Wise pattern skin reduction mastectomy with prepectoral placement of the device is a recent technique for reconstruction in patients with large and ptotic breasts. Expanders in the first stage, followed by implant exchange in the second stage are placed above the pectoralis major muscle, totally covered by acellular dermal matrix and an inferior dermal flap. This technique was performed on 6 breasts in 4 obese patients with macromastia and grade 2 and 3 ptosis. Two patients experienced complications at the T-junction. One patient experienced superficial skin sloughing managed conservatively. The second patient developed full-thickness necrosis treated with excision and primary closure. No implant loss occurred. All patients were exchanged in a second stage to an implant, and 2 of them had symmetry procedures, with good cosmetic results. Larger, long-term studies are required to further characterize results and define the limitations of this newer surgical technique.