Annals of Surgical Oncology

, Volume 25, Issue 9, pp 2579–2586 | Cite as

Robotic Prophylactic Nipple-Sparing Mastectomy with Immediate Prosthetic Breast Reconstruction: A Prospective Study

  • Benjamin Sarfati
  • Samuel StrukEmail author
  • Nicolas Leymarie
  • Jean-François Honart
  • Heba Alkhashnam
  • Kim Tran de Fremicourt
  • Angelica Conversano
  • Françoise Rimareix
  • Marie Simon
  • Stefan Michiels
  • Frédéric Kolb
Breast Oncology



Robotic nipple-sparing mastectomy (RNSM) could be a significant advancement in the treatment of breast cancers and prophylaxis because the mastectomy is performed without leaving any scar on the breast. The aim of this study was to assess the feasibility and the safety of RNSM with immediate prosthetic breast reconstruction (IPBR).


In this prospective study, RNSM with IPBR was offered to patients with breast cup size A, B or C and ptosis grade ≤ 2. In case of oncologic surgery, RNSM was proposed only if the tumor was located more than 2 cm away from the nipple-areola complex (NAC) and if postoperative radiation was not indicated. In case of prophylactic surgery, RNSM was proposed only if a high-risk genetic mutation had been identified. The primary endpoint was the rate of skin or NAC necrosis. The rate of conversion to open technique, the duration of the procedure, and postoperative complications were also analyzed.


Sixty-three RNSM with IPBR were performed in 33 patients. There were no cases of mastectomy skin flap or NAC necrosis. We had to convert to an open technique in one case (1.6%). Three infections occurred (4.8%), one leading to implant loss (1.6%). No other major complications were observed.


Preliminary data attest to the feasibility, the reproducibility, and the safety of this approach. However, long-term data are needed to confirm the oncological safety and the esthetic stability of the result.

Trial registration identifier NCT02673268.



The authors thank the members of the IDMC and Anthony Mangin for data management.

Supplementary material

10434_2018_6555_MOESM1_ESM.png (1.4 mb)
Supplemental Fig. 1 Preoperative drawings. A lateral-thoracic approach is associated with a high vertical scar of 3 to 5 cm, located within the footprint of the bra, with a subcentimeter vertical scar, located 8 to 9 cm below the previous incision. These incisions are located 6 to 7 cm posterior from the lateral-mammary fold (PNG 1404 kb)
10434_2018_6555_MOESM2_ESM.png (1.7 mb)
Supplemental Fig. 2 Robot docking. Robot docking is guided by the target sign, which has to be aligned both with the skin incision and the nipple (PNG 1726 kb)
10434_2018_6555_MOESM3_ESM.png (1.5 mb)
Supplemental Fig. 3 Carbon dioxide insufflation. Carbon dioxide insufflation creates a working space and replaces the retractors used in the open technique (PNG 1495 kb)
10434_2018_6555_MOESM4_ESM.png (1015 kb)
Supplemental Fig. 4 Robotic dissection of the gland. Dissection is performed with monopolar-curved scissors whereas traction, counter-traction, exposure, and cauterization are carried out using bipolar grasping forceps. Subcutaneous dissection of the gland (A) is completed in a lateral to medial direction, up to the limits of the gland. Then, the gland is separated from the pectoralis major muscle (B) in a lateral to medial direction (PNG 1015 kb)
10434_2018_6555_MOESM5_ESM.png (1013 kb)
Supplemental Fig. 5 Preoperative photographs of the 14th patient (PNG 1012 kb)
10434_2018_6555_MOESM6_ESM.png (1024 kb)
Supplemental Fig. 6 Three-month postoperative photographs after bilateral RNSM with IPBR (PNG 1023 kb)
10434_2018_6555_MOESM7_ESM.png (1.3 mb)
Supplemental Fig. 7 Appearance of the scar (PNG 1352 kb)
10434_2018_6555_MOESM8_ESM.png (1.1 mb)
Supplemental Fig. 8 Preoperative photographs of the 16th patient(PNG 1079 kb)
10434_2018_6555_MOESM9_ESM.png (1 mb)
Supplemental Fig. 9 Three-month postoperative photographs after bilateral RNSM with IPBR (PNG 1063 kb)
10434_2018_6555_MOESM10_ESM.png (1 mb)
Supplemental Fig. 10 Preoperative photographs of the 19th patient (PNG 1040 kb)
10434_2018_6555_MOESM11_ESM.png (1008 kb)
Supplemental Fig. 11 Three-month postoperative photographs after bilateral RNSM with IPBR (PNG 1008 kb)
10434_2018_6555_MOESM12_ESM.png (1020 kb)
Supplemental Fig. 12 Preoperative photographs of the 20th patient (PNG 1019 kb)
10434_2018_6555_MOESM13_ESM.png (950 kb)
Supplemental Fig. 13 Three-month postoperative photographs after bilateral RNSM with IPBR (PNG 950 kb)
10434_2018_6555_MOESM14_ESM.png (1.3 mb)
Supplemental Fig. 14 Appearance of the scar (PNG 1343 kb)
10434_2018_6555_MOESM15_ESM.png (1 mb)
Supplemental Fig. 15 Preoperative photographs of the 25th patient (PNG 1041 kb)
10434_2018_6555_MOESM16_ESM.png (993 kb)
Supplemental Fig. 16 Three-month postoperative photographs after bilateral RNSM with IPBR (PNG 993 kb)
10434_2018_6555_MOESM17_ESM.png (1.3 mb)
Supplemental Fig. 17 Appearance of the scar (PNG 1327 kb)
10434_2018_6555_MOESM18_ESM.png (861 kb)
Supplemental Fig. 18 Six months after the first fat grafting session (PNG 861 kb)


