Single-incision robotic nipple-sparing mastectomy with immediate breast reconstruction: a comprehensive surgical technique and strategy

Introduction

Breast cancer is the most common malignancy among women worldwide (1). In China, it is the second most frequently diagnosed cancer among females, accounting for approximately 18.4% of global breast cancer cases (2). Notably, the incidence rate of breast cancer in China is increasing at twice the global average, with a significant trend of younger age at diagnosis (3,4). The breast, as a vital component of female identity and self-esteem, plays a crucial role in women’s psychological well-being. Breast surgical treatment that maintains physical aesthetics is closely associated with patients’ quality of life and represents one of the fundamental objectives in modern breast cancer management. As the cornerstone of comprehensive breast cancer treatment, surgical approaches have evolved from focusing on extensive resection to the emphasizing minimally invasive and effective techniques. The current surgical idea aims to enhance postoperative aesthetic outcomes and quality of life while ensuring oncological safety (5,6).

Minimally invasive surgery has become the mainstream of modern surgical practice, with endoscopic and robotic techniques deeply integrated into the surgical management of breast tumors (7,8). Conventional nipple-sparing mastectomy (C-NSM) with immediate breast reconstruction (IBR) has undergone significant innovation, leading to the widespread adoption of endoscopic NSM (E-NSM) and robotic NSM (R-NSM) with IBR (9). Minimally invasive NSM (MI-NSM) accomplishes all surgical procedures through inconspicuous small incisions while maintaining the equivalent resection scope to C-NSM. This approach results in reduced postoperative pain, superior aesthetic outcomes with scar-free breast skin, ultimately improving patient satisfaction and quality of life. Furthermore, MI-NSM demonstrates lower postoperative complication rates, particularly a significant reduction in nipple-areola complex (NAC) necrosis, along with faster wound healing (7,10-12).

The robotic surgical systems have further advanced minimally invasive breast surgery by providing high-definition, three-dimensional magnified visualization and highly flexible robotic arms capable of 540° rotation (13,14). These features enable extensive surgical procedures through small incisions, overcoming the spatial constraints of narrow surgical fields and addressing various technical challenges associated with endoscopic surgery (15,16). Studies have demonstrated that R-NSM is a safe and feasible approach (9,11,17). Compared to E-NSM, R-NSM is associated with reduced intraoperative blood loss, higher patient satisfaction with surgical incisions, and a significantly shorter learning curve, estimated at 10–15 procedures (7,9,18,19). However, as robotic breast surgery is still in its early stages, the availability of robotic surgical systems is currently limited to a select number of large-scale medical institutions. Moreover, the standardized and systematic surgical protocols for robotic breast surgery have not yet been fully established, which may impact the reproducibility and safety of surgical outcomes across different institutions (13,20). Here, we provide a detailed and comprehensive description of the surgical procedure for single-incision R-NSM with IBR through a case report video (Video 1) and accompanying text. This includes critical surgical techniques, strategic considerations, and key technical points, aiming to contribute to the establishment of standardized and systematic surgical protocols. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-151/rc).

Preoperative preparations and requirements

The patient underwent the surgical procedure at The Sixth Affiliated Hospital, Sun Yat-sen University using the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). The surgical team consisted of one surgeon, two assistants, one anesthetist, one scrub nurse, and one circulating nurse. All procedures performed in this study were in accordance with the ethical standards of the ethics committee of The Sixth Affiliated Hospital, Sun Yat-sen University and with the provisions of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

The patient underwent physical examination, breast ultrasound, mammography, and magnetic resonance imaging to evaluate the breast and axillary conditions. Liver ultrasound, chest computed tomography (CT), and head CT were performed to assess distant metastases. The inclusion criteria for single-incision R-NSM with IBR were early-stage breast cancer with a tumor diameter <5 cm and no multiple lymph node metastases; breast size ≤ C cup with no severe ptosis; patients with high aesthetic demands who voluntarily opted for single-incision R-NSM with IBR; and prophylactic mastectomy. Exclusion criteria included tumor invasion of the NAC, skin, or chest wall; inflammatory breast cancer; and poor systemic conditions rendering the patient unable to tolerate surgery (12,18,21).

