Endoscopic nipple-sparing mastectomy with immediate breast reconstruction and sentinel lymph node biopsy for early-stage breast cancer: a prospective case series

Introduction

Breast cancer is the most frequently diagnosed malignancy in women and continues to represent a major global health and socioeconomic burden (1). Beyond disease control, breast aesthetic preservation and improved post-treatment quality of life have become key priorities in comprehensive cancer care (2). For patients with early-stage breast cancer, breast-conserving surgery or mastectomy with immediate reconstruction can facilitate physical recovery, reduce psychological distress and improve self-confidence and social reintegration (3-5).

The landscape of breast cancer surgery has evolved remarkably, ranging from early radical operations like the Halsted and Patey procedures involving en bloc pectoralis resection (6,7) to less invasive techniques such as the Auchincloss mastectomy, which preserves the pectoralis muscles (8). However, conventional reconstruction techniques, characterized by long incisions and extensive dissection are associated with higher morbidity, longer hospital stays and more conspicuous scarring which may adversely affect aesthetic outcomes and patients long-term quality of life (9-11).

In the study by Fisher et al., a 20-year follow-up of a randomized trial demonstrated no statistically significant differences in overall survival and disease-free survival between the three treatment groups: (I) total mastectomy, (II) breast-conserving surgery alone, and (III) breast-conserving surgery combined with radiotherapy (12). These findings provided a scientific foundation for the development and evaluation of less invasive surgical techniques in subsequent studies.

Recent studies have demonstrated the oncological safety of skin-sparing mastectomy and breast-conserving surgery (13,14), thereby expanding the indications for minimally invasive approaches, such as endoscopic and robotic-assisted breast reconstruction.

Comparative studies between endoscopic surgery and open or skin-sparing mastectomy have shown that the endoscopic approach is safe and feasible in selected patients with early-stage disease, including T₁/T₂ breast cancer and high-grade ductal carcinoma in situ (DCIS). It may be particularly suitable for skin-sparing mastectomy with immediate breast reconstruction. In addition, endoscopic breast surgery is particularly beneficial for patients with smaller breasts or in breast-conserving procedures. This explains why the technique is widely adopted by numerous authors across Asia (15-18). In Vietnam, evidence regarding the use of endoscopic breast reconstruction in patients with breast cancer remains scarce. Therefore, we conducted a prospective case series at the Department of Breast, Cho Ray Hospital, to evaluate endoscopic nipple-sparing mastectomy (E-NSM) with immediate breast reconstruction and sentinel lymph node biopsy (SLNB). The aim of this study was to assess the feasibility, safety, and early clinical outcomes of this approach, as well as patient satisfaction following surgery. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0287/rc).

Methods

Study design: a prospective case series

Statistical: data were collected and processed using SPSS version 25.0. Qualitative variables were presented as frequencies and percentages. Quantitative variables were expressed as mean ± standard deviation (SD) for normally distributed data, or as median and interquartile range (IQR) for non-normally distributed data.

Study period and setting: from January 2023 to July 2024 at the Department of Breast, Cho Ray Hospital.

Study population: the study enrolled patients with breast cancer who underwent E-NSM, SLNB, and immediate breast reconstruction with submuscular implants or LD flaps.

The study was conducted in accordance with the local legislation and institutional requirements. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Cho Ray Hospital Scientific Council (No. the registration number of ethics board) and informed consent was obtained from all individual participants.

Patient selection criteria: to ensure appropriate patient selection, predefined inclusion and exclusion criteria were applied (Table 1).

Diagnosis: breast cancer was confirmed by histopathology and immunohistochemistry. Clinical staging included evaluation of the primary tumor and regional lymph nodes through physical examination and bilateral breast ultrasonography. Assessment for distant metastasis was performed using abdominal ultrasound, chest radiography, computed tomography (CT), or positron emission tomography (PET)-CT as clinically indicated.

