Robot-assisted Mastectomy Followed by Immediate Autologous Microsurgical Free Flap Reconstruction: Techniques and Feasibility in Three Different Breast Cancer Surgical Scenarios

Abstract Nipple-sparing mastectomy (NSM) and immediate breast reconstruction has been proven to be a safe and reliable procedure in selected breast cancer patients with better aesthetic outcome. Robot-assisted nipple-sparing mastectomy (R-NSM), facilitated by articulated instruments and 3-dimensional camera, further allows mastectomy and reconstruction to be accomplished through a smaller incision over the lateral chest wall with complete preservation of the breast skin envelope without anterior scar. The small incision of R-NSM has limited the reconstructions to be implant- or small pedicle flap-based. Perforator flaps, with the most natural-looking and permanent results, have never been applied in R-NSM. In this preliminary report, microsurgical breast reconstruction with free deep inferior epigastric artery perforator (DIEP) flap (N=1) or profunda artery perforator (PAP) flaps (N=2) were performed successfully along with R-NSM. One patient had nipple-areolar excision due to positive nipple margin under frozen section, but the reconstructed nipple using PAP flap skin paddle successfully concealed the peri-areolar scar. Two patients received post-mastectomy radiotherapy (PMRT) because of more extensive cancer involvement. The flaps tolerated PMRT well without contracture or compromised aesthetic results. Microsurgical breast reconstruction is feasible after R-NSM and provides additional oncological and aesthetical advantages. Compared to breast implants, autologous tissue tolerates radiotherapy better and can be transferred safely when PMRT is required. These novel approaches brought robot-assisted mastectomy to its next level with wider clinical applications free of restriction to early breast cancer. Larger series report and longer follow-up should be anticipated to prove its clinical value.