Red Breast Syndrome: Complete Resolution Following Replacement of Acellular Dermal Matrices With Acellular Collagen Matrices

A 42-year-old premenopausal woman with stage 2 T2N0Mx breast cancer presented for consultation for bilateral breast reconstruction after bilateral skin-sparing mastectomy (Figure 1). The patient elected for reconstruction with subpectoral tissue expanders with the use of  acellular dermal matrices (ADM; AlloDerm).

During postoperative visits for expansion, the patient presented with bilateral red discoloration overlaying the position of the ADM. No signs of systemic infection such as fever, swelling, or tenderness to palpation were present on examination. The patient was initially managed conservatively; however, the erythema failed to resolve following 1 month of observation, and she developed pruritus with associated bilateral excoriations (Figure 2). Given lack of evidence to suggest infection, the patient was prescribed topical hydrocortisone cream and hydroxyzine with a working diagnosis of red breast syndrome (RBS).

Because of persistent RBS, ADM removal and placement of acellular collagen matrices (ACMs, SurgiMend) were performed to support the permanent implant as well as treat the RBS.

Upon her 3-week postoperative follow-up, the patient demonstrated appreciable improvement in both breast erythema and pruritus. By her 3-month postoperative follow-up, the patient experienced complete resolution of symptoms (Figure 3). She demonstrated good wound healing, breast shape, and symmetry.

RBS is a clinical diagnosis that describes the development of erythema in a very localized and predictable pattern on the breast skin overlying an ADM.^1,2 Signs of infection such as fever, swelling, warmth, and pain are generally absent, although more severe cases may include pruritus and tenderness. In the recent past, RBS has emerged as a hot topic in the plastic surgery literature. Although this syndrome has been similarly described by several authors with the emergence of erythema along the distinct boundaries of the ADM, this clinical phenomenon remains poorly understood regarding risk factors, demographics, etiology, management strategies, and long-term sequelae.

When RBS was first described, a type I hypersensitivity allergic reaction secondary to packaging additives was suspected to be the likely culprit.^1-3 Another author theorized a similar mechanism involving a processing agent utilized during the manufacturing of the ADM and, therefore, recommended intraoperative rinsing of the product prior to implantation.² Other immunology-based theories have since emerged. A type IV delayed hypersensitivity reaction was suggested after one author identified histologic evidence consistent with this mechanism in a punch biopsy of a breast with RBS.⁴ Other mechanisms to explain this phenomenon have been proposed including foreign body reaction, dependent erythema, neovascularization, graft incorporation, and lymphatic obstruction.^2-6 Some authors have speculated that dermal vs basement membrane orientation of the ADM, presence of free fat between the ADM and the skin flap, and residual DNA in the ADM could also explain RBS.^2,5,7-10

Whereas ADMs are considered nonimmunogenic and nonreactive,⁴ this reaction occurs in an appreciable number of patients. In a recent review of the literature, RBS had occurred in an average of 6.4% of patients' status post implant–based breast reconstruction.¹¹ Additional studies have attempted to identify a relationship between ADM processing technique and RBS development. One study comparing aseptic and sterile ADMs identified slightly differing rates of RBS development: 7.5% and 2.7%, respectively.¹² Given the development of RBS even within terminally sterilized products, the authors concluded that the etiology of RBS is unlikely to be related to ADM processing techniques. Nahabedian and colleagues¹¹ further expounded on this notion, stating that the incidence of RBS did not decrease with increased sterility of the ADM in their review. Contrarily, this idea was challenged by a study comparing ADM and DermACELL, in which RBS was found to occur in 26% of patients who underwent reconstruction with AlloDerm, compared with 0% of patients who underwent DermACELL-based reconstruction.¹³ Of note, DermACELL is sterilized to 10-6, whereas ADM is only sterilized to 10-3.

Although some have described RBS as a self-limiting disease, many patients will not have resolution without explanation of the ADM. In our case report, we presented the treatment of RBS with the replacement of ADMs with ACMs (SurgiMend). After a prolonged period of conservative management and observation, the patient failed to experience symptom relief, ultimately necessitating operative intervention. At the time of operative debridement of the ADM, exchange of the tissue expanders for permanent implants was achieved with the use of an ACM. The patient experienced significant symptom improvement in the initial weeks following surgery, and ultimately complete resolution in the months following.

Affiliations: ¹Department of Surgery, University of Louisville, Louisville, KY; ²University of Louisville School of Medicine, Louisville, KY; ³Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Louisville, Louisville, KY

Correspondence: Samuel L Corey, MD; drcorey@samuelcoreymd.com

Disclosures: The authors report no known or perceived conflicts of interest regarding the material presented in this manuscript.