Robotic Assisted Versus Conventional Open Nipple Sparing Mastectomy With Implant Based Reconstruction for Breast Cancer: A Systematic Review of Oncologic Outcomes and Surgical Safety

Abstract

Robotic assisted nipple sparing mastectomy (RNSM) has been increasingly adopted for therapeutic breast cancer surgery. However, comparative evidence regarding oncologic outcomes and surgical safety relative to conventional open nipple sparing mastectomy (CNSM) remains limited. A systematic review was conducted in accordance with PRISMA 2020 guidelines. MEDLINE, Embase, Scopus, Web of Science, and Cochrane CENTRAL were searched for studies reporting outcomes of RNSM and/or CNSM with implant based reconstruction for invasive breast cancer or ductal carcinoma in situ. Both comparative studies and single arm robotic series were included. Prophylactic mastectomies were excluded. Primary outcomes were locoregional recurrence and disease free survival (DFS). Clinical characteristics, follow up duration, and surgical complications were descriptively summarized. Of 63 identified studies, 7 met inclusion criteria, comprising comparative cohorts and single arm robotic series. Patients were predominantly middle aged, with early stage disease, small tumor size, hormone receptor positive tumors, and low prevalence of smoking and major comorbidities. Median or mean follow up ranged from approximately 6 to 36 months. Compared with CNSM, RNSM was associated with longer operative time but lower intraoperative blood loss. Overall complication rates ranged from 0% to approximately 30%, with infrequent major complications. Rates of nipple areolar complex necrosis, skin necrosis, infection, seroma, hematoma, and implant loss were comparable between approaches. Locoregional recurrence was uncommon, ranging from 0% to approximately 2%, and no meaningful differences in DFS were observed across comparative studies. Single arm robotic series demonstrated similarly low recurrence rates and acceptable safety profiles during available follow up. This systematic review suggests that RNSM with implant based reconstruction provides oncologic and surgical outcomes comparable to CNSM in selected breast cancer patients. While short to mid term recurrence and complication rates are low, longer follow up and prospective studies are required to confirm long term oncologic safety.

Plain Language Summary

This manuscript presents a systematic review conducted in accordance with the PRISMA 2020 guidelines, synthesizing current evidence comparing robotic-assisted nipple-sparing mastectomy (RNSM) and conventional nipple-sparing mastectomy (CNSM) with implant-based reconstruction in patients with breast cancer. The primary outcomes evaluated were locoregional recurrence and disease-free survival, with secondary outcomes including perioperative variables and postoperative complications. Given the increasing global interest in minimally invasive and robotic breast surgery, we believe this review is timely and relevant to the readership of Breast Cancer: Basic and Clinical Research. Our findings suggest that RNSM offers comparable short-to mid-term oncologic outcomes and surgical safety to conventional techniques in carefully selected patients, while highlighting important limitations of the current evidence base and areas requiring further prospective research.

Keywords

robotic-assisted surgery nipple-sparing mastectomy breast cancer implant-based reconstruction locoregional recurrence disease free survival surgical complications

Introduction

Breast cancer is the most commonly diagnosed cancer among women worldwide. According to GLOBOCAN 2022,¹ approximately 2.3 million new cases were diagnosed globally, accounting for 11.6% of all cancers, with an estimated 666,000 deaths (6.9% of all cancer related deaths).

Robotic nipple-sparing mastectomy (RNSM) with immediate breast reconstruction (IBR) was first described in 2015 by Toesca et al.² Since then, interest in robotic breast surgery has increased because of its minimally invasive approach, improved visualization, enhanced dexterity, and potential cosmetic advantages. Robotic nipple-sparing mastectomy with direct-to-implant reconstruction has emerged as a promising technique with favorable cosmetic outcomes.³ Subpectoral breast implant reconstruction through a transaxillary approach is feasible and has been increasingly utilized.⁴ RNSM performed through a small axillary incision may provide favorable aesthetic outcomes without visible anterior breast scarring while maintaining low nipple–areolar complex ischemic complication rates and acceptable postoperative complication profiles.^5-7 In addition, high-resolution three-dimensional magnification and robotic instrument articulation may improve visualization of surgical planes and surgical precision in confined operative fields.^5,8 Robotic systems may also improve surgeon ergonomics and reduce physical fatigue during lengthy procedures.^9-11

Current evidence suggests that RNSM may achieve oncologic and surgical outcomes comparable to conventional nipple-sparing mastectomy (CNSM). Park et al¹² demonstrated in a cadaveric study that RNSM resulted in minimal residual breast tissue and may achieve oncologically sound tissue clearance. Furthermore, currently available evidence¹³ suggests comparable outcomes between RNSM and CNSM in terms of margin status, locoregional recurrence, disease-free survival, and overall survival. A 2023 meta-analysis by De la Cruz-Ku et al¹⁴ reported comparable margin positivity rates and no early recurrences following robotic nipple- and skin-sparing mastectomy during follow-up periods ranging from 90 days to 32.1 months. Similarly, a retrospective study from Southwest Hospital, China¹⁵ involving approximately 2,400 patients demonstrated no significant differences in 5-, 10-, or 15-year survival between minimally invasive and conventional breast surgery approaches.

However, despite increasing interest in robotic nipple-sparing mastectomy, the currently available literature remains heterogeneous and limited by relatively small sample sizes, retrospective study designs, variations in reconstructive techniques, and relatively short follow-up durations. Furthermore, many published studies represent early institutional experiences and may not fully reflect contemporary robotic platforms, evolving surgical expertise, and advances in perioperative breast reconstruction. Concerns also remain regarding operative time, costs, learning curve, and the absence of haptic feedback associated with robotic surgery.^2,13,16 As a result, uncertainty persists regarding the comparative oncologic safety and perioperative outcomes of RNSM versus CNSM in patients undergoing implant-based breast reconstruction.

Despite increasing interest in robotic nipple-sparing mastectomy, the currently available literature remains limited by heterogeneous study designs, relatively small sample sizes, variations in reconstructive techniques, and inconsistent reporting of oncologic and surgical outcomes. Furthermore, many published studies represent early institutional experiences and may not fully reflect contemporary robotic platforms, evolving surgical expertise, and advances in perioperative breast reconstruction. As a result, uncertainty remains regarding the comparative oncologic safety and perioperative outcomes of robotic nipple-sparing mastectomy versus conventional nipple-sparing mastectomy in patients undergoing implant-based breast reconstruction.

