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Immediate prepectoral reconstruction after an NSSM is the technique of choice in women undergoing mastectomy due to its low morbidity, adequate oncological safety, and good cosmetic results. This procedure can be performed with endoscopic assistance, allowing for minimal incisions in areas of low visibility and better visualisation for dissection of the inner quadrants. These techniques have become more popular in recent years, but their implementation has been limited due to the lack of prospective studies with long-term follow-up, the high cost of endoscopic/robotic equipment, and the increased surgical time.
The E-NSSM technique described by our breast unit differs in some aspects from those described by other authors. First, positioning the upper limbs close to the trunk protects the brachial plexus from injury due to hyperextension of the arm. Furthermore, this position facilitates the movement of endoscopic instruments during dissection of the lower quadrants.
Secondly, the inframammary fold incision is a low-visibility access point that contributes to a good cosmetic result, even when this incision is enlarged to remove the specimen and/or place the implant.
The third advantage relates to the dissection method, which is performed with monopolar energy. This facilitates CO2 dispersion in the subcutaneous plane and allows for the preservation of a greater amount of subcutaneous fat. This methodology differs from most groups that use sealing instruments, infuse Klein's solution subcutaneously, and perform indiscriminate tunnelling with scissors, which can inadvertently damage the subcutaneous vascularisation. Fourthly, the dissection is performed by continuously alternating between the subcutaneous and prepectoral planes, as the surgeon sees fit, unlike other authors who complete the dissection of each plane before moving to the next. This change of planes facilitates the progression of the dissection and allows for a comprehensive view from different perspectives, reducing the possibility of thermal injury to the skin. Fifth, the nipple-areola complex is dissected after specimen removal, allowing for optimal cleaning of the glandular tissue without thermal injury to the areola. Using this technique, the complication rate was similar to that of open breast mastectomies performed by the same group.
Finally, in the described method, each area of the breast is dissected through an exposure that allows for greater visibility and access. Thus, the dissection of the prepectoral plane and the lateral and inferior skin flaps is performed using an open technique, while the medial quadrants, which are difficult to access through an incision in the
inframammary fold, are approached endoscopically. This combination of open and endoscopic techniques facilitates optimisation of surgical time.
The main limitations in the implementation of endoscopic mastectomy have been the increased surgical time, the longer hospital stay, and the learning curve required to reduce these factors. In our experience, the mean surgical time for a unilateral E-NSSM was 189 min, longer than the time for open mastectomy (138 min), and shorter than the mean time reported by most groups performing (234–282 min). Lai et al.18 performed a hybrid approach through an axillary incision without gas insufflation and reported a mean surgical time shorter than that of endoscopic mastectomy and slightly longer than that of the present study (210.1min). In our breast unit, bilateral mastectomy is performed by two simultaneous surgical teams during the open surgery phase, followed by lymph node staging in the oncological breast while the opposing team performed the endoscopic phase. This strategy reduced the surgical time and brought it in line with the times for open bilateral E-NSSM described in the PreQ-20 study. In the experience of Yang et al.,16 the mean operative time stabilised at approximately 172.55 min after 18 cases. This figure was higher than the learning curve for both the open and robotic techniques, with the latter
improving from the 10th procedure onward and stabilizing by the 19th. In our experience, starting with patient number 11, the time for bilateral mastectomy stabilized at 80 min. The average stay our patients is 1 day, which is shorter than that of the P-NSSM patients in the PreQ-20 study and much shorter than the 5–6 days described by other groups performing endoscopic surgery.
The clinical context in our experience is primarily oncological (92.9%). This scenario is more complex than that of risk-reducing mastectomy, as it requires planning and technical execution that ensures adequate disease removal and tumour-free margins. The main challenge of endoscopic NSSM in an oncological breast is the ease with which
tumour landmarks can be lost, especially due to the absence of tumour palpation during the endoscopic phase. However, although there is no direct contact with the tumour, an experienced surgeon can develop haptic sensation, allowing them to perceive the consistency and resistance of the tissues through the instruments. Another challenge inherent to ultra-conserving mastectomies, and therefore shared with O-NSSM, is the superficial margin of the mastectomy specimen. Therefore, its evaluation is necessary to rule out involvement of this margin, which, if present, may require an extension or the indication of adjuvant radiotherapy. Finally, another added difficulty is the
fragmentation of the surgical specimen during its extraction through the wound, which leads to an inadequate assessment of the superficial margin. For this reason, it is important to consider enlarging the surgical wound in cases where extraction of the mastectomy specimen is difficult, either due to its size or the presence of dense glandular tissue.
Our initial experience has also allowed us to explore other previously non-described indications, such as irradiated breasts, tumours close to the skin, or breasts requiring minimal skin reduction.
This latter scenario is possible in patients with breasts exhibiting mildto-moderate aptosis who are candidates for mastectomy with skin and superior pedicle reduction. The experience in this study is limited (2 patients), but it has confirmed the technical feasibility of this approach through de-epithelialisation of the pattern and preservation of the skin envelope.
