Optimizing aesthetics in immediate breast reconstruction following robot-assisted mastectomy reconstruction: a narrative review focused on cosmetic outcomes

Introduction

Background

The landscape of breast cancer surgery has undergone stunning transformation over the past decades, evolving from radical mastectomies to increasingly conservative approaches that prioritize both oncologic outcomes and aesthetic preservation (1,2). This paradigm shift reflects not only good oncological outcome with less invasive surgeries, but also evolving patient expectations, where cosmetic outcomes have become as crucial as oncologic safety in determining treatment satisfaction and quality of life (3). The modern breast cancer patients seek treatment options that provide excellent oncologic control while preserving or restoring natural breast appearance, leading to increased demand for sophisticated mastectomy and reconstructive techniques.

The introduction of robot-assisted surgery represents the latest milestone in this evolution, offering unprecedented precision on mastectomy and cosmetic advantages of preserving the entire breast skin pocket and nipple-areolar complex (NAC) through minimally invasive techniques (4-7). Robot-assisted nipple-sparing mastectomy (R-NSM) has emerged as a groundbreaking approach that enables complete tumor extirpation through small lateral incisions, fundamentally changing the paradigm of breast reconstruction (8). The procedure begins with incorporation of implant-based reconstruction because of the limited incision (4,9). With time, the reconstruction was further advanced with autologous tissue reconstruction (10). The integration of robotic technology with immediate microsurgical reconstruction represents a convergence of oncologic safety and cosmetic excellence that was previously unattainable through conventional approaches (11). This synthesis has created new opportunities for achieving superior aesthetic outcomes while maintaining the highest standards of cancer care, effectively eliminating the historical trade-off between complete tumor removal and cosmetic preservation.

Rationale and knowledge gap

Despite the growing adoption of robot-assisted mastectomy and reconstruction techniques, comprehensive reviews specifically addressing aesthetic optimization strategies and surgical innovations in this rapidly evolving field remain limited. While individual studies have reported favorable outcomes, a synthesized analysis integrating technical considerations, aesthetic evaluation methodologies, and comparative outcomes data is needed to guide clinical practice and inform future research directions. Furthermore, the evolution from implant-based to autologous reconstruction in the robotic era, including modifications in flap design, recipient vessel selection, and innovative surgical techniques, requires comprehensive examination to establish best practices and optimize patient outcomes.

Objective

This narrative review aims to provide a comprehensive, evidence-based overview of immediate breast reconstruction following robot-assisted mastectomy, with particular emphasis on aesthetic optimization strategies. We synthesize contemporary literature with extensive institutional experience to analyze technical innovations, surgical strategies, and aesthetic outcomes that define current practice. Specific objectives include: (I) examining the historical development and technical evolution of robot-assisted mastectomy and reconstruction; (II) evaluating aesthetic outcomes through comparative analysis of robotic versus conventional approaches; (III) analyzing patient selection criteria and contraindications; (IV) assessing safety profiles and complication rates; and (V) reviewing learning curves and skill development considerations for clinical implementation. We present this article in accordance with the Narrative Review reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-458/rc).

Methods

Search strategy

A comprehensive literature search was performed to identify relevant publications on robot-assisted mastectomy and immediate breast reconstruction with emphasis on aesthetic outcomes. The search strategy summary is presented in Table 1.

Data synthesis

Data extracted from selected publications included study design, patient demographics, surgical techniques, reconstruction methods, aesthetic evaluation tools, complication rates, and learning curve analyses. Given the narrative nature of this review, formal quality assessment and meta-analysis were not performed. Instead, we synthesized the available evidence thematically, organizing findings by key topic areas including technical evolution, aesthetic outcomes, patient selection, safety analysis, and skill development. Institutional data from Chang Gung Memorial Hospital was integrated throughout to illustrate technical innovations and provide real-world clinical context for the evolving practice patterns in reconstruction following robot-assisted mastectomy.

Historical development and technical evolution

The development of robot-assisted mastectomy began with the recognition that traditional approaches, while oncologically sound, often resulted in visible scar in the anterior breast or a long scar along lateral breast border. This significantly compromised aesthetic outcomes (12). The pioneering work by Toesca et al. in 2017 marked a watershed moment in breast surgery, as they reported the first R-NSM performed through a small lateral chest wall incision using the da Vinci robotic system (13). This initial breakthrough demonstrated the feasibility of performing total mastectomy through minimal access approaches, paving the way for subsequent innovations that have refined both the oncologic and aesthetic aspects of the procedure.

