characteristics indicated for small, thick ADM use were selectively included owing to the study design. These factors should be considered when interpreting the results (Table 1). As observed in cases of partial breast reconstruction using a small, thick ADM, partial volume deficits can be effectively filled by adding a small, thick patch of ADM to the oncoplastic technique (Figures 4,5).

Strengths and limitations

In the present study, thick ADM was used to restore the approximate required volume through a less extensive intraoperative approach, avoiding the need for additional donor-site surgery. Since this approach did not cause serious complications and demonstrated stability in follow-up monitoring, even after the cases reported, the authors have continued to implement these techniques when required, after providing thorough preoperative explanations to the patients. Although the prospective design offers several advantages, there are also important limitations. First, despite the prospective approach, clinically and statistically significant differences existed in baseline characteristics between the thick ADM cohort and the reference group, particularly regarding reconstructive technique, adjuvant radiotherapy, and TNM stage. These imbalances may have influenced both complication profiles and satisfaction scores, and thus our findings should be regarded as exploratory and hypothesis-generating. Second, the sample size of the thick ADM group was relatively small (n=20), and several outcome measures did not reach statistical significance. Given the small sample size and significant baseline imbalances, the statistical power of the present study is insufficient to draw definitive conclusions, and larger adequately powered studies are required. Larger, adequately powered studies, ideally with multicenter participation, are required to confirm and extend these preliminary observations. Third, most clinical and patient-reported outcomes were assessed within 6 months postoperatively, reflecting our institutional follow-up pattern during adjuvant treatment and early recovery. This relatively short observation period limits evaluation of long-term safety, stability of volume correction, and late aesthetic changes, especially in irradiated breasts, and longer-term follow-up studies are warranted. Fourth, patient satisfaction was evaluated exclusively using a modified KNU Breast-Q questionnaire, which, although practical in our setting, remains a subjective self-reported instrument.

Related literature and technical considerations

ADM has recently gained attention as a prosthetic material for breast reconstruction, with multiple reports describing various surgical techniques and methods of use (19). ADM can facilitate integration with surrounding tissue and deformity prevention by providing a framework in part of the defect site. ADM-assisted reconstruction has been associated with decreased capsular contracture and favorable aesthetic outcomes in long-term follow-up (20). This benefit is most evident in prepectoral implant-based reconstruction versus subpectoral placement and likely reflects both surgical plane selection and careful patient selection rather than ADM alone. When using ADM, it is recommended to place the dermal side away from the tissue requiring integration, and then fix the patch with 3–4 sutures to minimize the risk of malposition. Standard ADM thickness is typically 0.5 cm. Therefore, for example, a 4 cm × 5 cm × 0.5 cm patch will occupy a volume of approximately 10 cm³. Given that the ADM is relatively firm, placing it immediately deep to the skin flap is not recommended because it may be visible or palpable postoperatively. ADM should be folded accurately and firmly fixed. Designs in which the ADM is rolled into a cylindrical shape, or bunches together, are not recommended because they can lead to central necrosis (21) [The following scenario reflects prior published experience by the same authors (22,23) and was NOT used in the current study; it is included for contextual reference only]. In urgent cases with no other method (e.g., patients who absolutely refused a prosthesis and wanted coverage with an LD flap alone), when the LD muscle was too small or thin despite using a boomerang LD flap to maximize the effectiveness, these authors placed a large, thick ADM in the middle of the muscle flap, folded it bilaterally like a sandwich, and confirmed that the patients recovered without major problems. However, outcomes for tactile sensation and aesthetic appearance were short of exceptional (22,23). While ADM is generally unnecessary in reconstruction using abdominal flaps (transverse rectus abdominis myocutaneous flap or deep inferior epigastric perforator flap), which have ample volume, when performing breast reconstruction with an LD flap, a triangular depression can develop around the pedicle where it crosses over to the breast via the axillary tunnel. ADM can serve an adjunctive role to correct deficiencies during flap in-setting. Conversely, in cases of prosthetic breast reconstruction, it is not recommended to stack multiple small ADM patches to apply to a partial volume deficit. Broadly wrapping ADM around a silicone implant for reconstruction, especially when only using round breast implants, can fail to perfectly capture the appearance of natural breasts. However, when small patches of ADM are stacked together, integration between patches may fail outside of the suture locations, leading to the formation of separate capsules and malposition when the sutures dissolve or unravel. In such cases, volume deficit remains uncorrected, and migrating ADM can cause difficulties for the patient and the surgeon.

Explanations of findings

As demonstrated in this study, appropriately positioning a small-to-moderate-sized patch of thick ADMcan restore the preoperative appearance with a high success rate. When ADM is placed deep to a glandular or muscle flap rather than directly below a skin flap, it acts as scaffolding that can elevate the volume without showing palpable ADM. Consistently with this, in cases where thick ADM was placed superficial to the LD pedicle—a region where the overlying skin flap is generally thicker than the breast skin flap—on clinical follow-up, none of the patients reported bothersome palpability of the ADM. Thus, ADM was confirmed to be a very useful material for the correction of deficits in both partial mastectomy with partial breast reconstruction and total reconstruction, and radiological examinations during long-term follow-up also demonstrated successful integration. In the context of interdisciplinary care provided by a team including the Departments of Radiology, Breast Surgery, Hematology, and Oncology, it is important to share the characteristics of ADM to prevent errors in diagnosis or treatment. In particular, the Radiology Department must be informed that, in mammography, ADM can cause slightly higher fibroglandular density compared to the healthy side, and ADM can appear as a hypoattenuating mass-like lesion on computed tomography (CT) (Figure 8) (10,24,25).

Figure 8 Clinical correlations in breast CT and mammography. (A,B) In patients who underwent glandular reshaping with a small, thick ADM following partial mastectomy, the ADM demonstrates a hypoattenuating appearance on CT. (C) On mammography, fibroglandular density appears to be slightly increased; therefore, accurate communication of surgical details to the radiology department is essential. The arrows indicate the hypoattenuating area corresponding to the implanted ADM on chest CT. The circle indicates the area of increased fibroglandular density on mammography corresponding to the ADM site. ADM, acellular dermal matrix; CT, computed tomography.

Implications and actions needed

Future studies should incorporate more objective and quantitative measures—such as three-dimensional volumetric analysis, blinded surgeon-based aesthetic scoring, and imaging-based contour assessments—to strengthen the objectivity and robustness of the conclusions. Additional research is warranted to expand the small patient pool analyzed herein. Given the relatively short follow-up period, a comparative analysis is planned in a future study based on the continuing patient cohort. Although clinical safety was examined to some extent in this study, it would be advisable to conduct further objective data analysis to better specify various aspects of the indications for thick ADM.

Conclusions

This report shows that a thick ADM can be used safely and effectively to fill areas with a volume deficit of approximately 20–30% of the breast volume, requiring partial volume correction in breast reconstruction after partial or total mastectomy. With the appropriate manipulation and placement, depression and distortion can be effectively prevented, and breast contour and symmetry can be effectively maintained without increasing short-term complication rates.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0131/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0131/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0131/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-1-0131/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This prospective study was approved by the Institutional Review Board of Kyungpook National University Chilgok Hospital (No. 2022-05-004-001), and all patients provided informed consent to have their data (including de-identified photographs) recorded, analyzed, and published for research purposes.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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