The three main options for soft-tissue support in implant-based breast reconstruction — non-biological synthetic mesh, human- or porcine-derived dermal ADM, and bovine pericardium biological matrix such as ExaShape® — compared on origin, integration, supply, cost and regulatory status.
Choosing a biological matrix for breast reconstruction means weighing three families of soft-tissue support. In implant-based breast reconstruction, surgeons reinforce the implant pocket with a soft-tissue support. These fall into two broad classes. The first is non-biological synthetic mesh (often a knitted polymer, sometimes titanium-coated). The second is the biological matrix class — decellularised biological scaffolds that support host-tissue integration. Within the biological-matrix class there are two families that are often conflated: dermal ADM (acellular dermal matrix), from human allograft or porcine dermis, and bovine pericardium biological matrix, such as ExaShape®. Both dermal ADM and bovine pericardium matrix are acellular biological scaffolds — so a bovine pericardium matrix is itself a biological matrix, sitting in the same family as ADM rather than opposite it. What sits outside that family is synthetic mesh, which is not biological. The table below sets out all three side by side.
For a full overview of the biological matrix for breast reconstruction, see our dedicated guide. ABC’s device in this class is the ExaShape® line — a 100% bovine pericardium acellular scaffold engineered for prepectoral and direct-to-implant techniques.
| Synthetic mesh (non-biological) |
Dermal ADM (human or porcine dermis) |
Bovine pericardium biological matrix (e.g. ExaShape®) |
|
|---|---|---|---|
| Class | Non-biological synthetic implant (polymer, sometimes titanium-coated). | Biological — acellular dermal matrix. | Biological — acellular pericardial matrix. |
| Tissue of origin | Manufactured polymer (e.g. polypropylene); no biological tissue. | Human cadaveric dermis (allograft) or porcine dermis (xenograft), decellularised. | Bovine pericardium (the sac around a cow’s heart), decellularised. |
| Structure | Engineered knitted or woven synthetic scaffold. | Dermal collagen matrix retaining native dermal architecture. | Collagen-rich pericardial membrane; ExaShape® is a bilayer configuration. |
| Tissue integration | Host tissue grows around the mesh, which remains a permanent synthetic implant. | Well-documented host integration; long clinical track record, especially human ADM. | Supports host cell repopulation and revascularisation; 100% biological, no synthetic residue. |
| Supply & consistency | Fully manufactured; highly scalable and batch-consistent. | Human ADM depends on tissue-bank donor supply; porcine ADM is manufactured. | Xenograft supply is scalable and not dependent on human donor availability; batch-consistent. |
| Relative cost | Generally the lowest unit cost of the three. | Human ADM is typically the most expensive; porcine ADM sits in between. | Generally lower unit cost than human ADM. |
| Regulatory status (EU) | CE-marked medical device. | Varies by product; human-derived products face additional tissue-donation regulation. | CE-marked under EU MDR 2017/745. |
| Typical use | Prepectoral and subpectoral support, often chosen as a lower-cost option. | Prepectoral and subpectoral reconstruction; sling and full-coverage techniques. | Prepectoral and direct-to-implant (DTI) reconstruction; pocket, wrap and meshed variants. |
| Considerations | Non-biological; different long-term tissue interaction than a biological matrix. | Human- or porcine-derived origin may matter for specific patient preferences. | Bovine origin may matter for specific patient preferences; not human-derived. |
Educational summary for surgical audiences. Both dermal ADM and bovine pericardium matrix are biological (acellular) matrices; synthetic mesh is non-biological. Product selection should be based on individual clinical judgement, patient factors, current evidence and the applicable Instructions for Use.
This is not to say dermal ADM has no role: human ADM in particular has an extensive clinical evidence base and dermis-specific handling characteristics that many surgeons know well. Both are biological matrices, so the choice between them is a within-family decision that depends on the case, the evidence and the patient. What distinguishes the biological-matrix family as a whole from synthetic mesh is true biological integration — host repopulation and revascularisation rather than a permanent synthetic implant. The point is simply that a bovine pericardium biological matrix is a credible member of the biological-matrix family alongside ADM — often with advantages in supply and cost.