While the procedure enhances aesthetic outcome in breast cancer patients who are eligible for nipple-sparing mastectomy (NSM), implant-based reconstruction also significantly limits its application only in patients with no ptotic breast and early stage without requirement of excision of the NAC or postmastectomy radiotherapy (PMRT) (14). The subsequent development trajectory has focused on expanding surgical indications and refining reconstructive techniques, with particular emphasis on the evolution from simple implant-based reconstruction to complex microsurgical procedures following robot-assisted mastectomy. This advancement represents a significant leap forward in the field, as the ability to perform immediate autologous reconstruction through small lateral incisions has fundamentally altered the risk-benefit calculation for patients considering breast reconstruction options (15,16).

Advantages of autologous reconstruction in the robotic era

The shift toward autologous reconstruction in robot-assisted mastectomy has been driven by several compelling advantages over implant-based reconstructions. Unlike breast implants, which carries potential complications including capsular contracture, implant migration, infection, exposure, and the minimal but concerning risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) (17,18), autologous breast reconstruction offers more consistent, natural-looking, and permanent results (10). Among all the available autologous tissue, the use of free deep inferior epigastric perforator (DIEP) flaps has become particularly valuable in this context, providing reliable tissue sources that age naturally with the patient (19).

In conventional mastectomy, autologous tissue demonstrates superior tolerance to PMRT compared to implant-based reconstruction (20,21). The Mastectomy Reconstruction Outcomes Consortium (MROC) study showed lower complication rates and higher satisfaction with irradiated autologous reconstruction at two years (22), while systematic reviews confirm superior long-term outcomes with reduced capsular contracture and reconstructive failure (20). These findings, however, do not extend to R-NSM, where the minimally invasive technique preserves the entire mastectomy skin envelope even in advanced disease. This preservation creates unique reconstructive conditions when PMRT is indicated: implant-based reconstruction demonstrates limited capacity to maintain aesthetic outcomes in irradiated, well-preserved skin envelopes, whereas autologous free flap reconstruction can fully exploit the intact tissue architecture to achieve superior aesthetic results despite greater technical complexity.

The transition to minimally invasive mastectomy has revolutionized breast reconstruction approaches, fundamentally altering both flap design principles and vessel selection strategies because of the lateral incision. This anatomical constraint has redirected surgical planning toward recipient vessel selection, that are optimally positioned for lateral access approaches. The small laterally positioned incision of robot-assisted mastectomy has driven a paradigmatic shift of recipient vessel selection from traditional internal mammary vessels to thoracodorsal and lateral thoracic vessels as primary recipients since the small incision limits the access to the internal mammary artery/vein (IMA/V) that are traditionally used for microsurgical breast reconstruction (23,24).

This evolution has also catalyzed the increasing adoption of bilateral pedicle DIEP flaps for unilateral breast reconstruction, with our institutional utilization rates rising from 0.7% to 15.9% of cases, demonstrating the adaptive response to the perfusion challenges inherent in lateral vessel access (23). The thoracodorsal system has emerged as the preferred recipient choice due to its accessibility through small lateral incisions and reliable flow characteristics suitable for DIEP flap perfusion (25). When thoracodorsal vessels prove inadequate due to anatomical variations or previous surgical interventions, lateral thoracic vessels provide dependable alternatives, ensuring consistent reconstructive options across diverse patient populations.

The implementation of bilateral pedicle techniques transforms traditionally marginal perfusion zones into robustly vascularized territories, significantly reducing fat necrosis risk while enabling larger flap volumes to accommodate varying breast sizes and shapes (26,27). This application is important in doing breast reconstruction in patients with small flap volume from the DIEP flap. The recipient artery flow from the thoracodorsal artery (TDA) may not be as strong as the flow from IMA; the inclusion of bilateral pedicle in free DIEP flap also reduces the possibility of fat necrosis from insufficient recipient flow. This technical innovation exemplifies the adaptive strategies that have emerged to optimize outcomes within the constraints of minimally invasive surgery.

