Robotic nipple-sparing mastectomy after periareolar incision: a surgical technical approach to subareolar dissection in a previously operated field
Surgical Technique

Robotic nipple-sparing mastectomy after periareolar incision: a surgical technical approach to subareolar dissection in a previously operated field

Toshikatsu Nitta1 ORCID logo, Jun Okuno2, Kosei Kimura1,3, Kae Nishihara1, Yurika Sugano2, Ayumi Tsujino1,3, Yuko Takashima1,3, Tomo Ayukawa1, Masatsugu Ishii1, Atsushi Takeshita4, Takashi Ishibashi1, Mitsuhiko Iwamoto3

1Division of Surgery, Breast Center, Medico Shunju Shiroyama Hospital, Osaka, Japan; 2Department of Breast and Endocrine Surgery, Osaka International Cancer Center, Osaka, Japan; 3Department of Breast Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan; 4Department of Pathology, Medico Shunju Shiroyama Hospital, Osaka, Japan

Contributions: (I) Conception and design: T Nitta, J Okuno, M Ishii; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: T Nitta, K Kimura, K Nishihara, Y Sugano, A Tsujino, Y Takashima, T Ayukawa, M Ishii, A Takeshita, T Ishibashi, M Iwamoto; (V) Data analysis and interpretation: A Takeshita; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Toshikatsu Nitta, MD, PhD. Division of Surgery, Breast Center, Medico Shunju Shiroyama Hospital, 2-8-1 Habikino Habikino-city, Osaka 583-0872, Japan. Email: nitta@shiroyama-hsp.or.jp.

Abstract: Nipple-sparing mastectomy (NSM) after a prior periareolar incision is technically demanding because fibrosis, altered tissue planes, and possible vascular compromise around the nipple-areola complex (NAC) may increase the difficulty of subareolar dissection. Although robotic nipple-sparing mastectomy (R-NSM) has been reported as a minimally invasive option, its specific role in re-operative subareolar fields remains uncertain. This surgical technical report describes R-NSM performed with the da Vinci Xi system in a 51-year-old woman who previously underwent diagnostic lumpectomy through a periareolar incision for atypical ductal hyperplasia, followed by an indication for additional resection after ductal carcinoma in situ with microinvasion was identified. A 3.5-cm mid-axillary incision was used for access with a GelPOINT Mini platform. The key technical elements were lateral access without reopening the periareolar incision, low-pressure CO2 insufflation, hydrodissection, maintenance of uniform flap thickness, limited use of bipolar energy, and cold scissors dissection immediately beneath the NAC under magnified three-dimensional visualization. The retroareolar margin was confirmed intraoperatively by frozen section. The total operative time was 248 min, and console time was 71 min. No intraoperative complications occurred. The postoperative course was uneventful, the patient was discharged on postoperative day 7, no nipple or skin necrosis was observed, and final surgical margins were negative. This case suggests that R-NSM may facilitate controlled subareolar dissection in selected patients with prior periareolar surgery. However, this single-case report does not demonstrate superiority over open or endoscopic approaches, and the absence of objective perfusion assessment precludes conclusions regarding NAC vascular preservation.

Keywords: Nipple-sparing mastectomy (NSM); robotic surgery; da Vinci Xi

Submitted Apr 30, 2026. Accepted for publication Jun 29, 2026. Published online Jul 07, 2026.

doi: 10.21037/gs-2026-0265

Highlight box

Surgical highlights

• This report describes robotic nipple-sparing mastectomy (R-NSM) performed through a 3.5-cm mid-axillary incision in a patient with a previous periareolar lumpectomy.

• Key technical steps included low-pressure CO2 insufflation, hydrodissection, maintenance of flap thickness, limited use of bipolar energy, and cold subareolar dissection beneath the nipple-areola complex (NAC).

What is conventional and what is novel/modified?

• Nipple-sparing mastectomy (NSM) after prior periareolar incision is technically challenging because fibrosis and altered tissue planes may make subareolar dissection less predictable and may increase concern regarding NAC ischemia.

• The modified aspect of this technique is the use of a lateral robotic approach with articulated instruments and three-dimensional visualization to facilitate controlled subareolar dissection in a previously operated field without reopening the previous periareolar incision.

What is the implication, and what should change now?

• This single-case technical report suggests that R-NSM may be feasible in carefully selected patients with prior periareolar surgery. However, it does not demonstrate superiority over open or endoscopic approaches or prove a benefit in NAC perfusion. Future comparative studies with objective perfusion assessment are required.

Introduction

Breast endoscopic surgery has been introduced to improve cosmetic outcomes; however, its use has been limited because of technical complexity, restricted instrument maneuverability, and poor reproducibility (1,2). In particular, procedures requiring precise dissection in confined anatomical planes remain challenging with conventional endoscopic approaches (1).

