Patent Publication Number: US-11642216-B2

Title: Soft tissue repair grafts and processes for preparing and using same

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a continuation of U.S. patent application Ser. No. 16/125,435, filed Sep. 7, 2018, now issued as U.S. Pat. No. 10,813,743 on Oct. 27, 2020, and which is hereby incorporated herein in its entirety. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates generally to grafts for soft tissue repair and capable of supporting, covering or retaining an implant positioned in the body of a subject. More particularly, the present invention relates to grafts capable of supporting, covering and retaining an implant for breast reconstruction and similar plastic surgery procedures, and especially for pre-pectoral breast reconstruction procedures. 
     BACKGROUND OF THE INVENTION 
     Surgical procedures for the repair, reconstruction and modification of tissues, organs, and other body parts of humans and other species are common. Such surgical procedures include, for example, the repair of ventral abdominal hernias and other abdominal wall defects, the repair and reconstruction of bone and skin having damage from injury or disease, and the reconstruction or modification of the breast, nose, buttocks and other organs and body parts to repair damage from injury or disease or for aesthetic reasons. 
     These repair, reconstruction and modification procedures often involve the use of grafts which serve to replace, restore or supplement the structure or function of the tissues, organs, or other body parts being treated. In some cases, grafts are used to support, cover and/or retain one or more other devices (e.g., an implant), to achieve the desired repair and reconstruction. Grafts may also be used to deliver and administer therapeutic agents or substances, such as pharmaceutical compounds, antibiotics, tissuegenic agents, bioactive substances, etc. 
     Grafts must generally be biocompatible and not immunogenic. In addition, depending on the particular surgical procedure, differences in the size, shape, flexibility, density, tensile strength, ability to retain or release therapeutic agents or substances, ability to support and grow cells, and other properties, may be beneficial. For example, materials initially having a generally planar or sheet-like configuration, with good flexibility and tensile strength, have been found useful for making grafts to support and retain a breast implant such as that implanted during breast reconstruction. 
     Breast reconstruction procedures are sometimes performed to repair and reconstruct a breast from which tissue has been removed, such as by mastectomy to remove cancerous tissue, in which case a breast implant substitutes for the removed tissue. Sometimes breast reconstruction is performed for breast augmentation and the breast implant adds volume to existing tissue. In any case, the breast implant should enable formation of a natural breast shape. 
     Materials used to make grafts for breast reconstruction should possess biomechanical properties including predictable suppleness, flexibility and uniform pliability sufficient for such grafts to stretch and expand without tearing during tissue expansion (i.e., using the breast implant and/or a tissue expander), as well as to conform to both the shape and contour of the implant and the shape and contour of the breast pocket. The most suitable materials for breast reconstruction and similar plastic surgery procedures should also possess sufficient tensile strength to preclude suture tear-out, both during implantation and expansion through the post-operative phase, and allow rapid and efficient cellular ingrowth equally from either side of the graft. 
     For example, processed dermal tissue, which has been decellularized to reduce immunogenicity, is generally known to possess the aforesaid biomechanical properties and has been used in breast reconstruction procedures with some success as grafts for covering, supporting, and/or retaining breast implants. Such acellular dermal matrices (“ADMs”) are commercially available, including FlexHD Structural® ADM and FlexHD Pliable® ADM, both of which are marketed by Musculoskeletal Transplant Foundation (Edison, N.J.), as well as AlloDerm® ADM and AlloDerm® Ready to Use (“RTU”) ADM, both of which are marketed by LifeCell Corporation (Branchburg, N.J.). The ADMs are cut to suitable dimensions and shape to conform to the breast implant and the implant location in the patient. Furthermore, while suitable ADM may be derived from almost any animal having skin, ADMs used for breast reconstruction procedures have most often been derived from mammals, and especially humans and pigs. 
     Historically, the first breast reconstruction procedures were performed with a breast implant simply placed in a breast pocket, such as created by mastectomy, to replace the excised breast tissue. Unfortunately, this method was fraught with problems, mainly related to capsular contracture, with resulting hardening of the implants and externally visible rippling or puckering of the skin and underlying tissue. This capsular contracture was found to be reduced when muscle coverage is added over the implant. Therefore, to overcome the capsular contracture problem, the breast implants were then placed under (i.e., behind) the chest muscles, i.e., the pectoralis major and serratus anterior. This, however, resulted in other complications, including a much less natural shape for the reconstructed breast (due to muscle forces over the implant) and significantly more discomfort for the patient. 
     To address the foregoing issues, grafts made from ADM were developed and positioned to support the breast implant inferiorly (i.e., from underneath), which allowed the implant to still be placed under the pectoralis major. It has been shown that use of grafts made of ADM for breast reconstruction with breast implants decreased capsular contracture. 