Step-by-step description

The patient was a 42-year-old female patient with a body mass index of 23.15 kg/m². Ultrasound examination revealed multiple solid nodules in the right breast, including a hypoechoic lesion at the 1–2 o’clock position measuring up to 25 mm, which was classified as Breast Imaging Reporting and Data System (BI-RADS) category 6. CT scan revealed a nodule in the upper inner quadrant of the right breast, with a suspected malignancy. The lesion was classified as BI-RADS category 6. No abnormal lymphadenopathy was observed in the axilla. Pathological examination of the core needle biopsy confirmed ductal carcinoma in situ. Preoperative evaluation excluded distant metastasis. She had no history of smoking nor alcohol consumption and was deemed suitable for general anesthesia and surgery. The images and video are solely for academic and educational purposes.

Step 1: preoperative surgical planning

The patient was positioned standing with hands on the hips, head held high, gaze directed forward, and feet shoulder-width apart. The surgeon should mark the projected location of the mass on the breast skin, clearly delineate the anatomical boundaries of the breast and the planned resection margins (Figure 1).

Figure 1 Preoperative drawings. (A) The image shows the frontal view of the preoperative breast appearance and preoperative drawings; (B) The image shows the lateral view of the preoperative breast appearance and preoperative drawings.

Step 2: anesthesia and positioning

After inducing general anesthesia and performing tracheal intubation, the patient was positioned in the supine position with the affected side adjacent to the edge of the operating table. Elevate the affected side using appropriate padding and maintain the ipsilateral upper extremity in 90° abduction. Sterilize the surgical site with povidone-iodine skin disinfectant, then wrap the upper extremity with sterile drapes and secure it in 90° abduction.

Step 3: sentinel lymph node biopsy (SLNB)

Prepare the sentinel lymph node tracer by aspirating a 1:1 mixture of carbon nanoparticles and saline into a 1 mL syringe. Inject the tracer into three distinct sites within the parenchyma of the outer upper quadrant of the breast. Following injection, perform gentle massage of the area for 5 minutes, then allow an additional 5 minutes for tracer distribution prior to proceeding with the surgical procedure. The SLNB was conducted through a curvilinear incision of approximately 5 cm along the posterior border of the pectoralis major muscle, following the natural transverse fold of the axillary skin. The anterior margin of the incision was carefully maintained within the anterior axillary line, with the option for controlled posterior extension when additional surgical exposure and access were necessary. The intraoperative frozen section analysis confirmed a negative SLNB.

Step 4: establishment of working space and docking

Identify the lateral border of the pectoralis major muscle through the axillary incision, and then the subpectoral, retromammary, and premammary spaces were carefully developed by 3 cm. The glandular tissue was sutured to the skin using silk sutures, while the pectoralis major fascia was closed to the skin with 3-0 Vicryl sutures. The pre-establishment of three well-defined surgical planes significantly enhanced operative efficiency and reduced robotic system setup time. During transitions between surgical planes, the color-coded sutures were selectively released in accordance with the predetermined surgical sequence, ensuring precise surgical exposure.

The wound protector was inserted into the axillary incision and connected to the four-channel unit port. To establish the air cavity, the inferior channel was attached to a constant-pressure insufflation device for CO₂ insufflation, with the gas pressure set at 8 mmHg and an airflow rate maintained at 40 L/min. The robotic arms were positioned with an inter-arm distance of 5–10 cm, with fenestrated bipolar forceps mounted on Arm 2, the 30° endoscope on Arm 3, and monopolar curved scissors on Arm 4. These arms were assigned to specific channels: Arm 2 to the left-sided channel, Arm 3 to the superior channel, and Arm 4 to the right-sided channel. In most cases, the patient’s external position remains unchanged, as maintaining the upper extremity on the operative side abducted at 90° sufficiently accommodates the robotic arms’ movement requirements. However, under specific surgical circumstances, the upper extremity may be temporarily elevated and positioned above the head as dictated by the surgical needs.