A comprehensive optimization framework: the Chang Gung experience

Doing microsurgical breast reconstruction via the small lateral incision has several challenges. The first challenge, as mentioned above, is the shifting of recipient vessel selection from the IMA/V to the thoracodorsal artery/vein (TDA/V) or lateral thoracic artery/vein (LTA/V). Exploration of the TDA/V, which lies deep in the axilla area, is difficult via a small incision. The second challenge is from insetting of the flap. It is difficult to reach the most medial inferior location of the breast pocking in sending the flap via the small incision. The flap monitoring is another difficulty without monitor skin but an aesthetic challenge leaving a monitor skin flap. After inset, it is difficult to maintain the inferior medial pole without laterally displacement in this technique. To overcome, our institutional experience has led to the establishment of a comprehensive six-step optimization framework that addresses the unique challenges posed by minimal-incision surgical access inherent to robot-assisted mastectomy (28).

This framework begins with strategic anterior axillary line incision placement, balancing oncologic access requirements with aesthetic imperatives to ensure surgical scars remain concealed while providing adequate exposure for complex reconstructive procedures. The incision is specially placed in the most laterally bulging area, allowing a small monitor skin flap without damaging the aesthetics. The integration of computed tomography angiography with geometric planning constraints guides perforator selection, typically favoring peri-umbilical vessels that offer optimal reach for vessel positioning. Selection is deliberately limited to one or two carefully chosen perforators to minimize the risk of vascular compromise during transfer through restricted access points.

External trial shaping emerges as a critical intermediate step, permitting dimensional optimization and strategic tissue preparation before attempting definitive reconstruction. This preliminary assessment phase reduces procedural complexity while enhancing the precision of volume and contour matching. The implementation of transcutaneous medial fixation addresses the challenges of flap positioning within confined spaces through strategic suture placement that creates guidance mechanisms, facilitating precise tissue positioning while protecting delicate vascular structures throughout the transfer process. Addressing the extensive pocket over-expansion by pneumatic insufflation during mastectomy, deliberate footprint recreation reconstructs the natural breast boundaries through meticulous pocket border definition, utilizing gravitational positioning to achieve accurate symmetry assessment and projection optimization. Postoperatively, custom-fitted compression systems provide continued refinement of breast contour, transforming the reconstruction process from a single surgical event into a dynamic shaping continuum.

Successful implementation of this framework requires specialized microsurgical instrumentation, including self-retaining retractors designed for limited spaces and instruments optimized for restricted visual fields (10,29). Systematic training programs and standardized protocols help surgeons navigate the substantial learning curve associated with these advanced techniques. Flap inset presents the greatest technical challenge, as traditional extensive exposure methods cannot be employed in this minimally invasive setting. Transcutaneous fixation sutures have emerged as a versatile solution, simultaneously facilitating flap guidance, enabling internal shaping, and achieving optimal projection through mechanical advantage (29). Success depends on meticulous planning and precise execution to maintain aesthetic objectives while avoiding complications.

Aesthetic outcomes and comparative analysis

Aesthetic outcomes following robot-assisted mastectomy and reconstruction remain an area of active investigation. Our comprehensive retrospective analysis of 63 patients comparing R-NSM with conventional approaches revealed significant aesthetic advantages for the robotic technique when combined with immediate free flap reconstruction (10). Objective aesthetic evaluation conducted by nine board-certified plastic surgeons demonstrated statistically significant superiority of R-NSM across multiple parameters: inframammary fold symmetry (3.628±0.1343 vs. 4.184±0.08463, P=0.046), scar location (3.61±0.01606 vs. 4.308±0.1932, P=0.042), scar visibility (3.626±0.166 vs. 4.469±0.1396, P=0.017), and overall aesthetic outcome (3.504±0.1133 vs. 4.001±0.1123, P=0.038). These findings provide robust objective evidence supporting the aesthetic superiority of robotic approaches (Figure 1).