     A more recently developed technique, known as pre-pectoral breast reconstruction, involves placement of the breast implant in front of the patient&#39;s chest muscles (i.e., pectoralis major), with total anterior coverage of the breast implant by an ADM graft instead. Such pre-pectoral ADM grafts have been cut from an ADM, at the time of the reconstruction procedure, to a size and shape suitable to cover the anterior of the breast implant and thereby support the breast implant without the need of pectoralis muscle. The ADM graft extends around the breast implant and is sutured to the pectoralis major at its peripheral edge to form a three-dimensional structure within which the breast implant is held. Thus, the shape of the ADM graft is important for achieving close conformance between the ADM graft, implant and surrounding tissue to reduce patient discomfort and aesthetically undesirable rippling or puckering. This arrangement provides improved results over the technique of placing the breast implant beneath the chest muscle, including a more natural shape for the reconstructed breast and reducing post-operative patient discomfort, while still minimizing capsular contracture and the complications caused thereby. 
     Nonetheless, further improvements to the results achieved by pre-pectoral breast reconstruction are desired, including more precise positioning of the graft with relation to the nipple, overall breast configuration and breast implant, as well as minimizing post-operative suture tear out, capsular contracture and development of externally visible rippling and other aesthetically unattractive, or physically painful and/or uncomfortable post-operative features. Accordingly, design modifications to grafts used to cover and support the breast implants in pre-pectoral breast reconstruction procedures, regardless of whether the grafts are made of ADM, have been developed that address the foregoing issues. 
     SUMMARY OF THE INVENTION 
     The present invention relates to a graft for soft tissue repair, and more particularly to a graft configured for use in pre-pectoral breast reconstruction surgical procedures. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The present invention will be further explained with reference to the attached drawings, wherein like structures are referred to by like numerals and/or letters throughout the several views. The drawings shown are not necessarily to scale, with emphasis instead generally being placed upon illustrating the principles of the present invention. 
         FIG.  1    is a top plan view of an exemplary embodiment of a soft tissue repair graft; 
         FIG.  2 A  is a perspective view of a subject having a breast to be reconstructed; 
         FIG.  2 B  is a cross-sectional side view of the subject of  FIG.  2 A , taken along the plane P, showing the breast B after reconstruction by a pre-pectoral reconstruction technique with a breast implant and a graft according to  FIG.  1   ; 
         FIG.  2 C  is a perspective view of the subject and reconstructed breast of  FIG.  2 B , where the skin flap S has been removed to show the chest muscle and implanted graft; 
         FIG.  3    is a perspective schematic view of a section of human skin and the various components thereof, from which acellular dermal matrices (ADMs) may be fabricated; 
         FIG.  4    is perspective schematic view of the section of human skin shown in  FIG.  3   , showing the cutting steps performed according to an improved fabrication process to produce improved ADMs; 
         FIG.  5   a    is a perspective schematic view of a section of human skin showing where cuts may be made according to a previously known fabrication process for preparing ADMs useful for making soft tissue repair grafts as described herein; and 
         FIG.  5   b    is a perspective schematic view of a section of human skin showing where cuts may be made according to an improved process for preparing ADMs useful for making soft tissue repair grafts as described herein. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     Detailed embodiments of the present invention are disclosed herein. It should be understood that the disclosed embodiments are merely illustrative of the invention which may be embodied in various forms. In addition, each of the examples given in connection with the various embodiments of the invention is intended to be illustrative, and not restrictive. Further, the figures are not necessarily to scale, and some features may be exaggerated to show details of particular components. In addition, any measurements, specifications and the like shown in the figures are intended to be illustrative, and not restrictive. Therefore, specific structural and functional details disclosed herein are not to be interpreted as limiting, but merely as examples for teaching one skilled in the art to variously employ the present invention. 
     The term “graft” refers to a biologically compatible material, tissue, or substance which is introduced into the body of a subject, either permanently or temporarily, to replace, improve or supplement the structure or function of tissue, an organ, or other body feature of the subject and includes, but is not limited to, those used for the administration or delivery of a therapeutic agent or substance. In the case of the grafts described herein which are used in pre-pectoral breast reconstruction procedures, planar grafts are generally most suitable, however, the term “graft” as used herein is not limited only to those having planar configurations. Grafts may be integrated into a patient&#39;s body after implantation. 
     Where a graft is made of material obtained from the same individual into whom it is implanted, it is “autologous.” Where the graft is made of material obtained from a different individual of the same species than the individual into whom it is implanted, it is “allogeneic.” Where the graft is made of material obtained from an individual of a different species than the individual into whom it is implanted, it is “xenogeneic.” The soft tissue grafts may be autologous, allogeneic or xenogeneic. 
     The term “implant” means a device or material that replaces a missing body feature or portion thereof, which may be lost through trauma, disease, or congenital conditions, and is intended to restore the normal function(s) of the missing body part. Furthermore, an implant can be any material, device or substance which is introduced into the body of a subject, either permanently or temporarily, to replace, improve or supplement the structure or function of tissue, an organ, or other body feature of the subject and includes, but is not limited to, those used for the administration or delivery of a therapeutic agent or substance. 
     The term “biocompatible” means that the graft or implant, when implanted in a subject, does not cause adverse effects such as, for example without limitation, toxicity, foreign body reaction, or cellular disruption. 
