INTRODUCTION
In South Korea, breast cancer is the most commonly diagnosed cancer among women, and the proportion of early stage cases has steadily increased due to widespread national screening programs and heightened awareness [1-3]. Breast-conserving surgery (BCS) has become the standard treatment for early stage breast cancer, offering oncological outcomes comparable to those of total mastectomy while preserving the natural breast contour [4-7]. Despite these advances, postoperative volume deficits and contour deformities remain significant challenges, particularly when the excised tissue is large relative to the breast size. Such cosmetic concerns can negatively affect the psychological well-being and quality of life of patients, highlighting the need for reconstructive techniques to restore volume while maintaining symmetry [8,9].
Various oncoplastic techniques have been developed to improve the esthetic outcomes following BCS. The acellular dermal matrix (ADM) has gained attention for its biocompatibility, ease of use, and potential to support tissue regeneration [10,11]. Derived from cadaveric dermis through proprietary processing, ADM retains the biochemical and structural components of the extracellular matrix (ECM), promoting tissue remodeling and neovascularization. Its low antigenicity allows safe integration into the host tissue, minimizing complications, such as resorption, fibrosis, or encapsulation. ADM have been widely used in both implant-based and autologous breast reconstructions and have recently been applied to enhance cosmetic outcomes in partial breast reconstruction [12-14].
Pulverized or micronized forms of ADM have been introduced to enhance volume replacement, particularly for small-to-moderate defects after BCS. Compared with sheet-type ADM, pulverized ADM may offer advantages such as better conformity to irregular surgical cavities, reduced foreign body sensation, and potentially lower complication rates owing to its fine particulate nature and improved tissue integration [15,16].
Despite its increasing use, clinical studies on pulverized ADM in partial breast reconstruction remain limited. Most published data have focused on sheet-type ADM or their use in implant-based reconstruction, leaving a gap regarding their utility in volume replacement after BCS. Therefore, this study aimed to evaluate the early surgical outcomes of pulverized ADM in patients undergoing BCS for early stage breast cancer, with an emphasis on its safety, complication rates, and feasibility in clinical practice.
METHODS
Patient selection
A retrospective review of patients who underwent BCS with concomitant insertion of pulverized ADM for early stage breast cancer at a single tertiary institution between June and December 2024, was conducted. The inclusion criteria were as follows: (1) histologically confirmed early stage invasive breast cancer or ductal carcinoma in situ (DCIS), (2) eligibility for BCS based on tumor size and breast volume, and (3) immediate volume replacement using pulverized ADM. Patients who underwent total mastectomy or had incomplete medical records were excluded from the analysis. The patients were selectively enrolled based on the surgeon’s intraoperative assessment of the anticipated cosmetic defect.
Surgical technique
All procedures were performed by a single breast surgeon with clinical experience in breast surgery and more than 200 BCS cases annually.
Pulverized ADM was utilized when the estimated excision volume was judged to be sufficient to cause a noticeable contour deformity, particularly in patients with a relatively small breast volume or tumors located in cosmetically sensitive areas, such as the upper inner quadrant.
After tumor excision, negative margins were confirmed intraoperatively using frozen section biopsy. The surgical cavity was irrigated with sterile saline and meticulous hemostasis was achieved before ADM placement.
Pulverized ADM (Megafill; L&C BIO, Seoul, Korea) was hydrated with sterile saline in a sterile container and gently mixed to form a soft, pliable material suitable for filling the defect (Figure 1). Each unit measured 2.5 cc, and the number of units used was determined intraoperatively at the surgeon’s discretion based on the cavity size and shape. The hydrated ADM was carefully inserted to restore volume and maintain breast contour and, if needed, was stabilized with absorbable sutures. Layered closure of the breast tissue was performed using standard techniques (Figures 2,3). The surgical drain placement was performed at the discretion of the surgeon. When used, the drain was clamped for the first 3 hours postoperatively to allow local tissue stabilization before initiating drainage.
Data collection
Data were retrospectively collected from electronic medical records, including patient demographics (age, sex, body mass index [BMI], and underlying medical conditions), tumor characteristics (tumor size, histologic grade, pathological tumor (T) and node (N) stages, and biomarker status, including estrogen receptor [ER], progesterone receptor [PR], human epidermal growth factor receptor 2 [HER2], and Ki-67), and surgical variables. Operative details, such as the date of surgery, operative time, surgical site (left or right breast), anesthesia type, axillary procedure (sentinel lymph node biopsy [SLNB] or not), and weight of the resected tissue were recorded.
Postoperative outcomes included length of hospital stay, surgical site infection (SSI), seroma, other complications, and need for reoperation. All post-operative complications were monitored for 30 days. The data were anonymized and managed in accordance with institutional ethical standards.
Statistical analysis
Descriptive statistics were used to summarize the patient demographics, tumor characteristics, and surgical outcomes. Continuous variables are presented as means±standard deviations, and categorical variables as frequencies and percentages. All analyses were performed using IBM SPSS Statistics for Windows, version 29.0 (IBM Corp., Armonk, NY, USA). Statistical significance was set at p<0.05.
RESULTS
Patient characteristics
A total of 30 patients underwent BCS with immediate volume replacement using pulverized ADM. The mean age was 49.3±7.2 years, and the mean BMI was 23.8±4.7 kg/m2. All patients were female. Most tumors were located in the left breast (56.7%), with a mean tumor size of 11.5±7.0 mm. Sedative anesthesia was used in 83.3% of cases, while 16.7% received general anesthesia. Drain insertion and neoadjuvant chemotherapy were performed in 96.7% and 6.7% of the patients, respectively. Axillary surgery included SLNB in 66.7% of the patients, axillary lymph node dissection in 3.3%, and no axillary procedures in 30.0%.