We hypothesized that robotic nipple-sparing mastectomy with implant-based reconstruction would demonstrate oncologic outcomes and surgical safety comparable to those of conventional nipple-sparing mastectomy, while potentially offering advantages in visualization, cosmetic outcomes, and patient-centered recovery. Therefore, the primary objective of this systematic review was to evaluate the oncologic outcomes of robotic nipple-sparing mastectomy compared with conventional nipple-sparing mastectomy, including local recurrence, disease-free survival, overall survival, and margin status. Secondary objectives included assessment of perioperative safety outcomes, such as postoperative complications, operative time, nipple–areolar complex ischemia or necrosis, implant loss, hematoma, infection, seroma formation, and other surgery-related adverse events.

Therefore, this systematic review aims to synthesize the current evidence regarding oncologic outcomes and surgical safety of robot-assisted nipple-sparing mastectomy compared with conventional nipple-sparing mastectomy in patients undergoing implant-based breast reconstruction.

Methods

Study Design and Search Strategy

This systematic review was conducted in accordance with the PRISMA 2020 guidelines. However, prospective registration in PROSPERO or a similar registry was not performed. Electronic databases including MEDLINE, Embase, Scopus, Web of Science, and Cochrane CENTRAL were systematically searched from database inception to the most recent available update. The final literature search was conducted on January 15, 2026 to March 2026. The search strategy included combinations of keywords and Medical Subject Headings (MeSH) related to “robotic,” “robot-assisted,” “nipple-sparing mastectomy,” “breast cancer,” and “implant-based reconstruction.” An example MEDLINE search strategy was as follows: (“robotic” OR “robot-assisted”) AND (“nipple-sparing mastectomy” OR “NSM”) AND (“breast cancer”) AND (“implant-based reconstruction”). Reference lists of relevant articles were also manually screened to identify additional eligible studies. The search strategy was developed collaboratively by the authors using predefined keywords, MeSH terms, and reference screening from previously published literature. No formal medical librarian or information specialist was involved in the development of the search strategy.

Study Selection and Recruitment Process

All retrieved records were imported into a reference management software, and duplicate studies were removed prior to screening. Title and abstract screening, full-text assessment, and data extraction were performed by the author according to predefined eligibility criteria. Studies were included if they evaluated robotic nipple-sparing mastectomy and/or conventional nipple-sparing mastectomy with implant-based reconstruction and reported oncologic or surgical outcomes. The study selection process was summarized using a PRISMA flow diagram.

Eligibility Criteria

Studies Were Eligible if They

Included patients with invasive breast cancer or ductal carcinoma in situ;

Evaluated robotic nipple-sparing mastectomy (RNSM) and/or conventional nipple-sparing mastectomy (CNSM) with implant-based reconstruction;

Reported oncologic or surgical outcomes.

Prophylactic mastectomy-only studies, case reports, review articles, conference abstracts without sufficient data, non-human studies, and non-English publications were excluded.

Outcomes

The primary outcomes were locoregional recurrence and disease-free survival. Secondary outcomes included operative time, estimated blood loss, reconstruction type, postoperative complications, length of hospital stay, margin status, nipple–areolar complex ischemia or necrosis, implant loss, infection, seroma formation, and short-term oncologic outcomes. Missing or incompletely reported variables were recorded as “not reported (NR)” and no imputation was performed. Outcomes were summarized descriptively using reported proportions, means, medians, and ranges. Due to heterogeneity in study design, reconstruction techniques, and outcome reporting, quantitative meta-analysis was not feasible. No subgroup, sensitivity, or meta-regression analyses were performed.

Data Extraction and Synthesis

Data extraction was independently performed by the reviewer using a standardized data collection form. Extracted variables included study design, patient demographics, tumor characteristics, operative details, reconstructive techniques, perioperative complications, and oncologic outcomes. Due to heterogeneity among included studies, variations in outcome reporting, and limited event numbers, quantitative meta-analysis was not performed, and findings were synthesized descriptively.

Results

A total of 63 records(Figure 1) were identified through database searching. After removal of duplicates, all 63 records were screened based on titles and abstracts. Of these, 56 records were excluded for the following reasons: studies focusing on prophylactic nipple-sparing mastectomy only, absence of implant-based breast reconstruction, and publication types including case reports or review articles. Ultimately, seven studies met the eligibility criteria and were included in the qualitative synthesis.

Overall, ROBINS-I assessment indicated a moderate to serious risk of bias, mainly related to retrospective design, small sample sizes, and heterogeneity (Table 1). Formal assessment of publication bias was not performed because of the limited number and heterogeneity of included studies. Certainty of evidence using GRADE assessment was not performed because of study heterogeneity and limited comparative evidence.

Table 1.

Risk of Bias Assessment Using ROBINS-I Tool

ROBINS-I domain	Judgment	Color code	Rationale
Bias due to confounding	Serious	Red	Most studies were retrospective without adjustment for key confounders; robotic surgery often applied to selected low-risk patients.
Bias in selection of participants	Moderate–Serious	Orange/Red	Patient selection criteria incompletely described; unmatched cohorts and early robotic learning curve.
Bias in classification of interventions	Low	Green	Interventions clearly defined as RNSM vs CNSM with low risk of misclassification.
Bias due to deviations from intended interventions	Moderate	Orange	Variability in reconstruction methods and perioperative management.
Bias due to missing data	Moderate	Orange	Incomplete reporting of baseline characteristics and follow-up.
Bias in measurement of outcomes	Moderate	Orange	Heterogeneous outcome definitions and lack of blinded assessment.
Bias in selection of the reported result	Moderate	Orange	Selective emphasis on operative and cosmetic outcomes.
Overall Risk of Bias	Moderate–Serious	Orange/Red	Overall certainty limited by retrospective design and confounding.

Risk of Bias Assessment: Overall, the included studies demonstrated a moderate to serious risk of bias, primarily due to their retrospective design, small sample sizes, and heterogeneity in patient selection and outcome reporting.

Bias Due to Confounding: Most included studies were retrospective cohort studies, with only one randomized controlled trial. Important confounding factors such as age, BMI, breast size, tumor stage, neoadjuvant treatment, and reconstruction type were incompletely reported or not consistently adjusted for. In several studies, robotic procedures were preferentially performed in selected patients with smaller tumors, lower BMI, or earlier-stage disease, suggesting a moderate to serious risk of confounding bias.

