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Use of acellular dermal matrix for implant-based breast reconstruction appears to be associated with a lower incidence of capsular contracture compared with standard reconstruction. The majority of acellular dermal matrix studies were, however, of short duration; thus, long-term incidence of capsular contracture with acellular dermal matrix use is unknown.Patients undergoing acellular dermal matrix–assisted breast reconstruction from December of 2001 to May of 2014 at two institutions were evaluated. Cumulative incidence of capsular contracture was determined by the performing surgeon. A retrospective chart review was performed on prospectively gathered data on patient-, breast-, surgery-, and implant-related characteristics that were analyzed as potential risk factors for the development of capsular contracture.A total of 1584 breast reconstructions in 863 patients were performed. Mean follow-up of patients was 4.7 years; 45 percent of patients had greater than or equal to 5 years of follow-up. The cumulative incidence of capsular contracture was 0.8 percent. Smaller implant size (<400 ml) and postoperative radiotherapy were significantly associated with an increased risk of capsular contracture, but the incidence of capsular contracture was 1.9 percent in irradiated breasts. All capsular contractures developed within the first 2 years, with no new events with longer follow-up.In this long-term study, the cumulative incidence of capsular contracture with acellular dermal matrix–assisted reconstruction remains low, even in irradiated breasts. Capsular contracture appears to be an early event, and longer follow-up does not appear to increase the incidence, suggesting that acellular dermal matrix may truly mitigate the development of capsular contracture as opposed to delaying its occurrence.Therapeutic, IV.