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Discussion: Decreased Length of Postoperative Drain Use, Parenteral Opioids, Length of Stay, and Complication Rates in Patients Receiving Meshed versus Unmeshed Acellular Dermal Matrix in 194 Submuscular Tissue Expander-Based Breast Reconstructions: A Single-Surgeon Cohort Study.

898 T authors have confirmed, in an excellent study, the advantages of meshing acellular dermal matrix in immediate implant-based breast reconstruction.1 The advantages of meshing acellular dermal matrix have also been reported previously.2 Although there are many variables in the study, their conclusions are justified. In their study, acellular dermal matrices were meshed 1.5:1 and 1:1.We concur that 1.5:1 results in weakening of the acellular dermal matrix. Our experience has been that 1:1 meshing is preferable. We were able to mesh 1:1 on a Zimmer mesher using the HumecaV-carrier (Humeca, Borne, The Netherlands). The main advantage cited by the authors is decreased length of postoperative drainage, with the rationale being that meshing improves flow between compartments above and below the acellular dermal matrix. They also correctly state that rapid adherence of the mesh to the breast flap is important. This is where a dilemma occurs. The ideal pore size and the amount of openings per square centimeter have not been determined. Larger openings will allow a freer flow through the mesh. Smaller openings are closed off more rapidly by a plasma clot followed by fibroblast and vessel ingrowth. (See Figure, Supplemental Digital Content 1, which shows spaces in meshed acellular dermal matrix that are preferentially infiltrated with tissue ingrowth, http://links.lww.com/PRS/ D975.) It is our belief that multiple smaller openings will result in more rapid attachment and integration of the acellular dermal matrix. We further believe that rapid integration is more important than flow across the acellular dermal matrix in reducing seroma and its associated problems. For these reasons, we also believe that the drain should be placed between the implant and acellular dermal matrix and not between the acellular dermal matrix and the skin flap. Although the authors have shown that meshing reduces minor complications such as seroma and prolonged drainage time, and reduces postoperative pain, immediate breast reconstruction still carries a high complication rate.3 Complications have been shown to be reduced with prepectoral placement4 of the implant, and more so when acellular dermal matrix is not used. With the advent of skinand nipple-sparing mastectomies together with surgeons leaving thicker flaps, there is less need for acellular dermal matrix. Furthermore, flaps can be thickened by allowing for tissue contraction and/or fat grafting. Acellular dermal matrix can be added at a second stage if necessary, when the risk of complications is lower. When using acellular dermal matrix, our preference is for FlexHD Pliable (MTF Biologics, Edison, N.J.). This acellular dermal matrix is harvested from the deeper dermis, where the tissue is more porous, having an almost fine-meshed appearance. (See Figure, Supplemental Digital Content 2, which shows FlexHD Pliable. Open spaces between collagen fibers can be seen, http://links. lww.com/PRS/D976.) To reduce the complication