The Clinical Application of Mastectomy With Single Incision Followed by Immediate Laparoscopic-Assisted Breast Reconstruction With Latissimus Dorsi Muscle Flap

Endoscopic Nipple- or Skin-Sparing Mastectomy and Immediate Breast Reconstruction with Endoscopic Harvesting of the Latissimus Dorsi Flap: A Preliminary Experience of an Innovative Technique

Background

Endoscopic nipple- or skin-sparing mastectomy (E-N/SSM) and endoscopic latissimus dorsi muscle flap (E-LDMF) harvest have been operational difficulties over decades. The aim of this study was to describe the preliminary outcomes of our novel surgical technique, which allows the performance of E-N/SSM and E-LDMF harvest for immediate breast reconstruction (IBR) through a single cosmetic axillary incision for breast cancer patients.

Methods

This prospective study included 20 breast cancer patients who underwent E-N/SSM and E-LDMF harvesting through a single axillary incision in our hospital from September 2020 to June 2022. The outcomes were statistically calculated, including patient characteristics, operative data, complication rate, hospital length of stay and costs, and patient-reported outcomes.

Results

A total of 20 breast cancer patients underwent our sufficiently mature novel endoscopy technique. The mean LD flap harvest time was 96.5 ± 25.3 min, the mean operation time was 262.6 ± 54.4 min, and the average length of LDMF was 26.9 ± 3.1. During the median follow-up time of 7.5 months, 4 patients developed donor-site seroma. One of them was also complicated by hypopigmentation of the nipple areola, and one of them suffered from breast cellulitis. No bleeding or flap necrosis happened. No tumor recurrence or metastasis was found until the last follow-up. In the BREAST-Q evaluation, although they gave a lower score beginning at 1-month post-operation than preoperatively (P > 0.05, except for physical well-being: chest and physical well-being: back and shoulder, P < 0.01), there was an uptrend at 3 months postoperatively. Because of the hidden and short incision, the mean score of the appearance scale of the SCAR-Q at 3 months post-operation was 74.2 ± 8.8.

Conclusions

The novel endoscopy technique, which was first reported to perform lymph node surgery, N/SSM, and LDMF harvesting in an operation for breast cancer patients through a single axillary incision, is associated with a shorter surgery time, lower complication rates, and better patient-reported outcomes.

Superomedial pedicle skin-reducing mastectomy in ptotic and large-sized breasts with two-stage reconstruction through transaxillary video-assisted technique: An effective surgical and anesthetic approach

Introduction

Skin-reducing mastectomy has been applied to several surgical techniques in which subcutaneous mastectomy is associated with various types of skin reduction, with preservation of a lower dermal flap to reinforce the inferior lateral seat of an implant. The aim of the study is to present a case series of patients with pendulous/ptotic and/or large-sized breasts treated for breast cancer at the Breast Surgery Unit of Istituto Nazionale Tumori IRCCS Fondazione "G. Pascale", Naples, Italy, with the superomedial pedicle skin-reducing mastectomy technique, two-stage reconstruction, and transaxillary video-assisted technique, when a postoperative radiotherapy was indicated. We verified its effectiveness by discussing its results, especially in patients who are candidates for postmastectomy radiotherapy.

Materials and methods

A single-center retrospective study was performed between January 2020 and March 2021 on a prospectively filled database of conservative mastectomies. Of the 64 patients who underwent nipple/skin-sparing mastectomies in the mentioned period, 17 (mean age 46 years, range 30-62 years) were treated with superomedial pedicle skin-reducing mastectomy, with two-stage breast reconstruction through transaxillary video-assisted replacement expander with definitive prosthesis and contralateral symmetrization, selected for postmastectomy radiotherapy.

Results

We had only three minor complications. No flap necrosis, no infections, no breast seromas, and no reconstructive failures were observed. During follow-up of the patients treated with video-assisted reconstruction, there were no cases of infection, hematoma, implant rupture, or suture dehiscence in the reconstructed breast.

Discussion

Skin-reducing mastectomy with superomedial pedicle is a safe and reliable procedure to treat breast cancer in selected patients, i.e., those with pendulous/ptotic and or large-sized breasts. Particularly, in patients who undergo postmastectomy radiotherapy, the two-stage reconstruction with video-assisted transaxillary endoscopic approach can find its main indication, using incisions positioned far from the mammary region, offering numerous advantages.

Robotic-assisted skin sparing mastectomy and immediate reconstruction using latissimus dorsi flap a new effective and safe technique: A comparative study

INTRODUCTION

Breast reconstruction is an essential part of breast cancer treatment. After skin sparing mastectomy, Immediate Breast Reconstruction (IBR) can be achieved using breast implants, autologous flaps (i.e. latissimus dorsi-myo-cutaneous flap (LDF)) or an association of both. Robotic assistance has gained popularity in many surgical fields including breast surgery. This study aims to compare the post-operative results of Robotic Assisted Latissimus Dorsi Flap (RALDF) to Traditional Latissimus Dorsi Flap (TLDF) for IBR after Skin Sparing Mastectomy (SSM) without nipple conservation.

MATERIALS AND METHODS

Between March 2016 and June 2019, all patients who underwent a SSM and a concurrent IBR with a TLDF were retrospectively compared to patients who underwent SSM and a concurrent IBR with a RALDF. Outcomes compared included operative time, length of hospital stay and complications rate.