Figure 1 A case of 30-year-old female patient with right breast cancer who received robot-assisted nipple-sparing mastectomy and immediate breast reconstruction with free DIEP flap. Her mastectomy size was 690 grams. (A) Pre-op anterior view of her breast and donor site. (B) Free DIEP flap harvested for reconstruction. (C-E) Post-op result at the follow-up of 12 months of anterior, left lateral and right lateral view. Note that a monitor skin flap is seen in right lateral chest wall (D), which will be removed after treatment. DIEP, deep inferior epigastric perforator.

These findings are substantiated by emerging evidence from multiple institutions demonstrating consistent aesthetic advantages of robotic approaches across diverse reconstruction techniques and patient populations. Elameen et al. conducted a systematic review and meta-analysis revealing that R-NSM with free perforator flaps resulted in smaller lateral chest wall scars and statistically significantly greater patient satisfaction compared to conventional surgery (30). In the realm of autologous reconstruction, Eo et al. conducted a prospective single-institution study of 57 patients demonstrating that robot-assisted breast reconstruction with latissimus dorsi muscle flap after partial mastectomy achieved significantly higher patient satisfaction than conventional open methods, including improved satisfaction with donor site scarring (31).

Building upon these foundational findings, large-scale comparative studies have provided increasingly robust evidence supporting the superiority of robotic techniques. Kim et al. reported results from a retrospective comparison of 473 conventional and 164 robot-assisted mastectomy and breast reconstructions, demonstrating that robot-assisted mastectomy and autologous reconstruction yielded higher patient-reported physical well-being scores on the BREAST-Q questionnaire while achieving lower skin necrosis rates (32). Complementing these outcomes, Haddock and colleagues documented favorable cosmetic results, patient satisfaction, and preserved breast sensation in R-NSMs with immediate profunda artery perforator (PAP) flap reconstruction. Their approach utilized remote axillary incisions for optimal scar concealment, directly supporting our observation that 100% anterior axillary line placement in R-NSM patients contributed to superior scar location scores compared to the varied incision patterns observed in conventional approaches (33).

Critically, revision rates following robot-assisted mastectomy and reconstruction have been comparable to or lower than conventional approaches, indicating that aesthetic advantages are achieved without compromising surgical outcomes or requiring increased secondary procedures (34). This finding is particularly significant given the technical complexity of performing intricate reconstruction through minimally invasive incisions, suggesting that the robotic learning curve does not adversely impact long-term aesthetic results or patient safety.

Patient selection and contraindications

Patient selection for robot-assisted mastectomy and reconstruction balances oncologic safety with reconstructive feasibility. Oncologic criteria follow established NSM principles, requiring early-stage breast cancer with favorable tumor characteristics and absence of clinically apparent skin or NAC involvement to ensure adequate margins while preserving anatomical structures (35).

Reconstructive success depends on patient anatomy, disease status, the extension of mastectomy, and planned reconstruction type. Small to moderate-sized, non-ptotic breasts optimize robotic approaches with implant-based reconstruction, while larger or ptotic breasts may presented with compromise aesthetic outcomes with implant-based reconstruction (35). Autologous reconstruction generally present more favorable aesthetic outcome in the aforementioned criteria, but it requires additional prerequisites: adequate donor tissue, favorable perforator anatomy, and appropriate body habitus for successful minimal access techniques.

Besides the above-mentioned advantages, autologous tissue also provides good backup in robot-assisted mastectomy, in particular, facilitating unavoidable nipple involvement known in intraoperative frozen section, and advanced disease status requiring postoperative radiotherapy, but good candidate for NSM. Traditional contraindications in robot-assisted mastectomy have evolved with advancing techniques. While the 2019 International Endoscopic and Robotic Breast Surgery Symposium (IERBS) consensus designated NAC involvement as a contraindication due to poor aesthetic outcomes from linear scar closure, autologous reconstruction now enables precise defect coverage using same-sized round skin paddles from donor flaps (15). Staged nipple reconstruction further eliminates aesthetic concerns, expanding technique applicability. This evolution is clinically validated, with robot-assisted mastectomy successfully employed for skin-sparing procedures in 15% of cases in our case series (36).