Multidisciplinary team consultation: following confirmation of breast cancer, all cases were reviewed by a multidisciplinary team to develop individualized treatment plans. Patients recommended for surgery by the multidisciplinary team were assessed to determine the most appropriate surgical approach based on tumor characteristics and disease stage. Patients with T₁, T₂, or extensive Tis tumors located at least 2 cm from the nipple who desired immediate reconstruction were selected for endoscopic mastectomy. Surgical management included SLNB or axillary lymph node dissection followed by immediate breast reconstruction using either implants or LD flaps, according to patient preference and clinical indication.

Preoperative assessment: patients scheduled for surgery underwent a comprehensive preoperative assessment, including detailed chest wall measurements for optimal implant selection or planning of autologous tissue reconstruction.

The following preoperative anthropometric measurements were recorded: suprasternal notch to nipple distance (SSN-N), breast width (BW), breast height (BH), inter-mammary distance (IMD), and nipple to infra-mammary fold distance (N-IMF).

Surgical steps

Step 1

SLNB was performed using methylene blue dye, radioisotope, or indocyanine green (ICG) via a 4–5 cm infra-axillary incision (Figure 1). Intraoperative frozen section analysis was conducted; if metastasis was detected, conversion to level I–II axillary lymph node dissection was performed.

Figure 1 Using methylene blue dye during sentinel lymph node biopsy.

Step 2

E-NSM: the patient was positioned supine with the ipsilateral arm abducted to 90°. A 4–5 cm incision was made at the highest natural axillary fold (utilizing the same approach as for SLNB). The inframammary fold was marked with a solid line, and a parallel line was drawn 1.5 cm below it to define the inferior limit of the dissection plane. A wound protector was then inserted.

Step 3

Creation of the operative space: the working field was established using either a mechanical skin-lifting technique or CO₂ insufflation. A mechanical lifting device was employed as shown in Figure 2. For the CO₂ insufflation technique, a wound protector with a sealed cap and a built-in 10-mm trocar was used. Two additional 5-mm trocars were inserted for endoscopic instruments using either a single-port (Figure 3) or dual-port configuration (Figure 4). CO₂ insufflation was maintained at 10–12 mmHg to ensure adequate visualization and maintenance of the operative space.

Figure 2 Creation of working space via mechanical skin-lifting.

Figure 3 Creation of CO₂ operative space via single-port wound protector.

Figure 4 Dual-port CO₂ insufflation via wound protector.

Step 4

Dissection was initiated in the upper outer quadrant and extended to the base of the nipple. The retroareolar tissue was transected and submitted for intraoperative frozen section analysis. If margins were negative for malignancy, the nipple-areola complex (NAC) was preserved. An electrosurgical hook was used to dissect the lower-inner and lower-outer quadrants. Skin flaps were elevated using endoscopic scissors, maintaining a thickness of approximately 5 mm. The subdermal vascular plexus was preserved throughout dissection to ensure flap viability. The mammary gland was then dissected down to the pectoralis major fascia. After completion of the superior, inferior, medial, and lateral skin flap elevations, the gland was separated from the underlying muscle in a medial-to-lateral direction. When the dissection reached the lateral border of the pectoralis major and the axillary tail, the specimen was removed through the initial axillary incision.

A submuscular pocket was created through dissection along the posterior aspect of the pectoralis major muscle, and the breast implant was subsequently placed within the pocket. When additional lower-pole expansion or implant support was required, an acellular dermal matrix (ADM) was selectively used. Alternatively, a polypropylene (Prolene) mesh was employed as a cost-effective synthetic substitute to reinforce the inferior pole, provide additional implant support, and reduce tension on the pectoralis major muscle. Under endoscopic guidance, a mechanical lifting device was used to elevate the pectoralis major muscle, facilitating precise dissection and pocket creation. When mesh reinforcement was indicated, the polypropylene mesh was endoscopically secured to the inferior border of the pectoralis major muscle before implant insertion. This approach provided adequate implant coverage and facilitated lower-pole support and shaping. Finally, two closed-suction drains were placed in the breast and axillary regions, and the incisions were closed using a subcuticular suture technique.

