Mastectomy with Immediate Breast Reconstruction with or without Robotic Surgery: Results of 310 Consecutive Patients in 2-Years

Special Article – Robotic Surgery

Austin J Surg. 2019; 6(23): 1224.

Mastectomy with Immediate Breast Reconstruction with or without Robotic Surgery: Results of 310 Consecutive Patients in 2-Years

Houvenaeghel G1*, Bannier M2, Van Troy A2, Rua S2, Barrou J2, Heinemann M1, Buttarelli M2, Jauffret Fara C2, Lambaudie E1 and Cohen M2

¹Department of surgical oncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille Universitey, France

²Department of surgical oncology, Paoli Calmettes Institute, France

*Corresponding author: Gilles Houvenaeghe, Department of surgicaloncology, Paoli Calmettes Institute and CRCM, CNRS, INSERM, Aix Marseille University, France

Received: September 03, 2019; Accepted: October 24, 2019; Published: October 31, 2019


Background: Immediate Breast Reconstruction (IBR) is offered according to patient’s wishes, previous treatment, breast cup-size and ptosis. We analyze a 2-years’ experience of consecutive patients with IBR after Skin-Sparing- Mastectomy (SSM) or Nipple-Sparing-Mastectomy (NSM) with or without robotic procedure.

Methods: Among 854 mastectomies we performed 310 IBR (36.3%). Characteristics of patients and surgery, complication rate, time of surgery, Post- Operative Hospitalization (POH) stay were determined.

Results: NSM were realized in 112 patients (36.1%). Implant-IBR was performed for 211 patients (68.1%) and Latissimus-Dorsi-Flap (LDF) for 99 patients (31.9%): robotic-NSM in 22.3% (25/112) of NSM, robotic LDF in 60.6% (60/99). Significant factors associated with LDF-IBR were BMI 25-29.9 and ›30 (OR=2.749 and 4.027), previous radiotherapy (OR=7.313) and neoadjuvant- chemotherapy (OR=4.839). The overall complication rate was 31.9% (99/310) with 29 re-operations (9.4%). Significant factors associated with any complication were cup-size›C (OR=2.165), LDF-IBR (OR=3.990), robotic-NSM (OR=3.953). Complications rates grade 2-3-4 were: 10.3% (32/310) for breast complications and 2.0% (2/99) for LDF. Implant loss rate was 4.6% (11/237). Significant factors associated with Grade 2-3 breast complications were robotic- NSM (OR=5.983) and tobacco (OR=2.234). Significant factors associated with POH›3-days were LDF-IBR (OR=21.77) and mastectomy for ipsilateral-localrecurrence (OR=5.786). Significant factors associated with time of surgery ›180mn were cup-size›C (OR=3.581), LDF-IBR (OR=779) and bilateral mastectomy (OR=9.335).

Conclusion: We reported a high rate of IBR and NSM and an increase of LDF reconstruction. IBR for ipsilateral -local-recurrence with LDF was the preferred procedure. Robotic-LDF reconstruction without dorsal scar was realized in 60.6% of patients with a low complication rate.

Keywords: Immediate breast reconstruction; Breast cancer; Robotic surgery; Mastectomy


IBR: Immediate Breast Reconstruction; SSM: Skin-Sparing- Mastectomy; NSM: Nipple-Sparing-Mastectomy; POH: Post- Operative Hospitalization; LDF: Latissimus-Dorsi-Flap; BC: Breast Cancer; NAC: Neo-Adjuvant Chemotherapy; ILBCR: Ipsilateral Local BC-Recurrence; BMI: Body Mass Index; PMRT: Post Mastectomy Radiotherapy; ALND: Axillary Lymph Node Dissection; DCIS: Ductal Carcinoma In Situ; DIEP: Deep Inferior Epigastric Perforator; TRAM: Transverse Rectus Abdominis Musculocutaneous; ERAS: Enhanced Recovery After Surgery.


