Is minimal-accessed (endoscopic- or robotic-assisted) nipple-sparing mastectomy contraindicated for large breasts?

BACKGROUND: In the developmental stage of minimal-accessed nipple-sparing mastectomy (MA-NSM), selecting patients with small to medium-sized breasts was common for better cosmetic outcomes and oncological safety. However, the suitability of MA-NSM for large, ptotic breasts remained uncertain. This retrospective study aim to assess MA-NSM outcomes in patients with large breasts. MATERIALS AND METHODS: This retrospective study included patients receiving conventional NSM (C-NSM) and MA-NSM from January 2011 to September 2022, at a single institution. We analyzed perioperative parameters and clinical outcomes based on breast specimen size, classified as small (≤300 g), medium (>300-450 g), large (>450-600 g), and very large (>600 g). RESULTS: A total of 728 patients was enrolled. C-NSM was performed in 51% (371/728) of cases, while MA-NSM was done in 49% (357/728). The overall complication rate of MA-NSM was comparable to C-NSM (p = 0.573), but severe complications (Clavien-Dindo, CD III) was significantly reported more following C-NSM, regardless of breast size. During a median follow-up of 52 months, no significant difference in oncological outcomes was observed. Comparing MA-NSM and C-NSM outcomes in large-very large breasts (>450 g), MA-NSM demonstrated significantly less blood loss (p = 0.036) and lower incidence of severe complications (CD ≥ III) compared to C-NSM (p = 0.002). CONCLUSION: MA-NSM is feasible for large breasts and offers benefits by reducing blood loss and decreasing the incidence of severe complications (CD ≥ III) in this patient group.

Scarless totally implantable venous access port (TIVAP) implantation: Surgical technique, preliminary results, learning curve, and patients-reported outcome in 125 breast cancer patients.

BACKGROUND: Minimal-access (endoscopic or robotic-assisted) breast surgery has been increasingly performed and shown better cosmetic results. However, location of totally implantable venous access port (TIVAP) for systemic treatment at anterior chest may compromise its aesthetic benefits. Therefore, we proposed a new scarless technique for TIVAP implantation, and reported the preliminary results, learning curve, and patients-surveyed outcome. METHODS: Surgical technique of the new "scarless" TIVAP implantation was proposed. Patients receiving this procedure in a single institution were included. The preliminary results of the scarless TIVAP implantation, learning curve, and patient-reported outcome were analyzed and reported. RESULTS: A total of 125 breast cancer patients received scarless TIVAP procedures were enrolled. The primary success rate of the scarless TIVAP implantation was 100%. Mean operative time was 46 ± 14 min. Mean amount of blood loss was 8.5 ± 3.2 ml. The cumulative sum plot showed operation time significantly decreased after 24th cases. In the initial learning phase, the mean operative time was 55 ± 17 min, and decreased to 43 ± 12 min in the later mature phase (P = 0.003). There were 5 (4%) complications detected, which included 1 (0.8%) seroma formation, 2 (1.6%) revisions, and 2 (1.6%) unplanned explantations. From patients-evaluated questionnaires, more than 90% of responders were satisfied with aesthetic results, experience during surgery, and application of scarless TIVAP for systemic therapy. CONCLUSIONS: The scarless TIVAP implantation is a safe & reliable procedure with high patients-reported aesthetic satisfaction, and could be an alternative TIVAP procedure for patients requiring chemotherapy and desiring a less noticeable scar.

Comparing Surgical Site Infection Rate Between Primary Closure and Rhomboid Flap After Stoma Reversal.