Bias in Selection of Participants: Patient selection criteria were often unclear or not fully described, particularly in early robotic series and single-arm studies. Some cohorts included highly selected patients undergoing robotic surgery during the initial learning phase, while others compared unmatched robotic and conventional groups. As a result, the risk of selection bias was judged as moderate to serious in most studies.

Bias in Classification of Interventions: Classification of interventions (RNSM vs CNSM) was generally clear and well defined across studies. Surgical approaches were explicitly reported, and misclassification was unlikely. Therefore, the risk of bias in this domain was considered low.

Bias Due to Deviations from Intended Interventions: Perioperative management and reconstruction techniques varied considerably across studies, including differences in implant-based versus autologous reconstruction, use of latissimus dorsi flaps, and immediate versus delayed reconstruction. These deviations were not consistently controlled or analyzed, leading to a moderate risk of bias in this domain.

Bias Due to Missing Data: Several studies reported incomplete baseline characteristics, missing information on comorbidities, smoking status, genetic mutation status, and adjuvant treatments. Additionally, loss to follow-up and incomplete reporting of complications were noted in some series. Consequently, the risk of bias due to missing data was considered moderate.

Bias in Measurement of Outcomes: Short-term surgical outcomes and complications were generally well defined; however, definitions of complications and grading systems were not uniform across studies. Oncologic outcomes such as locoregional recurrence and survival were limited by short follow-up durations in most cohorts. Outcome assessors were rarely blinded, resulting in a moderate risk of measurement bias, particularly for subjective outcomes such as cosmetic satisfaction and patient-reported measures.

Bias in Selection of the Reported Result: Selective reporting was a concern, as several studies focused primarily on operative feasibility and cosmetic outcomes, while oncologic endpoints and long-term complications were incompletely reported. This resulted in a moderate risk of reporting bias.

Overall Risk of Bias Judgment: Taking all domains into account, the overall risk of bias was assessed as moderate to serious for most non-randomized studies. The single randomized controlled trial demonstrated a lower overall risk of bias, although limitations related to sample size and follow-up duration remained. These factors should be considered when interpreting the comparative safety and oncologic outcomes of robotic versus conventional nipple-sparing mastectomy.

Table 2 summarizes the study design, patient demographics, tumor characteristics, operative details, follow-up duration, postoperative complications, and postoperative outcomes of the included studies evaluating robotic nipple-sparing mastectomy (RNSM) in comparison with conventional nipple-sparing mastectomy (CNSM), as well as single-arm RNSM series. Overall, the included studies were predominantly retrospective cohort analyses, with one randomized controlled trial and several single-center experiences. Sample sizes ranged from small feasibility cohorts to larger comparative studies. The results of each individual study are described below.

Table 2.

Summarizes the Key Clinicopathologic Characteristics, Operative Details, and Postoperative Outcomes of the Included Studies Comparing Robotic Nipple-Sparing Mastectomy (RNSM) and Conventional Nipple-Sparing Mastectomy (CNSM), as Well as Single-Arm RNSM Series