Complications and safety analysis

Robot-assisted mastectomy with immediate reconstruction demonstrates comparable or superior safety profiles to conventional techniques, as evidenced by our institutional experience and broader literatures (7,36). Our largest matched cohort analysis of 246 patients revealed significantly reduced breast skin necrosis rates for robotic approaches (10% vs. 26%, P=0.002) without compromising overall complication rates or increasing NAC necrosis in nipple-sparing procedures (36). These findings demonstrate a substantial improvement in one of the most common and aesthetically significant complications of breast reconstruction, suggesting that the enhanced precision and tissue handling capabilities of robotic systems translate into meaningful clinical benefits.

In reviewing our experience, our comprehensive analysis of 169 patients undergoing robotic versus conventional NSM with immediate DIEP or PAP flap reconstruction over a 5.5-year period (November 2018 to May 2024) included well-matched cohorts with similar age (45.7±7.6 vs. 47.2±7.7 years), body mass index (BMI), and cancer staging, though the conventional group had higher rates of previous breast-conserving surgery (19.0% vs. 2.8%, P<0.001) and prior radiotherapy (11.1% vs. 0%, P<0.001) (Table 2). No significant differences were observed in major complications, including fat necrosis (17.9% vs. 14.3%, P=0.538), flap partial loss (1.9% vs. 1.6%, P=1.000), or requirements for operative debridement of either the breast (8.5% vs. 6.3%, P=0.769) or donor site (4.7% vs. 6.3%, P=0.729) (Table 3). Importantly, revision surgery rates remained comparable between robotic and conventional approaches (55.7% vs. 58.7%, P=0.697), with similar frequencies of monitor skin excision, flap contouring procedures including liposuction (23.6% vs. 22.2%, P=0.839), and lipofilling (24.5% vs. 23.8%, P=0.916) (Table 4). These findings were corroborated by our series examining robot-assisted mastectomy and free perforator flap reconstruction, which showed no significant differences in major complications while achieving superior aesthetic outcomes (10). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Chang Gung Medical Foundation (No. 202500978B0) and the Institutional Review Board approved the waiver of the participants’ consent.

These institutional findings are strongly supported by multicenter evidence. Toesca et al.’s randomized controlled trial confirmed similar complication profiles between robotic and conventional approaches (37), while international pooled analyses have validated significantly reduced nipple necrosis rates and Clavien-Dindo grade III complications (requiring surgical, endoscopic, or radiological intervention) following R-NSM (6,7,34,38). The consistent reduction in mastectomy skin flap-related complications across studies likely reflects the enhanced visualization and precision afforded by robotic systems, which enable improved tissue handling and better preservation of the breast envelope through meticulous dissection (35,39).

The evolution toward comprehensive robot-assisted breast reconstruction continues with emerging developments in robot-assisted DIEP flap harvest. Early reports describe intra-abdominal robotic dissection of deep inferior epigastric vessels through minimal anterior rectus abdominis fascial incisions, potentially reducing donor site morbidity including abdominal wall bulge and hernia formation while minimizing postoperative pain and accelerating recovery (Figure 2) (15). This advancement positions the field toward fully integrated robotic breast cancer surgery, encompassing robot-assisted mastectomy, robotically harvested flaps, and potentially robotic microsurgical anastomosis—a comprehensive approach that promises to optimize patient outcomes across every aspect of breast reconstruction (40).

Figure 2 Donor site of robot-assisted free DIEP flap harvest. (A) Perforator dissected via a 1.5 cm incision on anterior rectus sheath of left abdomen. (B) The appearance after harvesting the DIEP flap with the assistance of robot. Note the very limited incision of the ARS for pedicle (yellow circle). The three blue circles indicated the incision site for port to apply robot for flap harvest. ARS, anterior rectus sheath; DIEP, deep inferior epigastric perforator.

Learning curves and skill development

The adoption of robot-assisted techniques in breast reconstruction demonstrates encouraging learning curves that support clinical integration and program development. Studies utilizing cumulative sum (CUSUM) analysis demonstrate that surgeons achieve technical competency in R-NSM within 12–15 cases (16,41). Ryu and colleagues’ multicenter study of 82 procedures revealed significant operative efficiency improvements after the 13^th case, with mastectomy time decreasing from 121.5±58.54 to 89.38±22.79 minutes (P=0.018) and total operative time improving from 287.2±77.43 to 235.6±30.69 minutes (P=0.019) (16).

