Here, we present detailed surgical procedures for endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction. This procedure is a secure and viable method for breast cancer patients.
Oncoplastic breast surgery, with its focus on improving cosmetic outcomes while maintaining oncological safety, has fundamentally transformed the landscape of breast cancer surgical treatment, giving rise to an array of techniques for breast reconstruction. Nipple-sparing mastectomy (NSM) with immediate implant-based breast reconstruction (IBBR) has emerged as a cornerstone in managing early breast cancer. Aligned with the principles of minimally invasive surgery, recent years have witnessed the widespread integration of endoscopic approaches in breast surgery, encompassing procedures like endoscopic breast-conserving surgery (E-BCS) and endoscopic nipple-sparing mastectomy (E-NSM), among others. Capitalizing on the advantages of inconspicuous and shorter incisions, improved visibility, and the avoidance of radiation therapy, the popularity of E-NSM with IBBR is on the rise. However, conventional E-NSM with IBBR often requires two or more incisions, which can result in suboptimal cosmetic outcomes and even prosthesis loss.This paper presents a comprehensive account of the intricate surgical procedures involved in endoscopic bilateral nipple-sparing mastectomy with immediate pre-pectoral implant-based breast reconstruction. The insights shared are drawn from the collective experience of our institution. Notable benefits associated with the described surgical approach encompass enhanced cosmetic outcomes, improved postoperative quality of life, and enhanced physiological functions attributable to the application of pre-pectoral implant-based breast reconstruction through a single incision.
As breast cancer treatment continues to advance, an increasing number of breast surgeons are shifting their focus beyond solely addressing malignant tumors. They also place greater emphasis on addressing the post-treatment appearance and quality of life of their patients. Nipple-sparing mastectomy (NSM), characterized by comparable oncologic outcomes, favorable patient satisfaction, and cosmetic outcomes, has now become a standard surgical option for patients with bilateral early breast cancer and those undergoing prophylactic mastectomy1,2,3.
Endoscopic breast surgery (EBS) is an emerging and forward-looking surgical approach that is gaining popularity in both nipple-sparing mastectomy (NSM) and breast-conserving surgery. When compared to traditional breast surgery methods, EBS has demonstrated superior cosmetic outcomes, increased patient satisfaction owing to its less noticeable incisions, and similar levels of oncological safety4,5,6.
However, the conventional approach to endoscopic nipple-sparing mastectomy (E-NSM) with immediate implant-based breast reconstruction (IBBR) often requires two or more incisions, typically located in the axilla, anterior axillary line, and peri-areolar regions4,7. Unfortunately, this technique frequently yields suboptimal cosmetic outcomes. This is especially pronounced in cases involving peri-areolar incisions, where E-NSM eliminates the vertical blood supply route to the nipple-areola complex (NAC), relying solely on the dermal vascular network for nourishment8. This scenario potentially leads to ischemic necrosis in the NAC. Moreover, for pre-pectoral breast reconstruction, incisions on the breast surface can create openings for infection or flap ischemia, increasing the risk of prosthetic exposure, nipple necrosis, and even prosthesis loss7,9,10. Given the rapid advancements in endoscopic techniques and instrumentation, novel variations of E-NSM with IBBR predominantly focus on a single axillary incision and insufflation technique11,12. These innovations offer distinct advantages, including reduced risk of nipple necrosis, decreased patient discomfort leading to quicker recovery, significantly improved cosmetic outcomes, and optimized patient benefits, among others12,13.
This article provides a comprehensive description of the surgical procedures involved in endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction. The aim is to showcase the feasibility, exceptional cosmetic outcomes, and physiological considerations associated with this surgical approach.
To facilitate readers' comprehension of the protocol, we present a representative case for elucidation. The patient was a 33-year-old female who exhibited bilateral breast lumps on ultrasound, categorized as BI-RADS 4, with relatively large-sized lumps (Figure 1). Histopathological confirmation through Mammotome-assisted minimally invasive resection identified bilateral ductal carcinoma in situ14 (Figure 2). This young woman had bilateral nipple asymmetry and a strong desire to rectify it. Given her passion for dance, she also had a significant demand for favorable cosmetic outcomes. After introducing our surgical plan, the patient ultimately opted to undergo endoscopic bilateral nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction.
Represented by mastectomy, conventional breast surgery often yields unsatisfactory cosmetic outcomes and can adversely affect the functioning of the affected upper limb. This situation can cause considerable psychological distress, ultimately resulting in a reduced postoperative quality of life for patients24,25,26. Minimally invasive surgery represents a pivotal advancement in modern surgical practices. With the introduction of endoscopic techniques, significant improvements have been made to address the shortcomings of conventional surgery. Simultaneously, breast reconstruction has gained popularity as it offers the ability to restore the breast contour in breast cancer patients24. It has been shown to reduce the incidence of postoperative depression among breast cancer patients and enhance their postoperative quality of life27. This aligns with the emerging paradigm of the "biopsychosocial" medical model. With the integration of endoscopic techniques and breast reconstruction, breast surgery has entered a novel phase characterized by a focus on humanization and the optimization of patient outcomes. These objectives stand as the central tenets we strive for and uphold.
