Direct-to-Implant Breast Reconstruction without the Use of an Acellular Dermal Matrix Is Cost Effective and Oncologically Safe

We read with great interest the article entitled “Direct-to-Implant Breast Reconstruction without the Use of an Acellular Dermal Matrix Is Cost Effective and Oncologically Safe” by Serrurier et al.1 We congratulate the authors for the excellent results shown. This article analyzes in detail the cost reduction in immediate breast implant reconstruction (direct-toimplant) without the use of acellular dermal matrix. In fact, the use of acellular dermal matrix, although facilitating breast implant reconstruction, requires higher costs that are not always accessible. In our plastic surgery unit, we have to face the lack of sufficient acellular dermal matrix in breast reconstruction, and thus we often have to resort to alternative techniques. As the authors have well described, when we are to reconstruct a medium-large breast (C to D cup), we perform a skin-reducing mastectomy and reconstruction with prostheses according to the Bostwick technique,2 where we use a dermal flap to cover the lower pole of the prosthesis. This technique, established over the years, offers good coverage of theprosthesis with excellent aesthetic outcomes. The contralateral breast is reduced by reductive mastoplasty according to the technique most widely used.3 When the authors discuss the surgical technique, they offer an interesting possibility; that is, to use the lower flap of the mastectomy to cover the lower third of the prosthesis. In our clinical practice, we do not use this technique, as we try to obtain a cover of the implant with the serratus muscular fascia or with the muscle itself. Because coverage may be difficult, we often find that breast implants are slightly smaller than initial estimates. This implies a limit on the use of our technique in medium-large breasts. Thus, in our clinical protocol we perform an immediate reconstruction with prosthesis after skin-sparing mastectomy or after nipple-sparing mastectomy in medium-small breasts, whereas in large breasts we always use a skin-reducing mastectomy. In fact, with small prostheses, we always have a covering with the muscle fascia or muscle. For surgical training, we have always been skeptical of covering the lower pole with the lower flap of the mastectomy. One-stage breast reconstruction with implants is a challenge for the plastic surgeon, and in our experience the management of complications was difficult. We ask the authors whether they undertake a patientselection protocol in their clinical practice4 to perform a breast reconstruction with prosthesis and the cover with a lower flap of the mastectomy. Specifically, we would like to know whether the thickness of the lower flap is evaluated before surgery or intraoperatively. We would like to know about the thickness of the flap and whether they have ever been faced with precarious and insufficient cover regarding thickness.