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Sir: We would like to thank Dr. Atiyeh and colleagues for their comments regarding our article. All patients included in this study underwent immediate two-stage implant-based breast reconstruction. Mastectomy incisions were always designed horizontally in an ellipse shape by the oncologic surgeon to include the nipple-areola complex. Rapidly initiated expansion is certainly common practice and well documented as safe in the literature.1 However, regardless of one’s specific surgical technique and treatment approach, expander-to-implant breast reconstructions maintain nonnegligible complication rates.2,3 As stated in Table 2 of the article, expander implants were filled to exert reasonable tension onto the mastectomy skin flaps. This intraoperative fill typically ranged from 100 to 200 cc, representing a mean of 29.7 percent of expander implant total volume in our series. At our institution, patients with an adequate amount and quality of breast skin following mastectomy typically undergo reconstruction with a single-stage direct-to-implant approach; such patients were not included in this study. Patients with relative skin shortage undergo reconstruction in essentially a two-stage fashion. Consequently, the paucity or abundance of breast skin did not play a role in our decision to formally investigate the delayed expansion approach described in our study. However, as noted in the article, wound healing principles and anecdotal surgeon experience were key factors behind the suggestion of the delayed approach. Our goal is certainly not to advocate for the delayed approach at all costs; we simply wanted to see whether the clinical and ultrastructural endpoints outlined demonstrated differences depending on the expansion strategy used. From our perspective, the study we designed was necessary to ascertain whether larger scale clinical studies based on a delayed approach were needed and justifiable. The goal was never to put into question the relative safety of rapid expansion, but rather to explore the potential benefits of a delayed approach in relation to Biocell and Siltex expander implants. In fact, our study demonstrated lower incidences of biofilm and double capsule and greater ultrastructural capsular stability in the delayed expansion Biocell group. Although Atiyeh et al. write that cephalad migration of the Biocell expander in our study is of potential concern, our clinical and scanning electron microscopy observations seem to suggest otherwise. Lastly, Atiyeh et al. suggest that superior aesthetic results are achievable with dual-plane or subcutaneous placement of the expander implant. This is not a common strategy used by surgeons at our institution; especially in the context of breast radiation therapy, we believe that total implant coverage, whether by total muscle or with acellular dermal matrix as an adjunct, is essential. Acellular dermal matrix products have indeed significantly changed the treatment paradigm of implant-based breast reconstruction. The scientific evidence on the safety and effectiveness of such products is certainly growing. At our institution, acellular dermal matrix products are currently used only selectively for breast reconstruction because of the associated costs and lingering concerns of complications such as infection and seroma. DISCLOSURE Dr. Danino is a consultant and speaker for Allergan, Inc. Neither of the other authors has any commercial associations or financial interests to declare with respect to any of the information or products presented in this communication. Operational study costs were partially supported by an Allergan, Inc., industry research grant. Jean-Philippe Giot, M.D., Ph.D. Laurence S. Paek, M.D. M. Alain Danino, M.D., Ph.D. Division of Plastic and Reconstructive Surgery University of Montreal Hospital Center Université de Montréal Montreal, Quebec, Canada

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