The figures below are drawn from peer-reviewed literature and ABC’s curated evidence library. They summarise outcomes reported for acellular bovine pericardium matrix and dermal ADM in implant-based breast reconstruction, with primary sources cited for every data point.
| Outcome | Synthetic mesh | Dermal ADM | Bovine pericardium biological matrix |
|---|---|---|---|
| Reference dataset | Randomised ADM-vs-mesh comparison (Gschwantler-Kaulich 2016). | Meta-analysis n=2,667 (Zhu & Liu 2023); real-world registry n=1,450 across 30 centres (iBAG, Masià 2020). | Multicentric prepectoral DTI series, n=65 (De Vita 2024); safety series n=20 (Casella STEP 2025). |
| Major complications | 31% overall in randomised ADM-vs-mesh data, similar across arms — Gschwantler-Kaulich 2016. | Commonly 15–30% across published series — Zhu & Liu 2023. | 9.2% (6/65) — De Vita 2024. |
| Implant loss / explantation | Limited comparative data reported for mesh specifically. | 6.5% in the largest multicentre prepectoral ADM dataset — iBAG (Masià 2020). | 0.9% pooled (1/111) — ABC Evidence Library (Mazzocchi; Varvaras). |
| Capsular contracture | Reported variably; limited pooled data. | 2.1% in the iBAG registry (Masià 2020). | Reported low in published bovine-pericardium cohorts; see the evidence library for cohort-level figures. |
| Additional note | Titanium-coated mesh is studied as a lower-cost, non-biological option; a comparative relative risk versus biological matrix is not established. | Longest published evidence base of the three, especially for human ADM. | No major complications; rippling 25% (n=20) — Casella STEP 2025, J Clin Med. |
Beyond individual products, meta-analytic data supports biological soft-tissue support in general: pooled analysis has associated matrix use with a relative risk of 0.74 for implant removal and 0.73 for infection versus no matrix, though these did not reach statistical significance (Carrillo et al. 2024, Gland Surg).
Both are biological (acellular) matrices — decellularised biological scaffolds used for soft-tissue support in breast reconstruction. "ADM" (acellular dermal matrix) refers specifically to matrices from human or porcine dermis, while ExaShape® is a bovine pericardium biological matrix. So a bovine pericardium matrix is not the opposite of ADM: it belongs to the same biological-matrix family, just derived from pericardium rather than dermis. What sits outside that family is non-biological synthetic mesh.
A biological matrix — whether dermal ADM or bovine pericardium matrix — is a decellularised biological scaffold that supports host cell repopulation and revascularisation. Synthetic mesh is a manufactured polymer (sometimes titanium-coated) that host tissue grows around but which remains a permanent synthetic implant. Biological matrices integrate biologically; synthetic mesh does not.
Within the biological-matrix family, the main alternative to dermal ADM is a bovine pericardium biological matrix (for example ExaShape®, including its PREPEC® and BioShield Pocket variants). Outside the biological family, synthetic and titanium-coated meshes are non-biological alternatives with different tissue-interaction profiles.
Both are biological matrices, so this is a within-family comparison rather than a biological-versus-non-biological one. In the largest multicentric prepectoral direct-to-implant series, acellular bovine pericardium matrix showed a 9.2% major-complication rate (De Vita 2024), and pooled bovine-pericardium cohorts report a 0.9% implant-loss rate (1 loss / 111 reconstructions). Human ADM has a longer published evidence base, including the iBAG registry of 1,450 procedures. Neither is universally "better"; selection depends on the clinical scenario, available evidence and patient factors.
For acellular bovine pericardium matrix, published data include a 9.2% major-complication rate (6/65; De Vita 2024, Clinical Breast Cancer) and a 0.9% pooled implant-loss rate (1/111). Dermal ADM series commonly report complication rates of 15–30% (Zhu & Liu 2023 meta-analysis, n=2,667) and a 6.5% implant-loss rate in the largest prepectoral ADM registry (iBAG, Masià 2020). For synthetic mesh, a randomised ADM-versus-mesh study reported around 31% overall complications, similar across arms (Gschwantler-Kaulich 2016). These figures come from separate studies with different populations and definitions of complication, so they are indicative rather than a like-for-like comparison.
Yes. ExaShape® and its variants are CE-marked under EU MDR 2017/745 and used in over 23 countries.
Synthetic mesh generally carries the lowest unit cost, human ADM is typically the most expensive, and porcine ADM and bovine pericardium matrix sit in between; a bovine pericardium biological matrix generally costs less than human ADM. Cost-effectiveness, however, depends on clinical outcomes and local pricing, not unit price alone.
Every figure on this page — and the complete set of peer-reviewed studies, comparative data and clinical dossiers behind the ExaShape and EXAFAT lines — lives in our searchable evidence library.
See ExaShape®, PREPEC® and the BioShield Pocket family.
View Products →Talk to the ABC clinical team about the ExaShape® bovine pericardium biological matrix.
Get in touchExaShape and PREPEC are registered trademarks of Advanced Biomedical Concept Srl. This page is educational and is not a substitute for clinical judgement or the applicable Instructions for Use.
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