LD flap harvest: in patients undergoing reconstruction with an LD flap, a pedicled LD flap was harvested using meticulous dissection. Flap volume was tailored to approximate the volume of the resected breast specimen. When indicated, a transaxillary endoscopic approach was used to harvest a muscle-only flap. Given its limited volume, this technique was reserved for patients with small breast volumes (less than 180 mL), those undergoing combined reconstruction with submuscular implants, or patients willing to undergo postoperative autologous fat grafting. Conversely, a conventional open approach through a dorsal incision was used to harvest a myocutaneous flap consisting of the muscle, overlying skin, and subcutaneous tissue. This technique provided adequate tissue volume for reconstruction in patients with larger breasts. Following endoscopic mastectomy, the flap was transposed into the subcutaneous pocket created at the recipient site. Closed-suction drains were placed at both the donor (back) and recipient (chest) sites. Skin closure was performed using layered aesthetic suturing techniques.

Step 5

Postoperative monitoring, follow-up, and early outcome assessment:

• Postoperative monitoring: patients were monitored for postoperative complications, including hemorrhage, surgical site infection, and nipple ischemia or necrosis in nipple-sparing mastectomies. Pain was evaluated, with particular attention to implant-related tension and donor-site discomfort following LD flap harvest.
• Follow up: patients were discharged upon removal of all surgical drains, provided no postoperative complications were present. A follow-up visit was scheduled one-week post-discharge to initiate further postoperative management.
• Postoperative outcomes and cosmetic assessment: postoperative complications were recorded, including infection, erythema, nipple ischemia, seroma at the recipient or donor (back) site, implant exposure, and capsular contracture. Patient satisfaction was assessed using Cosmetic outcomes and the cosmetic evaluation system proposed by Ueda et al. (19). Both the operating surgeon and the patient independently evaluated the postoperative results based on four aesthetic parameters: breast shape, volume, symmetry, and scar appearance. The overall outcomes were then categorized according to the predefined grading criteria of the Ueda framework.

Results

Between January 2023 and July 2024, 130 patients met the inclusion criteria. All underwent minimally invasive mastectomy followed by reconstruction using either autologous flaps or implants.

Age: the mean age of the study population was 44.9±6.3 years (range, 30–63 years).

Breast cancer staging: the mean clinical tumor size was 2.4 cm, while the mean tumor size on ultrasound was 1.5 cm × 1.4 cm. No clinical evidence of regional lymph node involvement or distant metastasis was observed.

Clinical characteristics and staging: as shown in Table 2, all patients were diagnosed with stage 0–IIB breast cancer. Neoadjuvant chemotherapy was administered to 23 patients (17.7%), including all 18 patients with stage IIB, two patients with extensive ductal carcinoma in situ, and three patients with bilateral breast cancer. The bilateral cases were staged as follows: right-sided cT₂N₀M₀ with contralateral cTis; left-sided cT₂N₀M₀ with contralateral cT₁N₀M₀; and bilateral cT₁N₀M₀.

TNM stage distribution: The majority of patients were classified as stage IA (36.2%), followed by stage IIA (29.2%), stage 0 (20.8%), and stage IIB (13.8%).

Surgical characteristics: implant-based reconstruction was performed in 15.4% (20 patients), whereas 84.6% (110 patients) underwent reconstruction using LD flap (Table 3). In the implant group, 85.0% of patients underwent unilateral nipple-sparing mastectomy with axillary lymph node dissection and implant placement, while 15.0% underwent bilateral nipple-sparing mastectomy with the same procedure.

The mean incision length was 5 cm, confined to the axilla. Mean mastectomy specimen volume was 255±80 mL (range, 120–550 mL). Regarding aesthetic baseline, the majority of patients presented with no ptosis or mild (grade I) ptosis.

Intraoperative frozen section analysis of all retroareolar tissue specimens was negative for malignancy. The mean operative time was 209.0±16.5 minutes (Table 4). For the implant-based cohort, Mentor breast implants were used. Polypropylene mesh reinforcement was required in 18 patients (90.0%), while 2 (10.0%) underwent reconstruction without additional synthetic matrix support.

As shown in Table 5, implant volumes predominantly ranged from 250 to 300 mL, with 275 mL being the most frequently used size (40.0%). Only two patients received implants smaller than 250 mL (200 and 225 mL), and two patients received 325 mL implants. Intraoperatively, a pectoralis major muscle tear occurred in one case (5.0%) during pocket creation; no other intraoperative complications were observed.