When compared with conventional E-NSM with IBBR, the benefits of endoscopic nipple-sparing mastectomy via a single axillary incision with immediate pre-pectoral implant-based breast reconstruction are evident. Firstly, this approach allows for the completion of all surgical procedures through a discreet single axillary incision, ensuring minimal visibility and achieving favorable postoperative cosmetic outcomes11,28,29. Moreover, the technique of E-NSM disrupts the vertical blood supply system to the nipple-areola complex (NAC), relying exclusively on the dermal vascular network. Avoiding incisions on the breast skin reduces the likelihood of NAC and flap ischemic necrosis8,30,31,32. In comparison to subpectoral reconstruction, pre-pectoral reconstruction is simpler, resulting in a more natural breast contour and minimizing chest functional deficits and pain33. However, in the context of pre-pectoral reconstruction, the absence of protection from the pectoralis major muscle means that direct contact between implants or meshes and the breast surface incision could lead to prosthetic exposure or even loss. Such complications may arise due to flap infection or ischemic necrosis34,35. Hence, the technique we present not only ensures the safety of tumor management but also yields superior cosmetic outcomes and a higher postoperative quality of life.
Several critical technical aspects warrant attention. First, it is imperative to preoperatively demarcate the extent of the patient's breast. Experienced surgeons can preoperatively manually mark the extent of the breast, while less experienced surgeons can employ preoperative ultrasound to delineate the breast boundaries. The circummammary ligaments are considered the natural boundaries of the breast and can serve as anatomical landmarks for breast dissection15,36. They can be observed both preoperatively with ultrasound and intraoperatively under endoscopic vision. Second, follow the dissection sequence from the retromammary space to the subcutaneous layer of the breast, which is recognized as a convenient and efficient strategy37. Third, while conducting the dissection of the retromammary space, meticulous attention is required when separating along the edges of the breast. This can be assessed through the utilization of dyes, finger press, and the pressure feedback sensation from endoscopic instruments. Whether through preoperative marking or employing techniques such as dyeing to delineate the breast boundaries, the central aim remains to guide surgeons to expose and identify the circummammary ligaments and precisely excise mammary glands. This is crucial for breast reconstruction surgery and contributes to achieving favorable postoperative cosmetic outcomes36. Fourth, it is advisable to ensure consistent flap thickness during the dissection of the subcutaneous layer within the breast. A technique we employ involves turning off the operating room lights and observing the extent to which the endoscope's light source penetrates through the breast's surface skin within the cavity, thereby assessing the uniformity of flap thickness.
There are some limitations to this method. First, even though E-NSM with IBBR has garnered extensive adoption and is considered a relatively mature technique, there remains a dearth of high-level evidence from evidence-based medicine to definitively establish its safety. Additionally, within our institution, we exclusively employ the single-port method for conducting endoscopic breast surgery. This decision is rooted in the fact that the lead surgeon has successfully overcome the learning curve and holds the belief that the single-port approach can reduce the number of incisions, obscure scars, and diminish the occurrence of ischemic necrosis in both the NAC and flap. Nevertheless, it's important to note that this perspective is subjective and currently lacks controlled studies to substantiate our standpoint.
In conclusion, when considering specific patients, the endeavor to enhance practice for improved cosmetic outcomes and heightened patient satisfaction holds significant value. This endeavor encapsulates the ethos of humanistic care and aesthetics. Our collective aspirations encompass the pursuit of beauty and the assurance of maximizing patient benefits.
The authors have nothing to disclose.
This work was supported by National Key Clinical Discipline.
Carbon nanoparticles suspension injection | LUMMY | H20041829 | |
Drainage tube | Yangtze River | 20142140359 | |
Electric hook | TNKJ | 20222010212 | |
Endoscopic scissors | YOUSHI | P20200702015 | |
5-mm 35cm 30° rigid endoscope | Karl Storz | 26046BA | |
Implant | MENTOR | 9718984-037 | |
Laparoscopic grasping forceps | YOUSHI | P20200108013 | |
Mesh | pfm medical titanium gmbh | 20163131539 | |
Methylene blue | JUMPCAN | H32024824 | |
1 mL syringe (0.45×16RWLB) | WEGO | 20163141593 | |
Single port | SURGAID | 5012151092 | |
10 mL syringe (0.8×38TWLB) | WEGO | 20163141593 |