Reference/Year/Study design	Chen et al, 2025¹⁷ retrospective cohort	Chen et al, 2025¹⁷ retrospective cohort	Chen et al, 2025¹⁷ retrospective cohort	Houvenaeghel et al, 2021¹⁸ retrospective cohort	Houvenaeghel et al, 2021¹⁸ retrospective cohort	You et al, 2025¹⁹ retrospective cohort	You et al, 2025¹⁹ retrospective cohort	Lee SB et al, 2025²⁰ single-arm study	Moon J et al, 2021²¹ retrospective cohort	Moon J et al, 2021²¹ retrospective cohort	Lai et al, 2018²² retrospective cohort	Toesca A et al, 2022²³ randomized controlled trial
Groups Compared	Robotic NSMIBR subgroups (LDMF)	Robotic NSMIBR subgroups (LDMF without skin island)	Robotic NSMIBR subgroups (pectoralis major fascia with implant)	Robotic NSM	Open NSM	Robotic NSM	Conventional NSM		Robotic NSM (RNSM)	Conventional NSM (CNSM)	Single-arm study (R-NSM + IBR)	Robotic nipple-sparing mastectomy vs open nipple-sparing mastectomy
Sample size	7	9	17	87	142	8	49	60 patients (66 procedures)	40	41	15	80 patients, 1:1 randomization
Age (mean ± SD), year	37.3 ± 4.3	39.1 ± 5.7	46.2 ± 7.0	NR	NR	51.3	48.3	47.0 (41.0–51.5)	46 ± 8	49 ± 10	46.5 ± 10.0	NR
BMI, kg/m²	23.5 ± 1.0	24.7 ± 2.6	25.1 ± 2.1	BMI ≤24.9→ 83.9%	BMI ≤24.9→ 83.8%	22.33	21.46	22.8 (21.3–24.5)	22.2 ± 3.5	23.9 ± 3.6	NR	NR
				BMI 25–29.9→ 10.3%	BMI 25–29.9→ 12%
				BMI ≥30 → 5.7%	BMI ≥30 → 4.2%
Cup size	NR	NR	NR	Cup size A–B→ 56.3%	Cup size A–B→ 64.8%	NR	NR	Small 24.2%, small–moderate 15.2%, Moderate 34.8%, Moderate–large 9.1%, large 9.1%, Huge 1.5%	NR	NR	NR	NR
				Cup size C → 27.6%	Cup size C→ 23.9%
				Cup size >C → 16.1%	Cup size >C→ 11.3%
Germline mutation status	NR	NR	NR	NR	NR	NR	NR	Mutated 3.3%, Wild-type 33.4%, Unknown 63.3%	NR	NR	NR	Breast cancer and BRCA mutation patients included (details NR)
Menopause status	NR	NR	NR	NR	NR	NR	NR	Premenopausal 73.3%, Postmenopausal 25.0%, Perimenopausal 1.7%	Premenopausal: 70%	Premenopausal: 64%	NR	NR
									Postmenopausal: 25%	Postmenopausal: 36%
									Perimenopausal: 5%	Perimenopausal 0%
Tobacco smoking	NR	NR	NR	29.9%	16.9%	NR	NR	Never 93.3%, Current 6.7%	Non-smoker: 93%,	Non-smoker: 88%	NR	NR
									Ex-smoker: 5%,	Ex-smoker: 10%
									Current smoker: 2% both	Current smoker: 2% both
Comorbid	NR	NR	NR	NR	NR	NR	NR	HTN 6.7%, DM 6.7%, liver disease 6.7%, Hx cancer 5%	ASA physical status I–III reported; specific comorbidities NR	ASA physical status I–III reported; specific comorbidities NR	NR	NR
Neoadjuvant treatment	71.4%	44.4%	11.8%	28.7%	8.5%	0%	12.2%	12.1%	13%,	27%	NR	NR
Tumor size (cm)	NR	NR	NR	NR	NR	NR	NR	Median 1.0 cm (0.1–2.7)	1.6 ± 1.3	1.8 ± 1.1	NR	NR
Lymph node surgery	SLNB 28.6%; SLNB+ALND/ALND 71.4%	SLNB 44.4%; SLNB+ALND/ALND 55.6%	SLNB 58.8%; SLNB+ALND/ALND 41.2%	NR	NR	NR	NR	SNB 100%, ALND 18.2%	SLNB only: 93%	SLNB only: 88%	Axillary lymph node surgery if indicated	NR
Lymph node surgery	SLNB 28.6%; SLNB+ALND/ALND 71.4%	SLNB 44.4%; SLNB+ALND/ALND 55.6%	SLNB 58.8%; SLNB+ALND/ALND 41.2%	NR	NR	NR	NR	SNB 100%, ALND 18.2%	SLNB→ALND: 8%	SLNB→ALND: 12%	Axillary lymph node surgery if indicated	NR
TNM stage	T1 28.6%, T2 28.6%, T3 28.6%, T4 14.3%; N0 28.6%, N1 42.8%, N2 28.6%	T1 44.4%, T2 44.4%; N0 55.5%, N1 11.1%, N2 33.3%	T1 23.5%, T2 64.7%, T3 5.9%; N0 58.8%, N1 11.8%, N2 23.5%, N3 5.9%	NR	NR	Stage 0 =2	Stage 0=13	Stage 0 10.6%, I 47.1%, II 33.3%, III 6.0%	Pathologic T and N stages reported, no significant difference.	Pathologic T and N stages reported, no significant difference.	DCIS 30.8%; stage I 30.8%; stage II 30.8%; stage III 7.7%	NR
						Stage I =5	Stage I=17
						Stage II=1	Stage II=14
						Stage II=1	Stage II=14		T1N0 predominant	T1N0 predominant
						Stage III=0	Stage III=5		T1N0 predominant	T1N0 predominant
Histopathologic grade	NR	NR	NR	NR	NR	IDC =5	IDC=33	IDC 81.8%, DCIS 10.7%, ILC 3.0%	G1–G3 reported; no significant difference	G1–G3 reported; no significant difference	NR	NR
						ILC=1	ILC=3
						DCIS=2	DCIS=9
						LCIS=0	LCIS=1
						Mucinous=0	Mucinous=2
						Papillary=0	Papillary=1
Molecular subtype	ER+ 57.1%; PR+ 57.1%; HER2+ 28.5%	ER+ 77.8%; PR+ 100%; HER2+ 22.2%	ER+ 58.8%; PR+ 52.9%; HER2+ 35.3%	NR	NR	HR+/HER2− predominant	HR+/HER2− predominant	ER+ 89.4%, PR+ 66.7%, HER2− 72.7%	HR+/HER2− predominant	HR+/HER2− predominant	NR	NR
Margin status	Posterior nipple margin negative 100%	Posterior nipple margin negative 100%	Posterior nipple margin negative 100%	NR	NR	Nipple margin negative (frozen)	NR	Positive superficial margin 1.5%	NR	NR	Positive margin 0%	NR
Operative time (min)	288.6 ± 108.7	272.2 ± 39.4	88.5 ± 14.9	184–224	130–197	148	117	NSM 154 min; reconstruction 133 min	279 ± 63	207 ± 46	Total operative time 282.8 ± 70.4 min; mastectomy & reconstruction time NR	Robotic longer by 1 hour 18 minutes
Reconstruction type	Implant + LDMF	Implant + LDMF	Implant + PM fascia	Implant 57.5%/LDF+ implant 13.7%/LBR LDF 28.7%	Implant 90.1%/Expander 4.9%/LDF 4.2%/LDF + implant 0.7%	Direct-to-implant	Direct-to-implant	Implant 57.6%; autologous 42.4%	Direct-to-implant: 80%, Tissue expander: 20%,	Direct-to-implant: 90% Tissue expander: 10%	Direct-to-implant (gel implant); tissue expander/Autologous NR	Immediate reconstruction (type NR)
Blood loss (ml)	31.4 ± 8.8	25.0 ± 5.8	10.6 ± 1.6	NR	NR	NR	NR	<10 mL	≤100 mL: 85%, >100 mL: 15%,	≤100 mL: 98%, >100 mL 2%	38.3 ± 45.3 mL	NR
Overall complication rate	0%	0%	17.6%	21.8%	27.5%	12.5% (capsular contracture 12.5%)	18.4% (skin necrosis 14.3%, infection 4.1%)	Clavien-Dindo ≥III: 7.6%	0-10%, Seroma, hematoma, wound dehiscence, infection, nipple necrosis, skin-flap necrosis; no significant difference	0-10%, Seroma, hematoma, wound dehiscence, infection, nipple necrosis, skin-flap necrosis; no significant difference	Delayed wound healing 1 case; transient nipple ischemia 13.3%; no NAC necrosis; others NR	No significant difference between groups
Clavien–Dindo ≥ III	0%	0%	17.6%	13.0%	17.3%	NR	NR	NR	NR	NR	NR	NR
Skin necrosis	0%	0%	11.8%	NR	NR	NR	Skin necrosis 14.3%,	NR	NR	NR	NR	NR
Nipple necrosis	0%	0%	0%	NR	NR	NR	NR	NR	NR	NR	NR	NR
Wound dehiscence	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR
Infection	0%	0%	Infection-related implant loss 17.6%; flap necrosis 11.8%	NR	NR	NR	Infection 4.1%)	NR	NR	NR	NR	NR
Seroma	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR
Hematoma	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR
Implant loss	0%	0%	17.6%	10.2%	6.7%	NR	NR	NR	NR	NR	NR	NR
Specimen weight (g)	NR	NR	NR	>300 g: 64.4%	>300 g: 35.2%	215.6	250.7	NR	388.7 ± 169.5	421.4 ± 176.0	NR	NR
Hospital stay(days)	NR	NR	NR	Median 3	Median 2	10.75	12.92	Median 5.5	9.2 ± 2.7	7.1 ± 2.0	6.7 ± 1.2	NR
Adjuvant chemotherapy	100%	88.9%	94.1%	NR	NR	0%	32.6%	26.7%	25%	29%	NR	NR
Hormonal therapy	Yes	Yes	Yes	NR	NR	NR	NR	NR	80%	67%	NR	NR
Targeted therapy	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR	NR
Radiotherapy	71.4%	44.4%	41.2%	31.0%	8.5%	0%	8.2%	16.7%	13%	20%	NR	NR
Follow-up (months)	∼10 ± 1	∼10 ± 1	∼10 ± 1	Short	Short	Short (∼12)	Short (∼12)	36	Complications assessed up to 90 days	Complications assessed up to 90 days	6.3 ± 2.1	Median 28.6 months
Follow-up (months)	∼10 ± 1	∼10 ± 1	∼10 ± 1	Short	Short	Short (∼12)	Short (∼12)	36	Complications assessed up to 90 days	Complications assessed up to 90 days	6.3 ± 2.1	Breast-Q and body image scores significantly improved in robotic group
Locoregional recurrence (%)	NR	NR	NR	NR	NR	0	0	1.7	NR	NR	0%	0%
Distant metastasis (%)	NR	NR	NR	NR	NR	0	0	0	NR	NR	0%	1 patient in each arm
Mortality (%)	NR	NR	NR	0	0	0	0	0	NR	NR	0%	NR