Step 5: subpectoral space dissection

Upon entering the subpectoral space, the loose connective tissue between the pectoralis major and minor muscles was dissected using monopolar curved scissors. When reaching the origin of the pectoralis major, the tendinous attachments to the costal cartilage were divided. The dissection extended inferiorly to 1.5 cm below the inframammary fold, medially to 1 cm from the parasternal line, superiorly to the upper border of the fourth rib, and laterally to the anterior axillary line. We recommend dividing the pectoralis major muscle at a distance of 0.3–0.5 cm from its origin to avoid hemostatic challenges caused by perforator vessels bleeding and to preserve a small portion of muscle to cover the lower pole of the implant, which is considered a “defensive strategy”. During dissection, careful attention should be given to protecting the perforating vessels between the pectoralis major and minor muscles to prevent thermal injury from hemostasis and to reduce the risk of muscle atrophy. Additionally, maximal preservation of the intercostal nerves, particularly the anterior and lateral cutaneous branches, is essential for maintaining postoperative sensation in the NAC and skin (22).

Step 6: retromammary space dissection

The assistant cut the purple Vicryl sutures securing the pectoralis major fascia to the skin and gently adjusted the wound protector to expose the retromammary space over the surface of the pectoralis major. Using monopolar curved scissor, the loose connective tissue within the retromammary space was dissected, with division of the lateral suspensory ligament, horizontal septum, and medial suspensory ligament until the circum-mammary ligament was identified and divided (23,24). Following the division of the circum-mammary ligament, the surrounding breast tissue visibly descended, while the glandular tissue posterior to the NAC remained relatively fixed, creating a “tenting effect”. The key to this step is ensuring dissection along the correct surgical plane. With the assistance of insufflated gas, the Cooper ligaments can be visualized within the retromammary space between the deep layer of the superficial fascia and the superficial layer of the deep fascia. Using the Cooper ligaments as anatomical guides during meticulous dissection helps preserve the vascular structures within these fascial layers.

Step 7: premammary space dissection

Subsequently, the assistant cut the black silk sutures connecting the glandular tissue to the skin and adjusted the wound protector to expose the premammary space over the glandular surface. The surgeon, operating from the console, performed the dissection using monopolar curved scissors, following a general sequence: superior-lateral, superior-medial, inferior-lateral, and inferior-medial, with the area posterior to the NAC addressed last. During the dissection of the premammary space, fenestrated bipolar forceps were used to grasp the glandular tissue, maintaining appropriate tension. Given the lack of haptic feedback in the robotic system, the surgeon must rely on the degree of tissue separation to gauge the appropriate force. For surgical safety, gentle traction near the dissection point is recommended. The dissection of the premammary space represents the most challenging step of the procedure. The key strategy here is the accurate identification of the Cooper ligaments, which traverse the breast, anchoring it anteriorly to the skin and posteriorly to the pectoral fascia (25). Dissection should be performed along the Cooper ligaments, specifically between the superficial layer of the superficial fascia and the anterior lamella fat, using monopolar curved scissors. This approach ensures complete glandular removal while preserving the subdermal vascular and lymphatic networks.

Following complete or near-complete dissection of the premammary space, special attention must be given to the area posterior to the NAC. Because of the turning point of the superficial fascia behind the NAC, it lacks subcutaneous fat and loose connective tissue (26). Therefore, the surgeon should use blunt dissection with non-energy instruments to carefully separate the base of the nipple. Fenestrated bipolar forceps were employed to maintain tissue tension, while the base of the nipple was carefully severed with small cuts using monopolar curved scissors to minimize the risk of NAC ischemia and necrosis associated with thermal injury from energy devices. Throughout the dissection, careful observation and preservation of the areolar venous plexus (of Haller), are crucial to maintaining the blood supply to the NAC (27). Subsequently, tissues from the base of the nipple were excised and sent for intraoperative frozen section analysis. If tumor involvement is detected, NAC removal and subsequent reconstruction will be necessary. Upon completing all steps of the single-incision R-NSM, the breast specimen should remain intact and be removed through the wound protector.

