Sir:
We have read with interest the article by Nahabedian1 on possible causes of red breast syndrome (RBS) after implantation of human acellular dermis matrix (ADM) in breast reconstruction surgery. We describe RBS and a newly described entity, red hand syndrome (RHS), associated with the presence of endotoxin in ADM.2 Endotoxin is a lipopolysaccharide contained in the cell wall of all Gram-negative bacteria and results in a robust sterile inflammatory reaction, consistent with that seen in RBS and RHS. Endotoxin is not inactivated by irradiation or other sterilization methods, and the inflammatory response is retained even if bacteria are nonviable and lyzed.3
In response to this finding, MTF Biologics (Edison, NJ) voluntarily introduced endotoxin screening of all ADM beginning in 2018 and have found reported dermis medical complaints overall to be dramatically reduced, and RBS-related complaints specifically to be eliminated, in all screened units as of 18 months of complaint follow-up (Fig. 1).
Fig. 1.
RBS and overall medical complaint occurrence rates for FlexHD and BellaDerm acellular dermal matrix by allograft packaging date, MTF Biologics, January 2017–June 2019.
To conclude, RBS, and the analogous RHS, can be caused by sterile inflammation due to endotoxin. This finding has implications for tissue processing and also for RBS diagnosis and treatment because steroids would be the preferred therapy for sterile inflammation (in contrast to antibiotics) if cultures are negative. Notably, polymerase chain reaction testing may be positive even if bacteria are nonviable. Further investigation is needed to elucidate the source of endotoxin in skin, presumably from colonization by Gram-negative organisms in dermal structures.4,5
DISCLOSURE
Dr. Kuehnert is the medical director of MTF Biologics and Dr. Kulber is on the MTF Biologics Board of Directors and Medical Board of Trustees.
Footnotes
Published online 21 November 2019.
Disclosure Dr. Kuehnert is the medical director of MTF Biologics and Dr. Kulber is on the MTF Biologics Board of Directors and Medical Board of Trustees.
REFERENCES
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