Abbreviations: C-NSM, conventional nipple-sparing mastectomy; R-NSM, robotic NSM; BMI, body mass index; DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; IBR, immediate breast reconstruction; LDF, latissimus dorsi flap; LDMF, latissimus dorsi muscle flap; NR, Not reported.

Colors were used only to differentiate studies and comparison groups for readability purposes.

Abbreviations

C-NSM, conventional nipple-sparing mastectomy; R-NSM, robotic NSM; BMI, body mass index; DCIS, ductal carcinoma in situ; LCIS, lobular carcinoma in situ; IDC, invasive ductal carcinoma; ILC, invasive lobular carcinoma; IBR, immediate breast reconstruction; LDF, latissimus dorsi flap; LDMF, latissimus dorsi muscle flap; NR, Not reported.

Chen et al (2025)¹⁷ conducted a retrospective cohort study evaluating robotic nipple-sparing mastectomy (RNSM) with immediate implant-based reconstruction using different reconstructive techniques, including latissimus dorsi muscle flap (LDMF) with or without a skin island and pectoralis major fascia with implant. The study included three robotic subgroups (n = 7, 9, and 17). Patients were relatively young, with mean ages ranging from 37.3 to 46.2 years and mean BMI between 23.5 and 25.1 kg/m². All cases achieved negative posterior nipple margins. Operative time varied according to reconstructive technique and represented the total operative time including reconstruction. Estimated blood loss was minimal. Overall complication rates ranged from 0% to 17.6%, including implant loss in 17.6% and skin necrosis in 11.8% in the pectoralis major fascia subgroup, while no nipple necrosis was reported. During a mean follow-up period of approximately 10 months, no locoregional recurrence, distant metastasis, or mortality was observed.

Houvenaeghel et al (2021)¹⁸ compared robotic and conventional nipple-sparing mastectomy with immediate breast reconstruction in a large retrospective cohort. The robotic group included 87 patients, while the conventional group comprised 142 patients. Most patients had BMI ≤25 kg/m² and small-to-moderate breast sizes. Operative time was longer in the robotic group; however, the reported operative duration included both mastectomy and reconstruction procedures. Estimated blood loss was comparable. Overall complication rates were 21.8% in the robotic group and 27.5% in the conventional group. Implant loss occurred in 10.2% and 6.7% of patients, respectively. Hematoma, skin necrosis, and nipple necrosis were also reported without significant differences between groups. No significant differences in oncologic outcomes were observed, and recurrence rates remained low during short-term follow-up.

You et al (2025)¹⁹ reported a single-center retrospective comparison of robotic versus conventional nipple-sparing mastectomy. The study included 8 patients who underwent robotic nipple-sparing mastectomy (6 unilateral and 2 bilateral procedures) and 49 patients who underwent conventional nipple-sparing mastectomy (37 unilateral and 12 bilateral procedures). Patients undergoing RNSM were slightly younger and had lower BMI than those undergoing CNSM. Operative time was longer in the robotic group (mean 148 vs. 117 minutes), although the study did not clearly specify whether this represented mastectomy time alone or the total operative time including reconstruction. Estimated blood loss was low in both groups. Overall complication rates were 12.5% in the robotic group and 18.4% in the conventional group, including capsular contracture in the robotic group and skin necrosis and infection in the conventional group, with no statistically significant differences. Oncologic outcomes were favorable, with no locoregional recurrence or mortality reported during approximately 12 months of follow-up.

Lee et al (2025)²⁰ evaluated the feasibility and outcomes of RNSM using the da Vinci SP system in a single-arm retrospective study including 60 patients (66 procedures). The mean patient age was 47 years, and the median tumor size was 1.0 cm. Sentinel lymph node biopsy was performed in all patients, with axillary lymph node dissection required in 18.2%. The reported operative time included both mastectomy and reconstruction procedures, with mean mastectomy time of 154 minutes and reconstruction time of 133 minutes. Clavien–Dindo grade III or higher complications occurred in 7.6% of cases. No nipple–areolar complex necrosis was observed. At a median follow-up of 36 months, no locoregional recurrence or distant metastasis was reported.

Moon et al (2021)²¹ compared postoperative outcomes between robotic and conventional nipple-sparing mastectomy in 81 patients (40 RNSM and 41 CNSM). Tumor characteristics, pathological stages, and molecular subtypes were comparable between groups. Operative time was significantly longer in the robotic group (279 ± 63 minutes vs. 207 ± 46 minutes). The reported operative duration represented the total operation time, although the study did not clearly distinguish between mastectomy and reconstruction time or specify unilateral versus bilateral procedures. Blood loss was minimal in both groups. Complication profiles, including skin-flap and nipple-related complications, did not differ significantly. Reported complications included seroma, hematoma, wound dehiscence, infection, nipple necrosis, and skin-flap necrosis, with overall complication rates ranging from 0% to 10%. One distant metastatic event occurred in each group during follow-up, with no differences in survival outcomes. Postoperative complications were primarily assessed within 90 days.