BACKGROUND: Primary closure (PC) is a common wound closure procedure after stoma reversal and is associated with a high rate of surgical site infection (SSI). This study introduced a new method of skin closure, a rhomboid flap (RF), for skin closure after stoma reversal and compared the SSI rate between the 2 techniques. METHODS: This is a single-center retrospective study. Patients who underwent colostomy or ileostomy closure performed using either rotation flap (n = 33) or PC (n = 121) techniques for skin closure after stoma reversal between April 2019 and July 2022 were enrolled in this study. Medical records were retrospectively reviewed to obtain data. Both groups were followed up postoperatively at 1 month for wound infection. Wound infection within 30 days after surgery was indicated by the presence of purulent discharge, erythema, local heat, or positive culture for bacteria. RESULTS: In the PC group, the infection rate was 25.6% (n = 121) compared with 12.1% (n = 33) in the RF group (P = 0.158). Among the patients who underwent colostomy reversal, the infection rate of the RF group was significantly lower compared with that of the PC group (11.1% vs 36.9%, P = 0.045). Among the patients who underwent ileostomy reversal, no significant differences in the infection rates between the groups were found (13.3% vs 12.5%, P = 1.000). CONCLUSIONS: Although the RF technique requires slightly longer operative time for flap design in practice than the linear closure method, the technique can significantly reduce the SSI rate after colostomy reversal through the dissection of the surrounding inflammatory tissues and obliteration of the dead space. Additional studies are required to evaluate this technique, compare it with other existing methods, and explore long-term complications.

Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P).

OBJECTIVE: To compare the clinical and patient-reported outcomes of minimal access and conventional nipple-sparing mastectomy (C-NSM). The secondary outcomes investigated included medical costs and oncological safety. BACKGROUND: Minimal-access NSM has been increasingly applied in the treatment of patients with breast cancer. However, prospective multicenter trials comparing robotic-assisted NSM (R-NSM) versus C-NSM or endoscopic-assisted NSM (E-NSM) are lacking. METHODS: A prospectively designed 3-arm multicenter, nonrandomized trial (NCT04037852) was conducted from October 1, 2019 to December 31, 2021, to compare R-NSM with C-NSM or E-NSM. RESULTS: A total of 73 R-NSM, 74 C-NSM, and 84 E-NSM procedures were enrolled. The median wound length and operation time of C-NSM was (9 cm, 175 minutes), (4 cm, and 195 minutes) in R-NSM, and (4 cm and 222 minutes) in E-NSM. Complications were comparable among the groups. Better wound healing was observed in the minimal-access NSM group. The R-NSM procedure was 4000 and 2600 United States Dollars more expensive than C-NSM and E-NSM, respectively. Wound/scar and postoperative acute pain evaluation favored the use of minimal access NSM over C-NSM. Quality of life in terms of chronic breast/chest pain, mobility, and range of motion of the upper extremity showed no significant differences. The preliminary oncologic results showed no differences among the 3 groups. CONCLUSIONS: R-NSM or E-NSM is a safe alternative if compared with C-NSM in terms of perioperative morbidities, especially with better wound healing. The advantage of minimal access groups was higher wound-related satisfaction. Higher costs remain one of the major limiting factors in the widespread adoption of R-NSM.

Factors associated with alteration of nipple or skin sensation and impact of duration of time following nipple-sparing mastectomy (NSM): an analysis of 460 cases with comparison of conventional versus endoscopic- or robotic-assisted NSM.