Postoperative pain and breast tension occurred in 60.0% and 40.0% of patients, respectively. No implant rupture or capsular contracture requiring surgical revision was observed. The mean time to chest drain removal was 2.4±1.3 days, whereas the axillary drain was removed at a mean of 5.9±2.6 days. The mean postoperative period was 7.6±1.5 days, with a total hospital stay of 9.0±1.1 days (Table 4).

Perioperative outcomes

Early postoperative assessment demonstrated that all patients were satisfied with their breast reconstruction. Breast symmetry was preliminarily evaluated through postoperative observation (Figures 5-8). Specifically, the proportion of patients who were “very satisfied” was 40.0% in the implant-based group, compared with 85.5% in the LD flap group (Table 6).

Figure 5 Postoperative aesthetic result after LD flap reconstruction. LD, Latissimus Dorsi.

Figure 6 Bilateral endoscopic breast reconstruction with implants: 1-week (A) and 3-month (B) postoperative views.

Figure 7 Short-term outcomes of endoscopic LD flap reconstruction: 1-week (A,B) and 1-month (C,D) postoperative views. LD, Latissimus Dorsi.

Figure 8 Postoperative aesthetic result after 3-month LD flap reconstruction. LD, Latissimus Dorsi.

Discussion

In recent years, ENSM has gained increasing acceptance as a minimally invasive alternative to conventional breast surgery. Beyond the cosmetic advantages associated with remote-access incisions, these techniques have attracted growing interest because of their potential to reduce ischemic complications involving the NAC and mastectomy skin flaps while maintaining oncologic safety. Nevertheless, evidence regarding patient selection, reconstructive outcomes, and oncologic feasibility remains limited in several clinical settings.

Despite these technical advantages, oncologic safety remains the primary consideration when expanding the indications for minimally invasive breast surgery.

Skin-sparing mastectomy, first described by Toth and Lappert in 1991 (21), involves the resection of breast glandular tissue while preserving the majority of the native skin envelope. The oncologic safety of this approach has been demonstrated in multiple studies involving patients with early-stage breast cancer. The procedure typically mandates excision of the NAC, incorporation of prior biopsy sites, and provision of adequate access for axillary management (22). According to Lim et al., skin-sparing mastectomy followed by immediate reconstruction has been demonstrated to be oncologically safe in patients with early-stage breast cancer (23). In a retrospective analysis of 50 cases, Toth et al. observed zero local recurrences over a mean follow-up of 57 months, with 48% of the patients diagnosed with stage 0 disease (24). Foster et al. reported that among 25 patients with stage IIB–III disease, only 1 patient (4%) developed local recurrence during a mean follow-up of 49.2 months (25). In a cohort of 372 procedures for T₁–T₂ breast cancer, Newman et al. reported a local recurrence rate of 6.2% after 26 months of follow-up (26). In a cohort of 154 patients with T₁–T₂ breast cancer, Kroll et al. reported comparable local recurrence rates between skin-sparing and non-skin-sparing mastectomy after 6 years of follow-up (7.0% vs. 7.5%, respectively) (27). Similarly, Drucker-Zertuche et al. reported only one loco-regional recurrence among 105 patients after a mean follow-up of 48 months (28).

However, this procedure is considered a relative contraindication for locally advanced breast cancer (defined as T₃N₀ or stage III). Caution is advised due to the potential risks of local recurrence, delays in adjuvant therapy, and the adverse aesthetic impact of adjuvant radiotherapy on the reconstructed breast (29,30). Evidence regarding the oncological safety of skin-sparing mastectomy followed by immediate reconstruction in locally advanced breast cancer (stage III, including T₃ disease) remains limited. While preliminary reports, including those by Foster et al. (n=25) (25) and Downes et al. (n=38; 34 patients at stage ≥ IIB and 8 T₃ cases), have suggested the oncological safety of skin-sparing mastectomy in locally advanced breast cancer, the clinical evidence remains constrained by limited sample sizes (31).

