Correction: Experience sharing of endoscopy-assisted total mastectomy with and without immediate breast reconstruction
Year: 2026
Type: erratum
Abstract: Breast cancer remains the most prevalent malignancy affecting women globally, with rising emphasis on balancing oncologic efficacy and quality-of-life outcomes [1].Advances in surgical techniques have transitioned from extensive resections to minimally invasive, aesthetically driven approaches, reflecting the paradigm shift toward personalized cancer care [2]. Implant-based breast reconstruction has gained traction due to its technical feasibility and immediate cosmetic benefits. Current IBR strategies include direct-to-implant (DTI) and two-stage expander-implant (TE-I) techniques [3][4][5][6][7][8]. Traditional approaches, however, often necessitate visible incisions (e.g., inframammary fold, periareolar), resulting in suboptimal scar concealment.Endoscopic surgery, renowned for its minimally invasive nature and enhanced visualization, has revolutionized procedures in gynecology and general surgery [9][10][11][12][13].Nonetheless, endoscope applications in breast surgery have been limited by anatomical challenges, including restricted operative space and difficulties in pneumoperitoneum maintenance. As a result, the application of endoscope-assisted breast surgery has been limited. It was not until 1992 that Kompatscher first introduced endoscopic techniques into breast surgery [14]. Advancements in single-port laparoscopy have enabled axillary access for radical mastectomy, combining concealed incisions with stable workspace establishment [15][16][17][18]. The integration of single-incision axillary endoscopy-assisted total mastectomy endoscope (EATM) with immediate breast reconstruction (IBR) represents a transformative approach. This technique minimizes visible scarring, reduces postoperative morbidity, and aligns with patient demands for aesthetic preservation [19][20][21][22]. Besides, this approach meets the desire of breast cancer patients for scar-free skin surfaces and perfect breast remodeling. It helps avoid the psychological and physical impacts caused by breast loss, contributing to reducing their psychological stress and improving overall well-being [2,7,23]. Despite its potential, comparative data on EATM combined with IBR remain sparse.This study evaluated the clinical outcomes and patient satisfaction of EATM with IBR, providing evidence to guide surgical decision-making in breast cancer management.This retrospective cohort study reviewed 213 breast cancer patients who underwent radical mastectomy at Fuzhou University Affiliated Provincial Hospital (December 2020-February 2023). Participants were stratified into four groups based on surgical technique and reconstruction status:(1) Group A (n = 128): Conventional total mastectomy (CTM).(2) Group B (n = 46): Endoscopy-assisted total mastectomy endoscope (EATM).(3) Group C (n = 17): CTM with immediate breast reconstruction (IBR).(4) Group D (n = 16): EATM combined with IBR.All patients provided written informed consent after comprehensive discussions of surgical risks and alternatives. All surgical procedures, encompassing the oncologic mastectomy and the immediate prosthetic reconstruction, were performed by the same surgeon who is dual-trained and highly experienced in both oncologic breast surgery and oncoplastic reconstruction techniques.(1) Females aged 21-41 years.(2) Unilateral breast cancer confirmed by histopathology.(3) Tumor characteristics: Ductal carcinoma in situ (DCIS) without size restriction;Invasive carcinoma ≤ 3 cm in diameter (post-neoadjuvant chemotherapy residual tumors ≤3 cm); Tumor distance >0.2 cm from gland surface, no chest wall fixation, skin dimpling, or peau d'orange changes.(4) Breast volume <500 mL, no significant ptosis (nipple position above inframammary fold).(5) Patients with a high aesthetic demand who, after comprehensive counseling on all oncologically sound options, explicitly chose mastectomy with immediate reconstruction for personal reasons.. (6) No distant metastasis.(1) Bra size >E or post-mastectomy breast weight >600 g.(2) Nipple involvement or skin/pectoralis major muscle invasion.(3) Comorbidities: uncontrolled hypertension, diabetes, cardiac/renal/hepatic dysfunction.A single-port endoscopic system (4-channel, 70 cm), long-handled ultrasonic scalpel, 30°laparoscope, Tiloop® mesh (PFM Medical), and silicone implants were prepared (Figure 1A). All patients undergoing immediate breast reconstruction (Groups C and D) received a Tiloop® Bra mesh (PFM Medical) to support the implant. The implants used were all round, smooth-shell silicone gel implants.Prior to surgery, the patient assumed an upright standing position for anatomical reference. The following anatomical landmarks were demarcated: (1) bilateral lower inframammary folds, (2) superior/medial/lateral mammary boundaries, and (3) A 3-4 cm curvilinear incision positioned horizontally within the axillary region. This incision was strategically placed at the midpoint between the anterior axillary fold and the breast margin, ensuring complete concealment during neutral arm positioning (Figure 2B).For sentinel lymph node mapping, a dual-tracer protocol was implemented: 0.5 mL methylene blue (1% w/v) combined with 0.5 mL nano-carbon suspension (25 mg/mL) was administered via intradermal injection periareolarly (within the 3-9 o'clock quadrant) to optimize lymphatic visualization.Following induction of general anesthesia, the patient was positioned in a standard supine orientation with the torso strategically