BACKGROUND: The current study aims to evaluate the nipple and skin sensation following nipple-sparing mastectomy (NSM) and identify patient-, surgical-, or treatment-related factors affecting nipple or skin sensation in this cohort. METHODS: Patients who received NSM with postoperative nipple and skin sensation test evaluation at a single institution over the past 10 years were retrospectively retrieved from a prospectively collected breast cancer surgery database. RESULTS: A total of 460 NSM procedures were included in this current study, with the mean age of 48.3 ± 9.1. Three-hundred eighty-three (83.3%) patients had breast reconstructions. One-hundred seventy-four (37.8%) received conventional NSM (C-NSM), 195 (42.4%) endoscopic-assisted NSM (E-NSM), and 91 (19.8%) robotic-assisted NSM (R-NSM) procedures. For nipple sensation assessment, 15 (3.3%) were grade 0, 83 (18.2%) grade I, 229 (49.7%) grade II, and 133 (28.9%) grade III (normal sensation), respectively, with mean grade score of 2.1 ± 0.7. The preserved (grade III) nipple sensation rate was 36.2% (63/174) in the C-NSM group, 26.7% (52/195) in the E-NSM group, and 19.7% (18/91) in the R-NSM group (P = 0.06). The "time since surgery to last evaluation" was significantly longer in the C-NSM group (45.6 ± 34 months) or E-NSM group (44.7 ± 35.8 months) as compared to R-NSM group (31.8 ± 16 months, P < 0.01). In multivariate analysis, peri-areolar incision showed higher grade of nipple sensation (OR: 2.1, P = 0.02) compared to upper outer quadrant incision, and longer follow-up time post-NSM showed significant improvement of nipple or skin sensation (> 60 months vs. ≦ 12 months: nipple odds ratio (OR) = 5.75, P < 0.01; skin, OR = 1.97, P < 0.05). CONCLUSION: Our current analysis showed some factors to be related to postoperative nipple or skin sensation, and longer "time after surgery" was associated with significant improvement of nipple and skin sensation in patients who received NSM, regardless of the surgical approaches. SYNOPSIS: Our current analysis showed a significant portion of patients with decrease or loss of nipple or skin sensation after nipple-sparing mastectomy (NSM). Several factors associated with preserved nipple or skin sensation were identified, including age, surgical methods, surgical wound location, and association of time from surgery showing that improvement of partial nipple or skin sensation was evident after a longer follow-up.

Oncoplastic and reconstructive breast surgeon performance and impact on breast reconstructions: Clinical outcomes, learning curve, and patients' satisfaction.

BACKGROUND: Compared to mastectomy alone, the addition of breast reconstruction could improve quality of life and it is usually performed by two-team approach, which consisted of both breast surgeons and plastic surgeons. This study aims to illustrate the positive impacts of the dual-trained oncoplastic reconstructive breast surgeon (ORBS) and reveal the factors influencing reconstruction rates. METHODS: This retrospective study enrolled 542 breast cancer patients who undergone mastectomy with reconstruction performed by a particular ORBS between January 2011 and December 2021 at a single institution. Clinical and oncological outcomes, impact of case accumulation on performance and patient-reported aesthetic satisfactions were analyzed and reported. Furthermore, in this study 1851 breast cancer patients treated with mastectomy combined with or without breast reconstructions, which included 542 performed by ORBS, were reviewed to identify factors affecting breast reconstructions. RESULTS: Among the 524 breast reconstructions performed by the ORBS, 73.6% were gel implant reconstructions, 2.7% were tissue expanders, 19.5% were transverse rectus abdominal myocutaneous (TRAM) flaps, 2.7% were latissimus dorsi (LD) flaps, 0.8% were omentum flaps, and 0.8% involved LD flaps and implants. There was no total flap loss in the 124 autologous reconstructions, and the implant loss rate was 1.2% (5/403). Patient-reported aesthetic evaluations showed that 95% of the patients were satisfied. As the ORBS's accumulated case experiences, the implant loss rate decreased, and the overall satisfaction rate increased. According to the cumulative sum plot learning curve analysis, it took 58 procedures for the ORBS to shorten the operative time. In multivariate analysis, younger age, MRI, nipple sparing mastectomy, ORBS, and high-volume surgeon were factors related to breast reconstruction. CONCLUSION: The current study demonstrated that a breast surgeon after adequate training could become an ORBS and perform mastectomies with various types of breast reconstruction with acceptable clinical and oncological outcomes for breast cancer patients. ORBSs could increase breast reconstruction rates, which remain low worldwide.

Using 3D Microscope for Hepatic Artery Reconstruction in Living Donor Liver Transplant.