     Grafts for soft tissue repair described herein are suitable for supporting, covering, retaining, or any combination thereof, an implant positioned in the body of a subject. More particularly, the soft tissue repair grafts are capable of being more accurately positioned in a subject and more securely attached to adjacent tissues than previously known grafts. Furthermore, the soft tissue repair grafts are capable of greater expansion without tearing during tissue expansion (i.e., using breast implant and/or tissue expander), while concurrently conforming more closely to the shapes and contours of both the implant and adjacent body tissues, than previously known grafts. The improved ability of the soft tissue graft to conform closely to the shapes and contours of the implant and adjacent body tissues is more significant and apparent when those contours are more rounded, curved, protruding, or recessed (e.g., concave, convex, projecting, etc.), such as, without limitation, for a breast, knee joint, elbow joint, chin, fingertip, toe, heel, other similar body features, and implants for such body features. 
     While the aforesaid soft tissue grafts will be described in detail hereinafter as used in surgical procedures for breast reconstruction, their utility is not limited to such surgical procedures. Rather, persons of ordinary skill will recognize that the soft tissue grafts are advantageous for other surgical procedures as well, particularly those involving repair, reconstruction or modification of body features such as those mentioned above and others. 
     The features of the soft tissue repair grafts that provide the aforesaid improved characteristics will now be discussed with reference to  FIGS.  1 - 2 C . More particularly,  FIG.  1    is a top plan view of an exemplary soft tissue repair graft  10  suitable for use in a surgical procedure such as breast reconstruction. The soft tissue repair graft  10  has an arcuate peripheral edge  12  and a focal point F which is located generally at or near the geometric center of the graft  10 . An imaginary vertical axis V passes through the focal point F. An imaginary horizontal axis H also passes through the focal point F, with the vertical and horizontal axes V, H intersecting at the focal point F. In embodiments where the graft  10  is intended for use in pre-pectoral breast reconstruction procedures, for example, the focal point F will be positioned at the nipple of the breast undergoing reconstruction. 
     As shown in  FIG.  1   , the graft  10  has a generally circular or slightly oval shape. As will be understood by persons of ordinary skill in the relevant art, the graft  10  will have dimensions suitable for the location and size of the surgical site with which it is intended for use. For example, a larger sized graft  10  will be suitable and selected for a larger sized breast or breast pocket, and a smaller sized graft  10  will be suitable and selected for a smaller breast size. Generally, when the graft  10  has a generally oval shape and is intended for use in a breast reconstruction procedure, the vertical axis V will be of greater length than the horizontal axis H. More particularly, in some embodiments of grafts for use in pre-pectoral breast reconstruction, the ratio of the length (L v ) of the vertical axis V to the length (L H ) of the horizontal axis H may be from about 1.05 to about 1.30, such as from about 1.10 to about 1.20, or about 1.15. 
     Additionally, as shown in  FIG.  1    and for purposes described hereinafter, the graft  10  has at least three notches  14 ,  16 ,  18  at the peripheral edge  12 , including a top notch  14  located where the vertical axis V meets the peripheral edge  12  above the focal point F, and first and second side notches  16 ,  18  located where the vertical axis V meets the peripheral edge  12  on opposite sides of the focal point F. In embodiments of the graft  10  having three notches  14 ,  16 ,  18 , as shown in  FIG.  1   , for example, a user (e.g., surgeon) handling the graft  10  prior to implantation in a subject will be able to readily discern which is the top notch  14  and, therefore, which way to orient the graft  10  to ensure it is positioned properly to align with the shape and anatomy of the breast or breast pocket being reconstructed. More particularly, when the graft  10  has three notches  14 ,  16 ,  18  as described above and shown in  FIG.  1   , a user may determine a sequence of the notches  14 ,  16 ,  18  which extends the shortest overall distance and the notch  14  positioned in the middle of the other two  16 ,  18  is the top notch  14 . 
     With reference still to  FIG.  1   , due to the presence of the notches  14 ,  16 ,  18 , the peripheral edge  12  is discontinuous and a plurality of cuff elements  20 ,  22 ,  24  are formed. Each cuff element  20 ,  22 ,  24  is foldable along a respective imaginary arcuate line  26 ,  28 ,  30  (see dotted lines in  FIG.  1   ) which extends from the base of a respective pair of notches which forms each cuff element  20 ,  22 ,  24  to form a folded edge (see folded edge  32  shown in  FIG.  2 C ). For example, with reference to  FIG.  1   , one cuff element  20  is foldable along its respective imaginary arcuate line  26  between the notches  14 ,  16  which form that cuff element  20 . When all cuff elements  20 ,  22 ,  24  are thus folded, a reinforced folded edge  32  (see  FIG.  2 C ) extends substantially around the entire graft  10 . When thus folded, the cuff elements provide a superior ring (i.e., the reinforced folded edge  32 ) of contact with the muscle M for improved long term support of the implant I (see, particularly,  FIGS.  2 B and  2 C ). Each cuff element  20 ,  22 ,  24  may, for example without limitation, have a width W, measured from the peripheral edge  12  of the graft  10  (see  FIG.  1   ), of from about 7 millimeters to about 20 millimeters. In some embodiments, each cuff element  20 ,  22 ,  24  has a width of from about 10 millimeters to about 20 millimeters, or from about 15 millimeters to about 20 millimeters, or from about 10 millimeters to about 15 millimeters, or even from about 12 millimeters to about 18 millimeters. The width of each cuff element  20 ,  22 ,  24  will typically be based on the size of the breast implant being used, as is readily determinable by persons of ordinary skill in the relevant art. It should be further noted that where the graft  10  has more than one cuff element, they need not all have the same widths as one another. 