Robotic-assisted surgery provides articulated instruments and stable three-dimensional visualization (3), which may overcome some of these limitations. Robotic nipple-sparing mastectomy (R-NSM) applies these characteristics to nipple-sparing mastectomy (NSM), wherein precise subareolar dissection is required for the preservation of both oncological safety and cosmetic outcomes (2).

NSM after a prior periareolar incision represents a distinct technical challenge. Previous surgery may result in fibrosis and altered vascular anatomy, making subareolar dissection more difficult and potentially increasing the risk of nipple-areola complex (NAC) ischemia (4).

For patients who have undergone prior periareolar surgery, the central technical issue is safe, controlled subareolar dissection in fibrotic tissue. Therefore, we need to determine whether robotic articulation and stable three-dimensional visualization can facilitate precise subareolar dissection (3) while minimizing thermal injury beneath the NAC. In this report, we describe a technical approach combining a lateral robotic access route with low-pressure CO2 insufflation, hydrodissection, and cold subareolar dissection in a patient with a history of prior periareolar surgery, with the aim of defining a technical concept that may inform future comparative studies rather than demonstrating superiority. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0265/rc).

Preoperative preparations and requirements

A 51-year-old Japanese woman presented with a self-detected lump in the right breast. Her height was 164 cm, and her weight was 43 kg (body mass index 15.9 kg/m2). She had no history of smoking. Mammography showed no detectable mass [Breast Imaging Reporting and Data System (BI-RADS) Category 1, Figure 1A], whereas ultrasonography revealed a hypoechoic lesion with coarse calcifications (BI-RADS Category 4, Figure 1B). Vacuum-assisted biopsy demonstrated atypical ductal hyperplasia. A diagnostic lumpectomy was performed through a periareolar incision (Figure 2A). The surgical margin was positive for atypical ductal hyperplasia, and additional resection with NSM was performed 1 month later. In the present case, the indication for additional surgery was based on oncological necessity instead of cosmetic considerations. Pathological examination of the lumpectomy specimen revealed ductal carcinoma in situ with microinvasion measuring 500 µm (pT1mi). Immunohistochemical analysis revealed estrogen receptor and progesterone receptor positivity, and the human epidermal growth factor receptor 2 score was 1+. No distant metastasis was identified, and the disease was staged as T1miN0M0 (stage I, Figure 2B) (5). All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Preoperative imaging findings. (A) Mammography does not reveal a definite mass lesion, and the finding is classified as BI-RADS Category 1. (B) Breast ultrasonography reveals a hypoechoic lesion (white arrow) with coarse calcifications, which is classified as BI-RADS Category 4. BI-RADS, Breast Imaging Reporting and Data System.
Figure 2 Findings after the prior diagnostic lumpectomy. (A) A diagnostic lumpectomy was performed through a periareolar incision. This previous incision is clinically relevant because of the potential risk of fibrosis and altered vascularity in the subareolar field. (B) Pathological examination of the lumpectomy specimen reveals microinvasive carcinoma measuring 500 µm (pT1mi).

Step-by-step description

Patient positioning

The patient was placed in the supine position with the ipsilateral arm lowered (Figure 3).

Figure 3 Patient positioning, access route, and robotic port configuration. The patient was placed in the supine position with the ipsilateral arm lowered. A 3.5-cm mid-axillary incision was used to insert the GelPOINT Mini access platform. Three 8-mm robotic ports were inserted through the access platform. The robotic arm configuration was as follows: R1, fenestrated bipolar forceps; R2, camera; and R3, monopolar curved scissors. The working space was maintained using the AirSeal robotic insufflation system.

Incision and access

A 3.5-cm incision was made along the mid-axillary line, and a GelPOINT Mini access platform® (Applied Medical Resources Corporation, Rancho Santa Margarita, CA, USA) was inserted (Figure 3).

After initial dissection under direct vision, axillary lymph node dissection was performed because of the lack of sentinel lymph node biopsy after the prior surgery. The subsequent mastectomy procedure was performed in a working space under gas insufflation.

Hydrodissection

Hydrodissection was then performed using diluted lidocaine with epinephrine to facilitate separation of the tissue planes.

Insufflation

After initial dissection under direct visualization, the working space was maintained under CO2 insufflation using the AirSeal system (AirSeal® 8-mm Robotic Cannula; ConMed Corporation, Utica, NY, USA) at 10 mmHg.