aligned with the ipsilateral bed edge to optimize surgical access. The affected limb was configured as follows: (1) shoulder joint abducted to 90°with external rotation, (2) ipsilateral thoracic elevation to 30°using adjustable foam bolsters (Figure 1C). Routine draping and disinfection were performed, and the affected arm was wrapped with a sterile towel and fixed with towel clamps. The affected arm was then immobilized to the head (Figure 1E).The initial 3-5 cm incision was strategically placed at the midpoint between the anterior axillary fold and the breast edge. In cases where ALND was anticipated or required, the incision could be extended posteriorly as needed to optimize exposure., ensuring it did not extend beyond the anterior axillary line. In cases of larger breast volume, the incision was extended posteriorly. Sentinel lymph node biopsy was performed under direct visualization. The stained or significantly enlarged axillary sentinel lymph node was identified and excised for intraoperative frozen section pathological examination. If the sentinel lymph node was found to be positive, axillary lymph node dissection was carried out following total mastectomy. The affected arm was flexed and secured to the head support, with the arm support then removed.Under direct visualization, the lateral edge of the pectoralis major muscle was exposed through the axillary incision, extending into the space between the pectoralis major and minor muscles. A wound protector was inserted, and a single-port endoscope device was connected (Figure 1F). Pneumoperitoneum was established using CO2 at a pressure of 8-10 mmHg (1 mmHg = 0.133 kPa) and a flow rate >20 L/min to create a working space for the mastectomy. Using an ultrasound knife, the loose connective tissue between the pectoralis major and minor muscles was separated (Figure 1G). The pectoralis major was transected up to the preoperative marking, ensuring the perforating blood vessels were preserved to avoid hemostasis complications, which could necessitate conversion to open surgery.The wound protector was removed, and the space between the breast and the posterior tissue was cleared by approximately 2 cm. The wound protector and single-port endoscope device were reinserted, the pneumoperitoneum was reopened, and the working space was re-established. Using the ultrasound knife, the space behind the breast was freed (Figure 1H), including the pectoralis major fascia. This dissection extended from below the clavicle medially to the sternal margin, inferiorly to the inframammary fold, and laterally to the outer edge of the breast gland.The endoscope device was removed, and adrenaline saline (1:500,000) was injected subcutaneously on the surface of the breast (Figure 1I). The anterior space of the breast was then dissected by approximately 2 cm under direct visualization. The wound protector and single-port endoscope device were reconnected, and the pneumoperitoneum was re-established. Using a dissector, the breast gland was retracted inferiorly to expose the superficial layer of the superficial fascia. Endoscope scissors were used for sharp dissection of the skin flap (Figure 1J), following the sequence: upper outer, posterior to the nipple, lower inner, upper inner, and lower outer. The anterior space of the breast was completely separated.To achieve hemostasis, the endoscope scissors were then connected to an electrocautery hook. This helped prevent thermal damage to the skin flap caused by the ultrasound knife, which could lead to ischemia and necrosis of the nipple-areola complex (NAC). The gland was transected along the edge of the breast using an ultrasound knife. Tissue from behind the nipple was sent for intraoperative frozen section pathology. The procedure performed was a nipple-sparing mastectomy via an axillary approach, which involves the removal of all breast glandular tissue while preserving the NAC and the skin envelope.The wound protector and single-port endoscope device were removed, and the specimen was extracted. Thorough lavage and hemostasis were performed. If the sentinel lymph node was positive, an axillary lymph node dissection was carried out.The pectoralis major muscle was retracted, and the fatty lymphatic tissue in the intermuscular space between the pectoralis major and minor was removed. The pectoralis minor muscle was retracted, and the clavicopectoral fascia was dissected to expose the axillary vein. The axillary lymphatic adipose tissue was carefully dissected along the axillary vein, ensuring precise protection of the long thoracic nerve, thoracodorsal nerve, and associated vessels. The lymphatic adipose tissue from axillary levels I and II was cleared. The ultrasound knife was used for precise hemostasis and sealing of lymphatic vessels, and the wound was irrigated with sterile injectable water.Immediate breast reconstruction was performed following EATM. Cefazolin sodium (2.0 g) was administered 30 minutes prior to surgery as prophylaxis. After completing the mastectomy, the surgeon changed gloves and disinfected the skin. The volume of the excised breast was measured using the drainage method, and the diameter of the prosthesis was measured to determine the base width, ensuring proper prosthesis selection. The patch and prosthesis were soaked in a cefazolin sodium saline solution (2 g in 500 mL) for 5 minutes. A 2-0 microjo suture was used to secure the patch around the prosthesis (Figure 1K). The prosthesis and patch were placed in the subpectoralis muscle on the affected side. The lateral patch was sutured to the serratus anterior muscle to