Commentary on “Videoendoscopic Single-Port Nipple-Sparing Mastectomy and Immediate Reconstruction”

Dear Editor:

Throughout the last several decades, advances in mastectomy techniques and breast reconstruction have revolutionized the approach to treating patients with breast cancer. We commend the authors of “Videoendoscopic Single-Port Nipple-Sparing Mastectomy and Immediate Reconstruction” ¹ in their pursuit of applying endoscopic methods to breast surgery. Indeed, minimizing incision length, optimizing esthetic outcomes, and achieving successful oncologic resection are the ultimate goals of nipple-sparing mastectomy. Tukenmez et al. ¹ report their outcomes in a series of 10 patients, but there are certain implications that should not be taken out of context in this relatively small and selective cohort.

First, the authors refer to “dilute infiltration,” “blind use of long scissors,” and creating a “thin flap” as the etiology of poor outcomes in nipple-sparing mastectomies. Although dilute infiltration and the use of scissors are viable options for dissection, our experience at our institution and those of many other institutions include complete glandular excision with electrocautery dissection. Both remain viable options. Specific to nipple-sparing mastectomy is the concern for developing nipple areolar necrosis and locoregional recurrence. Nipple-sparing mastectomy is supported in properly selected patients. We challenge the notion that complications are less likely to occur as a result of the videoendoscopic technique. Recent studies have elucidated that nipple areolar necrosis is significantly more likely to occur in patients with larger-sized breasts (C-cup and larger) ² and increased breast weight. ³ Moreover, Endara et al. ⁴ conducted a systematic review and pooled analysis of over 6600 patients that found transareolar incisions and periareolar incisions to have extraordinarily high rates of nipple necrosis: 81.82% and 17.8%, respectively. Radial, mastopexy, and inframammary incisions were shown to have lower rates (4%–8%) of nipple area necrosis. It should be noted that most patients do not manifest total necrosis of the nipple.

Second, the authors only describe prosthetic implant reconstruction, both single- and two-stage procedures, for methods of reconstruction. Muscle-sparing techniques have minimized the donor site morbidity, allowing for certain patients to favor autologous over prosthetic reconstruction. Using free tissue transfer would require greater exposure of recipient vessels, likely limiting its use in videoendoscopic mastectomy. However, we encourage the authors to push the boundaries of their techniques to pedicled flaps as robotic techniques have been described in harvesting the latissimus dorsi. ⁵

Nipple-sparing mastectomy and prosthetic reconstruction can be performed immediately with the one- or two-stage method as described in the aforementioned 10 patients. Proponents of permanent implant reconstruction immediately following nipple-sparing mastectomy advocate simplicity, decreased costs, and lower complication rates. Supporters of the two-stage method claim superior outcomes with a second operation to improve symmetry. ⁴ In the event of a positive subareolar tissue biopsy, this can be addressed upon return to the operative room during the second surgery.

Lastly, we also emphasize that endoscopic breast surgery is not without risk. Incorporating CO₂ insufflation may facilitate a subcutaneous mastectomy plane, but it has been implicated in subcutaneous emphysema and pulmonary embolism. ⁶ It is difficult to draw a safety profile or even strong conclusions from a novel technical procedure performed in only 10 patients. However, we applaud the authors for incorporating new modalities to improve esthetic outcomes in patients undergoing nipple-sparing mastectomy.