Transaxillary Nipple-Sparing Mastectomy, Lymphadenectomy and Direct-to-Implant Submuscular Breast Reconstruction Using Endoscopic Technique: A Step toward the “Aesthetic Mastectomy”

摘要

Sir: We read with great interest the article by Sarfati et al. on robotic nipple-sparing mastectomy with immediate prepectoral implant reconstruction.1 The authors elegantly demonstrated their surgical technique for robotic nipple-sparing mastectomy using two vertically oriented incisions in the lateral thoracic breast area and their final reconstructive results. In the last decade, nipple-sparing mastectomy has known an exponential diffusion worldwide for prophylaxis and for therapeutic mastectomies in selected candidates. It is oncologically safe, and improves reconstructive outcomes and patient satisfaction thanks to preservation of the entire breast envelope and footprint. The two most common skin incisions are the radial and inframammary fold ones. They represent an imperfect solution between the oncologic/reconstructive needs (i.e., surgical control during mastectomy and preservation of skin and nipple-areola complex perfusion, along with mastectomy skin flap thickness control for prepectoral versus submuscular implant reconstruction) and the cosmetic outcomes (scar visibility).2,3 The increasing demand for further cosmetic outcome improvement led the surgeons to move the access far from the breast footprint in the search for the ideal incision for nipple-sparing mastectomy, as also shown by Sarfati et al., who used a lateral thoracic approach. We believe that the ideal nipple-sparing mastectomy incision is the axillary one. This single access allows us to perform a safe, nonendoscopic mastectomy in A and B cup breasts, node surgery, and nonendoscopic immediate prepectoral reconstruction when feasible (i.e., thick skin flaps) or endoscopic submuscular-subfascial direct-to-implant reconstruction, with the main advantage of a hidden and well-concealed scar. In our experience, a 6-cm incision located on the lowest axillary fold along the midaxillary line allows a safe, nonendoscopic mastectomy using a long blade (19 cm) light retractor. First, the mastectomy skin flap is incrementally elevated from breast tissue, and retroareolar tissue is excised and sent for frozen section analysis; then the entire gland is elevated on the prepectoral plane, preserving the superficial pectoralis fascia. The gland is then completed detached by joining the inferolateral and superomedial border detachment. The same axillary incision is conveniently used for node surgery. Finally, an operative rigid endoscope with working channel (Richard Wolf, Vernon Hills, Ill.) is used to dissect the entire submuscular-subfascial pocket, and a definitive, anatomical, textured breast implant is inserted. The cosmetic outcome is very pleasant for both the surgeon and the patient, with the main advantage of a “scarless” mastectomy [Fig. 1 and Figure, Supplemental Digital Content 1, which shows a 43-year-old patient planned for transaxillary right breast nipple-sparing mastectomy for breast cancer and direct-to-implant submuscular endoscopic reconstruction and contralateral symmetrization with implant (above) and a 1-year postoperative view of pleasant cosmetic outcomes and a well-hidden mastectomy scar (below), https://links.lww.com/PRS/D426].Fig. 1.: (Above) Preoperative view of a 43-year-old patient planned for transaxillary right breast nipple-sparing mastectomy for breast cancer and direct-to-implant submuscular endoscopic reconstruction and contralateral symmetrization with implant. (Below) One-year postoperative view shows pleasant cosmetic outcomes and a well-hidden mastectomy scar.Although transaxillary endoscopic breast augmentation is nowadays a very common procedure, the few reports available on transaxillary mastectomy and direct-to-implant reconstruction are from Asian colleagues reporting endoscope-assisted mastectomies mainly for subcutaneous mastectomies (prophylaxis) rather than for therapeutic nipple-sparing mastectomy.4,5 This is very likely due to a more technically challenging procedure, as stated by Sarfati and colleagues,1 which in our