A Smaller Incision Offers a New Approach to Nipple-Sparing Mastectomy

A minimally invasive approach to nipple-sparing mastectomy may offer some patients the benefits of a smaller incision, improved surgical visualization and a potentially easier recovery.

Dr. Jean Bao, a Clinical Associate Professor in our Division of General Surgery, recently performed her first endoscopic nipple-sparing mastectomy (E-NSM) case at Stanford Health Care in Emeryville. Like a traditional nipple-sparing mastectomy (NSM), the procedure removes the breast tissue while preserving the breast skin and nipple. Traditional NSM is commonly performed through a long incision along the inframammary fold beneath the breast. With the endoscopic technique, the surgeon instead works through a vertical incision approximately 3 to 3.5 centimeters long on the side of the chest.

“Being able to offer the same procedure through a smaller scar gives patients another choice,” said Bao. 

Why Endoscopic?

During the procedure, about half of the dissection is performed via direct visualization, and the rest with the endoscopic approach. During the endoscopic portion, a gel port that holds multiple instruments is placed in the incision. A camera and laparoscopic instruments can then be introduced through the port. The breast is gently insufflated with air, creating room for the surgeon to see the tissue planes and complete the dissection while looking at a video monitor. The endoscopic view provides a clearer perspective in areas that can be difficult to see during an open operation while also being more ergonomic.

There are also a multitude of potential benefits for the patient: 

• It may reduce the amount of physical retraction required to hold the skin and tissue away from the surgical field. 

• The smaller incision may result in less pain and a quicker recovery

• The technique may reduce stress on the preserved skin and nipple by limiting the amount of cutting and retraction required during the operation. 

Maintaining blood flow to the breast skin and nipple is critical in any nipple-sparing mastectomy. If that blood supply is compromised, portions of the skin or nipple can develop necrosis. Bao said early studies suggest endoscopic surgery may be associated with fewer necrosis complications, although additional evidence is needed. Whether the technique improves preservation of breast or nipple sensation also remains an open question. 

Placing the incision on the side of the chest may provide another healing advantage. In a traditional inframammary incision, a reconstructed breast or implant can place pressure on the scar when a patient is upright. A lateral incision avoids positioning the scar directly beneath the reconstructed breast. 

The endoscopic approach does not prevent patients from pursuing reconstruction. Through the same small incision, a plastic surgeon can place a tissue expander or implant. In some autologous reconstruction procedures, the surgeon may also be able to connect the patient’s tissue flap to blood vessels near the armpit without creating an additional breast incision.

An option for cancer treatment and risk reduction

Endoscopic nipple-sparing mastectomy may be considered for patients undergoing surgery to treat breast cancer as well as for those choosing a prophylactic, or risk-reducing, mastectomy. When lymph-node evaluation is needed, the surgical team may  reach the axilla through the lateral incision, adjusting its position slightly when necessary. 

As with traditional nipple-sparing mastectomy, the size of the breast, nipple position relative to the inframammary fold, cancer size and distance to nipple remain important considerations for the endoscopic approach.

“As with any new technique, we want to be conservative and thoughtful about selecting the right patients,” Bao said.

Endoscopic nipple-sparing mastectomy has been performed in parts of Europe and Asia for some time, but adoption in the United States has been more recent. Bao learned more about the approach after attending a presentation at the American Society of Breast Surgeons meeting and subsequently completed a training course sponsored by Applied Medical. 

Bao expects to perform more of these procedures in Emeryville, where she frequently works with plastic surgeons on combined breast surgery and reconstruction cases. She sees the technique not as a replacement for open nipple-sparing mastectomy, but as an additional option for appropriately selected patients. 

“For patients who are candidates, it has real benefits,” she said. “It is about giving patients a choice.” 

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