Lai et al (2018)²² reported early outcomes of robotic nipple-sparing mastectomy with immediate gel implant reconstruction in a single-arm study of 15 patients. Most patients had early-stage breast cancer, with T1N0 disease predominating. Mean blood loss was low (38.3 ± 45.3 mL), and no major postoperative complications or implant loss were observed. The reported operative time represented the total operative duration (282.8 ± 70.4 minutes), although separate mastectomy and reconstruction times were not specified. Minor postoperative complications included one case of delayed wound healing and transient nipple ischemia in 13.3%, without nipple–areolar complex necrosis. All surgical margins were negative, and no locoregional recurrence or mortality was reported during a mean follow-up period of 6.3 ± 2.1 months.

Toesca et al (2022)²³ conducted the only randomized controlled trial comparing robotic versus open nipple-sparing mastectomy in 80 patients with breast cancer or BRCA mutation. Patients were randomized 1:1 to robotic or open surgery. Operative time was significantly longer in the robotic arm by approximately 78 minutes. However, the study did not clearly specify whether this represented mastectomy time alone or total operative time including reconstruction, nor whether unilateral or bilateral procedures were included. However, complication rates, including major complications, did not differ between groups. Oncologic outcomes were comparable, with no significant differences in recurrence or survival. At a median follow-up of 28.6 months, patient-reported outcomes demonstrated significantly improved Breast-Q and body image scores in the robotic group.

Discussion

This systematic review expands upon existing literature by directly comparing oncologic and surgical outcomes between robotic nipple-sparing mastectomy (RNSM) and conventional nipple sparing mastectomy (CNSM) with implant-based reconstruction. Overall, our findings are largely consistent with previously published studies, while also addressing limitations and unanswered questions highlighted in earlier reports.

Previous Evidence

Advantages

Perioperative Safety

Robotic nipple-sparing mastectomy with direct-to-implant reconstruction has emerged as a promising technique with favorable cosmetic outcomes.³ Subpectoral breast implant reconstruction through a transaxillary approach is feasible and is being used more commonly.⁴ Historically, subpectoral implant placement via a transaxillary approach was widely utilized and has been shown to provide complete muscular implant coverage involving the pectoralis major, serratus anterior, and external oblique muscles.⁴ However, with advances in mastectomy flap preservation, acellular dermal matrix use, and implant technology, prepectoral reconstruction has become increasingly favored in modern practice. Nevertheless, subpectoral reconstruction continues to play a role in selected clinical scenarios.

RNSM performed through a small axillary incision achieves high patient satisfaction and favorable cosmetic results without anterior breast scarring and demonstrates low nipple–areolar complex ischemic complication rates, likely related to preserved nipple vascularity.^5,6 A recent systematic review and meta-analysis demonstrated comparable postoperative complication rates between conventional NSM and RNSM, with no statistically significant differences observed in implant loss, hematoma, flap necrosis, infection, or seroma.⁷

Improved Technical Precision, Visualization, and Control

High-resolution three-dimensional magnification improves visualization of surgical planes, allowing RNSM with immediate reconstruction through a small axillary incision, while robotic dexterity enhances precision in limited operative fields.^5,8

Ergonomics and Surgeon Well-Being

Robotic systems reduce surgeons’ physical workload by translating hand movements into precise robotic actions, improving ergonomics and minimizing fatigue during lengthy procedures.^9-11

Oncological Safety

Park et al¹² conducted a cadaveric study to evaluate the presence and distribution of residual breast tissue(RBT) following RNSM. Using full-thickness biopsies obtained radially from predefined locations around the mastectomy skin flap and nipple–areolar complex, the authors demonstrated that RNSM is technically feasible and generally results in minimal residual breast tissue. RBT was detected in a minority of specimens and was most commonly located in the nipple areolar complex, while no residual tissue was identified in the peripheral skin flaps. These findings are consistent with prior reports from open nipple-sparing mastectomy and suggest that RNSM can achieve an oncologically sound mastectomy in terms of tissue clearance. Nevertheless, as this study was limited to a small cadaveric series and relied on histologic surrogates rather than clinical outcomes, further clinical studies with long term follow up are required to confirm the oncologic safety of RNSM in patients undergoing breast cancer surgery. Current evidence¹³ indicates that robotic nipple-sparing mastectomy demonstrates oncologic outcomes comparable to conventional techniques in terms of margin status, locoregional recurrence, disease free survival, and overall survival. A 2023 meta-analysis by De la Cruz-Ku et al¹⁴ reported comparable margin positivity rates between techniques, with no early recurrences following robotic skin- and nipple-sparing mastectomy over a 90 day to 32.1 month follow-up. A 2022 single-center retrospective study from Southwest Hospital, China,¹⁵ involving approximately 2,400 patients, found no significant differences in 5, 10, or 15 years survival between minimally invasive and conventional breast surgery.

Disadvantages

Economic Constraints

A major limitation of robotic surgery is its high cost, including substantial initial investment and maintenance expenses, which may limit accessibility, particularly in resource constrained settings.¹³

Prolonged Operative Times

Longer operative time remains a barrier to widespread adoption of robotic surgery. A randomized study by Toesca et al² reported that robotic unilateral nipple-sparing mastectomy required an additional 78 minutes compared with the conventional approach.

Learning Curve and Training Limitations

Lai et al¹⁶ reported that approximately 13 cases are required to achieve a meaningful reduction in operative time, underscoring the importance of surgeon experience.

Limited Haptic Feedback and Technical Challenges

The absence of haptic feedback in robotic surgery may limit real time tissue assessment, potentially affecting surgical judgment and precision. In addition, technical or software failures necessitate experienced support teams and standardized protocols to ensure patient safety.¹³

Several studies have reported acceptable oncologic and surgical outcomes following robotic nipple-sparing mastectomy; however, the available evidence remains heterogeneous and limited by small sample sizes and relatively short follow-up durations.

Comparison With Previous Evidence on Oncologic Outcomes

Several studies have reported clinical outcomes of robot-assisted nipple sparing mastectomy (RNSM) with respect to complication rates and local recurrence. Medina-Franco et al²⁴ evaluated 173 patients and reported a local recurrence rate of 4.5%, although complication data were not available. Agrawal et al²⁵ included 81 patients and observed a local recurrence rate of 2%, with no reported complication rates. Kroll et al²⁶ analyzed outcomes in 114 patients and reported a local recurrence rate of 7%, while Gerber et al²⁷ reported a higher local recurrence rate of 11.7% in a cohort of 60 patients; neither study provided detailed complication data. In the largest cohort to date, Orzalesi et al²⁸ evaluated 913 patients undergoing RNSM and reported a complication rate of 4.4% and a local recurrence rate of 2.9%. Wijayanayagam et al²⁹ reported a higher complication rate of 36% in a cohort of 43 patients, although local recurrence outcomes were not available. Garwood et al³⁰ reported outcomes in 106 patients, demonstrating a complication rate of 11.8% and a very low local recurrence rate of 0.6%. Toesca et al² who included 24 patients, did not report either complication rates or local recurrence outcomes.