While conventional skin-sparing mastectomy is well established, several studies have reported favorable long-term oncological outcomes with ENSM, supporting its oncological safety and its role as a minimally invasive alternative to conventional surgery.

In a retrospective study of 157 patients undergoing ENSM with immediate implant-based reconstruction, the majority of whom had stage 0–II breast cancer, with only 4 patients (2.5%) presenting with stage III disease, Du et al. reported a 0% local recurrence rate after a median follow-up of 74 months (range, 52–111 months). Distant metastases developed in 7 patients (4.5%), and 5 patients (3.2%) died during follow-up, indicating acceptable long-term oncological safety (16). Similarly, Liu et al. reported favorable oncologic outcomes in a retrospective cohort of 71 patients with stage I–II breast cancer treated with single-port insufflation E-NSM. Following a mean follow-up of 81.1±21.3 months, only one local recurrence (1.4%) was documented, with no cases of distant metastasis. Together with previous studies, these results provide further evidence supporting the oncological safety of ENSM in appropriately selected patients with early-stage disease (18).

Within the present study, 130 patients with breast cancer were followed for a median of 32 months (range, 20–38 months), during which no local recurrences or distant metastases were detected. Among them, 18 patients were initially diagnosed with stage IIB breast cancer, including 14 with cT₂N₁M₀ and 4 with cT₃N₀M₀. Following completion of neoadjuvant chemotherapy, all patients were reassessed by a multidisciplinary team and were downstaged to ycT₂N₀M₀ prior to surgery (Table 2). Preoperative evaluation demonstrated a residual tumor-to-nipple distance greater than 2 cm in all patients. Intraoperative frozen-section examination confirmed negative subareolar margins in every case. Furthermore, all patients who had initially presented with stage IIB disease received postoperative adjuvant radiotherapy according to the institutional treatment protocol. Given these findings, the reduced tumor burden achieved after neoadjuvant chemotherapy may facilitate the application of skin-sparing surgical techniques, while the increased tumor-to-nipple distance may reduce the risk of occult nipple involvement. Taken together, these findings support the feasibility of ENSM with immediate reconstruction in carefully selected patients with initially stage IIB breast cancer who demonstrate a favorable response to neoadjuvant treatment. Importantly, unlike most published ENSM series that focused primarily on stage 0–II disease, our cohort included patients with initially stage IIB breast cancer. Although based on a limited sample, the absence of recurrence or metastasis suggests that ENSM with immediate reconstruction may be feasible beyond traditional indications following a favorable response to neoadjuvant chemotherapy and careful multidisciplinary patient selection.

Despite these favorable oncological trends, we encountered several technical and surgical challenges associated with ENSM, axillary lymph node dissection, and immediate breast reconstruction using either implants or LD flaps. During the mastectomy phase, a limited incision through the SLNB site is used to achieve total glandular tissue removal while ensuring negative oncological margins. However, this narrow surgical corridor complicates thorough breast dissection. Axillary lymph node dissection was performed in 21.6% of patients following a positive SLNB. Limited surgical access often complicates the assessment of dissection limits within deep tissue planes, potentially resulting in incomplete resection. When employing an axillary endoscopic approach, space creation in the medial quadrants (upper-inner and lower-inner) is particularly challenging, attributed to the increased working distance and unfavorable instrument angles. To address these technical challenges, two primary strategies were employed. First, an additional 5-mm port was placed at the inframammary fold, enhancing instrument access and maneuverability for dissection and cauterization within the medial quadrants (Figure 4). Second, a hydrodissection technique was utilized, consisting of infiltration of a solution (500 mL normal saline with 1 mL adrenaline) into the subcutaneous fat layer, thereby creating a distinct plane between the skin and glandular tissue. This plane was further developed using sharp dissection prior to endoscopic space creation, thereby facilitating the subsequent procedure. Collectively, these approaches may improve procedural efficiency (32).

In our study, meticulous flap dissection under intraoperative ultrasound guidance facilitated accurate identification of the dissection plane and maintenance of a uniform skin flap thickness, thereby helping to balance oncologic safety and tissue perfusion. In addition, the use of endoscopic scissors rather than electrocautery during flap elevation may have preserved the subdermal vascular plexus and NAC perfusion by minimizing thermal injury. These technical considerations may have contributed to the favorable ischemic outcomes observed in our cohort.