RESULTS

105 cases of SSM with a LDF based IBR were included in the study. 46 patients underwent RALDF and 59 patients underwent TLDF. Mean operative time was longer in the RALDF group (290.5min versus 259.7min). In binary regression, the concomitant placement of breast implant was the only factor associated with an operative time exceeding 290 min (p = 0.032). Univariate analysis showed no significant difference concerning the rate of complications (p = 0.061). After logistic regression, RALDF was associated with a decreased rate of complications (p = 0.042; OR 0.37; IC 95% (0.142-0.966)).

DISCUSSION

SSM with IBR using RALDF is an effective and safe technique. This technique is actually associated with a lower complication rate at the expense of a longer operative time.

Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With Robotic Latissimus Dorsi Flap Harvest: Technique and Results

Introduction. Only few cases of robotic latissimus dorsi flap reconstruction (RLDFR) have been reported in indication of reconstruction for breast cancer (BC). We report our experience of combined robotic nipple-sparing mastectomy (R-NSM) and RLDFR, and analyze technique, indications, and reproducibility. Methods. All patients with R-NSM and RLDFR from November 2016 to August 2, 2018, were analyzed, and technics have been described. Complication rate with Clavien-Dindo grading and postoperative hospitalization length (days) are reported. Results. Thirty-five R-NSM with RLDFR were performed in 22 cases for primitive BC and 13 for local recurrence. In 12 patients, another surgical procedure was performed during the same time (axillary lymph node dissection or contralateral breast surgery). R-NSM was realized through a short axillar incision, with inside-only installation for 12 patients (34.3%): 18 nonautologous and 17 autologous RLDFR associated with implant in 9 patients. In logistic regression, mastectomy weight >330 g was significantly associated with the use of implant (odds ratio [OR] = 17, P = .015), and significant factor of the time of anesthesia ≥380 minutes was 2 installations (OR = 10.4, P = .049). The median duration of hospitalization stay was 4 days. Complications rates were 51.4% (18/35; 9 grade-1, 2 grade-2, and 7 grade-3). In logistic regression, associated other surgical procedure was predictive of grade-3 complications (OR = 6.87, P = .053). Conclusion. We confirmed the reproducibility and safety of R-NSM and RLDFR with a decreased complication rate. NSM was performed in 42.8% of our patients after previous radiotherapy. We observed an increase of grade-3 complications when R-NSM and RLDFR was combined to another surgical procedure.

Skin sparing mastectomy and robotic latissimus dorsi-flap reconstruction through a single incision

Background

Robotic latissimus dorsi-flap reconstruction (RLDFR) after skin-sparing mastectomy (SSM) for breast cancer (BC) has been performed through a single nipple incision. We report results of SSM with RLDFR, mainly with analysis of feasibility, morbidity, indications, and technique standardization.

Methods

We determined characteristics of patients, previous treatment of BC, and type of reconstruction. Surgical technique, duration of surgery, and complication rate were reported according to three successive periods: P1–3.

Results

Forty RLDFR, with breast implant for 16 patients, with previous breast radiotherapy in 30% had been performed. In logistic regression, factors significantly associated with duration of surgery ≥ 300 min were P2 (OR 0.024, p = 0.004) and P3 (OR 0.012, p = 0.004) versus P1. The median mastectomy weight was 330 g and 460 g for BMI < and ≥ 23.5 (p = 0.025). Length of hospitalization was 4 days. Total complication rate was 20% (8/40): seven breast complications (four re-operations) and one RLDF complication with re-operation. Periods were significantly predictive of complications (p = 0.045).

Conclusion

SSM with RLDFR is feasible, safe, and reproducible. We reported a decrease of duration of surgery, length of post-operative hospitalization, and complication rate.

Breast cancer robotic nipple sparing mastectomy: evaluation of several surgical procedures and learning curve

BACKGROUND

Few studies of robotic nipple sparing mastectomy (NSM) were reported. We report feasibility of robotic NSM and determine standard surgical procedure and learning curve threefold.

METHODS

A cohort of patients with robotic NSM for breast cancer was analyzed. Complications and post-operative hospitalization stay were reported. The same technic was used for all patients except for skin and nipple areolar complex (NAC) dissection. Differences between three surgical procedures of NAC dissection were analyzed: group 1, dissection with robotic scissors using coagulation; group 2, dissection with robotic scissors without coagulation; and group 3, dissection with non-robotic scissors and then robotic dissection. We explored possible effect of learning curve among patients from group 1 with the same surgical procedure.

RESULTS

Twenty-seven NSM with immediate breast reconstruction for breast cancers, 22 invasive and 5 in situ, were performed, with robotic latissimus dorsi-flap (RLDF) only in 17 cases, RLDF and breast implant in 6 cases, and implant alone in 4 cases. Repartition according to 3 surgical procedure groups was 16, 5, and 6 patients. Mean time of surgery and anesthesia decrease according to groups 1 to 3. Among 16 patients from group 1, time of surgery and anesthesia decreased with learning curve. Post-operative hospitalization decreased from group 1 to 3. We reported a total of 11 complications, with significant difference between groups (10 for group 1). Skin complications were higher for group 1 in comparison with groups 2-3 (p = 0.02).

CONCLUSION

Robotic NSM can be performed with a brief learning. Standardized technique is proposed with non-robotic scissors superficial dissection and then dissection with robot.