The histopathological diagnoses included invasive ductal carcinoma in 43.3% of cases, DCIS in 36.7%, and other histological types (invasive lobular carcinoma, lobular carcinoma in situ, and other invasive carcinomas) in the remaining cases. The pathologic T stage distribution was 43.3% pTis, 50.0% pT1, and 6.7% pT2, with 96.7% of patients being node-negative. Regarding tumor biology, ER and PR were positive in 76.7% and 73.3% of the patients, respectively, while HER2 overexpression was observed in 16.7%. The mean Ki-67 proliferation index was 23.2±25.1%, and the mean specimen weight was 24.5±21.9 g. The baseline clinicopathological characteristics of the study population are summarized in Table 1.
Operative and postoperative outcomes
The mean operative time was 60.8±14.4 minutes, and the average hospital stay was 5.1±2.9 days. Postoperative complications were minimal: SSI and seroma occurred in one patient (3.3%). No other complications, such as hematoma, delayed wound healing, or adverse events, were reported. Importantly, none of the patients required re-operation during the early postoperative period. The surgical and postoperative outcomes are summarized in Table 2.
Follow-up ultrasonography performed 2 weeks postoperatively showed a well-maintained volume at the surgical site, with no fluid collection or inflammation around the inserted ADM (Figure 4). The implanted ADM appeared as a hypoechoic region consistent with soft tissue integration, without evidence of infection or adverse reactions.
DISCUSSION
This study aimed to assess the early surgical outcomes of using pulverized ADM for volume replacement after BCS in early stage breast cancer, focusing exclusively on outcomes within the first 30 postoperative days. Our findings indicate that using pulverized ADM is technically feasible, safe, and well-tolerated for immediate defect reconstruction following partial mastectomy. All 30 patients successfully underwent BCS with immediate volume restoration using pulverized ADM, without intraoperative complications or the need for early revision. The overall complication rate was low, with only one case (3.3%) of SSI and one case (3.3%) of seroma, both of which were managed conservatively without additional surgical intervention.
The average operative time was approximately 60 minutes, and the length of hospital stay was aligned with the standard postoperative recovery following BCS with oncoplastic reconstruction. These results suggest that pulverized ADM does not substantially prolong surgery or increase perioperative morbidity.
Although ADMs are widely used in implant-based and autologous breast reconstruction [17,18], their application in partial breast reconstruction after BCS, particularly in pulverized or micronized forms, has been less studied. Traditional sheet-type ADM, while effective, may be difficult to shape and conform to irregular lumpectomy defects [11,19]. In contrast, pulverized ADMs offer greater pliability and adaptability to cavity geometry, enabling more natural restoration of the breast contour without extensive dissection or anchoring sutures. This is particularly advantageous for small- to moderate-volume excisions, in which subtle asymmetry is particularly noticeable in women with smaller breast volumes.
The biomechanical and biological properties of pulverized ADM may contribute to its favorable profile. By preserving ECM components such as collagen, elastin, and glycoproteins, while removing immunogenic cellular elements, ADM supports neovascularization, fibroblast migration, and host tissue integration [20,21]. Its fine particulate structure increases the surface area, potentially accelerating tissue ingrowth, and reducing the risk of encapsulation or fibrosis, which are common concerns with larger ADM constructs [22]. Additionally, its low antigenicity and lack of rigid architecture likely reduce the incidence of foreign body sensation, a frequent issue with sheet-type ADM, especially in superficial planes.
Another key advantage is the intraoperative handling and adaptability of pulverized ADM. Its prehydrated, malleable consistency allows surgeons to tailor the volume and distribution of each defect, enhancing aesthetic precision without a steep technical learning curve. In our study, all procedures were performed by a single surgeon experienced in oncoplastic techniques. However, the simplicity of the technique suggests that it can be widely adopted, including in settings with limited access to complex reconstructive options.
These findings provide preliminary clinical insights into the growing demand for personalized and aesthetically considerate breast cancer care. As early detection increases and more patients become eligible for BCS, the maintenance or restoration of breast symmetry and volume remains an important consideration not only for cosmetic appearance but also for psychosocial well-being. Previous studies have reported that dissatisfaction with cosmetic outcomes may be associated with reduced self-esteem, body image concerns, and regret regarding treatment choice. In this regard, readily accessible volume replacement approaches, such as pulverized ADM, may represent potential adjunct options, pending further validation in well-designed comparative and long-term studies.
This study had several important limitations. First, its retrospective, single-institution design and small sample size limit the generalizability of the findings and preclude meaningful comparative analyses. Second, cosmetic satisfaction and objective aesthetic outcomes were not formally assessed using validated tools, such as BREAST-Q or standardized photographic analysis. Third, the evaluation was restricted to early postoperative outcomes (within 30 days); therefore, long-term data regarding volume retention, ADM resorption or fibrosis, patient satisfaction, and oncological safety, including local recurrence, were not available. These limitations underscore the preliminary nature of this study.
Accordingly, the results of this study should be interpreted as an early feasibility and safety assessment rather than as evidence of long-term clinical effectiveness. Future prospective studies incorporating control groups, standardized aesthetic evaluations, patient-reported outcomes, and long-term follow-ups are essential to establish the true clinical value of pulverized ADM in partial breast reconstruction.
In conclusion, pulverized ADM appears to be a feasible and safe option for immediate volume replacement after BCS, with favorable early surgical outcomes. However, these findings are preliminary, and larger prospective studies with objective aesthetic evaluation and long-term follow-up are required to confirm their clinical value.
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