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

Recent Advancements in Robotic-assisted Plastic Surgery Procedures: A Systematic Review

Background

There has been a delayed, yet steady uptake of robotic-assisted surgery over the past decade within the field of plastic surgery. In an era of rapidly evolving scientific and technological development, there is a need for an update on the current literature for robotic-assisted plastic surgery procedures.

Methods

Searches were conducted across major databases, including MEDLINE, Embase, and Central for published literature from March 2023 to December 2024. Only published articles written in English with full texts were considered for the final narrative synthesis.

Results

Initially, we identified 1200 articles in the database search. Subsequently, 46 articles were included in our final narrative synthesis. Among the selected studies, 4 focused on reconstruction in transoral robotic surgery, 14 on breast surgery, 10 on robotic microsurgery, 5 on abdominal wall reconstruction, 6 on vaginoplasty, and 5 on flap harvest.

Conclusions

The evidence to support the advantage of robotic plastic surgery procedures over traditional methods is relatively weak. However, there have been some advancements, specifically in transoral robotic surgery, robotic mastectomy, and breast reconstruction. Nevertheless, comprehensive exploration and prospective randomized trials are essential across all procedures to define the role of surgical robots in plastic surgery. The impediments to wider adoption include high costs, disruption to operative flow, and the absence of haptic feedback in robotic-assisted procedures within the specialty.

Nipple-areolar complex sensory recovery based on incision placement after nipple-sparing mastectomy: a prospective nonrandomized controlled trial

INTRODUCTION

Nipple-sparing mastectomy (NSM) aims to improve patient satisfaction by preserving the nipple-areola complex (NAC) while ensuring oncologic safety. Different surgical incisions, such as inframammary fold (IMF) and periareolar/radial incisions, are used in NSM; however, their impact on NAC sensory loss remains unclear. In this study, the authors aimed to assess NAC sensation after NSM and compare the results of different incisional approaches, specifically IMF versus periareolar/radial.

METHODS

In this prospective, single-center, nonrandomized controlled trial, 105 post-NSM patients were recruited from October 2019 to November 2021 and followed up at 24-48 months postsurgery. Of these, 97 (IMF: 65; periareolar/radial: 32) were analyzed for sensory assessment. NAC sensation was measured using the pin-prick test, with scores ranging from 0 (no sensation) to 2 (sharp sensation) across five NAC areas. Sensory loss was defined as a total score below 3.

RESULTS

The median total score on the pin-prick test for NAC sensation was significantly higher in the IMF incision group than in the periareolar/radial incision group (3.77±3.11 vs. 2.47±2.51; P=0.043). The rate of NAC sensory loss was significantly lower in the IMF group than in the periareolar/radial group (36.9% vs. 62.5%; P=0.017). Multivariable analysis revealed that the incisional approach (95% CI: 0.14-0.97; P=0.044) and radiotherapy (95% CI: 0.05-0.36; P<0.01) were independent determinants of NAC sensory loss.

CONCLUSION

Our study emphasized the importance of incision placement during NSM in preserving NAC sensation and may provide a valuable perspective for clinicians and patients considering this surgical approach.

Emerging Role of Robotic Surgery in the Breast

In recent years, there has been increased adoption of robotic technology in oncologic breast surgery, particularly with the use of robotic nipple sparing mastectomy (r-NSM). Here we review the emergence of robotic-assisted surgery in breast procedures, and discuss the safety, limited oncologic outcomes, apparent advantages, and potential limitations of r-NSM compared to conventional open-NSM (c-NSM). Limited data suggests that robotic-assisted surgery offers smaller incisions and potential for improved cosmesis and ergonomic advantage when compared to c-NSM. Similar periprocedural complication rates are seen with r-NSM compared with c-NSM. Short-term oncologic follow-up is reassuring however, but remains early and continues to be investigated. The increased cost of r-NSM compared to open surgery and feasibility of widespread adoption of the procedure are important considerations that need to be evaluated. Randomized trials are currently ongoing to address the apparent advantages, oncologic outcomes, and cost/feasibility of robotic breast surgery.

Reverse-sequence endoscopic nipple-sparing mastectomy with immediate implant-based breast reconstruction: an improvement of conventional minimal access breast surgery

Background

Our center proposes a new technique that effectively provides space to broaden the surgical field of view and overcomes the limitations of endoscopy-assisted nipple-sparing mastectomy (E-NSM) by changing the dissection sequence and combining it with air inflation. The purpose of this study was to compare the clinical outcomes of the new technique designated "reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with subpectoral breast reconstruction (SBR)" and the conventional E-NSM (C-E-NSM) with SBR.

Method

All patients undergoing E-NSM with SBR at our breast center between April 2017 and December 2022 were included in this study. The cohort was divided into the C-E-NSM group and the R-E-NSM group. The operation time, anesthesia time, medical cost, complications, cosmetic outcomes, and oncological safety were compared.

Results

Twenty-six and seventy-nine consecutive patients were included in the C-E-NSM and R-E-NSM groups, with average ages of 36.9 ± 7.0 years and 39.7 ± 8.4 years (P=0.128). Patients in the R-E-NSM group had significantly shorter operation time (204.6 ± 59.2 vs. 318.9 ± 75.5 minutes, p<0.001) and anesthesia time (279.4 ± 83.9 vs. 408.9 ± 87.4 minutes, p<0.001) and decreased medical costs [5063.4 (4439.6-6532.3) vs. 6404.2 (5152.5-7981.5), USD, p=0.001] and increase SCAR-Q scores (77.2 ± 17.1 vs. 68.8 ± 8.7, P=0.002) compared to the C-E-NSM group. Although trends increased in both the excellent rate of Ueda scores (53.8% vs. 42.3%, P = 0.144), excellent rate of Harris scores (44.0% vs. 63.1%, P=0.102), and decreased surgical complications (7.6% vs. 19.2%, P = 0.135) were observed in the R-E-NSM group, the differences were not significant. There were no significant differences in oncological outcomes between the two groups.

Conclusion

R-E-NSM improves cosmetic outcomes and efficiency of C-E-NSM, reduces medical costs, and has a trend of lower surgical complications while maintaining the safety of oncology. It is a safe and feasible option for oncological procedures that deserves to be promoted and widely adopted in practice.