     In some embodiments (not shown per se), the graft  10  may be symmetrical, such that the vertical and horizontal axes V, H each extend to the farthest and oppositely positioned points on the reinforced folded edge  32  and are substantially perpendicular with one another. In other embodiments such as that shown in  FIG.  1   , the graft  10  may be symmetrical only along the vertical axis V, such that the vertical and horizontal axes V, H each extend to the farthest and oppositely positioned points  34 ,  36 ,  38 ,  40 , respectively, on the folded edge  32  and are perpendicular with one another, but the focal point F is a shorter distance from a bottommost (i.e., inferior) point  36  than from a topmost (i.e., superior) point  34  on the folded edge  32 . In some embodiments of the graft  10  suitable for use in pre-pectoral breast reconstruction procedures, the distance between focal point F and the bottommost point  36  is from about 40% to about 50%, such as from about 42% to about 48%, or such as about 45%, of the total distance between the topmost point  34  and the bottommost point  36 , thus optimizing distribution of breast volume around the nipple for improved breast shape and aesthetic outcome. In still other embodiments (not shown), the graft  10  may be asymmetrical, such that the vertical and horizontal axes V, H each extend to the farthest and oppositely positioned points on the folded edge  32 , but are not perpendicular with one another. Embodiments of the graft  10  which are either symmetrical only about the vertical axis V or asymmetrical may align more closely with a breast and, therefore, may be more suitable for use in breast reconstruction procedures. In all embodiments, the focal point F will be located at the intersection of the vertical axis V and horizontal axis H. In fully or partially symmetrical embodiments of the graft  10  described above, the focal point F is also positioned at the midpoint of the horizontal axis H. 
     Although not shown in the figures, as will be recognized by persons of ordinary skill in the relevant art, the graft  10  may have different quantities of notches and cuff elements. For example without limitation, in some embodiments the graft  10  may not have any notches, in which case the cuff element may also be entirely absent. Alternatively, as will be described below, in some embodiments of the graft  10  which lack any notches, there may be a single cuff element which extends at least partially, or even entirely, around the periphery of the graft  10  for folding to form a reinforced edge which would be coextensive with the single cuff element. Furthermore, as will also be understood by persons of ordinary skill in the relevant art, the graft  10  may, for example without limitation, include only two notches or even a single notch (such as, but not necessarily, positioned at the topmost (i.e., superior) point  34  of the graft  10 ), which could form two cuff elements (by two notches), or a single cuff element or even no cuff element at all (by a single notch). For example, a graft might include one or more notches which are too shallow or small to form cuff elements wide enough to be used and beneficial in the manner described above, but the notches would still perform the function of providing guidance for properly orienting the graft during its placement in a breast undergoing reconstruction. Thus, it is possible to produce the respective benefits of the notches or the cuff elements separately, i.e., even in the absence of the other feature. All such embodiments are within the scope of the grafts contemplated and described herein. The configuration of three notches  14 ,  16 ,  18  and three cuff elements  20 ,  22 ,  24  shown in the figures and described in detail hereinabove provides an efficient and effective combination of these features to provide the positional guidance for orientation of the graft  10  by a surgeon during pre-pectoral breast reconstruction, as well as formation of the reinforced folded edge  32  for securing the graft  10  (and thereby, the implant I), such as with sutures, in the desired position within the reconstructed breast B. 
     The graft  10  may include a plurality of arcuate slots or openings  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  at least partially through the graft  10 , which form a plurality of circular patterns  44 ,  46 ,  48  which are concentric about the focal point F. The concentric, circular pattern of slots or openings  42 ,  44 ,  46 ,  48  about focal point F allow for expansion of the two dimensional graft  10  to reshape into a three dimensional structure which conforms in least in part to the spherical shape of the breast implant. In some embodiments, at least some of the arcuate slots or openings  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  are entirely through the graft  10 . In preferred embodiments of the graft  10 , the slots or openings  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  are not mere holes or perforations, but rather, each of them  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  is elongated. The length of each individual slot (e.g.,  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g ), for example without limitation, is typically from about 5 millimeters and about 15 millimeters, with longer slots (e.g., slot  42   a ,  42   b ) forming the outer circular patterns (e.g., pattern  44 ) and shorter slots (e.g., slot  42   e ) forming inner circular patterns (e.g., pattern  48 ). Additionally, for example without limitation, in some embodiments, the distance x (see  FIG.  1   ) between successive slots (end-to-end) (e.g., slots  42   a ,  42   b ) should be from about 5 millimeters to about 15 millimeters, such as about 10 millimeters. 