INTRODUCTION: This study compares the intraoperative process of hepatic artery anastomosis using conventional microscope and novel 3D digital microscope and discusses our technique and operative set-up. METHOD: A retrospective comparative cohort study with 46 hepatic artery reconstructions in living donor liver transplant patients. Either an operational microscope (control group) or a 3D digital microscope Mitaka Kestrel View II (study group) was used for hepatic artery anastomosis. We then discuss and share our institution's experience of improving surgical training. RESULTS: Both operation instruments provide effective and comparable results. There was no statistical difference regarding operational objective results between conventional microscope and exoscope. Both instruments have no hepatic artery size limit, and both resulted in complete vessel patency rate. CONCLUSIONS: There was no statistical differences regarding hepatic artery anastomosis between microscope and exoscope cohorts. Microsurgeons should perform hepatic artery anastomosis efficiently with the instruments they are most proficient with. Yet, exoscope provided better ergonomics in the operation room and lessened musculoskeletal strain, allowing surgeons to work in a more neutral and comfortable posture while allowing the first assistant to learn and assist more effectively. Using exoscope with micro-forceps and modified tie technique make artery reconstruction easier.

Minimal Access (Endoscopic and Robotic) Breast Surgery in the Surgical Treatment of Early Breast Cancer-Trend and Clinical Outcome From a Single-Surgeon Experience Over 10 Years.

OBJECTIVE: Endoscopic assisted breast surgery (EABS) or robotic assisted breast surgery (RABS) performed through minimal axillary and/or peri-areolar incisions has become the representative of minimal access breast surgery (MABS). We report the trend and clinical outcome of MABS for treatment of breast cancer. METHODS: Information on patients who underwent breast cancer operation by the principal investigator during the period of 2011 to 2020 was collected from a single institute for analysis. The clinical outcome, trend, and cost of MABS were analyzed and compared with conventional breast surgery (CBS). RESULTS: A total of 824 breast cancer patients operated by a single surgeon were enrolled in this study: 254 received CBS and 570 received MABS, namely, 476 EABS and 94 RABS. From 2011 to 2020, the number of MABS performed annually has shown an increasing trend. Compared with CBS, MABS such as breast conserving surgery and nipple sparing mastectomy (NSM) have effectively reduced wound scar length. Since the sequential uprise from conventional NSM (C-NSM), dual-axillary-areolar-incision two dimensional (2D) endoscopic assisted NSM (E-NSM), single-axillary-incision E-NSM, robotic assisted NSM (R-NSM), and single-port 3D E-NSM, the development of minimal access mastectomies increasingly paralleled with NSM. The operation time of various MABS decreased significantly and showed no statistical difference compared with CBS. R-NSM was associated with highest cost, followed by 3D E-NSM, E-NSM, and C-NSM. The positive surgical margin rate and local recurrence rate of MABS and CBS were not statistically different. CONCLUSION: MABS showed comparable clinical outcome and preliminary oncologic safety as CBS and has been increasingly performed as the surgical treatment of breast cancer, especially minimal access NSM.

Single-Port Three-Dimensional (3D) Videoscope-Assisted Endoscopic Nipple-Sparing Mastectomy in the Management of Breast Cancer: Technique, Clinical Outcomes, Medical Cost, Learning Curve, and Patient-Reported Aesthetic Results from 80 Preliminary Procedures.

BACKGROUND: The preliminary results of an innovative surgical technique, which incorporated single-port three-dimensional (3D) videoscope and instruments for endoscopic nipple-sparing mastectomy (E-NSM), were reported. METHODS: The medical records of patients who underwent single-port 3D E-NSM for breast cancer from August 2018 to September 2020 were analyzed, and the preliminary outcome of this procedure as well as the patient-reported aesthetic results are described in this article. RESULTS: The study enrolled 70 patients who received 80 procedures of single-port 3D E-NSM. The mean operation time was 158 ± 36 min, and the mean blood loss was 41 ± 26 ml. Three procedures (3.8 %) associated with delayed axillary wound-healing, eight cases of transient nipple ischemia (10 %), three cases of partial nipple ischemia/necrosis (3.7 %), and one case of total nipple-areolar complex (NAC) necrosis (1.3 %) were observed. No patient had margin involvement. Satisfaction rates of approximately 90 % were observed in terms of postoperative scar appearance, location, and length. Most of the patients (87.8 %) reported that they would choose the same operation again if given the chance to do so. The overall cost of a single-port 3D E-NSM was 7522 ± 470 U.S. dollars. According to cumulative sum (CUSUM) plot analysis, about 14 cases were needed for surgeons to familiarize themselves with single-port 3D E-NSM and immediate gel implant reconstruction and to decrease their operation time significantly in the initial learning phase. CONCLUSION: Single-port 3D E-NSM, a safe, efficient, lower-cost procedure, is associated with a good aesthetic result. It is a promising new technique for breast cancer patients indicated for mastectomy, but long-term oncologic safety follow-up evaluation still is needed.