Step 8: irrigation, drainage, and IBR

Irrigate the surgical cavity with 3,000 mL of warm sterile distilled water. Then, the implant pocket was soaked with 0.45–0.55% povidone-iodine solution for 10 minutes, followed by another irrigation with warm distilled water. A drainage tube was placed in both the superior and inferior aspects of the subcutaneous layer, with each tube connected to negative pressure suction.

Gloves should be changed before handling the implant. The implant was immersed in povidone-iodine for 10 minutes and then irrigated with sterile distilled water. Typically, mesh is not required for subpectoral reconstruction. Using an S-shaped retractor to expose the axillary incision and pectoralis major muscle, the implant was inserted into the subpectoral pocket and adjusted to the optimal position, with the upper portion positioned behind the pectoralis major and the lower portion behind the pectoralis major fascia. If necessary, the pectoralis major and minor muscles are sutured at the superior border of the implant to prevent upward displacement. The lateral borders of the pectoralis major and minor muscles were then sutured using 3-0 Vicryl to securely close the implant pocket. Finally, the subcutaneous tissue and skin were sutured in layers, thereby completing the surgical procedure.

Postoperative considerations and tasks

The breast and axilla were dressed with elastic bandages under appropriate pressure, taking care to avoid compression of the NAC. Prophylactic antibiotics were administered for 24 hours. Subsequently, the patient began to wear a pressure garment 24 hours after surgery (28). For the first three postoperative days, the shoulder joint on the affected side should be immobilized, avoiding abduction of the upper extremity. The volume and characteristics of the drainage were closely monitored and recorded. The drainage tube was considered for removal when the daily drainage volume consistently remained below 30 mL for three consecutive days. Special attention should be given to the blood supply to the NAC, with nitroglycerin applied to the NAC as needed to enhance perfusion. The total operative time for the patient was 190 minutes, with a console time of 80 minutes. Intraoperative blood loss was 20 mL. The patient experienced no postoperative complications. Postoperative routine pathology confirmed invasive breast cancer, with associated ductal carcinoma in situ (approximately 80%). No cancer invasion was observed at the peripheral margins or the base of the nipple. The patient was scheduled to receive standard adjuvant therapy in accordance with current guidelines. Follow-up evaluations were conducted at 1, 3, and 6 months postoperatively, followed by annual assessments thereafter.

Tips and pearls

During the robotic surgical procedure, the surgeon, positioned at the console, depends mainly on their comprehensive understanding and precise identification of anatomical structures to accurately determine the surgical resection margins, which is crucial for achieving optimal oncological and aesthetic outcomes. Consequently, a comprehensive knowledge of breast fascial anatomy is essential. For beginners, assistance can be provided by having the assistant apply pressure to the breast for localization or by preoperatively marking the resection margins with methylene blue (6,14).

Discussion

This video provides a detailed overview of all steps involved in single-incision R-NSM with IBR. The patient reported satisfaction with the aesthetic outcomes following surgery (Figure 2).

Figure 2 Postoperative outcomes. (A) The image shows the frontal view of the breast appearance at 7 days after surgery. (B) The image shows the lateral view of the breast appearance at 7 days after surgery.

Minimally invasive surgery is a key focus and area of innovation in modern surgical practice. E-NSM has been proven to provide reliable oncologic safety, improve patient satisfaction and postoperative aesthetic outcomes (9,10,29,30). It offers advantages such as smaller and more inconspicuous incisions, reduced complication rates, and particularly lower rates of NAC ischemia/necrosis (9,15,30). However, the two-dimensional endoscopic in-line camera generates an inconsistent optical window around the curvature of the breast skin flap with insufficient dissection angles (15,16). Additionally, surgeons must work with long instruments while viewing a screen with reduced haptic feedback, which diminishes fine motor control and complicates hand-eye coordination (31). These challenges are further compounded by the “chopstick effect” inherent to the single-port technique. These limitations have prevented E-NSM from gaining widespread global acceptance, with its implementation primarily concentrated in Asia (18). However, the robotic surgical system, featuring three-dimensional visualization, highly flexible robotic arms and instruments, and ergonomic and intuitive hand movements, has effectively overcome these limitations, making it well-suited for procedures in confined surgical spaces (13,32,33). In recent years, R-NSM has gained widespread recognition and adoption worldwide, contributing to advancements in minimally invasive breast surgery (5). This trend may be attributed to the shortened learning curve associated with the robotic approach (18,19).