Port placement and docking

Three 8-mm robotic ports were inserted through the GelPOINT Mini access platform® under direct visualization. Because all robotic ports were placed through the single access platform, conventional interport spacing was not applicable; however, the ports were positioned with maximal separation within the platform to minimize external arm collision. The patient-side cart was docked from the ipsilateral lateral side, allowing instrument access from the mid-axillary incision toward the subareolar region. The robotic arm configuration was as follows: R1, fenestrated bipolar forceps; R2, camera; and R3, monopolar curved scissors.

Flap creation

Skin-flap dissection was initiated in the superficial subcutaneous plane and extended circumferentially toward the NAC. A uniform flap thickness was maintained by staying within the same superficial dissection plane, avoiding excessive thinning of the skin flap, and preserving a thin layer of subcutaneous tissue on the skin side whenever possible. Excessive traction on the flap was avoided to reduce mechanical stress on the subdermal vascular plexus.

Subareolar dissection

Subareolar dissection was performed under magnified three-dimensional visualization. In the fibrotic area related to the previous periareolar surgery, the dissection was advanced layer by layer to maintain a consistent plane beneath the NAC. Cold scissors were preferentially used immediately beneath the NAC to minimize thermal injury (Figures 4,5). Bipolar energy was used only for limited hemostasis away from the immediate subareolar plane, and energy activation directly beneath the NAC was intentionally avoided. Low-pressure insufflation was maintained throughout the procedure to preserve the working space while minimizing subcutaneous emphysema and tissue compression.

Figure 4 Intraoperative view of subareolar dissection during robotic nipple-sparing mastectomy. Subareolar dissection was performed under magnified three-dimensional visualization. Cold cutting was preferentially used immediately beneath the nipple-areola complex to minimize thermal injury in the previously operated and fibrotic subareolar field.
Figure 5 Postoperative appearance after robotic nipple-sparing mastectomy. The procedure was completed through a 3.5-cm mid-axillary incision. This lateral access route avoided reopening of the previous periareolar incision while allowing robotic access to the subareolar region.

The retroareolar margin was intraoperatively confirmed by frozen section, and final pathology subsequently confirmed negative surgical margins.

Postoperative considerations and tasks

The total operative time was 248 min, and the console time was 71 min. Estimated blood loss was minimal. No intraoperative complications occurred (Figure 5). The postoperative course was uneventful, and the patient was discharged on postoperative day 7.

No nipple or skin necrosis was observed during postoperative follow-up. Final pathology confirmed negative surgical margins, and no postoperative complications were observed within 30 days. There was no clinical evidence of NAC ischemia, skin-flap necrosis, or wound complications during the postoperative follow-up period. However, objective perfusion assessments such as indocyanine green fluorescence imaging were not performed.

Tips and pearls

Careful patient selection is essential when considering R-NSM after prior periareolar surgery. The previous periareolar incision should be avoided when a lateral access route can provide adequate exposure. Hydrodissection may help identify the appropriate tissue plane in a fibrotic field. A uniform skin-flap thickness should be maintained, and excessive traction on the flap should be avoided. Immediately beneath the NAC, cold scissors should be preferentially used, and bipolar energy should be limited to hemostasis away from the immediate subareolar plane. Intraoperative frozen section of the retroareolar margin is useful for confirming oncological safety. Because objective perfusion assessment was not performed in this case, the absence of NAC ischemia should be interpreted cautiously.

Discussion

The present report addresses a specific technical problem, namely, subareolar dissection during NSM in a previously operated field. In such cases, fibrosis and altered tissue planes make dissection more difficult and less predictable than that in cases involving primary NSM. The key technical challenge for this procedure is maintaining a consistent dissection plane beneath the NAC while minimizing mechanical and thermal injury. This is particularly relevant after a prior periareolar incision, where normal anatomical landmarks may be distorted and tissue vascularity may be altered.

When comparing surgical approaches, the technical differences between endoscopic and robotic approaches (6) should be considered in relation to the subareolar working plane. Modern high-definition endoscopy provides excellent visualization; however, conventional endoscopic instruments (7,8) remain relatively linear and may be limited (1,2) when the shallow and narrow subareolar plane is approached via a lateral incision. In contrast, wristed robotic instruments allow fine movements at a favorable angle beneath the NAC (3,4). Tremor filtration and stable three-dimensional visualization may also facilitate precise manipulation in scarred tissue. These features are particularly relevant beneath the NAC, where small deviations from the intended plane may affect both margin control and flap viability. Nevertheless, these are potential technical advantages and should not be interpreted as proof of improved clinical outcomes.

The novelty of this report lies in the technical strategy used to manage a fibrotic retroareolar field, not merely in the application of R-NSM after a prior periareolar incision. The lateral robotic approach provided access to the subareolar region without reopening of the previous periareolar incision. Low-pressure CO2 insufflation and hydrodissection helped in maintaining the working space and identifying the appropriate dissection plane, whereas cold dissection beneath the NAC was used to avoid unnecessary thermal spread.

