ADM stands for Acellular Dermal Matrix. Its a type of skin that is derived from porcine (pig) or bovine (cow) origin and has all of the cells removed leaving behind the scaffold or "structure". It is becoming increasingly popular in its use in breast reconstruction

Why?

The use of an ADM allows a surgeon to create an internal bra like support or sling under the skin to allow placement of a permanent implant at the time of mastectomy, avoiding the need for a two stage procedure whereby the muscular pocket created is stretched with expansion of a saline fillled implant and after a period of time a second operation is performed to change the saline expander implant to a permanent one. On the surface of it, it sounds like a no-brainer, why have two operations when you can have one?. My initial enthusiasm has been tempered with caution for a number of reasons, many of which have only come from using it in a wide variety of reconstructive situations. I think my perspective comes because I am an Oncoplastic Breast Surgeon and my first and most important role is the treatment of breast cancer by surgery. My secondary role is that of breast reconstruction, and my priority and principles are always around the treatment of women with cancer, with aesthetics as a secondary issue. I have been using a product called Surgimend http://www.teibio.com/products/by-brand/surgimend/ and it is fantastic, it handles well, is strong, flexibile and seems to have all the properties one would want from an ADM, so why am I cautious in using it?. The main reason is that for some women, as oncologists, we do not know what other treatments may be needed until we have performed surgery, and after a mastectomy as reconstructive breast surgeons the one thing we "Fear" is that our reconstruction patient will need radiotherapy after the mastectomy and reconstruction and that the fear is that it will "ruin" our work. So for a patient where there may be a need for radiotherapy to the remaining skin and chest wall after a mastectomy (big tumour, positive nodes for example) then staggering the reconstruction may have advantages - a temporary implant first, which can be adjusted - followed by the radiotherapy - then the "real" reconstruction later, which could be a new permanent implant (not irradiated) with or without ADM, or their own tissues (an "autologous reconstruction". The flexibility to adjust the size of the implant before radiotherapy, the ability for the patient to make decisions about the final reconstruction after the dust of treatments has settled seems also to have advantages. Despite this fear i have often found a temporary implant reconstruction unrewarding - hard and painful, a bulge rather than a breast mound, little psychological benefit following the mastectomy and the inevitable capsule forming around the implant meaning the skin you hoped to "spare" is still removed at the final reconstruction. Sometimes I wonder whether with the right counselling a simple mastectomy and well planned delayed reconstruction is still a choice that sometimes we have forgottten about. The long and short of it is that it always comes back to the same principles - it is the patient who decides. Our job is to create the environment and provide the information that allows patients the time to reflect, choose and empower themselves to be in control of their treatment pathways, with us in the wings waiting to pick them up if they stumble, support them with little or lots of information and not choose the operation we want, but the operation that is right for them.