The low locoregional recurrence rates observed in this review (0–1.7%) and the absence of breast cancer related mortality during follow up are consistent with prior systematic reviews and meta-analyses evaluating RNSM. In particular, Filipe et al (2022),⁷ in a systematic review and meta-analysis published in Journal of Robotic Surgery, demonstrated no statistically significant differences in postoperative complications or early oncologic outcomes between RNSM and conventional nipple-sparing mastectomy. Similarly, De la Cruz-Ku et al (2023)¹⁴ reported comparable margin positivity rates and no early recurrences following robotic nipple- and skin-sparing mastectomy during a follow-up period ranging from 90 days to 32.1 months.

Our findings corroborate these results, suggesting that RNSM does not compromise short-term oncologic safety when compared with CNSM. Furthermore, the recurrence rates observed in the robotic cohorts included in this review are comparable to those reported in historical open nipple and skin sparing mastectomy series. For example, Garwood et al (2009)³⁰ reported a local recurrence rate of 0.6% following total skin-sparing mastectomy, while Orzalesi et al (2016),²⁸ in a large multicenter registry of 913 patients, observed a local recurrence rate of 2.9%. Higher recurrence rates reported in older studies, such as Gerber et al (2009)²⁷ and Kroll et al (1999),²⁶ likely reflect longer follow-up durations, differences in patient selection, tumor characteristics, and treatment era, rather than inherent differences in the surgical approach itself.

Importantly, unlike large population-based studies such as Wan et al (2022),¹⁵ published in JAMA Surgery, which demonstrated no significant differences in 5, 10, or 15 years survival between minimally invasive and conventional breast surgery, the studies included in the present review predominantly reported short-to mid-term outcomes. Therefore, while our findings align with earlier evidence suggesting oncologic equivalence, they cannot yet confirm long-term non-inferiority of RNSM.

Surgical Outcomes in the Context of Prior Robotic Literature

Consistent with earlier reports, RNSM was associated with longer operative times compared with CNSM. This finding mirrors the initial experience described by Toesca et al (2017)² in Annals of Surgery, who reported that robotic unilateral nipple-sparing mastectomy required approximately 78 additional minutes compared with the conventional approach. Similar increases in operative time were also reported in the randomized controlled trial by Toesca et al (2022)³⁰ and the case control study by Lai et al (2020)⁶ published in Journal of Plastic, Reconstructive & Aesthetic Surgery.

Despite longer operative times, estimated blood loss in robotic procedures was consistently low, a finding that aligns with reports by Park et al (2019)⁸ in Scientific Reports, which emphasized the role of enhanced visualization and precise robotic dissection in minimizing intraoperative bleeding.

Postoperative complication rates observed in this review were comparable between RNSM and CNSM, consistent with conclusions drawn by Filipe et al (2022)⁷ and Angarita et al (2020),³ both of whom reported no significant differences in rates of implant loss, infection, hematoma, seroma, or flap necrosis between robotic and conventional approaches. Notably, higher complication and implant loss rates reported in early robotic series such as those described by Wijayanayagam et al (2008)²⁹ were less prominent in more recent cohorts, supporting the learning curve effect described by Lai et al (2019),¹⁶ who suggested that approximately 13 cases are required to achieve improved operative efficiency and reduced complications.

Differences From Earlier Studies and Added Value of the Present Review

While prior reviews frequently focused on feasibility and cosmetic outcomes, oncologic endpoints were often underreported. For example, early reports by Toesca et al (2017)² primarily emphasized technical feasibility and aesthetic results without detailed recurrence data. In contrast, the present review specifically prioritized locoregional recurrence and disease free survival as primary outcomes, thereby addressing a critical gap in the literature.

Additionally, unlike some earlier meta-analyses that pooled heterogeneous reconstruction techniques, this review focused exclusively on implant-based reconstruction, reducing variability related to reconstructive approach and allowing for a more direct comparison between RNSM and CNSM.

Interpretation in Light of Risk of Bias

Similar to previous assessments, the overall quality of evidence in this review was limited by moderate to serious risk of bias. This finding parallels the conclusions of De la Cruz-Ku et al (2023)¹⁴ and Doll et al (2024),¹³ who highlighted confounding by indication, retrospective study design, and selective reporting as major limitations of the current literature. The preferential selection of younger patients with lower BMI, smaller breast size, and earlier stage disease for robotic surgery also observed in studies by Lai et al (2020)⁶ and Houvenaeghel et al (2021)¹⁸ likely contributes to the favorable outcomes reported and must be considered when interpreting comparative results.

Clinical Implications and Future Directions

In agreement with prior studies, including Doll et al (2024)¹³ and Jain et al (2024),⁹ our findings support RNSM as a safe and feasible option in selected patients, offering comparable short-term oncologic outcomes and acceptable surgical safety profiles. However, similar to conclusions drawn in earlier systematic reviews, the absence of robust long-term oncologic data, combined with higher costs and resource requirements, continues to limit widespread adoption. Several studies included in this review noted that RNSM requires increased operative resources compared with CNSM, primarily due to the use of robotic platforms, specialized instruments, longer operative times, and the need for dedicated surgical training and operating room staff. For example, Toesca et al²³ reported that robotic procedures required approximately 78 additional operative minutes compared with conventional surgery, while Moon et al demonstrated operative times of 279 ± 63 minutes for RNSM versus 207 ± 46 minutes for CNSM. Longer operative duration may contribute to increased anesthesia-related and operating room costs. In addition, robotic systems involve substantial capital investment, annual maintenance expenses, and disposable instrument costs. However, the currently available literature lacks standardized cost analyses and direct comparisons of total healthcare expenditures between RNSM and CNSM. Furthermore, potential benefits of RNSM, including improved cosmetic satisfaction, reduced visible scarring, and enhanced patient-reported body image outcomes, may partially offset these increased costs in selected patients.

