Present status of endoscopic mastectomy for breast cancer

An Innovative and Highly Efficient Single-Port Endoscopic Nipple-/Skin-Sparing Mastectomy and Dual-Plane Direct-to-Implant Breast Reconstruction: A Prospective Study from a Single Institution

BACKGROUND

The difficulty in creating and maintaining a stable workspace of the breast makes endoscopic nipple-/skin-spring mastectomy (E-N/SSM) develop slowly. This study aims to report the preliminary results of a novel endoscopic technique for N/SSM followed by dual-plane direct-to-implant (DP-DTI) breast reconstruction.

METHODS

A prospectively maintained database was reviewed that included patients who underwent single-axillary-incision E-N/SSM and DP-DTI breast reconstruction from September 2020 to April 2021 at a single institution by three surgeons. The data were collected prospectively and analyzed to determine the efficacy, feasibility, safety, and esthetic results of the operation, as well as quality of life (QoL).

RESULTS

During the study period, a total of 68 E-N/SSM and DP-DTI reconstruction procedures through a single axillary incision were performed in 63 female patients. Among all the procedures, the majority were performed for grade 1-3 ptotic breasts (n =46, 73.0%). During the median follow-up of 26.5 months, the major and minor surgical complication rates were 1.6% (1/63) and 9.5% (6/63), respectively. The cosmetic complication rate was 14.3%. One patient suffered local recurrence 4 months postoperation. The average scores in patient-reported outcomes at 2 years postoperation of satisfaction with breast (66.57), psychosocial well-being (75.93) and sexual well-being (56.29) were not significantly different compared with the baseline, except for physical well-being: chest (69.85).

CONCLUSIONS

The proposed procedure for E-N/SSM and DP-DTI breast reconstruction is feasible, time-saving and safe with good outcomes in terms of cosmetic results and QoL and expands the indications of DTI reconstruction to ptotic breasts, making it easier to popularize.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Preliminary Experience of Endoscopic Total Mastectomy With Immediate Free Abdominal-Based Perforator Flap Reconstruction Using Minimal Incisions, and Literature Review

PURPOSE

Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored.

METHODS

We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed.

RESULTS

Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed.

CONCLUSION

ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an "aesthetically scarless" mastectomy and reconstruction through minimal incisions.

Single axillary incision endoscopic surgery and liposuction for gynecomastia

Gynecomastia is a common type of breast tissue hypertrophy in men. Surgical excision is the most effective treatment for this condition. Minimally invasive surgical techniques can be used to avoid visible chest scarring. In this study, we evaluated the efficacy and safety of single-axillary-incision endoscopic mastectomy and liposuction for the treatment of gynecomastia. Nipple-sparing mastectomy via a single-port axillary incision was successfully performed in all patients. Twenty-four bilateral procedures were performed in total. Twenty patients underwent liposuction concomitantly. The median weight of the mastectomy pieces was 88.5 g (range: 42.5-440 g), and the median amount of liposuction was 262.5 cc (range: 25-350 cc). The median duration of surgery was 120 minutes (range, 73-195 minutes). Two patients developed a seroma, and 1 patient developed a hematoma in the early postoperative period. The mean satisfaction levels related to physical appearance, mental status, and social environment were 8.75 (standard deviation [SD]: 1.19), 9.17 (SD: 1.44), and 9.33 (SD: 0.76) points, respectively, on a 10-point visual analog scale. Endoscopic single-port nipple-sparing mastectomy combined with liposuction is a technically feasible method to avoid anterior chest wall scarring with good cosmetic results. Between June 2021 and June 2022, 30 patients underwent endoscopic single-port nipple-sparing mastectomy through a small axillary incision, while 20 underwent concomitant liposuction. The demographic information of the patients, duration of surgery, amount of tissue removed, and complications were recorded. Patients' levels of satisfaction with their physical appearance, mental status, and social environment were measured.

Video-assisted Transaxillary Nipple-sparing Mastectomy and Immediate Implant-based Breast Reconstruction: A Novel and Promising Method

Background

Although video-assisted breast surgery is gaining popularity, endoscopic reconstruction after mastectomy is still facing lots of problems, bring about that endoscopic method has not yet become a standard procedure for breast cancer reconstruction. Here, we introduce a novel surgical technique of video-assisted transaxillary nipple-sparing mastectomy and immediate implant-based breast reconstruction and describe the detailed surgical procedure using this technique.

Methods

Detailed steps of surgical procedure, the patient characteristics and the mean operative time of this new technique were described in this article. All patients were asked to score their satisfaction with their reconstructed breasts preoperatively, 1 month, 3 months, 6 months and 12 months postoperatively using the BREAST-Q.

