Journal Logo


Beyond Biologics

Absorbable Mesh as a Low-Cost, Low-Complication Sling for Implant-Based Breast Reconstruction

Loustau, Hugo D. M.D.; Mayer, Horacio F. M.D.

Author Information
Plastic and Reconstructive Surgery: August 2014 - Volume 134 - Issue 2 - p 323e-324e
doi: 10.1097/PRS.0000000000000334
  • Free


It was with great interest that we read the recent article entitled “Beyond Biologics: Absorbable Mesh as a Low-Cost, Low-Complication Sling for Implant-Based Breast Reconstruction” by Tessler et al.1 The authors present a retrospective review of 50 patients who underwent implant-based breast reconstruction with an absorbable mesh as an inexpensive alternative to acellular dermal matrices and state that “the authors report the first experience in the literature using an absorbable mesh as an inferolateral sling.” However, we would like to point out that this study itself has only a confirmatory character.

The use of an absorbable mesh in direct-to-implant breast reconstruction was already reported for the very first time by us in 2007 in a multiindexed English journal, the Journal of Plastic Reconstructive and Aesthetic Surgery.2 For indexing purposes, the article included prosthetic, breast, reconstruction, and mesh as keywords.

The omission of our previous work and corresponding credit denotes an inattentive database search during the preparation and review of the article by both authors and reviewers, which should be mandatory before claiming the novelty of a study. Notwithstanding, our work indeed has been previously recognized and cited in your Journal by plastic surgeons such as Salzberg et al.3 and Saint Cyr et al.4 Furthermore, there are some technical details we would also like to stress. Although Tessler et al. propose to use the mesh as one inferolateral sling, we advocate the use of two slings, one inferior for support and one lateral for lateral contention, following the principles of our technique called the “ensured subpectoral pocket,” which seems to be more effective in splinting the pectoralis muscle and avoiding implant displacement, which is especially important when dealing with anatomical implants (Fig. 1).2

Fig. 1
Fig. 1:
Placement of the absorbable mesh in direct-to-implant breast reconstruction. Schematic representation of the ensured subpectoral pocket technique using an anatomical implant and absorbable mesh as two slings (one inferior and one lateral) as originally published in 2007. [Reprinted with permission from Loustau HD, Mayer HF, Sarrabayrouse M. Immediate prosthetic breast reconstruction: The ensured subpectoral pocket (ESP). J Plast Reconstr Aesthet Surg. 2007;60:1233–1238.]

In our article, we also address the problem related to costs of acellular dermal matrix and its availability and recommend an absorbable mesh as a readily available and inexpensive option. With similar purposes, we also recently reported the use of capsular grafts and flaps in immediate prosthetic breast reconstruction in women who have previously undergone augmentation as other alternatives to expensive acellular dermal matrices.5

Finally, we are glad to know that another group had a good experience with a low complication rate, confirming our previous results. Our experience continued to be excellent, which encouraged us to extend the use of absorbable mesh in two-stage immediate prosthetic breast reconstruction for selected cases. A more detailed description of this approach with many advantages and promising results is forthcoming.


The authors have no financial interest to declare in relation to the content of this communication.

Hugo D. Loustau, M.D.

Horacio F. Mayer, M.D.

Department of Plastic Surgery

Hospital Italiano de Buenos Aires

University of Buenos Aires School of Medicine

Buenos Aires, Argentina


1. Tessler O, Reish RG, Maman DY, Smith BL, Austen WG Jr. Beyond biologics: Absorbable mesh as a low-cost, low-complication sling for implant-based breast reconstruction. Plast Reconstr Surg. 2014;133:90e–99e
2. Loustau HD, Mayer HF, Sarrabayrouse M. Immediate prosthetic breast reconstruction: The ensured subpectoral pocket (ESP). J Plast Reconstr Aesthet Surg. 2007;60:1233–1238
3. Salzberg CA, Ashikari AY, Koch RM, Chabner-Thompson E. An 8-year experience of direct-to-implant immediate breast reconstruction using human acellular dermal matrix (AlloDerm). Plast Reconstr Surg. 2011;127:514–524
4. Saint-Cyr M, Dauwe P, Wong C, Thakar H, Nagarkar P, Rohrich RJ. Use of the serratus anterior fascia flap for expander coverage in breast reconstruction. Plast Reconstr Surg. 2010;125:1057–1064
5. Mayer HF, Loustau HD. Capsular grafts and flaps in immediate prosthetic breast reconstruction. Aesthetic Plast Surg. 2014;38:129–138


Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

©2014American Society of Plastic Surgeons