Achieving adequate oncologic resection through a minimally invasive approach while preserving the integrity of the submuscular implant pocket represents a major technical challenge of this procedure. In our experience, an excessively tight prosthetic pocket generates substantial mechanical tension, which may complicate wound closure and increase the risk of pectoralis major muscle injury. Furthermore, excessive tension may adversely affect aesthetic outcomes by limiting lower-pole expansion and resulting in an unnatural postoperative breast contour. Our findings suggest that the use of either synthetic or biological matrices may help mitigate these challenges by reducing mechanical tension during pocket closure and providing additional support to the lower pole.

Beyond pocket design and reinforcement strategies, the choice of implant placement plane also warrants careful consideration. Although the prepectoral approach minimizes animation deformity, it has been associated with an increased risk of seroma formation. Conversely, subpectoral placement remains more susceptible to exercise-induced animation deformity. The relationship between implant profile and postoperative complications remains uncertain, with inconsistent findings reported across the current literature (33).

When evaluating the early clinical outcomes of endoscopic mastectomy, surgical complications and safety remain paramount. Nipple-sparing mastectomy is associated with superior aesthetic outcomes and enhanced postoperative psychological well-being. However, it carries a risk of NAC necrosis, which may adversely affect the final cosmetic result. The incidence of this complication is generally reported to range from 0% to 17.7% (34-36). To date, key concerns include the selection of the surgical approach, the extent of skin flap dissection, and techniques for subareolar tissue resection to minimize necrosis while reducing the risk of local recurrence. According to the technical recommendations by Stolier et al., three essential steps should be followed: an optimal incision should be established; subareolar dissection should be performed gently with meticulous point-by-point bipolar electrocautery for hemostasis; and excessive flap dissection beyond anatomical boundaries should be avoided to preserve the vascular supply to the breast skin flaps (36).

Nevertheless, complications in endoscopic breast procedures are generally similar to those observed in open surgery in both nature and incidence, with outcomes largely influenced by the surgical technique and reconstructive modality (37). Common complications include thermal skin injury and ecchymosis, often resulting from inadequate tissue protection, while seroma remains the most frequently reported adverse event (38). Infectious complications also warrant consideration. Surgical site infection rates generally range from 1% to 9% (39); however, substantially higher rates have been reported following mastectomy and breast reconstruction. Among patients with implant-based reconstruction who develop infection, approximately 10% ultimately require implant explantation (39).

In our study, nipple-areola complex ischemia occurred in two cases (1.5%). Both events were mild, limited to partial epidermal involvement, and likely associated with thin local flap dissection and extensive tissue harvesting beneath the areola. These patients were successfully managed with topical vaseline gauze dressings without surgical site compression. The ischemic changes resolved completely within one week postoperatively, without progression to full-thickness necrosis. No other complications, including postoperative seroma, hemorrhage, or implant rupture, were observed. No cases of surgical site infection were recorded. All patients received a 5–7-day course of postoperative antibiotics.

Beyond clinical safety, patient satisfaction serves as another critical indicator of successful reconstruction. Ueda et al. evaluated patient satisfaction using a 25-item survey administered to patients undergoing skin-sparing mastectomy with immediate reconstruction (n=71), total mastectomy (n=158), and breast-conserving surgery (n=154), with response rates of 70%, 77%, and 81%, respectively. The study found that skin-sparing mastectomy with immediate reconstruction was associated with low local recurrence rates, comparable to both breast-conserving surgery and total mastectomy. Furthermore, it yielded superior aesthetic outcomes, with satisfaction levels comparable to the breast-conserving surgery group and significantly higher than those observed in the total mastectomy group (19).

In our cohort, patient satisfaction was assessed postoperatively and at discharge. The implant group initially demonstrated a lower proportion of patients reporting high satisfaction compared to the LD flap group. This may be attributed to foreign body sensation and implant-related tissue tension during the early postoperative period (Table 6). At discharge, 20.0% of patients reported being “satisfied”, while 80.0% were “very satisfied” with their surgical outcomes. Patients in the “very satisfied” group expressed high contentment with the reconstruction, specifically noting a natural appearance and the absence of postoperative tension or pain. Those in the “satisfied” group reported general approval, albeit with mild discomfort related to residual pain and tightness. Notably, no patients required reoperation due to complications such as capsular contracture or infection.

