Sir: We read with great interest the article by Dr. Cemal et al. concerning the influence of changing mastectomy patterns on reconstructive rate and method.1 In their work, the authors report the increasing use of bilateral mastectomies in patients with unilateral cancer in the United States. Moreover, although heterologous reconstruction has increased for all mastectomy types, implant placement represents the most common reconstructive technique following prophylactic mastectomies. According to the authors, the increased incidence of prophylactic mastectomy is a major factor underlying the paradigm shift away from autologous tissue to implant-based reconstruction. We congratulate the authors for their work and would like to share our experience in this field. The percentage of mastectomies performed in Italian health centers is much lower than in the United States. In Italy, regardless of the type of mastectomy, breast implant placement is the most commonly performed reconstructive technique (Fig. 1), for several reasons. The first is patient choice. Most of our patients are psychologically strained by their diagnosis of cancer and, consequently, are reluctant to undergo a long-lasting procedure, with longer hospitalization time, and higher intraoperative and postoperative risks. Heterologous reconstruction is preferred by most of our patients because it is faster than autologous reconstruction, it leaves a single scar, and it avoids any donor-site morbidity. According to patients, these advantages outweigh the drawbacks of implant placement, such as the requirement for a two-stage procedure and the future need for implant substitution. A further reason for the high number of heterologous reconstructions performed in Italy is the overall cost of autologous reconstruction. Free flaps are currently considered the criterion standard in breast reconstruction.2 However, in our country, health care providers are reimbursed by the national health system by the same amount of money as for pedicled flaps. Moreover, compared with heterologous techniques, free and pedicled flaps show a higher rate of complications,3 thus requiring reintervention in some cases. As a consequence, in a health system that demands management skills and business administration from the surgeon, the higher costs of autologous reconstruction make such techniques less attractive to the modern surgeon/manager. Having to consider finances when dealing with medical conditions is neither easy nor pleasant. In an ideal setting, such considerations should not be made and economic crises should never hamper medical services. Nevertheless, the national health system is experiencing a real crisis, and we are currently making a huge effort to provide the patient with the best possible care under the circumstances. As the authors point out, the increase of heterologous breast reconstruction in the United States is related to the higher rate of prophylactic mastectomies. In contrast, in other sociocultural contexts such as Italy, the patient’s distrust of autologous techniques, in addition to economic issues, may be the main reasons for the increase in breast implant placement after mastectomy.Fig. 1: Breast reconstructive procedures performed in Italy in 2012 (from the database of discharge records of the Ministry of Health integrated with Assobiomedica information).DISCLOSURE None of the authors has any commercial associations that might pose or create a conflict of interest with information presented in this communication. No intramural or extramural funding supported any aspect of this work. Barbara Cagli, M.D. Francesco Segreto, M.D. Stefano Santoro, M.D. Riccardo Iannuzzi, M.D. Matteo Signoretti, M.D. Paolo Persichetti, M.D., Ph.D. Department of Plastic Reconstructive, and Aesthetic Surgery Campus Bio-Medico of Rome University Rome, Italy