     Typically, the slots  42   a ,  42   b  forming the outermost circular pattern  44 , are not closer than about 1.75 centimeters, such as without limitation, not closer than about 1.25 centimeter, or even about 1.5 centimeters, from the imaginary arcuate lines  26 ,  28 ,  30 , between the notches  14 ,  16 ,  18  (or from the reinforced folded edge  32  of the graft  10  after implanting). This placement of the slots  42   a ,  42   b  of the outermost circular pattern  44  minimizes the risk of unnecessarily weakening the tensile strength of the graft  10  during and after implantation. 
     The distance d (see  FIG.  1   ) between the slots (e.g., slots  42   b ,  42   d ) forming adjacent circular patterns (e.g., patterns  44 ,  46 ) should be from about 10 millimeters to about 20 millimeters, such as about 15 millimeters. In some exemplary embodiments, for larger sized grafts (such as having a largest diameter of from about 26 to about 22 centimeters, such as about 25 centimeters), the distance d between the slots (e.g., slots  42   a ,  42   c ) forming adjacent circular patterns (e.g., patterns  44 ,  46 ) should be from about 15 millimeters to about 20 millimeters. In some exemplary embodiments, for medium or average sized grafts (such as having a largest diameter of from about 24 to about 20 centimeters, such as about 22 centimeters), the distance d between the slots (e.g., slots  42   a ,  42   c ) forming adjacent circular patterns (e.g., patterns  44 ,  46 ) should be from about 13 millimeters to about 17 millimeters. In some exemplary embodiments, for smaller sized grafts (such as having a largest diameter of from about 18 to about 22 centimeters, such as about 20 centimeters), the distance d between the slots (e.g., slots  42   a ,  42   c ) forming adjacent circular patterns (e.g., patterns  44 ,  46 ) should be from about 10 millimeters to about 15 millimeters. 
     With reference now to  FIGS.  2 A,  2 B and  2 C , the use of the soft tissue graft  10  in connection with pre-pectoral breast reconstruction, and the benefits provided by the aforesaid features, will now be described. Embodiments of the soft tissue graft  10  intended for use in breast reconstruction procedures are generally implanted such that they at least partially cover, support and retain a breast implant I within the breast B of a subject. 
       FIG.  2 A  shows a perspective view of a subject having a breast B to be reconstructed.  FIG.  2 B  provides a cross-sectional side view of the subject of  FIG.  2 A , taken along the plane P, showing the breast B, after reconstruction using a pre-pectoral reconstruction technique to implant a breast implant I and an exemplary embodiment of the graft  10 . In  FIG.  2 B , the chest muscle M as well as the skin flap S and nipple N of the breast B are shown, with the graft  10  positioned in front of the chest muscle M and adjacent to the skin flap S, and the breast implant I positioned in a pocket formed between the chest muscle and the graft  10 . 
     One technique for performing pre-pectoral breast reconstruction, for example where a previous mastectomy procedure has already removed breast tissue and left a pocket between the breast muscle and skin, is to lift the skin flap S away from the chest muscle M of the breast, fold the cuff elements  20 ,  22 ,  24  of a graft  10  to form a reinforced folded edge  32  and insert the graft  10  superior to the chest muscle (pectoralis major) M and anterior and adjacent to the skin flap S of the breast B. The graft  10  is oriented and inserted in the pocket between the chest muscle M and skin flap S with its top notch  14  vertically aligned above the nipple N, and its focal point F directly underlying the nipple N. This cuff allows for some surface area of the graft that is folded under the implant to come in contact with the muscle and function as an anchor providing extra support for the graft-implant construct resulting in improved positioning of the implant long-term, thus counteracting forces of gravity long-term. Without the cuff, the graft-implant construct would only be in contact and supported by the breast skin, which stretches with time. 
     The graft  10  is affixed to the chest muscle M by suturing along almost the entire length of the reinforced folded edge  32  from the 4 o&#39;clock position to the 8 o&#39;clock position along the superior edge [ 26 ,  28 ,  30 ] and leaving a short portion (for example without limitation, from about 4.5 centimeters to about 8.5 centimeters in length) of the folded edge  32  unsutured so that a pocket (not shown per se) is formed between the chest muscle M and the graft  10 . A breast implant I or other biocompatible medical device (e.g., tissue expander) is inserted into the pocket and the pocket is then closed by suturing the remaining short portion of the folded edge  32  of the graft  10  to the chest muscle M. Suture failure, sometimes referred to as suture “tear-out,” often results in post-operative complications including, without limitation, the graft  10  and/or breast implant I shifting position relative to the natural breast B and nipple N, which may cause undesirable cosmetic changes and pain. The reinforced folded edge  32  formed by folding the cuff elements  20 ,  22 ,  24  of the graft  10  provides a location for suturing the graft  10  to the chest muscle M which reduces the risk of suture tear-out and corresponding complications. 
