Secondary Logo

Journal Logo

Transaxillary Nipple-Sparing Mastectomy, Lymphadenectomy and Direct-to-Implant Submuscular Breast Reconstruction Using Endoscopic Technique

A Step toward the “Aesthetic Mastectomy”

Visconti, Giuseppe, M.D., Ph.D.; Franceschini, Gianluca, M.D.; Barone-Adesi, Liliana, M.D.; Bianchi, Alessandro, M.D.; Masetti, Riccardo, M.D., Ph.D.; Salgarello, Marzia, M.D.

Plastic and Reconstructive Surgery: May 2019 - Volume 143 - Issue 5 - p 1122e–1123e
doi: 10.1097/PRS.0000000000005542

Department of Plastic and Reconstructive Surgery

Breast Unit

Department of Plastic and Reconstructive Surgery

Breast Unit

Department of Plastic and Reconstructive Surgery, Catholic University of “Sacro Cuore”, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy

Supplemental digital content is available for this article. Direct URL citations appear in the text on; simply click the URL to access this material.

Correspondence to Dr. Visconti, Largo A. Gemelli 8, 00169 Rome, Italy,

Back to Top | Article Outline


We read with great interest the article by Sarfati et al. on robotic nipple-sparing mastectomy with immediate prepectoral implant reconstruction.1 The authors elegantly demonstrated their surgical technique for robotic nipple-sparing mastectomy using two vertically oriented incisions in the lateral thoracic breast area and their final reconstructive results.

In the last decade, nipple-sparing mastectomy has known an exponential diffusion worldwide for prophylaxis and for therapeutic mastectomies in selected candidates. It is oncologically safe, and improves reconstructive outcomes and patient satisfaction thanks to preservation of the entire breast envelope and footprint.

The two most common skin incisions are the radial and inframammary fold ones. They represent an imperfect solution between the oncologic/reconstructive needs (i.e., surgical control during mastectomy and preservation of skin and nipple-areola complex perfusion, along with mastectomy skin flap thickness control for prepectoral versus submuscular implant reconstruction) and the cosmetic outcomes (scar visibility).2,3

The increasing demand for further cosmetic outcome improvement led the surgeons to move the access far from the breast footprint in the search for the ideal incision for nipple-sparing mastectomy, as also shown by Sarfati et al., who used a lateral thoracic approach.

We believe that the ideal nipple-sparing mastectomy incision is the axillary one. This single access allows us to perform a safe, nonendoscopic mastectomy in A and B cup breasts, node surgery, and nonendoscopic immediate prepectoral reconstruction when feasible (i.e., thick skin flaps) or endoscopic submuscular-subfascial direct-to-implant reconstruction, with the main advantage of a hidden and well-concealed scar. In our experience, a 6-cm incision located on the lowest axillary fold along the midaxillary line allows a safe, nonendoscopic mastectomy using a long blade (19 cm) light retractor. First, the mastectomy skin flap is incrementally elevated from breast tissue, and retroareolar tissue is excised and sent for frozen section analysis; then the entire gland is elevated on the prepectoral plane, preserving the superficial pectoralis fascia. The gland is then completed detached by joining the inferolateral and superomedial border detachment. The same axillary incision is conveniently used for node surgery. Finally, an operative rigid endoscope with working channel (Richard Wolf, Vernon Hills, Ill.) is used to dissect the entire submuscular-subfascial pocket, and a definitive, anatomical, textured breast implant is inserted. The cosmetic outcome is very pleasant for both the surgeon and the patient, with the main advantage of a “scarless” mastectomy [Fig. 1 and Figure, Supplemental Digital Content 1, which shows a 43-year-old patient planned for transaxillary right breast nipple-sparing mastectomy for breast cancer and direct-to-implant submuscular endoscopic reconstruction and contralateral symmetrization with implant (above) and a 1-year postoperative view of pleasant cosmetic outcomes and a well-hidden mastectomy scar (below),].

Fig. 1

Fig. 1

Although transaxillary endoscopic breast augmentation is nowadays a very common procedure, the few reports available on transaxillary mastectomy and direct-to-implant reconstruction are from Asian colleagues reporting endoscope-assisted mastectomies mainly for subcutaneous mastectomies (prophylaxis) rather than for therapeutic nipple-sparing mastectomy.4,5 This is very likely due to a more technically challenging procedure, as stated by Sarfati and colleagues,1 which in our opinion can be overcome by using a nonendoscopic mastectomy technique in small to moderate-sized breasts.

In conclusion, we believe that transaxillary incision for nipple-sparing mastectomy, node surgery, and direct-to-implant reconstruction may lead to safe and satisfactory outcomes in small to moderate-sized breasts, eliminating the stigmata of the oncologic procedure (i.e., no scar on and around breast area) and thus likely representing a step toward the “aesthetic mastectomy.”

Back to Top | Article Outline


The authors have no financial interests to disclose.

Giuseppe Visconti, M.D., Ph.D.

Department of Plastic and Reconstructive Surgery

Gianluca Franceschini, M.D.

Breast Unit

Liliana Barone-Adesi, M.D.

Alessandro Bianchi, M.D.

Department of Plastic and Reconstructive Surgery

Riccardo Masetti, M.D., Ph.D.

Breast Unit

Marzia Salgarello, M.D.

Department of Plastic and Reconstructive Surgery

Catholic University of “Sacro Cuore”

Fondazione Policlinico Universitario

“Agostino Gemelli” IRCCS

Rome, Italy

Back to Top | Article Outline


1. Sarfati B, Struk S, Leymarie N, et al. Robotic nipple-sparing mastectomy with immediate prosthetic breast reconstruction: Surgical technique. Plast Reconstr Surg. 2018;142:624–627.
2. Salgarello M, Visconti G, Barone-Adesi L. Nipple-sparing mastectomy with immediate implant reconstruction: Cosmetic outcomes and technical refinements. Plast Reconstr Surg. 2010;126:1460–1471.
3. Odom EB, Parikh RP, Um G, et al. Nipple-sparing mastectomy incisions for cancer extirpation prospective cohort trial: Perfusion, complications, and patient outcomes. Plast Reconstr Surg. 2018;142:13–26.
4. Owaki T, Kijima Y, Yoshinaka H, et al. Present status of endoscopic mastectomy for breast cancer. World J Clin Oncol. 2015;6:25–29.
5. Ho WS, Ying SY, Chan AC. Endoscopic-assisted subcutaneous mastectomy and axillary dissection with immediate mammary prosthesis reconstruction for early breast cancer. Surg Endosc. 2002;16:302–306.
Back to Top | Article Outline


Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Letters submitted should pose a specific question that clarifies a point that either was not made in the article or was unclear, and therefore a response from the corresponding author of the article is requested.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

The Journal requests that individuals submit no more than five (5) letters to Plastic and Reconstructive Surgery in a calendar year.

Supplemental Digital Content

Back to Top | Article Outline
©2019American Society of Plastic Surgeons