Results

At first, we used our “conventional method” and performed on 10 patients from April 2017 to June 2020; the operative time was 324.80 ± 66.39 minutes. After improving several procedures of the technique, the “optimized method” was performed on 14 cases from July 2020 to November 2020; the operative time decreased to 193.71 ± 28.75 minutes with shortest was 133 minutes; the optimized method was novel and easy to learn and be generalized. Most of the patients were satisfied with the reconstruction results. There was no significant difference between preoperative scores and scores at 3 months, 6 months and 12 months (p = 0.364). Since there is no wound on the breast dome, no obvious postoperative complications were observed except for one patient presented with infection.

Conclusions

This new technique has allowed surgeons to achieve excellent and reproducible outcomes in a single-stage procedure and represents an excellent technique for patients who wish to have a scarless and aesthetically pleasing appearance after mastectomy for breast cancer. This article also highlights the mean operative time (193.71 ± 28.75 minutes) that has been made possible with this new technique.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02527-6.

Subversion of Endoscopic Breast Reconstruction Surgery: Nipple-sparing Mastectomy and Immediate Reconstruction with a Latissimus Dorsi Flap/Latissimus Dorsi Flap and Implant Through a Single Axillary Incision

Our team has created a novel endoscopic technique (ET) to solve the problems of the former minimally invasive surgery (Inconvenient operation for ET, high cost for robotic technique, long-operation time for both) for breast cancer patients requiring nipple-sparing mastectomy and immediate breast reconstruction (BR) with a latissimus dorsi flap/latissimus dorsi flap and implant. This easy-to-grasp method will benefit more patients.

Evaluation of the Learning Curve in Robotic Nipple-sparing Mastectomy for Breast Cancer

BACKGROUND

This study discusses the preliminary results of robotic nipple sparing mastectomy (R-NSM) in patients with breast cancer and analyzes the learning curve of the same surgeon in a single medical center.

PATIENTS AND METHOD

Patients with breast cancer from a single center who received R-NSM between 2018 to 2020 were recruited for clinical and pathologic tumor characteristics including family history, grade, type of tumor, treatment, and outcome. The learning curve for R-NSM was analyzed by using cumulative sum (CUSUM).

RESULTS

A total of 85 R-NSM procedures from 78 patients were evaluated. In the CUSUM plot analysis of the learning curve, a significant decrease in time for mastectomy, reconstruction, and total operation appeared in the 22nd, 23rd, and 26th procedures, respectively. Patients' body weight, gel implant size, and specimen weight had significant correlations with the time for mastectomy. Four (5.6%) patients had nipple partial ischemia, and 1 (1.4%) had total nipple necrosis. The mean follow-up was 11.4 ± 6.2 months; only 1 patient showed recurrence.

CONCLUSION

Robotic breast surgery is a feasible method with good cosmetic outcome under suitable patient selection. Oncologic safety is not a reason to stop its development.

Nipple-sparing mastectomy combined with endoscopic immediate reconstruction via axillary incision for breast cancer: A preliminary experience of an innovative technique

INTRODUCTION

Nipple-sparing mastectomy (NSM) has known an exponential diffusion worldwide for prophilaxis and therapeutic mastectomies in selected candidates, being oncologically safe and improving reconstructive outcomes and patients' satisfaction. The two most common used skin incisions are the radial and inframammary fold ones, which represent an imperfect aesthetic solution. The aim of this work was to give insights on our surgical technique, which allows to perform the NSM, node surgery, and endoscopic direct-to-implant reconstruction using a cosmetic axillary incision.

MATERIALS AND METHODS

Between June 2016 and January 2019, 7 consecutive patients underwent NSM, lymph node surgery and endoscopic direct-to-implant reconstruction using a small cosmetic axillary incision for breast cancer treatment in a single Institution. An operative rigid endoscope with working channel (Richard Wolf) was used to dissect the entire submuscular-subfascial pocket. The mean age of the patients was 42.8 years old (range: 36-49 years). The evaluation methods were clinical and photography-based assessments, as well as the BREAST-Q which was used to quantify patient satisfaction.

RESULTS

The average follow-up time was 9 months (range 3-22 months). Tumor-free margins were obtained in all cases. No tumor recurrence or metastasis occurred during follow-up. No major complications were experienced. There were no cases of malposition, wrinkling, or rippling. All patients were satisfied with their esthetic results, especially the absence of visible scars.

CONCLUSIONS

From our preliminary experience, NSM combined with endoscopic immediate reconstruction via axillary incision for breast cancer treatment seems to be a promising new procedure in cup A and B breasts alternative to the conventional techniques, as it allowed to have safe and pleasant aesthetic and oncologic outcomes.