Acellular Dermal Matrix Reconstruction Research Articles

Reconstructing Nasal Defects With Acellular Dermal Matrix After Mohs Micrographic Surgery: A 12-year Experience.

Large defects of the nose after Mohs surgery pose a significant reconstructive challenge to both dermatologic and reconstructive surgeons. The authors present their 12-year experience utilizing acellular dermal matrices for nasal reconstruction. A retrospective review of patients undergoing Mohs surgery and alloplastic nasal reconstruction with acellular dermal matrices between 2010 and 2022 was performed. Patients who underwent single-stage reconstruction and dual-stage reconstruction with skin graft with at least 90 days of follow-up were included. Fifty-one patients met criteria with a median age of 77 years. Fifty-three lesions were reconstructed with acellular dermal matrices. The most common lesion location was nasal sidewall (50%) with a mean defect size of 10.8 cm 2 . 30.8% underwent same-day acellular dermal matrix reconstruction, with 69.2% undergoing two-stage reconstruction. Acellular dermal matrices successfully reconstructed acquired defects in 94.2% of lesions. Average time to re-epithelialization was 27.6 + 6.2 days. Average time to repigmentation was 145.35 + 86 days. No recurrences were recorded. Total complication rate was 9.62%. Average size for successful healing was 10.8 cm 2 . Average defect size for complication or failure was 14.7 cm 2 . Seven sites (13.46%) underwent aesthetic improvement procedures. Acellular bilayer wound matrix is an adequate reconstructive option for single or dual-stage reconstruction of the nose with low complication and revision rates.

Application of Xenogenic Acellular Dermal Matrix for Reconstruction of Cervical Tracheal Defects in a Rabbit Model

Application of Xenogenic Acellular Dermal Matrix for Reconstruction of Cervical Tracheal Defects in a Rabbit Model

Single-stage acellular dermal matrix reconstruction of defects in the nose and ears with exposed cartilage: a prospective case series

BackgroundThe treatment of soft tissue defects with exposed cartilage after tumor excision is challenging. Local flap reconstruction causes occasional scarring, especially in non-Caucasian populations. Scar treatment requires secondary procedures for aesthetic modifications. Two-step reconstruction with an acellular dermal matrix addresses this issue and yields highly acceptable aesthetic resultsWe aimed to investigate the efficacy of an artificial dermal matrix cover using one-step reconstruction for defects with cartilage exposure.MethodsFrom July 2018 to September 2020, seven patients were enrolled and underwent a single-stage operation using acellular dermal matrices. Patients were followed up for at least 6 months and the size of the wound, days to heal, patient satisfaction, and scar scale scores were recorded.ResultsPatients were followed up for an average of 25.7 months. The average time to heal was 23.4 days postoperatively. No hyperpigmentation, tumor recurrence, or retraction was noted. High acceptance and satisfaction with the outcome were observed in all patients.ConclusionsSingle-stage reconstruction yielded high acceptance of aesthetic results similar to that in two-stage reconstruction. Less time and cost make this an effective and efficient treatment for soft tissue defects compared with traditional techniques.

Complication Profile of Total Submuscular Versus Prepectoral Tissue Expander Placement: A Retrospective Cohort Study.

We sought to compare the safety profile of prepectoral breast reconstruction with total submuscular tissue expander reconstruction, previously our standard. Primary outcomes of interest in this retrospective cohort study were incidence of infection, hematoma, seroma, mastectomy flap necrosis, and reconstruction loss. Total submuscular and prepectoral with acellular dermal matrix reconstructions consecutively performed by a single surgeon (P.D.S.) between January 1, 2016, and December 31, 2019, were compared. Demographic and clinical characteristics, as well as complications and complication types, were extracted for all patients. A t test was used to assess differences in continuous variables. Multivariate logistics regression was used to assess the association between type of reconstruction and complication rate. The statistical significance was set at 0.05 for all comparisons. A total of 133 patients (234 breasts) were included. There was a significantly greater incidence of infection (16.5% vs 5.5%, P < 0.01) in the prepectoral/acellular dermal matrix cohort. However, reconstructive loss was low in both cohorts (2.5% and 3.0%, P = 0.83). Adjusted odds ratio for complications in the prepectoral cohort was 2.26, but this was not statistically significant (adjusted P = 0.24). Prepectoral breast reconstruction shares an overall complication profile that is not greater than that of total submuscular reconstruction. It is associated with a greater risk of infection; however, the ability to salvage the reconstruction with early, aggressive intervention results in low rates of reconstructive loss, comparable with those of total submuscular reconstruction.