Beyond oncologic and surgical outcomes, psychological well-being and patient-reported outcomes have become increasingly important considerations in modern breast cancer surgery. Body image perception, femininity, self-esteem, anxiety, emotional regulation, and quality of life may be significantly affected following mastectomy and breast reconstruction. Recent evidence has emphasized the importance of integrating psychological constructs and supportive interventions into breast cancer care, including psychoeducational support, body image interventions, mindfulness-based strategies, and patient-centered rehabilitation programs. Patients undergoing nipple-sparing approaches may experience improved psychosocial outcomes and body image satisfaction due to preservation of the native breast skin envelope and nipple–areolar complex.

Recent studies by Valentina Sebri and colleagues^31,32 further highlighted the importance of addressing psychological adaptation, emotional distress, interoceptive awareness, and quality-of-life related outcomes in breast cancer patients undergoing surgical treatment and reconstruction. Sebri et al demonstrated that psychological interventions focused on emotional regulation may help breast cancer survivors better manage distress and improve psychological adjustment during survivorship. In addition, mindfulness-based stress reduction approaches aimed at improving interoception and body image perception have shown potential benefits in supporting emotional well-being and adaptation following breast cancer treatment. These findings reinforce the importance of incorporating holistic and patient-centered care into modern breast cancer management, particularly as surgical innovations increasingly prioritize aesthetic preservation and survivorship outcomes alongside oncologic safety.

Therefore, evaluation of robotic nipple-sparing mastectomy should not be limited to perioperative safety and oncologic outcomes alone, but should also consider patient-centered and psychosocial dimensions of recovery.

Beyond current robotic platforms, future advances in breast surgery may increasingly incorporate emerging digital and visualization technologies to further optimize surgical planning, intraoperative precision, ergonomics, and patient-centered outcomes. Recent studies have explored the integration of augmented reality, three-dimensional (3D) visualization, holographic imaging, and digital surgical navigation into surgical education and operative planning. Triberti et al (2021)³³ demonstrated that 3D holographic visualization improved spatial understanding and ergonomics compared with conventional computed tomography imaging during preoperative assessment. In the context of robotic nipple-sparing mastectomy, such technologies may potentially enhance visualization of mastectomy planes, vascular supply to the nipple–areolar complex, implant positioning, and individualized reconstructive planning. In addition, future integration of artificial intelligence-assisted imaging analysis, fluorescence-guided surgery, and digital navigation systems may further improve patient selection, operative precision, and intraoperative decision-making. Nevertheless, these innovative technologies also present important challenges, including increased economic burden, limited accessibility, technical complexity, and the need for specialized multidisciplinary training. Therefore, future investigations into technology-assisted breast surgery should also explore the role of advanced visualization systems, artificial intelligence-assisted surgical planning, ergonomics, surgeon performance, and digital innovation in optimizing precision surgery and individualized patient care.

Limitations

This study has several important limitations. First, the number of retrieved and included studies was relatively small, reflecting the limited currently available literature regarding robotic nipple-sparing mastectomy with implant-based reconstruction. Second, most included studies were retrospective and heterogeneous in design, patient selection, reconstructive techniques, and outcome reporting, limiting direct comparability between studies. Third, although efforts were made to conduct a systematic and comprehensive literature search, the search strategy was developed by the authors without formal involvement of a medical librarian or information specialist. Fourth, literature screening and study selection were not performed using a formal dual-independent review process with adjudicated conflict resolution, which may increase the risk of selection bias. Finally, quantitative meta-analysis was not performed because of substantial heterogeneity, limited event numbers, and inconsistent reporting of oncologic and surgical outcomes across studies. Therefore, the findings of this review should be interpreted with caution.

Future research should focus on prospective multicenter studies and large-scale registries with extended follow-up, standardized reporting of oncologic and surgical outcomes, and incorporation of formal cost-effectiveness analyses, patient-reported outcomes, and quality-adjusted outcome measures. Such investigations will be essential to determine whether the favorable short-term outcomes and oncologic equivalence observed in this and prior studies translate into durable long-term oncologic safety, improved patient satisfaction, and overall clinical value across broader patient populations.

Conclusion

This study reviewed published research comparing robotic breast surgery with conventional open surgery in women undergoing nipple-sparing mastectomy with breast reconstruction for breast cancer. The findings suggest that robotic surgery appears to be as safe as conventional surgery in carefully selected patients. Rates of cancer returning after surgery were low and similar between the two approaches during the available follow-up periods. Robotic surgery usually took longer to perform, but blood loss during surgery and complication rates were generally low. Problems such as infection, poor wound healing, or implant-related complications occurred at similar rates in both groups. Some studies also suggested that patients who underwent robotic surgery were more satisfied with the cosmetic appearance of their breasts and reported better body image outcomes. However, the current evidence is still limited. Most studies included a small number of patients and followed them for only a relatively short period of time. In addition, patients selected for robotic surgery were often younger and had less advanced disease, which may have influenced the results. Overall, robotic nipple-sparing mastectomy with implant-based reconstruction appears to be a promising option for selected breast cancer patients. Larger studies with longer follow-up are still needed to better understand the long-term safety and benefits of this approach.

Supplemental Material

Supplemental Material - Robotic Assisted Versus Conventional Open Nipple Sparing Mastectomy With Implant Based Reconstruction for Breast Cancer: A Systematic Review of Oncologic Outcomes and Surgical Safety

Supplemental Material for Robotic Assisted Versus Conventional Open Nipple Sparing Mastectomy With Implant Based Reconstruction for Breast Cancer: A Systematic Review of Oncologic Outcomes and Surgical Safety by Puttiporn Naowaset in Breast Cancer: Basic and Clinical Research.

Footnotes

Acknowledgements

The author conducted this study independently and would like to express sincere appreciation to all healthcare professionals and multidisciplinary team members involved in the care of breast cancer patients, whose work and dedication inspired and informed this review. The author also acknowledges institutional support that facilitated completion of this systematic review.

ORCID iD

Puttiporn Naowaset

Ethical Considerations

Ethical approval was not required for this study as it is a systematic review of previously published literature.

Consent to Participate

Informed consent were not required for this study because this research was a systematic review of previously published studies and did not involve direct participation of human subjects or access to identifiable patient data.

Author Contributions

Conceptualization: Puttiporn Naowaset. Literature search and data collection: Puttiporn Naowaset. Data analysis and interpretation: Puttiporn Naowaset. Manuscript drafting: Puttiporn Naowaset. Critical revision of the manuscript: Puttiporn Naowaset. Final approval of the manuscript: Puttiporn Naowaset.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data are contained within the article and supplementary materials.*

Reporting Guideline

This systematic review was conducted and reported in accordance with the PRISMA 2020 guidelines.

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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