Long-term outcomes and cost effectiveness of dermal autograft in breast reconstruction: a systematic review of the literature

Introduction

Breast cancer is the most common cancer in women worldwide, with 2.3 million new diagnoses and 670,000 deaths in 2022, and its prevalence will rise by nearly 38% by 2050 (1,2). Mastectomy remains the standard surgery for most women, either for oncologic therapy or risk reduction. For women, reconstruction of the breast is an important factor in recovery from body image, improved psychological adjustment, and overall well-being (3). Reconstruction demand transcends the world across various populations and health systems, and identification of safe, effective, and cost-effective reconstructive options becomes the priority to public health.

Implant-based breast reconstructive surgery commonly utilizes acellular dermal matrix (ADM) as a soft-tissue support, for implant placement, and for improving aesthetic outcome (4). ADMs are, however, expensive and have also been associated with problems of seroma, infection, and increased operating room expense (5). In the low- and middle-income countries, ADMs’ expense is prohibitive, limiting their use, and cheaper alternatives are needed (6). Dermal autograft (DA), taken directly from the patient’s skin, offer physiological compatibility while avoiding immune rejection; these can also reduce implant loss incidence, capsular contracture, and infection (7). Taking these potential advantages into consideration, long-term clinical effectiveness as well as cost-effectiveness compared to ADM is not known, and systematic economic evaluations are limited. In addition, systematic reviews are lacking in areas that will uniformly compare these strategies across patient populations and health care settings.

This systematic review will determine the long-term clinical outcome and cost-effectiveness of DA in mastectomy after breast reconstruction. By synthesizing current literature, it will provide evidence-based data to aid surgeons’ clinical decision-making, policy-making, and resource allocation, particularly where the use of ADM is limited by financial constraints in resource-poor environments. The findings will be used to clarify the role of DA as a cost-conscious and effective alternative to ADM in modern reconstructive practice. We present this article in accordance with the PRISMA reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-25-28/rc).

Methods

Literature search

This review follows the Cochrane review methodology. Registered on the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD420251014570), it was conducted on March 1, 2025. Data was collected from four databases: EMBASE, PubMed, Scopus and Google Scholar, as a supplementary source to identify additional studies. Studies were searched from inception until February 2025.

The search strategy used the following keywords: (“Dermal autograft” AND “Breast reconstruction”) OR (“Dermal autograft” AND “Breast reconstruction” AND “Long-term outcomes” AND “Cost-effectiveness”) OR (“Dermal autograft” AND “Breast reconstruction” AND “Acellular Dermal Matrix”). A detailed search strategy for each database is provided in Appendix 1.

Study selection

The selection and assessment of studies were managed using Rayyan software (https://new.rayyan.ai/) (8). Two authors independently reviewed the titles and abstracts of studies found in the database searches to evaluate their eligibility to potentially meet the qualification requirement for a full review based on defined inclusion and exclusion criteria. In case of any discrepancies, the article is proceeded to a full-text review. The inclusion criteria for the systematic review is as follows: (I) studies involving adults (aged ≥18 years) undergoing breast reconstruction using DA; (II) studies reporting long-term outcomes such as durability, patient satisfaction, and cost-effectiveness; (III) randomized controlled trials (RCTs), cohort studies, case series and case-control studies; (IV) studies published in English until February 2025, with adequate statistical reporting and clear outcome measures related to long-term outcomes and cost-effectiveness of DA compared to ADM or other reconstructive techniques.

Studies were excluded if they met any of the following: (I) published in languages other than English; (II) studies with no available full-text; (III) focused on reconstruction techniques other than DAs; (IV) did not present original data (e.g., reviews, editorials, opinion pieces); (V) lacked sufficient information on outcomes or adequate statistical reporting, making meaningful interpretation or comparison unfeasible.

Screening and data extraction

Study selection will be conducted independently by at least two authors, using predefined inclusion and exclusion criteria. Disagreements will be resolved through discussion or with the involvement of a third reviewer. The selection process will be documented using a PRISMA flow diagram, including reasons for exclusion at each stage.

Data extraction will be independently performed by at least two authors using a standardized form. Extracted information will include study characteristics (e.g., author, year, country), participant demographics, intervention details (use of DA), comparators (e.g., ADM), and primary outcomes such as graft survival, complication rates, patient-reported satisfaction and quality of life, economic evaluations, and rates of additional surgical interventions. No attempts will be made to contact study authors for missing data. Incomplete studies lacking critical outcome data will be excluded.

