Endoscopic nipple-sparing mastectomy with immediate breast reconstruction is an emerging surgical technique that may improve cosmetic outcomes while maintaining oncologic safety in appropriately selected patients.

Performed endoscopically, this procedure enables breast tissue to be removed through a single incision that is substantially smaller than those used in conventional surgery. The technique may reduce functional impairment, improve cosmetic outcomes after reconstruction, facilitate postoperative recovery, and enhance quality of life while maintaining oncologic safety. Speaking with Medscape’s French edition, Anne Puchar, MD, breast surgeon and specialist in endoscopic mastectomy at Gustave Roussy, Villejuif, France, explained the technique.

Asian Origins

Whether performed prophylactically in women at high genetic risk or as part of curative treatment for selected patients with breast cancer, conventional mastectomy techniques have one feature in common: They leave a visible scar on the breast. Although not yet widely adopted in Europe, endoscopic mastectomy has emerged as a less invasive alternative with comparable oncologic outcomes in appropriately selected patients.

The procedure is performed under continuous endoscopic visualization through a single incision placed away from the breast. It allows immediate breast reconstruction while minimizing visible scarring because the incision is small and concealed within a natural skin crease, resulting in favorable cosmetic outcomes.

The technique was developed in Asia, particularly in Taiwan, China, and Japan, during the mid-1990s and has since been evaluated in numerous studies.

“The delay in its adoption in Europe is largely due to the technical challenges involved,” Puchar said. “However, interest in the technique is growing, and it is beginning to gain wider acceptance in France.”

Gustave Roussy is among the pioneering European centers and has performed more than 75 endoscopic mastectomies.

Hidden Incision

“Endoscopic mastectomy is reserved for patients with moderately sized breasts, moderate ptosis, no skin involvement, and tumors located away from the nipple-areola complex. Expert guidelines recommend a breast size no larger than a C cup,” Puchar said.

The procedure uses a minimally invasive approach to remove breast tissue through a discreet incision placed within a natural skin crease, such as the axilla or inframammary fold. The incision measures approximately 2.5-5.0 cm compared with 6.0-10.0 cm for conventional mastectomy.

“In patients with breast cancer, the same incision can be used for lymph node dissection, breast tissue removal, and immediate breast reconstruction. This also helps minimize scarring,” Puchar said.

Improved Visualization

After the incision is made, a camera and specialized endoscopic instruments are inserted. Carbon dioxide is then insufflated to create a working space and improve visualization. The procedure is performed under continuous endoscopic guidance and requires only limited additional equipment.

“Endoscopic mastectomy uses the same instruments as laparoscopy. That is the major advantage of this technique because it makes broader adoption more feasible,” Puchar said.

The endoscopic view also improves visualization of tissue planes throughout the dissection.

“This allows breast tissue to be removed more precisely, particularly around the nipple-areola complex, where identifying the correct dissection plane can be challenging. By minimizing trauma to the skin, the technique also improves the quality of breast reconstruction,” Puchar said.

Reconstruction Options

Another advantage is that the technique is compatible with all major approaches to immediate breast reconstruction, including implant-based reconstruction, fat grafting, and selected autologous tissue reconstruction procedures.

“Lipofilling is an excellent option for immediate reconstruction, although multiple procedures are often required to achieve the desired breast shape.”

Patient feedback has been highly positive. “I remember a 26-year-old woman whose anatomy made her an ideal candidate for this technique. She cried with joy when she learned she would not have a visible scar on her breast,” Puchar recalled.

She also noted that long-term cosmetic outcomes appeared to be better than those achieved with conventional mastectomy techniques, although the reasons for this observation have not yet been established.

As with any new technique, training remains the main challenge. “The learning curve is steep,” Puchar said. She expressed hope that more surgeons would receive training in endoscopic mastectomy, allowing the procedure to become more widely available to eligible patients.

This story was translated from Medscape’s French edition.