     Additionally, the reinforced folded edge  32  of the graft also provides an area for tissue ingrowth and stabilization of the pocket beyond sutures. As will be recognized by persons of ordinary skill in the relevant art, and although not specifically shown, even if the graft  10  does not include notches  14 ,  16 ,  18 , a portion of the graph proximate the peripheral edge  12  may nonetheless be folded against the graft  10 , in a single continuous cuff element, to form a reinforced folded edge  32  at which the graft  10  may be affixed to the chest muscle M with sutures (or staples, etc.), although there may be some slight puckering or gathering of the continuous cuff element portion of the peripheral edge  12 . Thus, the notches  14 ,  16 ,  18  serve not only as orientation guides as described above, but also minimize puckering and gathering along the folded edge  32  of the graft  10 . 
       FIG.  2 C  provides a perspective view of the subject and reconstructed breast B, where the skin flap S has been removed to render the chest muscle M and implanted graft  10  visible.  FIG.  2 C  also shows the nipple N artificially superimposed on the graft  10  to show its location relative to the graft  10  and its plurality of slots  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  and circular patterns  44 ,  46 ,  48 . The elongate and arcuate shape of the plurality of slots  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  enables the graft  10  to expand and stretch to a greater extent than if only holes or perforations were provided in the graft  10 , which allows the graft  10  to cover and more closely conform to the shape and contours of the implant I while avoiding failure (i.e., tearing) of the graft  10  itself The circular patterns  44 ,  46 ,  48  and concentric arrangement of the plurality of slots  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  around the focal point F further enable the graft  10  to conform more closely to the shapes and contours of both the breast implant I and the skin flap S and minimize post-operative complications such as rippling and puckering. 
     As already discussed above, the graft  10 , as described and shown in the figures, may include a plurality of both notches  14 ,  16 ,  18  and cuff elements  20 ,  22 ,  24 . However, the graft  10  may instead include one or more notches, or one or more or cuff elements, or one or more of both notches and cuff elements, and the quantities of notches and cuff elements need not be the same. Furthermore, the graft  10  may include a plurality of slots  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g  which are arranged in a plurality of concentric circular patterns  44 ,  46 ,  48 , as described above, regardless of whether or not the graft  10  includes also includes any notches, slots, or both. In some embodiments, for example without limitation, the graft  10  may include such a plurality of slots  42   a ,  42   b ,  42   c ,  42   d ,  42   e ,  42   f ,  42   g , but not have any notches or cuff elements. Although these features may cooperate to provide a graft having multiple advantages and improved results as compared to other grafts without such features, as described above, each of these features provides advantages and improved results independently of the others. 
     Suitable materials for making the soft tissue grafts  10  described herein include various tissues such as, without limitation, amnion, chorion, dermal, duodenum, dura, fascia lata, gastrointestinal, intestinal mucosa, intestinal submucosa, pericardium, peritoneum, placenta, and umbilical cord. The most suitable materials for breast reconstruction and similar plastic surgery procedures will possess sufficient tensile strength to minimize or avoid suture tear-out, both during implantation and expansion through the post-operative phase, and allow rapid and efficient cellular ingrowth equally from either side of the graft. 
     While not the only particularly suitable material, acellular dermal matrices (ADMs) have been known and used to make grafts for soft tissue repair procedures, including without limitation breast reconstruction and other cosmetic surgical procedures. Such materials are known to have suitable structural and biomechanical properties including, but not limited to, predictable suppleness, flexibility, uniform pliability sufficient to stretch and expand without tearing during tissue expansion (i.e., using a breast implant and/or tissue expander), and sufficient tensile strength. 
     The nature of the dermal tissue from which these ADMs are derived is explained with reference to  FIG.  3   , which illustrates the microstructure of human skin. Human skin is recovered from either live or deceased donors after receiving consent from the individual donor or donor&#39;s family. As illustrated in  FIG.  3   , human skin is made of several layer-like components, including the outer-most epidermis E, and the dermis D, which lies beneath the epidermis. The hypodermis H (also referred to as the subcutis) lies beneath the dermis D, but is not part of the skin. Rather, the hypodermis H contains adipose and muscle tissue. The dermis D itself includes the papillary dermis PD, which lies adjacent the epidermis E, and the reticular dermis RD, which lies between the papillary dermis PD and the hypodermis H. The papillary-reticular dermis interface PRI, lies between the papillary dermis PD and the reticular dermis RD. The dermis-epidermis junction (“the DEJ”) lies between the papillary dermis PD and epidermis E. 
     The process for deriving the foregoing ADMs from dermal tissue involves removing the epidermis E (e.g., by a chemical process that causes the epidermis to slough off), and thereby exposing the DEJ that was adjacent the epidermis E. Beneath the DEJ lies the papillary dermis PD, the papillary-reticular dermal interface PRI, and the reticular dermis RD. The dermal tissue that is recovered for the ADMs may therefore include the DEJ, papillary dermis PD and at least part of the reticular dermis RD. The recovered dermal tissue is decellularized and aseptically processed to meet sterility testing requirements. 
