Endoscopic Total Mastectomy Followed by Immediate Free Abdominal-based Flap Reconstruction: A Preliminary Experience Describing a Novel Approach to the “Aesthetically Scarless” Mastectomy

Abstract Background: Endoscopic total mastectomy (ETM) is predominantly offered with reconstruction utilizing prostheses, latissimus dorsi flap, omental flap, lipofilling, or a combination of techniques. Common approaches include periareolar, axillary or mid-axillary line incisions, which limits the technical ability to perform flap inset and microvascular anastomoses, as such the ETM with free abdominal-based flap reconstruction as not been robustly explored. Materials and Methods: We studied all female patients with breast cancer who received ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, type of surgery, complications, rate of recurrence, and aesthetic outcomes were reviewed. Results: 12 patients underwent ETM with pedicled or free abdominal-based flap reconstruction. Mean age was 53.4 years old (range: 36 - 65 years). 92.3% successfully received endoscopic NSM and 7.7% underwent conversion to SSM Mean tumor size was 35.4mm (range: 1 – 67mm). 33.3% of cancers were stage I cancer, 58.4% stage II, and 8.3% stage III. Mean specimen weight was 458.75g (range: 242 - 800g). Mean operative time for ETM was 139 minutes (range: 92 - 198 minutes) and average ischemic time was 37.3 minutes (range: 22-50 minutes). No cases required re-exploration, no cases of flap failure occurred, margins were clear, no skin or nipple-areolar complex ischemia or necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and 0% unsatisfactory. No recurrence was observed. Conclusion: ETM through a minimal-access inferior-mammary or mid-axillary line approach, followed by immediate Pedicled TRAM or Free AFR, is a safe means of achieving an “aesthetically scarless” mastectomy and reconstruction.