  1. 1.
    Endara M, Chen D, Verma K, et al. Breast reconstruction following nipple-sparing mastectomy: a systematic review of the literature with pooled analysis. Plast Reconstr Surg. 2013;132:1043–54.CrossRefPubMedGoogle Scholar
  2. 2.
    Headon HL, Kasem A, Mokbel K. The oncological safety of nipple-sparing mastectomy: a systematic review of the literature with a pooled analysis of 12,358 procedures. Arch Plast Surg. 2016;43:328–38.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Choi M, Frey JD, Alperovich M, et al. “Breast in a Day”: examining single-stage immediate, permanent implant reconstruction in nipple-sparing mastectomy. Plast Reconstr Surg. 2016;138:184e–91e.CrossRefPubMedGoogle Scholar
  4. 4.
    De Vita R, Zoccali G, Buccheri EM, et al. Outcome evaluation after 2023 nipple-sparing mastectomies: our experience. Plast Reconstr Surg. 2017;139:335e–47e.CrossRefPubMedGoogle Scholar
  5. 5.
    Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing mastectomy with immediate implant reconstruction: cosmetic outcomes and technical refinements. Plast Reconstr Surg. 2010;126:1460–71.CrossRefPubMedGoogle Scholar
  6. 6.
    Qureshi AA, Odom EB, Parikh RP, et al. Patient-reported outcomes of aesthetics and satisfaction in immediate breast reconstruction after nipple-sparing mastectomy with implants and fat grafting. Aesthet Surg J. 2017;37:999–1008.CrossRefPubMedGoogle Scholar
  7. 7.
    Donovan CA, Harit AP, Chung A, et al. Oncological and surgical outcomes after nipple-sparing mastectomy: do incisions matter? Ann Surg Oncol. 2016;23:3226–31.CrossRefPubMedGoogle Scholar
  8. 8.
    Choi M, Frey JD, Salibian AA, et al. Nipple-areola complex malposition in nipple-sparing mastectomy: a review of risk factors and corrective techniques from greater than 1000 reconstructions. Plast Reconstr Surg. 2017;140:247e–57e.CrossRefPubMedGoogle Scholar
  9. 9.
    Lai H-W, Chen S-T, Chen D-R, et al. Current trends in and indications for endoscopy-assisted breast surgery for breast cancer: results from a six-year study conducted by the Taiwan Endoscopic Breast Surgery Cooperative Group. PLoS One. 2016;11:e0150310.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Leff DR, Vashisht R, Yongue G, et al. Endoscopic breast surgery: where are we now and what might the future hold for video-assisted breast surgery? Breast Cancer Res Treat. 2011;125:607–25.CrossRefPubMedGoogle Scholar
  11. 11.
    Tukenmez M, Ozden BC, Agcaoglu O, et al. Videoendoscopic single-port nipple-sparing mastectomy and immediate reconstruction. J Laparoendosc Adv Surg Tech A. 2014;24:77–82.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Toesca A, Peradze N, Galimberti V, et al. Robotic nipple-sparing mastectomy and immediate breast reconstruction with implant: first report of surgical technique. Ann Surg. 2017;266(2):e28–e30.CrossRefPubMedGoogle Scholar
  13. 13.
    Toesca A, Peradze N, Manconi A, et al. Robotic nipple-sparing mastectomy for the treatment of breast cancer: feasibility and safety study. Breast. 2017;31:51–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Sarfati B, Honart JF, Leymarie N, et al. Robotic-assisted nipple sparing mastectomy: a feasibility study on cadaveric models. J Plast Reconstr Aesthet Surg. 2016;69:1571–2.CrossRefPubMedGoogle Scholar
  15. 15.
    Moss E, Halkos ME. Cost effectiveness of robotic mitral valve surgery. Ann Cardiothorac Surg. 2017;6:33–7.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Schroeck FR, Jacobs BL, Bhayani SB, et al. Cost of new technologies in prostate cancer treatment: systematic review of costs and cost effectiveness of robotic-assisted laparoscopic prostatectomy, intensity-modulated radiotherapy, and proton beam therapy. Eur Urol. 2017;72:712–35.CrossRefPubMedGoogle Scholar
  17. 17.
    Manciu S, Dragomir M, Curea F, et al. A solution in search of a problem: a Bayesian analysis of 343 robotic procedures performed by a single surgical team. J Laparoendosc Adv Surg Tech A. 2017;27:363–74.CrossRefPubMedGoogle Scholar
  18. 18.
    Clemens MW, Kronowitz S, Selber JC. Robotic-assisted latissimus dorsi harvest in delayed-immediate breast reconstruction. Semin Plast Surg. 2014;28:20–5.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Selber JC. Robotic latissimus dorsi muscle harvest. Plast Reconstr Surg. 2011;128:88e–90e.CrossRefPubMedGoogle Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Benjamin Sarfati
    • 1
  • Samuel Struk
    • 1
    Email author
  • Nicolas Leymarie
    • 1
  • Jean-François Honart
    • 1
  • Heba Alkhashnam
    • 1
  • Kim Tran de Fremicourt
    • 1
  • Angelica Conversano
    • 1
  • Françoise Rimareix
    • 1
  • Marie Simon
    • 2
    • 3
  • Stefan Michiels
    • 2
    • 3
  • Frédéric Kolb
    • 1
  1. 1.Service de Chirurgie Plastique et ReconstructriceGustave RoussyVillejuifFrance
  2. 2.Service de Biostatistique et d’EpidémiologieGustave RoussyVillejuifFrance
  3. 3.CESP, Inserm U1018Univ. Paris Sud, Univ. Paris-SaclayVillejuifFrance

Personalised recommendations