Our technique differs from those previously reported in the literature. The single-incision gas inflation method is the most frequently used technique, with the incision typically located in the axilla or the lateral chest wall (14,21,34,35). We propose that a single axillary incision can accommodate all surgical procedures, including SLNB, potentially reducing postoperative pain and shortening recovery time. Additionally, compared to other populations, Asian individuals have a higher risk of developing hypertrophic scars following skin injury. Consequently, an incision hidden within the axilla is favored due to its superior aesthetic outcomes (36,37). Our previous study comparing axillary and lateral chest wall approaches in single-port E-NSM demonstrated that the lateral chest wall approach resulted in a shorter operative time and learning curve. Compared to the axillary approach, the lateral chest wall approach runs parallel to the breast without forming an angle, providing a greater range of instrument movement, wider visualization, and shorter optical working distance (38). These factors facilitate the surgeon’s operation and enhance the assistant’s control of the endoscopic camera. Current literature indicates that single-incision R-NSM achieves high patient satisfaction and good aesthetic outcomes regardless of incision location (5,9,14). However, no studies have directly compared the impact of incision location on surgical outcomes. During the procedure, maintaining the patient’s upper extremity in 90° abduction is sufficient to meet surgical requirements without restricting the movement of the robotic arms. Prolonged positioning of the upper extremity above the head may increase the risk of brachial plexus injury. In terms of surgical sequence, we adopt a “deep-to-superficial” approach. Compared to the “superficial-to-deep” dissection sequence, this technique effectively leverages gas tension to create a tent-like elevation of the breast tissue, thereby providing an adequate working space for subpectoral and retromammary space dissection (6,39). Initiating dissection in the premammary space first causes the mammary gland to descend due to gravity, which can obstruct the surgical field, limit the working space, and ultimately increase the difficulty of the dissection (32,39,40).

NAC ischemia/necrosis represents the most common and concerning complication, and its prevention is crucial for the success of NSM with IBR, directly impacting patient satisfaction and postoperative aesthetic outcomes (9,41). The primary factor influencing NAC ischemia/necrosis is its blood supply. Wuringer et al. first introduced the concept of the horizontal septum, which originates from the pectoral fascia at the level of the fifth rib and accompanies the major vessels and nerves supplying the breast and NAC (22). As a key component of the breast fascial system, the horizontal septum primarily functions to provide fascial support for the breast’s vascular supply, innervation, and glandular tissue (42). However, NSM inevitably disrupts the horizontal septum, leaving the NAC’s postoperative blood supply predominantly dependent on the subdermal vascular network formed by the perforating branches of the internal thoracic artery and the branches of the lateral thoracic artery, which run along the medial and lateral suspensory ligaments, respectively (22,43). The aforementioned surgical techniques and strategies have a positive impact on reducing NAC ischemia/necrosis. First, the axillary incision avoids any incisions around the NAC or on the breast skin, thereby reducing the risk of disruption to the subdermal vascular network. Second, the theory of breast fascial anatomy guides the surgeon in accurately identifying the anatomical layers and surgical resection margins (23). During the procedure, we employ a “defensive strategy”. In the dissection of the retromammary space, every effort is undertaken to preserve identifiable neurovascular bundles whenever possible, with proactive identification and management of potential bleeding sites. During the dissection of the premammary space, particular emphasis is placed on preserving the subdermal vascular network, lymphatic network, and venous plexus of Haller. The robotic surgical system excels in this regard, aiding the surgeon in better identifying anatomical structures and performing precise surgery. Additionally, researchers have utilized indocyanine green fluorescence imaging to evaluate NAC perfusion preoperatively, classifying it into three distinct patterns: predominantly derived from the underlying breast tissue (V1), the subdermal vascular network (V2), or a combination of V1 and V2 (V3). The findings showed that the V1 perfusion pattern had the highest rate of NAC ischemia/necrosis (44). Therefore, preoperative assessment of NAC perfusion patterns can provide valuable guidance for surgical planning and contribute to reducing the incidence of NAC ischemia/necrosis.

