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Division of Plastic and Reconstructive Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Sheina A Macadam, Suite 1000-777 West Broadway, Vancouver, British Columbia V5Z 4J7. Telephone 604-876-1688, fax 604-876-1358, e-mail [email protected] Acellular dermal matrices (ADMs) were initially described for use in the resurfacing of burn injuries, abdominal wall repair, tympanic membrane replacement, dural repairs and gingival grafting (1-8). In the field of breast surgery, ADMs were first introduced for use in revisional aesthetic surgery, including correction of implant rippling, symmastia and soft tissue deficits (9,10). In 2005, Breuing and Warren (11) were the first to report on the use of ADMs in reconstructive breast surgery. They reported on a series of 10 patients who underwent bilateral mastectomies and direct-to-implant (single-stage) alloplastic reconstruction using a sling of AlloDerm (LifeCell Corporation, USA) inferiorly. These authors stated that their technique “avoids or shortens the tissue expansion/implant reconstructive process, avoids mastectomy flap contraction during the latency period of expansion, provides an additional layer of tissue between the skin and the implant, and offers an additional option for immediate, singlestage breast implant reconstruction”. The advantages of conversion of traditional two-stage reconstruction to a single-stage surgery in the appropriate patient were soon recognized and this approach has become standard of care in many surgical centres. Many surgeons also use ADMs in a two-stage approach using a tissue expander. This technique was first described by Bindingnavele et al (12) in 2007. They believed that advantages included decreased postoperative pain, faster expansion, elimination of the need for elevation of the serratus anterior muscle for lateral coverage of the prosthesis, improved lower pole projection, better aesthetic shape and improved soft tissue characteristics. The addition of ADMs to the traditional twostage tissue expansion reconstruction has become common; however, this application may be limited by cost in many centres. This evolution has resulted in the incorporation of ADMs into more than 60% of all alloplastic reconstructions in the United States in less than one decade (13). AlloDerm was the first ADM to be described in the literature and is human derived (ie, allogenic). Subsequently, multiple ADMs have entered the market derived from both allogenic and xenogenic donor sources. AlloDerm has the longest history and is most referenced in the literature, but other products include Flex HD (Ethicon, USA), DermaMatrix (Synthes, USA), AlloMax (Bard Davol, USA) and SurgiMend (TEI Biosciences, USA). Non-ADM synthetic mesh products have also been introduced and these include TiMesh (Biomet, USA) (titanized) and TIGR Matrix (Novus Scientific, USA) (absorbable synthetic) mesh. These products differ in their processing and, as a result, have differences in handling, incorporation, shelf life and cost. Presumably, many of these variables may affect outcomes; however, to date, differences in outcomes have not been established in the literature. Over the past decade, growth in the ADM market has been explosive. This has been due to increased surgeon and patient awareness, perceived benefits and reports of favourable outcomes. However, potential advantages need to be assessed in terms of cost in today’s economic environment. Additionally, well-designed studies are required to assess true outcomes and to compare these outcomes with those of non-ADM reconstruction.