Modified Stair-Step Flap With Turnover Flap for Drooling Correction After Lower Lip Composite Defect Reconstruction.

BACKGROUND: Oral commissure and buccal complex defects are commonly seen after cancer ablation. Free flap reconstruction can offer adequate soft tissue volume and outer skin lining. However, oral incompetence often occurs when an oral commissure has defects, particularly when the patient receives postoperative radiotherapy. The purpose of this article was to describe our method of the modified stair-step technique and improve the oral competence. METHODS: This study involves 22 patients who had partial lower lip and/or upper lip defects and underwent flap reconstruction and/or postoperative radiotherapy resulting in oral incontinence. Fourteen patients had been treated with an anterolateral thigh flap, 7 patients had been treated with a radial forearm flap, and 1 patient had been treated with a fibular osteocutaneous flap. Our modified stair-step commissuroplasty was done in all cases, and a debulking procedure was done in each second operation. RESULTS: Acceptable oral continence and contour were achieved in 19 patients. Some patients still had drooling after their second operation, but it was considerably less than before. CONCLUSIONS: This technique is an easy procedure for revision of lower lip deformities after oral commissure reconstruction.

Endoscopy-Assisted Total Mastectomy with and without Immediate Reconstruction: An Extended Follow-Up, Multicenter Study.

BACKGROUND: Endoscopy-assisted total mastectomy has been used for surgical intervention of breast cancer patients; however, large cohort studies with long-term follow-up data are lacking. METHODS: Breast cancer patients who underwent endoscopy-assisted total mastectomy from May of 2009 to March of 2018 were collected prospectively from multiple centers. Clinical outcome, impact of different phases, oncologic results, and patient-reported aesthetic outcomes of endoscopy-assisted total mastectomy were reported. RESULTS: A total of 436 endoscopy-assisted total mastectomy procedures were performed; 355 (81.4 percent) were nipple-sparing mastectomy, and 81 (18.6 percent) were skin-sparing mastectomy. Three hundred fourteen (75.4 percent) of the procedures were associated with immediate breast reconstruction; 255 were prosthesis based and 59 were associated with autologous flaps. The positive surgical margin rate for endoscopy-assisted total mastectomy was 2.1 percent. In morbidity evaluation, there were 19 cases (5.4 percent) with partial nipple necrosis, two cases (0.6 percent) with total nipple necrosis, and three cases (0.7 percent) with implant loss. Compared with the early phase, surgeons operating on patients in the middle or late phase had significantly decreased operation time and blood loss. With regard to patient-reported cosmetic outcomes, approximately 94.4 percent were satisfied with the aesthetic results. Patients who underwent breast reconstruction with preservation of the nipple had higher satisfaction rates. Over a median follow-up of 54.1 ± 22.4 months, there were 14 cases of locoregional recurrence (3.2 percent), three distant metastases (0.7 percent), and one mortality (0.2 percent). CONCLUSION: This multicenter study showed that endoscopy-assisted total mastectomy is a reliable surgical intervention for early breast cancer, with high patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Barrel-shaped design of the forearm free flap for lower lip reconstruction: a pilot case-control study.