BROWSE: A multicentre comparison of nine year outcomes in acellular dermal matrix based and complete submuscular implant-based immediate breast reconstruction-aesthetics, capsular contracture and patient reported outcomes

Approximately 60% of implant-based breast reconstructions (IBBR) are performed with an acellular dermal matrix (ADM), for which, reliable, good quality long-term outcome data is limited. In a retrospective multicentre cohort study, we aimed to determine long-term aesthetic and quality of life outcomes of IBBR with ADM (Strattice™) compared to a submuscular technique. MethodsCapsular contracture (Baker III/IV capsule) was determined by clinical examination by an independent researcher. Quality of life was assessed using BREAST-Q and aesthetic outcome by photographic assessment from a breast surgeon, breast care nurse and lay person, blinded to reconstruction type. ResultsWe recruited 117 (51 bilateral) patients with ADM reconstructions, median follow-up 62 months (range 29–113) and 49 patients (16 bilateral) with submuscular reconstructions, median follow-up 76 months (range 38–111). 17 (10.1%) ADM reconstructions were Baker 3/4 compared to six (9.2%) submuscular (p = 0.85). Of the Baker 1/2 reconstructions six (3.6%) ADM and eight (13.6%) submuscular had previously undergone revision surgery to correct capsular contracture (p = 0.01). Combining both findings gave an estimated rate of capsular contracture of 13.6% in the ADM group and 21.2% in the submuscular (p = 0.14). A higher mean score for satisfaction with breasts was demonstrated when comparing ADM to submuscular (62 and 55, respectively; p = 0.01) but no significant difference in other BREAST-Q domains. The mean ‘general satisfaction’ score was higher in the ADM group for all three photograph assessors. ConclusionThis study provides evidence of improved aesthetic outcome and reduction in capsular contracture with ADM reconstruction when compared to submuscular, consistent over long-term follow-up.

Reconstruction of Large Upper Eyelid Defects Using the Reverse Hughes Flap Combined With a Sandwich Graft of an Acellular Dermal Matrix.

To investigate the usefulness of the reverse Hughes flap procedure combined with a sandwich graft of an acellular dermal matrix for reconstruction of large full-thickness defects of upper eyelids after cancer excision. Clinical data were obtained from patients who underwent upper eyelid reconstruction using a reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix (AlloDerm) as a tarsal substitute. The tarsoconjunctival flap of the donor lower eyelid was mobilized to reconstruct the posterior lamella, and acellular dermal matrix was grafted onto the tarsoconjunctival flap. A skin-orbicularis muscle flap superior to the defect was advanced to cover the acellular dermal matrix graft, followed by application of lid crease formation sutures to prevent postoperative entropion. The tarsoconjunctival pedicle was divided 3-8 weeks after the surgery. Six patients with sebaceous carcinoma were included, and all had ≥70% full-thickness upper eyelid defects after tumor excision. After a median follow-up of 40 months (range 6-62 months), all 6 showed satisfactory functional and cosmetic outcomes. Tumor recurrence, exposure keratopathy, upper eyelid entropion, persistent use of bandage contact lenses, lower eyelid deformity, and dermal matrix-related complications were not observed by the last follow-up. Reverse Hughes flap combined with a sandwich graft of an acellular dermal matrix as a tarsal substitute was successful in reconstructing large upper eyelid defects. Acellular dermal matrix graft and lid crease formation sutures enhance marginal stability and prevent postoperative entropion of the reconstructed upper eyelid.

Explantation in Tissue Expander and Direct-to-Implant Reconstruction with Acellular Dermal Matrix: How to Avoid Early Reconstructive Failures.