This study has several limitations that should be acknowledged. One of the primary limitations of R-NSM is its higher cost. A prospective study by Lai et al. demonstrated that the overall medical costs of R-NSM were approximately 4,000 USDs higher than those of C-NSM and 2,600 USDs more than E-NSM, significantly limiting its widespread adoption (9). Furthermore, R-NSM is associated with prolonged operative times, which may increase anesthesia-related risks and the incidence of perioperative complications (9,45). Importantly, as an emerging surgical technique, R-NSM is currently supported by limited follow-up duration and oncological data, and there is a lack of robust evidence confirming its long-term oncological safety (20). Therefore, large-scale, high-quality studies are needed to further evaluate its safety and feasibility. Although this paper provides a detailed introduction to the surgical technique of single-incision R-NSM with IBR, it remains a descriptive technical report based on a single case. We plan to continue collecting data from a larger patient cohort to obtain more comprehensive outcome data in the future.

Conclusions

The paper and video provide a step-by-step introduction to the surgical techniques, strategies, and key considerations of single-incision R-NSM with IBR. This resource may serve as an instructive reference for both beginners and peers in the field and facilitate the development of standardized and systematic surgical protocols.

Acknowledgments

This work was supported by National Key Clinical Discipline.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-151/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-151/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-151/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the ethics committee of The Sixth Affiliated Hospital, Sun Yat-sen University and with the provisions of the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021;71:209-49. [Crossref] [PubMed]
2. Lei S, Zheng R, Zhang S, et al. Global patterns of breast cancer incidence and mortality: A population-based cancer registry data analysis from 2000 to 2020. Cancer Commun (Lond) 2021;41:1183-94. [Crossref] [PubMed]
3. Guo R, Si J, Xue J, et al. Changing patterns and survival improvements of young breast cancer in China and SEER database, 1999-2017. Chin J Cancer Res 2019;31:653-62. [Crossref] [PubMed]
4. Yang Y, Liu J, Peng M, et al. Introduction of a multicenter online database for non-metastatic breast cancer in China. Sci China Life Sci 2020;63:1417-20. [Crossref] [PubMed]
5. Selber JC. Robotic Nipple-Sparing Mastectomy: The Next Step in the Evolution of Minimally Invasive Breast Surgery. Ann Surg Oncol 2019;26:10-1. [Crossref] [PubMed]
6. Huang Z, Li Z, Zhong X, et al. Endoscopic Bilateral Nipple-sparing Mastectomy via a Single Axillary Incision with Immediate Pre-pectoral Implant-based Breast Reconstruction. J Vis Exp 2024;
7. Lai HW, Chen ST, Tai CM, et al. Robotic- Versus Endoscopic-Assisted Nipple-Sparing Mastectomy with Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Case-Control Comparison Study with Analysis of Clinical Outcomes, Learning Curve, Patient-Reported Aesthetic Results, and Medical Cost. Ann Surg Oncol 2020;27:2255-68. [Crossref] [PubMed]
8. Bishop SN, Selber JC. Minimally invasive robotic breast reconstruction surgery. Gland Surg 2021;10:469-78. [Crossref] [PubMed]
9. Lai HW, Chen DR, Liu LC, et al. Robotic Versus Conventional or Endoscopic-assisted Nipple-sparing Mastectomy and Immediate Prosthesis Breast Reconstruction in the Management of Breast Cancer: A Prospectively Designed Multicenter Trial Comparing Clinical Outcomes, Medical Cost, and Patient-reported Outcomes (RCENSM-P). Ann Surg 2024;279:138-46. [Crossref] [PubMed]
