Complications associated with acellular dermal matrix use in implant-based breast reconstruction

Acellular dermal matrix (ADM) has become an established adjunct in implant-based breast reconstruction, improving implant coverage, pocket control, and soft-tissue support and hastening the adoption of prepectoral techniques. Notwithstanding its more than two decades of use in breast reconstruction, breast reconstruction remains an off-label indication for ADM use in the US. Human, porcine, and bovine sources have all been used to provide ADMs. They undergo distinct processing and sterilization methods that may affect matrix architecture, host integration, and clinical performance. Following implantation, ADM serves as a biologic scaffold for cellular infiltration and neovascularization. However, its use remains associated with important complications, including seroma, infection, red breast syndrome (RBS), mastectomy skin flap necrosis (MSFN), implant exposure, and reconstructive failure. Reported outcomes vary widely across the literature, likely due to differences in reconstructive technique, mastectomy flap perfusion, ADM characteristics, perioperative management, and patient risk factors. Elevated body mass index (BMI), smoking, diabetes, prior radiation, larger ADM burden, and compromised skin flap vascularity consistently emerge as contributors to adverse outcomes. From a clinical standpoint, successful ADM use depends on judicious application, meticulous technique, and early recognition of evolving complications. Despite its off-label status, ADM use in breast reconstruction remains widespread and an important tool for plastic surgeons.