BACKGROUND: Radial free forearm flaps is indicated patients with total or near-total defects in their lower lip. The purpose of our study was to evaluate a simple and effective barrel-shaped design of the radial free forearm flap for lower lip reconstruction and to compare its clinical outcomes with those of a conventional rectangular shaped free forearm flap. METHODS: Twenty-two patients with a lower lip carcinoma who underwent radial forearm free flap reconstructive surgery were enrolled in this study between January 1, 2012, and December 31, 2017. A barrel-shaped design of radial forearm free flap for reconstruction was used in 8 patients (case group), and a rectangular design was used in 14 patients (control group). The patients' quality of life was evaluated preoperatively and postoperatively in all the patients using the European Organization for Research and Treatment of Cancer Quality of Life (EORTC-HN35) questionnaire. We analyzed the differences in the EORTC QLQ-HN35 scores pre- and postoperatively between the case and control group. RESULTS: The patients in the case group had better outcomes in swallowing, speech, social eating, social contact, and dry mouth than the control group at 1-year follow-up (P < 0.05). CONCLUSIONS: The use of a barrel-shaped design free forearm flap for lower lip reconstruction is an effective procedure and can achieve better results than the use of rectangular free forearm flap.

Robotic versus conventional nipple sparing mastectomy and immediate gel implant breast reconstruction in the management of breast cancer- A case control comparison study with analysis of clinical outcome, medical cost, and patient-reported cosmetic results.

BACKGROUND: Robotic nipple sparing mastectomy (R-NSM), which uses the da Vinci surgical platform, could perform NSM and immediate breast reconstruction through a small and inconspicuous extra-mammary axillary or lateral chest incision. R-NSM was reported with extremely low nipple areolar complex (NAC) necrosis rate, good cosmetic results, and high patient satisfaction. However, there was little evidence available comparing the effectiveness and safety of R-NSM and conventional NSM (C-NSM) in the management of breast cancer. METHODS: A case control comparison study was conducted for patients with breast cancer who underwent R-NSM or C-NSM with immediate gel implant breast reconstruction (IGBR) from July 2011 to September 2019 at a single institution to compare the clinical outcomes, patient-reported esthetic results, and medical cost. RESULTS: According to the study design, 54 procedures of R-NSM were compared with 62 procedures of C-NSM in the surgical management of breast cancer combined with IGBR. Compared with C-NSM, R-NSM was associated with higher overall satisfaction (92% excellent and 8% good versus 75.6% excellent and 24.4% good, P = 0.046), and wound/scar related outcome in patient-reported esthetic results. The NAC ischemia/necrosis risk, overall complication rate, and blood loss were not significantly different between R-NSM and C-NSM groups. However, longer operation time and higher overall medical cost (10,877 ±â€¯796 versus 5,702 ±â€¯661 US Dollars, P<0.01) was observed in R-NSM group. CONCLUSION: Compared with C-NSM, R-NSM showed comparable clinical outcomes and favorable patients' satisfaction with the esthetic results, but at the price of longer operation time and higher cost.

Robotic- Versus Endoscopic-Assisted Nipple-Sparing Mastectomy with Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Case-Control Comparison Study with Analysis of Clinical Outcomes, Learning Curve, Patient-Reported Aesthetic Results, and Medical Cost.

BACKGROUND: New surgical innovations of nipple-sparing mastectomy (NSM), such as endoscopic NSM (E-NSM) or robotic NSM (R-NSM), were emerging. However, there was a lack of evidence comparing the effectiveness and safety in the management of breast cancer. METHODS: A case-control comparison study was conducted for patients with breast cancer underwent E-NSM or R-NSM with immediate prosthesis breast reconstruction (IPBR) from July 2010 to February 2019 at a single institution to compare the clinical outcomes, learning curve, patient-reported cosmetic results, and medical cost. RESULTS: A total of 91 E-NSM and 40 R-NSM procedures were retrieved and analyzed. The surgical margin involvement rate in both R-NSM (2.5%) and E-NSM (4.4%) procedures were relatively low (P = 0.52). The R-NSM group was associated with higher satisfaction rates in terms of scar appearance, scar length, and surgical wound position compared with the E-NSM group. Compared with E-NSM, the R-NSM operation time took longer (241 ± 61 vs. 215 ± 70 min, P = 0.01), less blood loss (32 ± 29 vs. 79 ± 62 ml, P < 0.01), and higher medical cost (10,587 ± 554 vs. 6855 ± 936 U.S. dollars, P < 0.01). There was no statistically significant difference in nipple ischemia/necrosis or overall complication between R-NSM and E-NSM. In the learning curve analysis, it took the 27th procedure in E-NSM and 10th procedure in R-NSM to decrease operation time significantly. CONCLUSIONS: R-NSM was associated with higher wound-related satisfaction, lesser blood loss, and shorter learning curve compared with E-NSM, however, at the price of longer operation time and higher medical cost.