10. Kim JH, Ryu JM, Bae SJ, et al. Minimal Access vs Conventional Nipple-Sparing Mastectomy. JAMA Surg 2024;159:1177-86. [Crossref] [PubMed]
11. Toesca A, Sangalli C, Maisonneuve P, et al. A Randomized Trial of Robotic Mastectomy Versus Open Surgery in Women With Breast Cancer or BrCA Mutation. Ann Surg 2022;276:11-9. [Crossref] [PubMed]
12. Sarfati B, Struk S, Leymarie N, et al. Robotic Prophylactic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: A Prospective Study. Ann Surg Oncol 2018;25:2579-86. [Crossref] [PubMed]
13. Chen K, Zhang J, Beeraka NM, et al. Robot-Assisted Minimally Invasive Breast Surgery: Recent Evidence with Comparative Clinical Outcomes. J Clin Med 2022;11:1827. [Crossref] [PubMed]
14. Lai HW, Chen ST, Lin SL, et al. Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction with Gel Implant: Technique, Preliminary Results and Patient-Reported Cosmetic Outcome. Ann Surg Oncol 2019;26:42-52. [Crossref] [PubMed]
15. Lai HW, Lin SL, Chen ST, et al. Single-Axillary-Incision Endoscopic-Assisted Hybrid Technique for Nipple-Sparing Mastectomy: Technique, Preliminary Results, and Patient-Reported Cosmetic Outcome from Preliminary 50 Procedures. Ann Surg Oncol 2018;25:1340-9. [Crossref] [PubMed]
16. Sakamoto N, Fukuma E, Higa K, et al. Early results of an endoscopic nipple-sparing mastectomy for breast cancer. Ann Surg Oncol 2009;16:3406-13. [Crossref] [PubMed]
17. Farr DE, Haddock NT, Tellez J, et al. Safety and Feasibility of Single-Port Robotic-Assisted Nipple-Sparing Mastectomy. JAMA Surg 2024;159:269-76. [Crossref] [PubMed]
18. Ryu JM, Kim JY, Choi HJ, et al. Robot-assisted Nipple-sparing Mastectomy With Immediate Breast Reconstruction: An initial Experience of the Korea Robot-endoscopy Minimal Access Breast Surgery Study Group (KoREa-BSG). Ann Surg 2022;275:985-91. [Crossref] [PubMed]
19. Lai HW, Wang CC, Lai YC, et al. The learning curve of robotic nipple sparing mastectomy for breast cancer: An analysis of consecutive 39 procedures with cumulative sum plot. Eur J Surg Oncol 2019;45:125-33. [Crossref] [PubMed]
20. Rizk M, Mokbel K. The role of robot-assisted mastectomy: promise, challenges, and evidence gaps. Gland Surg 2025;14:579-83. [Crossref] [PubMed]
21. Lai HW, Toesca A, Sarfati B, et al. Consensus Statement on Robotic Mastectomy-Expert Panel From International Endoscopic and Robotic Breast Surgery Symposium (IERBS) 2019. Ann Surg 2020;271:1005-12. [Crossref] [PubMed]
22. Würinger E, Mader N, Posch E, et al. Nerve and vessel supplying ligamentous suspension of the mammary gland. Plast Reconstr Surg 1998;101:1486-93. [Crossref] [PubMed]
23. Rehnke RD, Groening RM, Van Buskirk ER, et al. Anatomy of the Superficial Fascia System of the Breast: A Comprehensive Theory of Breast Fascial Anatomy. Plast Reconstr Surg 2018;142:1135-44. [Crossref] [PubMed]
24. Matousek SA, Corlett RJ, Ashton MW. Understanding the fascial supporting network of the breast: key ligamentous structures in breast augmentation and a proposed system of nomenclature. Plast Reconstr Surg 2014;133:273-81. [Crossref] [PubMed]
25. Duncan AM, Al Youha S, Joukhadar N, et al. Anatomy of the Breast Fascial System: A Systematic Review of the Literature. Plast Reconstr Surg 2022;149:28-40. [Crossref] [PubMed]
26. Komiya T, Ito N, Imai R, et al. Anatomy of the superficial layer of superficial fascia around the nipple-areola complex. Aesthetic Plast Surg 2015;39:209-13. [Crossref] [PubMed]