Assessment of methodological quality

Risk of bias will be assessed using the Newcastle-Ottawa Scale (NOS) tool for cohort studies, and National Institutes of Health (NIH) tool for the case series. One reviewer will carry out the initial assessment, which will be independently checked by a second reviewer. This process will evaluate the methodological rigor of included studies without contacting original authors. Risk of bias due to missing results and the overall certainty of findings will not be assessed as per the protocol specifications.

Results

Literature findings

A systematic review of the literature identified a total of 527 articles. Including 111 (Scopus), 162 (Embase), 200 (PubMed), 54 (Google Scholar). One hundred and ninety duplicates were initially identified and removed giving a total of 337 for screening. After applying the inclusion and exclusion criteria, only 16 met the eligibility requirements. The reasons for exclusion included: 5 articles focusing on the use of ADM/Allograft only, 3 that lacked long-term outcome data, and 3 with incomplete or insufficient data. Ultimately, 5 articles were selected for inclusion: 3 retrospective cohort studies, 1 prospective comparative study, and 1 retrospective case series (9-13), as illustrated in Figure 1.

Figure 1 Study selection following PRISMA guidelines.

Characteristics of included studies

The 5 included studies, published between 2012 and 2017, collectively comprised 175 patients, with individual sample sizes ranging from 16 to 48 participants. Four of the studies were conducted in the United States, while one originated from South Africa (10). Retrospective cohort designs predominated (n=3), alongside a single prospective comparative study (11) and one retrospective case series (13). Patients were largely female with ages ranging from 26 to 73 years. Reported comorbidities included diabetes, hypertension, chronic obstructive pulmonary disease, hyperlipidemia, among others (9,12,13). The use of DA was reported in all studies, and 3 studies used ADMs as a comparator (n=81 patients) (9,12,13). Operative times varied among studies, and the types of implants or tissue expanders used were documented in 5 studies and mainly included silicone gel implants. The source of the DA (e.g., breast and abdomen) was furthermore specified in all studies. Key postoperative outcomes included incidence of infection (9,10,12), wound healing complications (9,12,13), reoperation rates (9,12), capsular contraction (9). Total costs of surgery ranged from $3,924 to $12,685 for DA, and $9,088 to $66,832 for ADM. More than 18 patients required additional procedures (9-13). A comprehensive summary of the characteristics of the included studies is provided in Table 1.

Long-term clinical outcomes of DAs versus acellular dermal matrices

The long-term clinical outcomes from the five included studies reported notable patterns across data. Infection rates were consistently lower in DA groups compared with ADM groups where both were reported. In North [2017], infection occurred in 17.6% of DA patients versus 26% of ADM patients (9). Lynch [2013] similarly reported a lower infection rate for DA (14.3%) compared with ADM (25.9%) (12). Hudson [2012] reported an infection rate of 9.5% in its DA cohort, while Lynch [2015] and Rinker [2012] did not specify infection rates (recorded as NM). Implant loss was not consistently reported (10,11,13). Lynch [2013] documented implant loss in 4.8% of DA cases versus 14.8% in ADM cases (12). Rinker [2012] reported no implant loss, while the remaining studies recorded no measurement (13). Seroma formation was infrequently documented. The only quantitative reporting was from Lynch [2013], which identified a seroma rate of 18.5% in the ADM group and none in the DA group. Wound healing complications varied between studies (12). North [2017] reported higher rates in DA patients (23.5%) compared with ADM (14.8%), while Rinker [2012] documented only one patient with wound healing issues. Other studies did not specify data (9,13).

Reoperation rates were provided in limited studies. North [2017] reported reoperation in 17.6% of DA cases versus 26% in ADM cases (9). Rinker [2012] reported no reoperations, while Lynch [2013] recorded a rate of 18.5% for the ADM group, with no corresponding DA rate stated. Revision surgery rates and capsular contracture were minimally reported (12,13). Lynch [2015] provided a mean Baker grade of 1.15 for capsular contracture in its DA cohort, while other studies did not specify values. Patient satisfaction scores were uniformly high when reported (11). Lynch [2013] recorded a mean score of 6.8 (±0.3) for DA and 6.4 (±0.8) for ADM on a 7-point scale, while Rinker [2012] found that 88% of patients rated satisfaction at the maximum score of 7/7 and 12% rated 6/7 (12,13). Other studies reported NM for satisfaction. Overall, the available data suggest that DA achieves comparable or lower complication rates than ADM in infection, implant loss, and seroma formation, with high patient satisfaction when measured. However, reporting across studies was inconsistent, limiting the ability to perform direct pooled comparisons for all outcomes.