Single-port 3-dimensional Videoscope-assisted Endoscopic Nipple-sparing Mastectomy in the Management of Breast Cancer.

The preliminary experience and results of an innovative surgical technique that incorporated a single-port and 3-dimensional (3D) videoscope system for endoscopic nipple-sparing mastectomy (E-NSM) were reported. The medical records of patients who underwent single-port 3D E-NSM for breast cancer during the period of August 2018 to October 2018 in a single institution were collected prospectively and analyzed. Patients' reported cosmetic outcome results were also obtained. During the study period, 11 patients received 15 procedures of single-port 3D E-NSM. The mean operation time for single-port 3D E-NSM and immediate prosthesis breast reconstruction was 181.8 ± 32.4 minutes. The mean blood loss was 38.3 ± 45.3 ml (15-60). In the postoperative morbidity evaluation, 1 patient (6.7%) had delayed axillary wound healing and 2 (13.4%) had transient nipple ischemia, but there were no cases of total nipple areolar complex necrosis and implant loss observed. In addition, there were no cases with margin involvement or locoregional recurrence during the follow-up period. In patient-reported cosmetic outcomes, high (93.3%) satisfaction rates were observed in terms of postoperative scar appearance, location, and length. All patients who had received 3D E-NSM and immediate prosthesis breast reconstruction reported that they would choose the same operation again if given the chance to do so. From our preliminary experience, single-port 3D E-NSM is a feasible and safe procedure with good cosmetic results. Hence, this technique could be a promising new technique for patients with breast cancer indicated for nipple-sparing mastectomy.

Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction with Gel Implant: Technique, Preliminary Results and Patient-Reported Cosmetic Outcome.

BACKGROUND: Experience with application of a robotic surgery platform in the management of breast cancer is limited. The preliminary results of the robotic nipple-sparing mastectomy (R-NSM) and immediate breast reconstruction (IBR) with Gel implant procedure are reported. METHODS: The medical records of patients from a single institution who underwent an R-NSM and IBR with Gel implant procedure for breast cancer during the period March 2017 to February 2018 were assessed. Data on clinicopathologic characteristics, type of surgery, complications, and recurrence were analyzed to determine the effectiveness and oncologic safety of R-NSM. Patient-reported cosmetic outcome results were obtained. RESULTS: A total of 22 patients who received 23 R-NSM and IBR with Gel implant procedures were analyzed. The mean operation time for R-NSM was 118.8 ± 50.6 min, and 74.5 ± 26.6 min for Gel implant reconstruction. Docking time quickly dropped from 20 to 6-8 min, and the time needed to complete R-NSM was usually completed within 100 min after accumulation of case experience. Mean blood loss was 37 ± 38.2 mL, and the positive surgical margin rate was 0%. Three (13%) patients had transit nipple ischemia change, and no total nipple-areolar complex necrosis cases were observed. No local recurrence or mortality was found during a mean 6.9 ± 3.5 months of follow-up. All 22 patients were satisfied with the postoperative aesthetic outcome. CONCLUSION: From our preliminary experience, R-NSM and IBR with Gel implant is a safe procedure, with good cosmetic results, and could be a promising new technique for breast cancer patients indicated for mastectomy.

The learning curve of robotic nipple sparing mastectomy for breast cancer: An analysis of consecutive 39 procedures with cumulative sum plot.