In the United States, approximately 57,000 tissue expander/implant-based breast reconstructions are performed each year. Complete submuscular tissue expander coverage affords the best protection against implant exposure but can restrict lower pole expansion. The benefits of using acellular dermal matrix are enticing, but questions remain as to whether or not its presence increases reconstructive failures. The purpose of this study was to investigate predictors of explantation in those patients with acellular dermal matrix reconstructions and to discuss salvage techniques. An approved retrospective review was conducted of 137 patients undergoing 234 individual breast reconstructions over 4 years performed by a single plastic surgeon (J.D.) at a single institution. Patients who underwent implant-based reconstruction with either immediate placement of a tissue expander that was subsequently exchanged for a permanent implant at a second operation or immediate placement of a permanent implant when indicated were included. One hundred thirty-seven patients who underwent 234 implant-based breast reconstructions using acellular dermal matrix met criteria. There was an overall 23 percent complication rate, including any cellulitis, seroma, skin necrosis, and hematoma formation. Significant preoperative risk factors for any postoperative complication included body mass index greater than 25 kg/m2 and a history of radiation therapy before acellular dermal matrix placement. Radiation therapy was found to be a significant risk factor for postoperative skin necrosis. Of explantations, many fluid cultures grew Gram-negative bacteria. Skin necrosis is a serious risk factor for explantation in implant-based reconstruction with acellular dermal matrix. The reconstructive surgeon should consider early excision of any skin necrosis as soon as it is identified. Risk, III.

Long-term outcomes of latissimus dorsi flap breast reconstructions: A single-centre observational cohort study with up to 12 years of follow up

The Latissimus Dorsi Myocutaneous Flap (LDMF) is used in post-mastectomy reconstruction. This study has evaluated long-term (up to 12 years) surgical- and patient-reported outcomes from LDMF procedures. A retrospective analysis of consecutive LDMF procedures in two UK hospitals, performed between 2006 and 2016. Case notes were reviewed for indications and outcomes. Patients were sent the BREAST-QⓇ survey by post. Outcomes, including surgical adverse events, revision, and implant loss rates, were correlated with patient risk factors. A BREAST-Q was posted to 199/248 LDMF patients in 2018, (excluding 49 patients due to death, reduced cognitive function and incorrect coding) of whom 77 patients responded (38.7%). In 188 cases (representing 208 LDMFs), surgical outcomes were assessable. Median time since LDMF surgery was 7 years (range 2-12). Rates of acute implant loss were 9/139 (6.4%), flap necrosis 7/208 (3.4%), shoulder stiffness 4/208 (1.9%), chronic pain 24/208 (11.5%) and unplanned revision surgery 13/208 (7%). Median satisfaction levels were high with 78% of patients satisfied with treatment outcomes, 65% of patients satisfied with their breasts, 71% of patients satisfied psychosocially and 75% of patients satisfied with their chest. Receipt of radiotherapy was not associated with a higher risk of flap necrosis or capsule formation. Long-term follow-up of a large cohort of LDMF reconstruction patients show relatively low levels of adverse events and unplanned revision surgery and high patient satisfaction, which demonstrates how temporally robust the technique is. With the rise in popularity of acellular dermal matrix reconstructions, the LDMF has relatively fallen out of favour but its potential in primary and delayed reconstruction is demonstrated.

Effects of Postmastectomy Radiation Therapy on Immediate Tissue Expander and Acellular Dermal Matrix Reconstruction: Results of a Prospective Clinical Trial

PurposePostmastectomy radiation therapy (PMRT) delivered to an immediate reconstruction increases the risk of surgical complications. Although acellular dermal matrix (ADM) has been used with immediate tissue expander (TE) reconstruction to improve cosmetic outcomes and minimize capsular contracture, there is a paucity of data on this approach in the setting of PMRT. Methods and MaterialsThirty-two patients with stage I to III breast cancer were treated with mastectomy, immediate TE-ADM reconstruction, and PMRT between 2009 and 2012 in a prospective single-arm study. The primary objective was the “success” rate, determined by the number of patients at 2 years after PMRT having an intact final reconstruction, no major complications, and a cosmetic outcome rated by a physician as excellent or good. ResultsThe median follow-up was 24 months. Final reconstruction status was known in 31 of 32 patients (96.9%; 1 patient left the country) and completed in 29 of 31 patients (93.5%; implant, n = 26; flap, n = 1; both, n = 2; none, n = 2). At 2 years, 6 patients were unevaluable (metastatic disease, n = 3; withdrawn consent, n = 1; left the country, n = 2). Of 26 evaluable patients, the success rate was 65.4% (17 of 26). Lack of success was the result of “fair” cosmesis (n = 2), infection (n = 2), severe capsular contracture (n = 1), major revision (n = 2), and no final reconstruction (n = 2). Most patients had good-to-excellent 2-year overall cosmesis based on patient perception (15; 62.5%) and physician evaluation (19; 79.2%). ConclusionsTo the best of our knowledge, this is the first dedicated prospective trial evaluating long-term cosmetic and complication outcomes in patients treated with immediate TE-ADM reconstruction followed by PMRT. Most patients (65.4%) met the success criteria in this prospective single-arm series. The great majority (93.5%) achieved final reconstruction; most had good-to-excellent overall cosmetic outcomes (79.2%). The results with longer follow-up will be of interest, and further investigation of strategies to optimize reconstruction with PMRT are warranted.

