INTRODUCTION: Patients who present for augmentation mammoplasty with poor quality mammary soft-tissue support may be at increased risk for post-operative complications. Non-crosslinked intact porcine-derived acellular dermal matrix (Strattice™ Reconstructive Tissue Matrix, LifeCell Corp., Branchburg, NJ, USA) may enhance soft-tissue support in such patients and reduce implant-related complications, including capsular contracture, rippling, palpability, and malposition. The objective of this case report series was to describe the outcomes of three patients with poor quality mammary soft-tissue support who underwent primary cosmetic breast augmentation with pre-emptive implantation of porcine-derived acellular dermal matrix. CASE PRESENTATION: Case 1 concerns a 40-year-old Caucasian woman with post-partum soft tissue laxity and grade II ptosis. Case 2 concerns a 30-year-old Caucasian woman with congenital soft-tissue laxity and grade I + ptosis. Case 3 concerns a 49-year-old Caucasian woman with post-partum and post-weight-loss-induced laxity and grade III ptosis. In all three of our patients, porcine-derived acellular dermal matrix was sutured to the chest wall along the infra-mammary and/or a neo-infra-mammary fold and then laid passively superiorly or sutured under tension to the breast parenchyma or caudal edge of the pectoralis major muscle. In cases 1 and 2, a modified internal mastopexy technique was performed. Suturing the porcine-derived acellular dermal matrix to the posterior aspect of the breast parenchyma and/or caudal pectoralis muscle under appropriate tension in conjunction with radial plication of the porcine-derived acellular dermal matrix created a snug 'hand-in-glove' pocket and resulted in only minimal peri-areolar scarring. Case 3 required a vertical scar mastopexy. During a mean of 18 months of follow-up, all three patients had positive outcomes and no complications (that is, infection, hematoma, seroma, rippling, malposition, or capsular contracture). The surgeon and patients were generally highly satisfied with the aesthetic outcome of the breasts. CONCLUSIONS: Pre-emptive use of porcine-derived acellular dermal matrix may be beneficial in patients with primary augmentation with poor quality mammary soft-tissue support.