BACKGROUND: The preliminary experience and learning curve of robotic nipple sparing mastectomy (R-NSM) in the management of breast cancer were analyzed and reported. METHODS: The medical records of patients who underwent R-NSM for breast cancer during the period of March 2017 to June 2018 were collected from the same surgeon in a single institute. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, and operation time were prospective collected. Learning curve of R-NSM was evaluated and analyzed by the cumulative sum (CUSUM) plot method. RESULTS: A total of 39 consecutive R-NSM procedures from 35 patients were analyzed. The time needed for "docking", "R-NSM", and "R-NSM and immediate prosthesis breast reconstruction (IPBR)" decreased after cases experience accumulated, and in mature phase procedures could finished within 10 min, 100mins, and 240 min, separately. In CUSUM plots analysis of learning curve, the cases needed to decrease operation time for "docking", "R-NSM", and "total time for R-NSM and IPBR" were 13th, 13th, and 12th procedures separately. Mastectomy weight and lymph node metastasis were factors related to operation time. The rate of total nipple areolar complex necrosis for R-NSM was 0%. One (2.9%, 1/35) R-NSM procedure was found to have positive margin involved in the final pathologic check-up. No implant loss, or local recurrence was observed during a mean follow-up of 8.6 ±â€¯4.5 (1.3-16.7) months. CONCLUSION: From our preliminary experience, R-NSM and IPBR (or R-NSM alone) is a safe procedure, and the operation time needed significantly decrease after cases experience accumulated.

Implant volume estimation in direct-to-implant breast reconstruction after nipple-sparing mastectomy.

BACKGROUND: Nipple-sparing mastectomy (NSM) is an increasingly popular alternative to more traditional mastectomy approaches. However, estimating the implant volume during direct-to-implant (DTI) reconstruction following NSM is difficult for surgeons with little-to-moderate experience. We aimed to provide a fast, easy to use, and accurate method to aid in the estimation of implant size for DTI reconstruction using the specimen weight and breast volume. METHODS: A retrospective analysis was performed using data from 145 NSM patients with specific implant types. Standard two-dimensional digital mammograms were obtained in 118 of the patients. Breast morphological factors (specimen weight, mammographic breast density and volume, and implant size and type) were recorded. Curve-fitting and linear regression models were used to develop formulas predicting the implant volume, and the prediction performance of the obtained formulas was evaluated using the prospective data set. RESULTS: Two formulas to estimate the implant size were obtained, one using the specimen weight and one using the breast volume. The coefficients of correlation (R2) in these formulas were over 0.98 and the root mean squared errors were approximately 13. CONCLUSIONS: These implant volume estimate formulas benefit surgeons by providing a preoperative implant volume assessment in DTI reconstruction using the breast volume and an intraoperative assessment using the specimen weight. The implant size estimation formulas obtained in the present study may be applied in a majority of patients.

Robotic Nipple-sparing Mastectomy and Immediate Breast Reconstruction with Gel Implant.

BACKGROUND: The experience of application of robotic surgery platform in the management of breast cancer was limited. The preliminary experience and results of robotic nipple-sparing mastectomy (R-NSM) and immediate breast reconstruction (IBR) with Gel implant was reported. METHODS: The medical records of patients who underwent R-NSM and IBR with Gel implant for breast cancer during the period March 2017 to October 2017 were collected from single institution. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, complications, and recurrence were analyzed to determine the effectiveness and oncologic safety of R-NSM. Patients' oriented cosmetic outcome report was also obtained. RESULTS: A total of 15 patients was analyzed, and the mean age of them was 46.5 ± 10.0 years. The pathologic stage was 30.8% ductal carcinoma in situ, 30.8% stage I, 30.8% stage II, and 7.7% stage III. The mean operation time was 282.8 ± 70.4 minutes, and mean hospital stay was 6.7 ± 1.2 days. The positive surgical margin rate was 0%. One patient suffered from delayed axillary wound healing. Two patients (13.3%) with transit nipple ischemia change, but no total nipple areolar complex necrosis case was observed. No local recurrence, distant metastasis, or case mortality was found during mean 6.3 ± 2.1 months follow-up. All 15 patients were satisfied with the postoperative aesthetic outcome. CONCLUSION: From our preliminary experience, R-NSM and IBR with Gel implant is a safe procedure, with good cosmetic results, and could be a promising new technique for breast cancer patients indicated for mastectomy.