Use of Acellular Dermal Matrix for Reconstruction of Massive Rotator Cuff Tears in an Older Population

Use of Acellular Dermal Matrix for Reconstruction of Massive Rotator Cuff Tears in an Older Population

Clinical value of human acellular dermal matrix in reconstruction of giant complex abdominal wall defects after open abdomen

Objective To explore the clinical value of human acellular dermal matrix (HADM) in giant complex abdominal wall reconstruction (GCAWR) after open abdomen. Methods The retrospective cross-sectional study was conducted. The clinical data of 6 patients with severe trauma who were admitted to the Nanjing General Hospital of Nanjing Military Command of Nanjing University School of Medicine between January 2013 and January 2014 were collected. After open abdomen, fascia of the abdominal wall was fully freed using the component separation, and abdominal wall defects were reconstructed using HADM in the rectus abdominis anterior sheath and peritoneal layers bridge-type suture. Observation indicators: (1) intra- and post-operative situations: operation time, volume of intraoperative blood loss, removal time of postoperative drainage-tube, postoperative com-plications, duration of hospital stay and hospital expenses; (2) follow-up situations: recurrence of abdominal wall hernia at postoperative year 2. Follow-up using outpatient examination and telephone interview was performed to detect the recurrence of abdominal wall hernia up to April 2016. Measurement data with normal distribution were represented as ±s. Results (1) Intra- and post-operative situations: 6 patients underwent successful surgery. Operation time, volume of intraoperative blood loss and removal time of postoperative drainage-tube were respectively (77±9)minutes, (225±57)mL and (8±3)days. Two patients with postoperative seroma were cured by conservative treatment. One patient with postoperative anastomotic leakage received continuously irrigation and drainage, and leakage was stopped using the biomedical fibrin glue. There was no abdominal bulge of the 6 patients in hospital. Duration of hospital stay and hospital expenses were respectively (10±3)days and (12±7)×104 yuan. (2) Followup situations: 6 patients were followed up for 14-28 months, with a median time of 23 months. Two patients had relaxation and bulge of HADM in peritoneal layer at postoperative 2 years, without bulge of HADM in the rectus abdominis anterior sheath layer. There were no occurrence of abdominal wall hernia, chronic pain, paraesthesia, swelling in the local area and other adverse reaction. Conclusion Using of HADM in the rectus abdominis anterior sheath and peritoneal layers bridgetype suture is safe and feasible for GCAWR, with good short-term outcomes. Key words: Complex abdominal wall defect; Open abdomen; Human acellular dermal matrix

Capsular contracture in implant based breast reconstruction-the effect of porcine acellular dermal matrix.

Irradiation of implant-based breast reconstructions (BR) is known to increase capsular contracture (CC) rates on average by 4-fold over non-irradiated reconstructions. The use of acellular dermal matrix (ADM) has been associated with lower CC rates in non-irradiated reconstructions (0-3%). Experimental and clinical studies suggest that ADM may also reduce CC rates in irradiated breasts. The aim of this study was to evaluate CC rates in non-irradiated and irradiated one- and two-stage BRs performed with the assistance of porcine ADM (PADM). A single centre, retrospective, cohort study was designed from December 2008 to October 2012. A total of 200 immediate implant-based BRs were performed using PADM for inferior pole reinforcement. We included non-irradiated BR with a minimum follow up of 6 month from primary surgery (one stage) or from explantation of expander and implantation of the definitive implant (two stage). Of the postoperatively irradiated BR we included patients with 1 year or more follow up time from termination of radiotherapy. CC was graded using the conventional Spear-Baker classification and modified version for irradiated BR. According to the literature Grade III and IV CC were defined as clinically significant CC. Of 200 BRs with PADM, 122 were included in this study (84 non-irradiated and 38 irradiated). Sixty-five BR were one stage and 57 were two stage BR. Grade III/IV CC was remarkable low in non-irradiated (6%) and irradiated BR (13%). There was a non-significant trend to increased Grade III and IV CC in irradiated BR vs. non-irradiated BR (13% vs. 6%, P=0.216). In this study follow up time (P<0.001) and the stage of ADM reconstruction (two vs. one stage, P=0.022) were significant risk factors for occurrence of grade III/IV CC on univariate analysis and remained significant for the follow up time (P=0.013) and remarkable for the stages (P=0.093) in multivariate analysis. Our data support the current clinical evidence that ADM use in implant-based BR is associated with a reduced risk of CC when compared to the standard submuscular techniques in literature. The reduced risk is maintained in the setting of radiotherapy. Two stage procedures in our study population showed increased grade III/IV CC compared to one stage procedures with or without exposure to radiation.