27. Zucca-Matthes G, Urban C, Vallejo A. Anatomy of the nipple and breast ducts. Gland Surg 2016;5:32-6. [Crossref] [PubMed]
28. Shang F, Zhao Z, Li Z, et al. The combination of endoscopic subcutaneous mastectomy and liposuction (Liu and Shang's 2-hole 7-step method) as the treatment of gynecomastia. Surgery 2023;174:159-65. [Crossref] [PubMed]
29. Mok CW, Lai HW. Endoscopic-assisted surgery in the management of breast cancer: 20 years review of trend, techniques and outcomes. Breast 2019;46:144-56. [Crossref] [PubMed]
30. Wan A, Liang Y, Chen L, et al. Association of Long-term Oncologic Prognosis With Minimal Access Breast Surgery vs Conventional Breast Surgery. JAMA Surg 2022;157:e224711. [Crossref] [PubMed]
31. Chen CC, Falcone T. Robotic gynecologic surgery: past, present, and future. Clin Obstet Gynecol 2009;52:335-43. [Crossref] [PubMed]
32. Toesca A, Peradze N, Manconi A, et al. Robotic nipple-sparing mastectomy for the treatment of breast cancer: Feasibility and safety study. Breast 2017;31:51-6. [Crossref] [PubMed]
33. Leal Ghezzi T, Campos Corleta O. 30 Years of Robotic Surgery. World J Surg 2016;40:2550-7. [Crossref] [PubMed]
34. Toesca A, Peradze N, Galimberti V, et al. Robotic Nipple-sparing Mastectomy and Immediate Breast Reconstruction With Implant: First Report of Surgical Technique. Ann Surg 2017;266:e28-30. [Crossref] [PubMed]
35. Go J, Ahn JH, Park JM, et al. Analysis of robot-assisted nipple-sparing mastectomy using the da Vinci SP system. J Surg Oncol 2022;126:417-24. [Crossref] [PubMed]
36. Suga H, Shiraishi T, Takushima A. Scar Assessment After Breast Reconstruction: Risk Factors for Hypertrophy and Hyperpigmentation in Asian Patients. Ann Plast Surg 2020;85:229-32. [Crossref] [PubMed]
37. Sun J, Mu D, Liu C, et al. Scar Assessment After Breast Augmentation Surgery with Axillary Incision versus Inframammary Fold Incision: Long-Term Follow-Up in Chinese Patients. Aesthetic Plast Surg 2016;40:699-706. [Crossref] [PubMed]
38. Li Z, Li H. A comparison study on the camera assistance effect and learning curve of single-port endoscopic subcutaneous mastectomy through lateral chest wall and axillary approach. Chinese Journal of Practical Surgery 2024;44:1286-90.
39. Yang H, Liang F, Xie Y, et al. Single axillary incision reverse-order endoscopic nipple/skin-sparing mastectomy followed by subpectoral implant-based breast reconstruction: Technique, clinical outcomes, and aesthetic results from 88 preliminary procedures. Surgery 2023;174:464-72. [Crossref] [PubMed]
40. Sarfati B, Struk S, Leymarie N, et al. Robotic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: Surgical Technique. Plast Reconstr Surg 2018;142:624-7. [Crossref] [PubMed]
41. Carlson GW, Chu CK, Moyer HR, et al. Predictors of nipple ischemia after nipple sparing mastectomy. Breast J 2014;20:69-73. [Crossref] [PubMed]
42. Gaskin KM, Peoples GE, McGhee DE. The Attachments of the Breast to the Chest Wall: A Dissection Study. Plast Reconstr Surg 2020;146:11e-22e. [Crossref] [PubMed]
43. Hamdi M, Van Landuyt K, Tonnard P, et al. Septum-based mammaplasty: a surgical technique based on Würinger's septum for breast reduction. Plast Reconstr Surg 2009;123:443-54. [Crossref] [PubMed]
44. Wapnir I, Dua M, Kieryn A, et al. Intraoperative imaging of nipple perfusion patterns and ischemic complications in nipple-sparing mastectomies. Ann Surg Oncol 2014;21:100-6. [Crossref] [PubMed]
45. Nessa A, Shaikh S, Fuller M, et al. Postoperative complications and surgical outcomes of robotic versus conventional nipple-sparing mastectomy in breast cancer: meta-analysis. Br J Surg 2024;111:znad336. [Crossref] [PubMed]