Cost analysis and resource utilization in breast reconstruction

The economic outcomes from the same five studies were also evaluated. Total surgical costs were reported in four studies, with consistent findings of lower expenditure for DA compared with ADM. North [2017] documented a mean total cost of $3,924.19±1,618.87 for DA versus $9,999.87±2,587.13 for ADM (9). Lynch [2013] reported unilateral reconstruction costs of $6,250 for DA and $9,088 for ADM, with bilateral procedures costing $8,517 for DA and $15,033 for ADM (12). Rinker [2012] presented total costs as $12,685 for all DA cases but did not provide a direct ADM comparator (13). Hudson [2012] did not report numerical costs, while Lynch [2015] qualitatively described DA as more cost-effective than ADM without specifying amounts (10,11).

Cost of reoperation was less frequently documented. North [2017] reported a mean reoperation cost of $9,999.87±2,587.13 for ADM, with no DA comparator stated. Rinker [2012] reported a total reoperation cost of $66,832 for DA cases, potentially influenced by the inclusion of high-cost revision procedures (9,13).

Additional procedures were more frequently required in ADM groups. For example, North [2017] reported that 10 DA patients required further intervention compared with 34 ADM patients, while Lynch [2013] recorded 5 patients requiring additional procedures in ADM versus 43 who did not. In DA cohorts, the proportion of patients avoiding secondary interventions was generally higher. Lynch [2015] noted that some DA patients required nipple reconstruction or breast augmentation, though the number was not specified (9,11,12).

Hospital stay duration was rarely reported. Only Rinker [2012] provided numeric values, noting a one-day hospital stay for DA cases. Other studies either did not measure or did not report hospital stay length (13).

Overall, the cost data indicate a clear trend toward lower primary surgical costs for DA compared with ADM, as there are potential downstream savings from reduced additional procedures. However, gaps in reporting particularly regarding reoperation costs and length of stay limit a comprehensive economic assessment.

Methodological quality and risk of bias

Two researchers independently assessed the risk of bias, and a third researcher resolved any disagreements. The quality of the included cohort studies was assessed using the NOS, which evaluates bias within three domains: (I) selection; (II) comparability; and (III) assessment of outcome. We judged the risk of bias based on each domain and classified the study as overall ‘poor’, ‘fair’, or ‘good’ quality. Four studies were evaluated as having poor quality, primarily due to the inadequate follow-up duration or completeness as seen in Table 2.

The single included case series was assessed using the NIH Quality Assessment Tool for Case Series Studies. Items 1–7 and 9 were rated “Yes”, while item 8 (“statistical methods well-described”) was rated “No” resulting in an overall good quality rating according to the AHRQ threshold as shown in Table 3.

Discussion

Clinical outcomes and cost-effectiveness of ADM versus DA in implant-based breast reconstruction were determined by this systematic review (Table 4). According to our results, DA shares the same clinical outcomes as ADM but with considerable reduction in healthcare expenditure. Combined outcomes revealed no statistically significant differences in rate of reoperation, infection, or wound complications between groups but with trends for all outcomes uniformly favoring DA. Notably, the economic analysis in all the studies uniformly favored the cost savings of autografts (9,17).

Although not statistically significant, our research revealed that DAs had fewer wound complications and lower reoperation rates than ADM, indicating similar or superior short-to-mid-term results. Compared to ADM, dermal grafts’ autologous origin may lower immunogenic potential risks (17,18). The sterile, patient-derived character of autografts may theoretically offer advantages than aseptically processed ADM, despite the fact that infection rates did not change considerably (12).

According to a study that gives an in-depth study of DAs in breast reconstruction, autologous dermal grafts have several advantages over synthetic materials and ADM, including better biocompatibility, a lower risk of immunogenic reactions, and a lower rate of infection. They also are free of the high costs of commercial ADM products. Despite these advantages, the study finds that DAs are still not widely used in modern practice, either as a result of perceived technical difficulties or a lack of broad understanding about the procedure (14).