prevent lateral displacement of the prosthesis. The shape of both breasts was adjusted to achieve basic symmetry (Figure 1L).A chest wall drain and an axillary drain were placed on the medial and lateral chest walls of the implant and fixed with continuous vacuum suction. The incisions were precisely sutured. A dressing was applied to the incision, and a compression bandage was placed on the upper edge of the prosthesis and armpit to maintain the shape. If the procedure lasted longer than 3 hours, additional cefazolin sodium (2.0 g) was given to prevent infection.Patients in the breast reconstruction group received 2.0 g of cefazolin sodium, administered twice daily (bid), for infection prophylaxis for two days after surgery.The patency of the chest wall and axillary drain was maintained with continuous negative pressure suction. The amount, color, and nature of the drainage fluid from the chest wall drain and axillary drain were observed and recorded daily. If the drainage volume was <20 mL over a 24-hour period for three consecutive days, the drainage tubes were removed.When changing the dressing, careful attention was paid to the blood circulation of the NAC and the healing status of the incision to prevent ischemia and necrosis of the NAC as well as incision infection. Postoperatively, patients were advised to minimize limb activity and gradually strengthen the function of the affected upper limb over the course of two weeks. A post-mastectomy compression garment was worn for up to three months to help maintain the shape of the reconstructed breast. Subsequent treatment plans were determined based on the results of postoperative pathological and immunohistochemical examinations [24].The relevant outcome measures defined by these parameters would comprehensively assess the surgical outcomes, patient satisfaction, and recovery trajectory associated with the various surgical methods used in this study.Comprehensive patient data were extracted from the hospital's electronic medical records. The data included duration of surgery, intraoperative bleeding, surgical incision length, duration with chest wall drain, duration with axillary drain, days in hospital, surgical cost, reconstruction time, and breast weight for both groups.Duration of surgery was defined as the total duration from skin incision to the completion of wound dressing. Days in hospital were defined as the time from the day of surgery to the day of discharge.The Breast-Q 2.0, a validated tool, was used to assess patient-reported aesthetic outcomes. Follow-up was conducted via in-hospital questionnaires or phone interviews at 1 month and 3 months post-surgery to collect information on postoperative recovery, complications, and breast condition. The Breast-Q 2.0 evaluated patient satisfaction with their breasts at three time points: preoperative, 1 month postoperative, and 3 months postoperative.Additionally, the tool evaluated satisfaction in other areas, including sexual life, psychosocial well-being, chest physical health, and abdominal physical health. The Scar-Q scale was also utilized at 1 month and 3 months postoperative to assess patient satisfaction with the appearance of scars.Timing: The Breast-Q and Scar-Q questionnaires were administered at three specific time points: preoperatively, 1 month postoperatively, and 3 months postoperatively. Breast-Q Domains: We specified that the study evaluated the following core domains from the Breast-Q Reconstruction module: Psychosocial Well-being; Sexual Well-being; Physical Well-being (Chest); Satisfaction with Breasts; Physical Well-being (Abdomen). Scar-Q Domain: The Scar-Q was used specifically to assess satisfaction with scar appearance.Data were analyzed using SPSS 26.0. Continuous variables were expressed as mean ± SD or median (IQR) and compared via t-test or Mann-Whitney U test.Categorical variables were analyzed by χ² or Fisher's exact test. The significance threshold was set at P < 0.05.This study strictly adhered to medical ethical standards and was approved by the Ethics Committee of Fuzhou University Affiliated Provincial Hospital. The research was conducted in full accordance with the principles outlined in the Declaration of Helsinki (2013 revision). Written informed consent was obtained from all enrolled patients or their authorized family members.The study enrolled 213 patients, categorized into radical surgery cohorts (Groups A/B: n = 174) and reconstruction cohorts (Groups C/D: n = 39). Demographic and clinical characteristics demonstrated comparability across all groups (Table 1). 2 illustrates the chest wall morphology of two representative patients at six months postoperatively following EATM with IBR.All procedures were completed successfully, with no cases requiring conversion to open surgery in Groups B and D.Patients in Group A exhibited a longer duration of surgery compared to Group B (Figure 3A, P < 0.05). However, Group A demonstrated superior outcomes in terms of intraoperative bleeding, surgical incision length, duration with chest wall drain, duration with axillary drain, and days in hospital (Figure 3B-F, P < 0.05).The duration of surgery was prolonged in Group D relative to Group C (Figure 3H, P < 0.05). Notably, Group D achieved favorable results in breast tissue mass preservation, minimized incision length, expedited drain removal, and reduced postoperative hospital stay (Figure 3J-M, P < 0.05). No statistically significant differences were observed between the groups in reconstruction duration or blood loss (Figure 3I, P > 0.05).Group A experienced 9 postoperative adverse