For robot-assisted free DIEP flap harvest, plastic surgeons reach proficiency within 9–10 cases, with pedicle dissection time decreasing from 69.7±50.8 to 32±11.9 minutes (P=0.001). Interestingly, general surgeons with prior robotic experience achieve competency even more rapidly, reaching proficiency after only five cases with final dissection times of 27.3±7 minutes (P=0.003) (42).

Mastectomy specimen weight emerges as the strongest predictor of operative time (odds ratio 1.203), while lymph node metastasis adds procedural complexity. However, these factors diminish in importance after achieving technical proficiency, suggesting that experience effectively mitigates the impact of challenging cases (16,42). This finding supports the importance of initial case selection during the learning curve period to optimize outcomes and minimize complications. Besides, the identification of predictive factors for procedural complexity enables surgeons to strategically plan their learning curve progression, beginning with technically favorable cases and gradually advancing to more challenging procedures as experience and confidence develop. This approach optimizes both patient safety and learning efficiency.

The safety profile remains excellent throughout learning periods, with no conversions to open surgery, minimal major complications (2.4–2.5%), and acceptable NAC ischemia rates (0–10.9%) that predominantly resolve spontaneously. These favorable safety outcomes are attributed to the three-dimensional visualization, tremor elimination, and intuitive controls provided by robotic systems (4,16). The maintenance of excellent safety profiles during the learning curve period provides reassurance for both surgeons and patients during program implementation. The low complication rates suggest that robotic systems provide inherent safety advantages that help protect patients even during the skill acquisition phase.

Strengths and limitations

Strengths of this review

This narrative review integrates contemporary literature with extensive institutional experience from a high-volume tertiary center, providing both evidence-based analysis and practical clinical insights. Key strengths include the incorporation of objective aesthetic evaluation data using validated assessment tools, comparative studies with matched cohorts, and multicenter evidence. The detailed description of technical innovations, including our six-step optimization framework, provides actionable guidance for program implementation. The comprehensive search strategy across multiple databases ensures current evidence representation in this rapidly evolving field.

Limitations of this review

As a narrative review, this work lacks the systematic methodology of formal systematic reviews or meta-analyses, potentially introducing selection bias. The search may not have captured all relevant publications, particularly non-English literature and gray literature. Heterogeneity in outcome reporting across studies—including varying aesthetic evaluation methodologies, surgical techniques, and patient populations—limits direct comparisons and precludes quantitative synthesis. Long-term follow-up data remain limited, precluding definitive conclusions regarding late aesthetic outcomes, oncologic recurrence, and complications. The lack of standardized aesthetic evaluation tools across institutions further complicates comparative analysis. Finally, incorporation of single-center institutional experience may introduce bias reflecting specific practice patterns and resources that may limit generalizability to centers with different experience levels, case volumes, or access to specialized equipment.

Conclusions

The evolution of robot-assisted mastectomy and immediate reconstruction represents a significant advancement in breast cancer treatment, combining oncologic efficacy and superior aesthetic outcomes. The strategic shifts in surgical approach, including modified flap design principles and specialized minimally invasive techniques, have achieved exceptional cosmetic results while maintaining oncologic safety. The objective evidence of aesthetic superiority, combined with favorable learning curves and excellent safety profiles, supports the feasibility of implementing these techniques across diverse clinical settings.

Future developments in robotic technology, including enhanced imaging capabilities, artificial intelligence-assisted surgical planning, and fully integrated approaches encompassing robot-assisted mastectomy and flap harvest, promise further optimization of patient outcomes. The continued collaboration between surgical specialties and commitment to evidence-based practice will be essential for advancing this rapidly evolving field.

As the field matures, the integration of long-term follow-up studies, patient-reported outcome measures, and comparative effectiveness research will refine optimal techniques and patient selection criteria. The goal remains providing every breast cancer patient with access to treatment options that optimize both survival and quality of life.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Sarah N. Bishop) for the series “Aesthetic Breast Reconstruction” published in Gland Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-458/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-aw-458/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-aw-458/coif). The series “Aesthetic Breast Reconstruction” was commissioned by the editorial office without any funding or sponsorship. The authors have no other 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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Chang Gung Medical Foundation (No. 202500978B0) and the Institutional Review Board approved the waiver of the participants’ consent.

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/.

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