In cases where panniculectomy is not conducted, abdominal tissue for autograft collection is unavailable, resulting in fewer reconstructive choices. These situations present a specific difficulty in individuals with a low body mass index (BMI) or those having skin-sparing or nipple-sparing mastectomies that lack considerable excess skin. ADM plays a crucial role in these situations by offering immediate structural assistance and enabling implant coverage when there is a lack of autologous tissue.

Other various methods have been suggested when panniculectomy-derived dermal tissue cannot be used, for example, by de-epithelializing mastectomy flaps or from contralateral breast tissue. These methods are promising but remain technically challenging and not widely standardized. Additional clinical data and protocol creation are required to establish their safety, reproducibility, and effectiveness (15).

Although ADM is commonly used, recent studies indicate that breast reconstruction can be effectively achieved without it. In a study involving patients who underwent nipple-sparing mastectomy, both ADM and non-ADM methods yielded comparable results, showing minimal to no variation in complications or aesthetic results (16). Likewise, another research indicated that prepectoral reconstructions lacking ADM achieved favorable 3-year outcomes, demonstrating robust implant positioning and low complication rates (14). These findings suggest that ADM may not be required for all reconstructions, particularly in prepectoral methods (15,16).

This is the first systematic review to directly compare ADM and DA in breast reconstruction, to present pooled outcome and cost data. Close methodological attention was paid at each stage of the search, selection, and data extraction to ensure the highest possible validity of our results.

But some of the limitations should be kept in mind. Included studies were mainly retrospective cohort designs with relatively low patient numbers. Surgical technique, autograft preparation technique, and complications definition varied between studies, and therefore heterogeneity was introduced. Besides, most of the studies have reported outcomes within a relatively short follow-up duration; therefore, inferences regarding late outcomes such as capsular contracture, aesthetic outcome, and patient satisfaction should be prudent.

Additionally, economic analysis did not rule out indirect costs such as operative time, hospital stay, or possible variation in revision surgery rates with longer follow-up. Publication bias is also irremovable since studies with positive results will get published. Though we tried to restrict this by having strict literature searches, inherent bias of the present evidence still remains a possible confounder. Another drawback is that the original authors of the included papers were not contacted for missing or ambiguous data, which would have compromised the thoroughness of our analysis.

These findings indicate that DAs are safe, efficient, and cheaper than ADM in breast reconstruction. Their increased usage could lead to reduced cost and improved rehabilitation access, especially in disadvantaged areas. Nevertheless, more extensive upcoming multicenter randomized controlled trials are needed to confirm these findings. More research should explore long-term outcomes, aesthetic satisfaction, quality of life, and cost-utility analysis to render a final verdict regarding the role of DA in current breast reconstruction protocols. Moreover, standard technical norms in terms of harvesting, processing, and implantation of DA need to be established in order to maximize the results and allow wider clinical application

Conclusions

For implant-based breast reconstruction, DAs are a safe and affordable substitute for ADM, as shown by this systematic review. Comparable clinical results between DA and ADM were found using pooled data from six studies, with non-significant trends favouring autografts in terms of infections, wound complications, and reoperation rates. Notably, DA continuously provided significant cost reductions, cutting medical expenses by thousands of dollars each surgery without sacrificing functional or aesthetic outcomes. Dermal grafts’ autologous origin removes the possibility of immunogenicity and biocompatibility problems linked to ADM, and their incorporation with native tissue may promote a positive recovery following surgery.

Limitations still exist in spite of these benefits, such as the prevalence of retrospective studies, limited sample numbers, and inconsistent methodology. Furthermore, conclusive findings on capsular contracture, durability, and patient satisfaction beyond the short-to-mid-term are not possible due to the absence of long-term follow-up data. However, the results highlight DA’s potential to increase access to reconstruction, especially in situations with limited resources where ADM costs are prohibitive.

Large-scale, prospective randomized controlled trials with standardized procedures and prolonged follow-up should be given priority in future research in order to validate long-term results. In the meantime, this evaluation backs the selective use of DAs as a practical, financially sound choice for breast reconstruction, in line with the increased focus on value-based surgical treatment.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-25-28/rc

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-25-28/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-25-28/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.

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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