     The foregoing ADMs are derived from recovered tissue that includes the entire papillary dermis PD. The microstructure of the papillary dermis PD is not uniform. More particularly, the papillary dermis PD has an upper portion, or side, that was immediately adjacent the DEJ and therefore closer to the epidermis E (i.e., “the epidermal portion”), and a structurally different lower portion, or side, that was farther from the DEJ and epidermis E, and adjacent the deeper reticular dermis RD (i.e., “the dermal portion”). The epidermal portion of the papillary dermis PD contains a more densely-packed collagen matrix than the relatively more open collagen matrix contained in the dermal portion. As such, the dermal portion is more porous than the epidermal portion. This dual structure is also a property of the foregoing ADMs, and is ideal for repairing ventral abdominal hernias and other abdominal wall defects, as the more densely-packed epidermal portion of the ADM (i.e., incorporating the epidermal portion of the papillary dermis PD) possesses the tensile strength and stiffness required for such load-bearing tissue repairs, and the more porous dermal portion of the ADM (i.e., incorporating the dermal portion of the papillary dermis PD, as well as at least a portion of the loosely-packed and porous underlying reticular dermis RD) provides an open collagen structure that promotes vascularization, cellular attachment and tissue ingrowth. Nevertheless, this dual structure, which may only be visible on a microscopic scale, presents concerns about identifying and maintaining the side orientation of the ADM, i.e., during a surgical procedure. 
     In an improved fabrication process, an ADM is derived from allograft dermal tissue that is recovered from deeper within the dermis, and is therefore farther from, and not adjacent the epidermis. Recovery of portions of the dermis D from the skin suitable for making such ADMs may be accomplished by various techniques and devices, such as, for example, a manual dermatome technique, or dissection with a scalpel. In an improved fabrication process illustrated in  FIG.  4   , a first cut  50  is made into the reticular dermis RD of the skin (e.g., a section of skin cut from the entire donor skin) proximate the underlying hypodermis H in order to remove it from the dermis D. A second cut  52  is then made into the epidermal portion of the papillary dermis PD containing the dense collagen matrix, as discussed above, in order to remove the epidermis E, the DEJ, and the underlying epidermal portion of the papillary dermis PD. The remaining portion of the dermis D (i.e., the deeper dermal portion of the papillary dermis PD and the reticular dermis RD) constitutes a collagen matrix (“the tissue”) having substantially uniform density and porosity. 
     This remaining portion of the dermis, i.e., the tissue, may then be minimally processed, e.g., according to the process disclosed in U.S. Pat. No. 7,723,108, the disclosure of which is incorporated by reference herein in its entirety. Alternatively, the tissue may be decellularized by chemically treating it with saline, detergent, peracetic acid, ethanol and propylene glycol. The tissue may then be washed with sterile water to remove residual processing chemicals. The resulting disinfected and acellular tissue (ADM) may be cut into rectangular-shaped sheets suitable for clinical uses. The tissue sheets may be further treated with aqueous ethanol and packaged to provide a hydrated ADM. 
     The ADM derived using the improved process(es) disclosed above exhibits properties that are ideal for its use as a sling in breast reconstruction, and its use in other plastic surgery applications. Use of this improved ADM minimizes adhesions and foreign body reactions while promoting vascularization, cellular attachment, and tissue ingrowth at the surgical site. Compared to the previously known ADMs (i.e., described above), this improved ADM possesses more uniform tensile properties (i.e., strength, pliability, stretchability and handling characteristics) that are optimal for its use in breast reconstruction and other plastic surgery applications. This improved ADM also possesses improved suture retention strength, and elasticity and deformability that are optimal for its intended use. For example, the improved elasticity of this improved ADM promotes better expansion of the tissue in breast reconstruction. This improved ADM is therefore very strong and closely mimics the biomechanical properties of the tissue that it is intended to replace. Further, this improved ADM is resistant to bacterial colonization and non-immunogenic, as a result of the treatment thereto and decellularization thereof. 
       FIG.  5   a    illustrates a previously known process for fabricating the previously known ADMs, including those commercially available under the names FlexHD® Structural™ ADM, AlloDerm® ADM and AlloDerm® RTU ADM), namely, cutting the lower portion of the dermis and hypodermis (represented by straight line  54 ), and chemically treating the tissue to remove only the epidermis (represented by uneven line  56 ) and expose the DEJ. 
       FIG.  5   b    illustrates the improved fabrication process mentioned hereinabove which produces improved ADMs having more uniform density and porosity, namely, the lower portion of the dermis and hypodermis are cut (represented by straight line  50 ), and then a second cut (represented by straight line  52 ) is made deeper into the dermis than the aforementioned chemical treatment used to fabricate previously known ADMs. In one embodiment of the alternative fabrication process, for example, the second cut results in the removal of the epidermis, the DEJ, and the upper, epidermal portion of the papillary dermis. As mentioned above, the substantially uniform density and porosity of the improved ADMs produced by this alternative fabrication process promotes more rapid and efficient cellular ingrowth equally from either side of the ADM grafts as compared to the previously known ADMs (i.e., the FlexHD Structural® ADM, FlexHD Pliable® ADM, AlloDerm® ADM and AlloDerm® RTU ADM). 
