A Pure Autologous Dermal Graft and Dermal Flap Pocket in Prepectoral Implant Reconstruction After Skin-Reducing Mastectomy: A One-Stage Autologous Reconstruction Alternative to Acellular Dermal Matrices

We read the article titled ‘‘A Pure Autologous Dermal Graft and Dermal Flap Pocket in Prepectoral Implant Reconstruction After Skin-Reducing Mastectomy: A One-Stage Autologous Reconstruction Alternative to Acellular Dermal Matrices” by Castagnetti F. et al. and found it very interesting and also stimulating. Prepectoral breast reconstruction (PBR) shows evident benefits such as breast reconstruction at the same time of the mastectomy and reduces psychological and physical distress with less morbidity compared to total or partial muscular coverage of the prothesis. Less pain, no breast animation deformity and a natural look could be obtained with PBR and therefore a satisfactory proprioceptive patients’ perception. The easy positioning of implants during PBR, achieving a satisfactory degree of ptosis, reducing the need of contralateral symmetrization. For this reason, PBR is becoming nowadays a popular procedure thanks to the advent of meshes. ADMs act as a scaffold to be repopulated by the patient’s own cells. Their integration is very similar to the wound healing process occurring with a moderate inflammatory response with production of exudate, migration of circulating monocytes that transform in macrophages, release cytokines that recall and activate fibroblasts in order to produce collagen fibers, elastin and extracellular matrix. ADM must mimic the host’s tissue to fool the patient’s immune system and avoid rejection. The authors described an interesting procedure covering the upper portion of the prothesis with an autologous dermal graft harvested from the contralateral breast avoiding the use of ADMs in order to reduce complications, but we have some elements to discuss. Due to the high risk in skin-flap vitality during skin reducing mastectomy (SRM), the disadvantages of ADMs should be considered. Therefore, the use of vascularized tissue, such as dermal flap must be taken into consideration even reconstructing smaller breasts. Since the Authors report bilateral breast reductions, adequate breast size reshaping could be preoperatively planned to obtain a dermal flap able to cover the entire outer surface of the implant. Although integration of the autologous dermal graft avoids immune system reaction and therefore less morbidity compared to ADM, in the presence of a high BMI, as reported in the Autor’s article, breast reshaping reductives with total autologous-dermal-flap implant coverage should be taken into consideration during SRMs. Moreover, compared to the dermal-graft, dermal-flap increases skin flap vitality reducing the incidence of complications and may allow the enrollment of a larger population that includes smokers, diabetics and patients who need adjuvant therapies, such as radiotherapy. Do the Authors use different drains for subcutaneous and peri-prothesis pocket? In which pocket was the hematoma reported? Do the Authors retain that dermal-graft meshing could represent an advantage to maximize implant coverage and periprosthetic drainage reducing the incidence of seromas?