From
Dr. Paula Escobar
Endoscopic nipple-sparing mastectomy: minimally invasive breast cancer surgery
With Dr. Paula Escobar · hosted by Dr. Dale Shepherd
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
1999 was the first nipple-sparing mastectomy reported.
Dr. Crowe at Cleveland Clinic was one of the pioneers who developed the open/conventional nipple-sparing mastectomy technique.
Endoscopic nipple-sparing mastectomy uses the same technique as conventional nipple-sparing mastectomy but with different tools (minimally invasive approach with less scarring).
The incision is placed in the mid-axillary line hidden by the arm or in the submammary fold, making it completely invisible.
The procedure involves inflating/expanding the breast with CO2, then introducing laparoscopic instruments through a single incision to remove breast tissue while preserving the envelope.
Immediate breast reconstruction is attempted at the time of mastectomy, with plastic surgeons adjusting their technique to work through the smaller incision.
The current endoscopic technique has approximately 5 years of history in its present form.
Minimally invasive breast surgery started in Asian countries approximately 20 years ago using mechanical arms to lift the breast, but early attempts had complications in skin flaps and nipples due to limited technology.
The technique developed in Europe (France, Spain, Italy) using CO2 insufflation and is now being learned in the US.
Very few surgeons in the US currently perform endoscopic nipple-sparing mastectomy, making it difficult for patients to access.
Three hands-on simulated model courses have been held in the US to train surgeons in the technique.
Cleveland Clinic has trained multiple surgeons in the endoscopic technique, with Dr. Escobar helping to train colleagues.
Robotic breast surgery takes a long time, requires a robot, has a long learning curve, and is not FDA approved (currently only available in trials at limited US centers).
Endoscopic surgery uses instruments already available for abdominal/hernia surgery, requiring no special equipment purchases.
Operating time for endoscopic surgery, when experienced, is similar to open/conventional surgery.
Indications for endoscopic nipple-sparing mastectomy are very similar to conventional nipple-sparing mastectomy.
Patients are not good candidates if tumor involves the skin, is very close to the muscle, is very close to the nipple, or involves the skin.
Best candidates have cup A, B, or C breasts (not larger breasts at current learning curve stage).
Procedure is performed on patients with no ptosis or ptosis grade 1 or 2, as higher grades result in poor cosmetic outcomes.
Patient advantages include superior cosmetic outcome, hidden/invisible scar, and likely quicker recovery with less pain (similar to laparoscopic vs open abdominal surgery).
Preliminary studies suggest patients have better sensation in the nipple and mastectomy skin flap, though quality trials are needed.
Initial patients have been very happy with the procedure and recovered very quickly.
Oncological safety of conventional nipple-sparing mastectomy has been proven by data.
Endoscopic technique may be better than conventional because the magnified screen visualization allows better handling of the mastectomy skin flap and improved visualization of breast tissue behind the nipple and axillary tail.
No insurance coverage problems have occurred; procedure is coded as skin-sparing mastectomy since no specific code exists yet.
Cleveland Clinic has performed endoscopic nipple-sparing mastectomy with endoscopically-assisted sentinel node retrieval through a single incision.
Future applications include axillary dissection and lumpectomy for tumors in inner portions of the breast (scar in axilla instead of breast).
The technique has been used for gynecomastia surgery in one male patient.
Dr. Escobar predicts widespread adoption will occur similar to laparoscopic cholecystectomy, driven by patient experience, outcomes, and faster recovery.