Although no clinical evidence of NAC ischemia was observed in the present case, this finding should be cautiously interpreted. Because objective perfusion assessments such as indocyanine green fluorescence imaging were not performed, the present report cannot determine whether robotic assistance contributed to the preservation of NAC vascularity.

Moreover, this single-case technical report does not demonstrate superiority over open or endoscopic approaches or prove a perfusion benefit of the robotic approach.

Regarding complications, NAC ischemia is a major concern in NSM, particularly after prior periareolar incision, which may compromise vascular supply and distort anatomical planes (4,9,10). Previous reports have revealed favorable outcomes with R-NSM, including low complication rates and acceptable oncological safety (11,12). Recent international consensus recommendations have also emphasized the importance of a standardized technique, appropriate training, careful patient selection, and multidisciplinary collaboration for safe R-NSM procedures (13).

The lower rate of grade III postoperative complications (Clavien-Dindo classification) with R-NSM than with conventional NSM was primarily attributed to the nipple necrosis rate (12). Specifically, the total and partial nipple necrosis rates were 0% and 0.6%, respectively, whereas the skin necrosis rate was 2.4% and the thermal injury rate was 0.6%. However, these findings are derived from selected cohorts and do not specifically address the technical challenge of re-operative subareolar dissection.

In the present case, R-NSM was selected because this procedure is associated with a low risk of nipple necrosis. Furthermore, the NSM procedure was successfully completed in our case. However, the present study does not demonstrate that robotic surgery improves clinical outcomes, and the absence of nipple necrosis in a single case cannot establish causality. In addition, avoidance of a periareolar incision itself is a known factor associated with reduced ischemic complications (9,10), and the relative contribution of incision choice versus the potential benefits of robotic technology, particularly in complex cases where it may improve surgical precision and facilitate operative performance, cannot be determined in this case. Prior periareolar incision may compromise NAC vascularity, making subsequent NSM technically challenging.

Therefore, this report should be interpreted as a technical description and hypothesis-generating study instead of evidence of superiority. Because postoperative follow-up was limited to 30 days, this report cannot evaluate long-term oncological safety or delayed reconstructive outcomes. Future studies should include techniques for objective assessment of NAC perfusion, such as indocyanine green fluorescence imaging, as well as direct comparisons of open, endoscopic, and robotic approaches as highlighted in recent comparative reviews of NSM techniques (4,7,8,14-19). In addition, robotic surgery is associated with increased operative time and cost (20,21). The total operative time of 248 min was relatively long. This may have reflected the careful dissection required in a previously operated and fibrotic subareolar field, intentional avoidance of thermal energy beneath the NAC, and docking and setup time during the early phase of introduction of the robotic approach. Any potential technical advantage must therefore be evaluated in the context of these limitations.

This report has some limitations. First, it is a single-case technical report, and the findings cannot be generalized to all patients undergoing R-NSM after prior periareolar surgery. Second, the follow-up period was limited, and longer follow-up is required to evaluate oncological safety and long-term reconstructive outcomes. Another important limitation is the lack of objective perfusion assessment. Although no clinical signs of NAC ischemia or skin-flap necrosis were observed, definitive conclusions regarding the effect of robotic assistance on NAC vascularity cannot be drawn from this single case.

This report is intended to define a technical concept and generate hypotheses for future comparative studies, rather than to demonstrate superiority.

R-NSM after prior periareolar incision is technically feasible and may provide advantages in terms of controlled subareolar dissection. However, its clinical benefit, particularly with regard to NAC perfusion, remains to be established and should be evaluated in prospective comparative studies with objective perfusion assessment.

Conclusions

In summary, the value of robotic surgery should not be defined by feasibility alone but by its ability to address specific technical limitations of existing approaches. The present case reveals that robotic assistance may facilitate controlled subareolar dissection in a previously operated field; however, its clinical significance remains to be established.

Acknowledgments

The authors thank the editorial reviewers for their constructive comments, which helped improve the focus and clarity of this technical report.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0265/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0265/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-2026-0265/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 institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images. 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/.

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Cite this article as: Nitta T, Okuno J, Kimura K, Nishihara K, Sugano Y, Tsujino A, Takashima Y, Ayukawa T, Ishii M, Takeshita A, Ishibashi T, Iwamoto M. Robotic nipple-sparing mastectomy after periareolar incision: a surgical technical approach to subareolar dissection in a previously operated field. Gland Surg 2026;15(8):238. doi: 10.21037/gs-2026-0265

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