Application of xenogenic acellular dermal matrix in reconstruction of oncological hypopharyngeal defects.

Acellular dermal matrix (ADM) can be used as a new membrane substitute for repairing mucosal defects. The objective of this study is to explore the effectiveness of xenogenic acellular dermal matrix (xeno-ADM) in hypopharynx reconstruction. A total of 40 patients were treated with this surgical method to reconstruct hypopharynx in our department between February 2011 and October 2012. Patients were diagnosed had hypopharyngeal cancer located at lateral and/or postpharyngeal wall. The mucosal defect size after hypopharyngeal resection was 3×4cm-6×7cm, and was repaired by xeno-ADM. Patients were followed up for 11-36months. 4 patients got infected, and two developed into pharyngeal fistula. Patients regained eating function 2-5weeks after surgery. No membrane was removed; no severe stenosis of hypopharynx was observed. All patients were successfully decannulated. The overall 3-year survival rate is 67.5%; the 3-year disease-free rate is 47.5%. Reconstruction of hypopharynx by xeno-ADM is proved to be a simple, safe and effective method with fewer complications.

Protocol for the prevention and management of complications related to ADM implant-based breast reconstructions.

Acellular dermal matrix (ADM) implant-based reconstructions have transformed direct-to-implant breast reconstruction (DTI). But like all surgery, it is not deplete of complications such as seroma, infections and wound healing problems. These are cited with varying frequencies in the literature. With increased experience and through a series of measures instituted to minimize complications, we have been able to improve outcomes for our patients. We report our technical refinements for prevention of ADM reconstruction associated complications including patient selection, implant selection, drains, dressing and our post operative antibiotic regime. We also outline our protocol for the management of ADM associated complications including seroma, simple and complex infection and red breast syndrome, such that the sequelae of complications are minimized and patients achieve a better long-term outcome.

Effects of Postmastectomy Radiation Therapy on Immediate Tissue Expander and Acellular Dermal Matrix Reconstruction

PTV was modified accordingly. Cosmesis was scored according to the Harvard scale at the 3 month follow up visit. Results: Since February 2014, ten patients were enrolled on this prospective registry. Median age was 57.4 (range: 42 e 77). Mean PTV volume was 76.4 cc (range: 131 e 54.6 cc), representing a 64% reduction in volume when compared to a conventional PTV margin. Mean time in treatment room was 36 min, of which 15 min was spent on patient set up and MR imaging. 100 online volumetric MR images were available for evaluation. The mean 90% and 95% prescription dose covered 99.7% (range: 99.1-100%) and 97.6% (range: 90.5 e 99.9%) of PTV respectively. Mean inter-fraction standard deviation in 90% and 95% prescription coverage was less than 1% of PTV (90% prescription coverage: 0.26% PTV, and 95% prescription coverage: 0.63% PTV). Evaluation of cine MR during treatment did not demonstrate significant intra-fractional motion. Maximum skin dose was less than prescription in all cases. Nine of the ten patients had 3 month cosmetic data collected per the Harvard scale for breast cosmesis. All nine patients had excellent (7/9) or good (2/9) cosmetic results. Conclusion: Delivery of MR-guided APBI with reduced margins achieved appropriate target coverage based on assessment of actual delivered dose with favorable short term cosmesis. To our knowledge, this is the first series of APBI patients to be treated using MR-IGRT with minimal margins, thereby sparing a greater proportion of normal breast. Efforts to collect local control and long term cosmetic data are currently underway. Author Disclosure: S. Acharya: None. B.W. Fischer-Valuck: None.M.C. Roach: None. R. Kashani: None. L.L. Ochoa: None. M. Yang: None. S. Mutic: Honoraria; Philips Healthcare. Consultant; ViewRay. Travel Expenses; American Association of Medical Dosimetrists, American Association of Physicists in Medicine, American Society for Therapeutic Radiation Oncology. Stock; TreatSafely, Radialogica. I. Zoberi: None. M.A. Thomas: None.

