Aesthetic Scar-Less Mastectomy and Breast Reconstruction

Abstract

Surgical approaches in breast cancer have been changing to ensure both oncologic safety and cosmetic results. Although the concept of "oncoplastic breast surgery" has been accepted for decades, breast and plastic surgeons have been striving to develop more advanced surgical skills that ensure non-inferior oncologic outcomes with better cosmetic outcomes. Endoscopic or robotic devices, which are currently available only for chest or abdominal surgeries, could be used for breast surgery to ensure better cosmetic outcomes. The authors refer to this surgical concept as "aesthetic scar-less breast surgery and reconstruction," a term that encompasses the consequential concepts rather than naming it with simple technical words such as endoscopy-assisted or robot-assisted surgery. The "scar-less" term simply means leaving less of a scar, and better results can be expected by designing incisions on invisible areas. Herein, we summarize our experiences with various techniques of "aesthetic scar-less" surgery and review the existing literature on this topic.

Keywords: Breast neoplasms; Esthetic; Mastectomy; Reconstructive surgical procedures.

Figure 1. “Aesthetic scar-less” breast-conserving surgery (dotted color circles) and partial mastectomy (solid color circles). The incisions during “aesthetic scar-less” breast-conserving surgery or partial mastectomy are designed in an area that can be easily hidden, such as the inframammary fold (A), axillary area (B), or periareolar line (C, D). When primary closure is difficult, the glandular flap can be performed after partial mastectomy.

Figure 2. Postoperative view of “aesthetic scar-less” breast-conserving surgery. The symmetry and shape of the ipsilateral breast is well maintained, with a rarely visible scar in the periareolar line.

Figure 3. The surgical process of absorbable implant insertion using oxidized regenerated cellulose (Interceed^® or Fibrillar^®). After removal of the breast tumor, the absorbable implant was inserted to fill the defect, and subcutaneous fat and dermis were closed using a layer-by-layer technique.

Figure 4. “Aesthetic scar-less” breast reconstruction using a mini LD flap after partial mastectomy. (A, B) Endoscopy-assisted breast reconstruction using a mini-LD flap after partial mastectomy. Operative view and intraoperative endoscopic view during dissection at the lateral border of the LD flap. (C, D) Robot-assisted breast reconstruction using a mini-LD flap after partial mastectomy. Operative view and intraoperative robotic scope view during dissection of the inferior border of the LD flap.

LD = latissimus dorsi.

Figure 5. Cosmetic outcomes of endoscopy-assisted breast reconstruction using the mini LD flap after partial mastectomy. (A) Preoperative view. (B) Immediate postoperative lateral view 3 days after surgery. Only a small lateral incision (arrow) remains for harvesting the endoscopy-assisted mini-LD flap. (C, D) Five months postoperative view after radiotherapy (anteroposterior and lateral views).

LD = latissimus dorsi.

Figure 6. (A-C) 1-year postoperative views of immediate breast reconstruction using laparoscopically harvested omental flap.

Figure 7. “Aesthetic scar-less” nipple-sparing mastectomy. (A) The incisions during “aesthetic scar-less” nipple-sparing mastectomy can be designed at the axillary crease (purple line), mid-axillary line (blue line), inframammary fold (green line), and periareolar line (red line), depending on the breast shape and ptosis. (B) Periareolar incision is performed for “aesthetic scar-less” nipple-sparing mastectomy. Typically, the mastectomy skin flap is dissected first from the incision, and the retromammary layer is dissected later. (C, D) The axillary incision (purple) and inframammary incision (green) can be used for “aesthetic scar-less” nipple-sparing mastectomy.

Figure 8. “Aesthetic scar-less” nipple-sparing mastectomy with breast reconstruction. (A, B) Endoscopy-assisted nipple-sparing mastectomy with breast reconstruction. Operative view and immediate postmastectomy view with specimen. (C, D) Robot-assisted nipple-sparing mastectomy with breast reconstruction. Operative view and immediate postmastectomy view with pulling of the breast specimen.

Figure 9. Robot-assisted breast reconstruction using an implant after nipple-sparing mastectomy (BellaGel BRSZ-L 175 mL, BellaCell HD 6 × 16 cm; subpectoral technique). (A) Preoperative view. (B, C) Ten-month postoperative findings after robot-assisted breast reconstruction using an implant (anteroposterior and lateral views). Only a small lateral incision (arrow) remains, not only for breast reconstruction but also for nipple-sparing mastectomy with sentinel lymph node biopsy.