Reverse‑sequence endoscopic nipple‑sparing mastectomy with direct‑to‑implant breast reconstruction and air inflation adjustment technique in patients with large or severely ptotic breast: a single-center prospective cohort study

Background: The applicability of reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with direct-to-implant breast reconstruction (DIBR) is worth exploring in patients with large or severely ptotic breasts (LSPB) who were not recommended or even considered contraindicated in open NSM, conventional endoscopic NSM, and robotic NSM. The study aimed to compare the safety and aesthetic outcomes between patients with LSPB and non-LSPB (NLSPB) undergoing R-E-NSM with DIBR. Materials and methods: The single-center prospective cohort study enrolled 562 patients undergoing R-E-NSM and DIBR. Surgical safety, aesthetic outcomes, and oncologic safety were compared between patients with LSPB and NLSPB. Results: After propensity score matching, 88 LSPB patients and 256 NLSPB patients were included (median [IQR] follow-up time: 21.0 [13.8, 32.4] vs. 23.0 [10.6, 32.2] months, P = 0.889). The mastectomy weight was significantly higher in the LSPB group (576.6 ± 144.8 g vs. 330.1 ± 105.7 g, P < 0.001). There were no significant differences in any complications (27.3% vs. 22.7%, P = 0.381), major complications (6.8% vs. 3.1%, P = 0.230), minor complications (20.5% vs. 21.1%, P = 0.889) and implant-related complications (21.6% vs. 24.6%, P = 0.566) between the LSPB and the NLSPB groups. In the LSPB group, the Ueda scores in patients with air inflation adjustment technique (AIAT) were better than those without AIAT, though no significant difference (P = 0.110). Compared to the NLSPB group without AIAT, the LSPB group with AIAT had similar Ueda scores (P = 0.870) and a significantly higher increase in BREAST-Q scores of breast satisfaction (P = 0.004). Oncologic outcomes had no significant difference between the two groups (all P>0.05). Conclusion: R-E-NSM with DIBR and AIAT provides comparable surgical safety and aesthetic outcomes for patients with LSPB and NLSPB, offering a new option for LSPB patients.