Breast reconstruction with a dermal sling: a systematic review of surgical modifications.

A dermal sling (DS) is used to cover the implant with two layers of tissue when immediate breast reconstruction is performed in women with large and ptotic breasts. It works as an autologous acellular dermal matrix/mesh that can be used to control the implant pocket and inframammary fold, without inferring an extra foreign material and higher costs. There is relatively little published about the DS technique. The primary aim of this study was to systematically review published surgical modifications to the dermal sling (DS). The secondary aim was to investigate what implants have been used. Relevant databases were searched for articles and abstracts published between January 1990 and September 2018. Inclusion criteria were studied and case reports on DS meeting the criteria defined in a PICO. Review articles were excluded. Total evidence for the different types of DSs was graded according to GRADE. A total of 428 abstracts were retrieved. Of these 373 abstracts did not meet the inclusion criteria and were excluded, leaving 54 abstracts. Nine categories of surgical modifications could be identified: classic dermal sling (DS) with minor modifications, non Wise-pattern mastectomy DS, nipple areola complex bearing DS, DS in combination with a matrix/mesh, DS as a suture line protection technique, DS with a modified circulatory basis, DS without an implant, DS as an immediate-delayed technique and pre-pectoral DS. The evidence for DS as a surgical technique is very low (GRADE ⊕). The DS can be used with both permanent implants and tissue expanders (GRADE ⊕).