     It will be understood that the embodiments of the present invention described hereinabove are merely exemplary and that a person skilled in the art may make variations and modifications without departing from the spirit and scope of the invention. All such variations and modifications are intended to be included within the scope of the present invention. 
     EXAMPLES 
     Example 1: Surgical Placement of an ADM Graft During Pre-Pectoral Breast Reconstruction 
     The graft is suitable for use in pre-pectoral breast reconstruction procedures and:
         is made of ADM;   has a vertical axis V and a horizontal axis H, where the ratio of the length of the vertical axis to the length of the horizontal axis is 1.15;   is symmetrical about its vertical axis;   has three notches (i.e., at 9, 12 and 3 o&#39;clock positions on the peripheral edge of the graft);   has three cuff elements formed by the three notches;   has a focal point positioned at the midpoint of the horizontal axis and at a point on the vertical axis which is 45% above the bottommost point on the peripheral edge of the graft;   has a plurality of slits which form a plurality of circular patterns which are concentric about the focal point.
 
In use, the foregoing ADM graft is placed and secured within a reconstructed breast to support a breast implant positioned anteriorly to the chest muscles of a patient during a pre-pectoral breast reconstruction procedure. The following steps are performed:
       1. Make markings on the breast and draw horizontal and vertical lines centered around the nipple, mark inframammary fold, medial, lateral and superior portions of the breast to outline the breast footprint;   2. Prepare the Breast Pocket with hemostasis and irrigation;   3. Place pocket defining sutures in the lateral aspect and inframammary fold;   4. Use a breast implant sizer to determine the appropriate implant volume;   5. Mark the medial and lateral borders of the implant sizer in the breast pocket;   6. Mark the superior and midpoint of the breast to define the position on the breast at which the topmost (superior) point ( 34 ) of the graft, which is proximate the top notch  14 , will be anchored   7. Triple wash the ADM graft with triple antibiotic solution alternating with betadine and squeeze excess fluid out of the ADM graft (a suitable triple antibiotic solution includes a mixture of 1 gram of cefazolin, 80 milligrams of gentamicin, and 50,000 International Units of bacitracin, in 500 milliliters of normal saline;   8. Mark the ADM graft to establish the X (i.e., horizontal H) axis by connecting the notches at points  38  and  40  and Y (i.e., vertical V) axis by drawing a perpendicular line starting at the superior notch at topmost point  34 . Marking of these axes allows for orientation of the ADM graft by correlating the markings on the ADM graft to the external markings on the patient&#39;s skin, thereby facilitating symmetrical inset and positioning of the ADM graft into breast pocket;   9. Drape the ADM graft over the implant sizer and mark the edge of the implant circumferentially on the ADM graft adjusting the folds (e.g., at imaginary arcuate lines  26 ,  28 ,  30  on the graft  10 , see  FIG.  1   ) and widths of the cuff elements to the size of the implant;   10. Fold the cuff elements (edges) of the ADM graft according to the markings then carefully place the marked ADM into the prepared breast pocket without touching the skin;   11. Adjust the ADM graft position accordingly by correlating the external markings of the aforesaid axes;   12. Find the superior point of the Y (vertical V) axis at the top of the pectoralis (Point A, e.g., the a topmost (i.e., superior) point  34  of the ADM graft, see  FIGS.  1  and  2 C );   13. Use a continuous 2-0 Monocryl (a commercially available suture manufactured and marketed by Ethicon of Cornelia, Ga., USA) to suture the medial edge of the ADM graft to the muscle from Point (A) to a Point (B) proximate to or on the inframammary fold, leaving an opening at the inferior edge of adequate size for insertion of the implant or tissue expander;   14. Use a continuous 2-0 Monocryl to suture the lateral edge of the ADM to the muscle, again starting from Point (A), and continuing to a Point (C), which is proximate to or on the inframammary fold and some distance away from Point (B), thereby leaving an opening adequate for placement of the implant or tissue expander;   15. Inject a pain relief agent (e.g., Exparel commercially available from Pacira Pharmaceuticals of Parsippany, N.J., USA) circumferentially to provide an long lasting intercostal block;   16. Open the final, permanent breast implant (I) and wash in the triple antibiotic solution;   17. Change gloves and place the permanent breast implant into the breast pocket utilizing a Keller funnel no touch technique;   18. Use a ribbon to protect and retract the implant while interrupted suture 2-0 Monocryl sutures are placed to close the aforesaid opening of the breast pocket at the inframammary fold;   19. Place two drains at the lateral aspect of the inframammary fold incision; and   20. Suture the incision in three layers using 2-0 Moncryl deeper interrupted sutures, followed by 3-0 Moncryl dermal and subcuticular sutures.