Despite these favorable reconstructive outcomes, certain anatomical factors continue to present technical challenges for endoscopic breast surgery and may influence patient selection.

In addition to technical factors regarding implant placement, anatomical variations such as large or ptotic breasts present further constraints during endoscopic approaches. To overcome these anatomical constraints in complex breast profiles, robotic-assisted nipple-sparing mastectomy (R-NSM) has recently emerged as a promising alternative. While conventional E-NSM can be technically demanding in large or ptotic breasts due to the axillary camera position limiting access to the lower-inner quadrant, R-NSM utilizes a lower lateral incision beneath the axilla. This approach provides a wider visual field and improved instrument maneuverability, thereby facilitating smoother surgical dissection in patients with macromastia or breast ptosis.

Several institutional barriers may also limit the widespread adoption of this technique, including its learning curve and limited familiarity with the surgical workflow. Based on subjective clinical experience, technical proficiency and procedural confidence appeared to improve after approximately the first five cases, particularly among surgeons with prior experience in endoscopic breast surgery and advanced endoscopic dissection techniques. However, because operative times and objective performance metrics were not systematically assessed, no formal learning-curve analysis could be performed. Further prospective studies are therefore needed to validate these observations and better define the learning curve associated with this procedure. Furthermore, during the initial adoption phase, surgeons should avoid selecting patients with grade II or higher breast ptosis. Large and significantly ptotic breasts demand greater endoscopic expertise. For patients with minimal or no breast ptosis, this technique may be considered a first-line treatment option (16,18).

This study has several limitations. First, the relatively small sample size, particularly within the stage IIB subgroup, may limit the generalizability of the findings. Second, the median follow-up duration of 32 months is insufficient to fully assess long-term oncological outcomes, and larger studies with extended follow-up are needed to confirm the durability of these results. Third, operative performance metrics were not systematically recorded, precluding definitive conclusions regarding the learning curve despite subjective improvements in surgical proficiency over time. Finally, patient satisfaction was assessed only during the early postoperative period; therefore, studies incorporating validated patient-reported outcome measures and longer follow-up are warranted to better characterize long-term aesthetic outcomes, satisfaction, and quality of life.

Conclusions

Patients with early-stage breast cancer, small-to-medium breast volume, and no significant ptosis were selected. The findings suggest that E-NSM with immediate breast reconstruction and SLNB is a feasible and effective surgical option, short-term oncologic outcomes appeared acceptable. Proper patient selection focusing on early-stage tumors is associated with favorable surgical and aesthetic outcomes, sparing patients the need for total mastectomy. The use of polypropylene mesh to support the implant pocket allows for optimal volume expansion and achieves a more natural degree of breast ptosis after reconstruction. Furthermore, endoscopically assisted LD flap harvesting, aimed at minimizing donor-site scarring and surgical trauma, has emerged as a prominent trend over the past decade.

Most patients reported high satisfaction with their reconstruction outcomes. While achieving perfect anatomical symmetry remains challenging, the procedure yielded significant psychological benefits, enabling patients to resume their daily activities and substantially enhancing their post-cancer. Whether utilizing CO₂ insufflation or mechanical skin-lifting technique, endoscopic breast reconstruction appears to be a feasible and effective procedure. Selecting a technique appropriate to local institutional conditions is essential to achieving optimal outcomes and may help improve the overall quality of care for patients with early-stage breast cancer.

Our findings suggest that endoscopic approaches offer significant advantages for carefully selected patients. Future studies with extended follow-up are essential to validate long-term oncological outcomes and the durability of aesthetic results.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0287/rc

Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0287/dss

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0287/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-2026-0287/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. The study was conducted in accordance with the local legislation and institutional requirements. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Cho Ray Hospital Scientific Council (No. the registration number of ethics board) and informed consent was obtained from all individual participants.

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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