Invited Discussion on: Skin Reducing Mastectomy and Prepectoral Breast Reconstruction in Large Ptotic Breasts

The applicability of acellular dermal matrix (ADM) for breast reconstruction is a consolidated reality, as skin and nipple sparing techniques became standard mastectomy approaches. ADM is a soft connective tissue graft generated via a decellularization process that preserves intact the extracellular skin matrix. ADM not only provides tissue reinforcement, but also better pocket control, and shape without the compressive effects of total sub-muscular coverage. Our preference is using one "Strattice®" ADM in pocket's format to cover the implant's inferior pole, protecting the totality of the implant in its inferior pole by the ADM. This technique besides its versatility is cheaper than other techniques presented. The success of ADM prepectoral breast reconstruction depends on three pillars: careful patient selection, flap perfusion and postoperative management. The challenge in large and/or ptotic breasts under the risk of large badly perfused flaps as well as of nipple, due to the nipple-furcules distance which can be handled with well-selected criteria as mentioned and safe management of nipple ascension as well as the nipple graft. Traditionally, they need to be associated with reducing mammoplasty techniques to achieve the expected aesthetic results in a single stage. Therefore, the plastic surgeon must be prepared for new reconstructive approaches postmastectomy, having the ADM as an excellent option for that.