Porcine acellular dermal matrix for reconstruction of the dura in recurrent malignant schwannoma of the scalp

We used acellular dermal matrix (ADM) to reconstruct the dura in a patient with recurrent malignant schwannoma of the scalp. The patient had previously undergone ablative surgery with reconstruction and radiation therapy. The present recurrence involved the dura. Full-thickness resection was performed. Reconstruction was carried out using ADM, a free muscle-flap covered with at split skin graft, and healed primarily. The patient recovered completely. Dural reconstruction may be performed using foreign materials. Biologic materials may prove superior as they favour ingrowth of the patients’ own supporting tissues. We found that ADM provided the patient with at fluid-tight dural reconstruction. ADM may be a feasible alternative to other dural substitutes.

P114. Acellular dermal matrix versus latissimus dorsi breast reconstruction: An investigation of the costs

P114. Acellular dermal matrix versus latissimus dorsi breast reconstruction: An investigation of the costs

P116. Effects of trastuzumab treatment on the patterns of survival and metastasis in Her-2 positive breast cancers

P116. Effects of trastuzumab treatment on the patterns of survival and metastasis in Her-2 positive breast cancers

The efficacy of botulinum toxin A in post-mastectomy breast reconstruction: a pilot study.

Botulinum toxin A has been successfully used in a variety of areas to temporarily obliterate muscle mobility for either functional or aesthetic gain. Tissue expander-based breast reconstruction has been plagued with pain and discomfort. The purpose of this pilot study was to evaluate the role of a neurotoxin (Botulinum toxin A) in expander-based breast reconstruction. Thirty patients underwent mastectomies with immediate expander or acellular dermal matrix reconstruction. The neurotoxin group (n = 15) received 40 units of neurotoxin (Botulinum toxin A, Allergan, Inc, Irvine, CA) into each pectoralis major muscle through 4 serial injections and the placebo group (n = 15) received 4 serial injections of 0.9% NaCl. All patients were followed over 1 year, and patient demographics, VAS (visual analog score), laterality, office visits, amount of expansion and number of times to full expansion, and amount of narcotics required were recorded. Statistical significance was considered as p < .05. There were no significant differences between the two groups in terms of age, laterality, expander size, or complications (p = .46-.66). There was a significant difference between the two groups in the VAS score, demonstrating decreased pain in the neurotoxin group (p < .05). In addition, there was a significant increase in the volume of expansion per visit in the neurotoxin group as compared to the placebo group (p < .05). There was no significant difference in narcotic use in the first 3 days after surgery; however, there was a significant decrease in use of narcotics from 7 to 45 days in the neurotoxin group (p < .05). There were no complications associated with the use of the neurotoxin. The infiltration of the pectoralis major muscle with neurotoxin in immediate, expander-based reconstruction may be beneficial in reducing pain and expediting expansions.

Minimally invasive hand surgery

fitting the scope portrayed in the title. There are good descriptions of surgical technique and how to avoid the pitfalls when performing nipple reconstruction. Sadly, there are no photographs or medical illustrations to help visualise the techniques. In conclusion, the book has great promise in its title but, unfortunately, the chapters do not deliver to a satisfactory level. It is difficult to know who would benefit most from this book. There is certainly not enough surgical technique in the book to satisfy plastic surgeons wishing to learn the techniques. For breast surgeons, the general discussion of the free flaps and pedicled flaps will be useful. However, the other chapters lack the detail to fulfil tantalising promise of solving complications and avoiding unfavourable results. One would also expect a book such as this to be discussing, in depth, acellular dermal matrix reconstruction, secondary pedicles, dual plane techniques for implant replacement and, of course, lipomodelling. I look forward to the next edition of this book where I hope many of the deficiencies will be addressed.