events: 3 cases of postoperative hemorrhage, 3 cases of subcutaneous seroma following drain removal, 1 case of surgical site infection, and 2 cases of upper limb thrombosis. In contrast, Group B 2 of postoperative hemorrhage, 1 case of limb and 1 case of subcutaneous No surgical site or were in Group Group a case of infection to prolonged drain Group D exhibited 3 1 case of subcutaneous and 2 cases of infection. The included infection to and due to drain prosthetic were with and surgical preservation of the breast Breast-Q for psychosocial well-being, sexual satisfaction, chest physical well-being, breast appearance satisfaction, and abdominal physical well-being demonstrated no significant differences between cohorts C and D (Figure P > 0.05). the postoperative both groups exhibited reduced Breast-Q compared to However, Group D achieved significantly than Group C in psychosocial well-being, sexual satisfaction, chest physical well-being, and breast appearance satisfaction (Figure P < 0.05). 3 months postoperatively, for all domains well-being, sexual satisfaction, chest physical well-being, and breast appearance both preoperative and postoperative levels in both Group D maintained statistically superior satisfaction relative to Group C < abdominal physical well-being satisfaction between groups (Figure P > 0.05). Scar-Q significantly scar appearance satisfaction in Group D compared to Group C at both and postoperative < the radical surgery the mean total for Group A was Group B a mean of the reconstruction Group C demonstrated a mean of compared to for Group procedures were associated with significantly relative to surgical in both cohorts (Figure P < a on This a to the of single-incision endoscope-assisted patients underwent for No significant differences were observed in patient-reported satisfaction for bilateral breast symmetry or NAC the study case of nipple and three cases of distant across both radical and reconstruction strictly adhered to nipple-sparing mastectomy with intraoperative in three NAC that EATM achieved and to open surgery, their cancer remains the most prevalent malignancy women globally, with rising in is in comprehensive breast cancer The of minimally invasive and oncoplastic techniques has options, both oncologic and quality-of-life outcomes Conventional often visible breast which psychosocial well-being In contrast, EATM combined with IBR concealed incisions and aesthetic outcomes without oncologic efficacy skin tissue of the breast not to the of breast The residual of the breast is the of of breast cancer preservation of the skin and complex not the rate of or distant of the for tissue to the significantly reducing muscle and tissue and while improving postoperative and patient satisfaction the continuous of in EATM with IBR, an of to be and evaluated in to and the of this this reviewed 213 breast cancer patients who underwent EATM CTM with IBR and EATM with IBR the and associated with The results that EATM or without longer operative time compared to This was to patient endoscope and the for during their initial of the As surgical the for EATM the operative time of undergoing EATM or without demonstrated significantly reduced intraoperative bleeding, incision length, drain removal, hospital and duration with chest wall and axillary < 0.05). The of seroma and infection observed in in the EATM were lower than in larger We that this be to the of endoscopic hemostasis, a and drain and the of a patient without major The of the endoscopic technique a significant additional of approximately case combined with IBR, to the of single-port This represents a to its and be the demonstrated in aesthetic outcome and patient axillary single-port endoscope approach the surgical incision from the anterior chest to the on the breast surface that could lead to scar or incision This technique also on the incision, reducing the of wound implant or loss The axillary incision to be a and access not for the mastectomy and reconstruction also for a oncologic ALND required, additional on the breast or chest The endoscope and of and and intraoperative and drain removal and as nipple subcutaneous infection, and in a of their and endoscope The of preserving the NAC is on patient and intraoperative of negative to a of evidence that in as in cohort with tumors than 2 cm from the nipple and without skin not to a of or outcomes compared to other mastectomy It is the residual in the breast than the skin or NAC that is the of provided the NAC is of by is used to assess breast reconstruction outcomes across domains including psychosocial health, sexual satisfaction, chest and abdominal physical well-being, and aesthetic satisfaction that breast surface incisions and chest wall morphology patient satisfaction with breast and psychological However, EATM with IBR has not a approach due to high implant and surgical the of a of while the and cohort the and of the the median of months of and this study to the feasibility of the technique and than to combined with IBR or represents an surgical for breast cancer This approach demonstrated in operative and aesthetic outcomes scar while postoperative of and patient support its clinical as a for patients both and cosmetic Group A total mastectomy, Group B total mastectomy, Group C total mastectomy with immediate breast reconstruction, CTM with and Group D total mastectomy endoscope with immediate breast reconstruction, EATM with
Source: Frontiers in Oncology
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $3,801
OpenAlex ID: W7126191127
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