Mastectomy with Immediate Breast Reconstruction (IBR) is a surgical strategy in Breast Cancer (BC) when breast-conserving surgery is not an option. This treatment strategy is also increasingly being used after Neo-Adjuvant Chemotherapy (NAC). In Skin- Sparing Mastectomy (SSM) the gland is removed and the whole breast skin is preserved. In Nipple-Sparing Mastectomy (NSM), the Nipple-Areolar Complex (NACx) is preserved as well as the skin. These conservative mastectomies are associated with superior aesthetic outcomes and patient satisfaction compared to nonconservative mastectomy. In a recent French large prospective study, satisfaction with the cosmetic outcome strongly influenced quality of life and an unsatisfactory outcome after IBR was still considered a better condition than simple mastectomy [1]. However, potential disadvantages include residual breast tissue under NACx or under the skin flaps and an increased risk of mastectomy skin flap or NAC necrosis [2].

In the US, variable rates of breast reconstruction were reported, depending a great deal on where patients lived, what kind of health insurance they had, how much money they made, and her race/ ethnicity [3]. In France, all reconstruction fees can be without financial charge for patients. Reconstruction with implant or Latissimus Dorsi- Flap (LDF) is usually proposed according to patient’s wishes, previous treatment, breast cup-size and ptosis. Moreover, since a few years’ robotic mastectomy and or robotic LDF-IBR has been proposed [4- 10]. The purpose of this study was to analyze a 2-year experience of consecutive patients with IBR after SSM or NSM with or without robotic procedure. The main aim of this study was feasibility and complications rates.

Materials & Methods

During 2-years (2016-17), 854 mastectomies were performed, including 310 with IBR (36.3%): 229 IBR among 690 mastectomies for primary BC (33.2%), 45 IBR among 126 mastectomies for ipsilateral local BC-recurrence (ILBCR) (35.7%) and 36 IBR for prophylactic mastectomy. For primary BC, 30 IBR were performed among 144 patients after NAC (20.8%) and 199 IBR among 546 patients without NAC (36.4%). This present study report retrospective analysis of 310 patients with IBR from institutional BC data base with distinction between robotic or non-robotic surgery. A program of robotic breast surgery has been started in February 2016 [11]. All patients were informed of robotic assistance surgery. Our institutional ethical committee approved robotic breast surgery procedures.

NSM had been undertaken for prophylactic mastectomy and for BC with a minimal 2 centimeters tumor-nipple distance on mammography and or MRI. Robotic muscular latissimus flap without skin-island was used for NSM and for SSM or wise pattern skin reducing mastectomy in order to avoid dorsal scar after patient’s information and choice. Robotics surgeries were achieved by two surgeons and the determination between robotic assisted or conventional surgery was in relation with availability of robotic operative room and choice of surgeon. Allocation of breast reconstruction operation type was depending patient’s wishes and surgeon’s choice in relation with breast volume and ptosis. We define autologous LDF or muscular latissimus flap as muscular flap harvested with fat around muscle and non-autologous LDF when fat around muscle was not harvested. At the end of robotic NSM, a biopsy of retro NACx tissue was performed and complete gland removal verification through axillar incision was systematically achieved [11].

Characteristics of patients and surgery were determined by age, BMI, indication of mastectomy, bilateral mastectomy, type of IBR and mastectomy, axillary surgery, ASA status, year of surgery, previous radiotherapy, NAC, previous conservative ipsilateral surgery, breast cup-size, mastectomy weight, tobacco use, diabetes, robotic mastectomy and/or robotic LDF (DaVinci SI or XI), bilateral mastectomy, Post-Operative Hospitalization (POH) stay, time of anesthesia and surgery. Breast cup-size had been compared with mastectomy weight in order to validate this qualitative criterion. Complication rate was analyzed with Clavien-Dindo grading [12] for all patients, for breast complications and for dorsal complications respectively. Grade 3 corresponded to any complication which requires re-operation and Grade 4 corresponded to severe general infection. Grade 1 or 2 complications corresponded to infection or dehiscence or hematoma or bleeding or skin necrosis but without necessity of re-operation.

The duration of anesthesia was recorded from anesthesia induction to tracheal extubation including pectoral bloc local anesthesia and the duration of surgery included all procedures and the times for changing surgical postures, from skin incision to the end of skin suture. The number of POH days was reported from day of surgery to discharge. Interval-time between surgery and adjuvant chemotherapy and or Post Mastectomy Radiotherapy (PMRT) was analyzed.


Quantitative criteria were analyzed with median, mean, CI 95% and range. Comparisons were determined using Chi2-test for qualitative criteria and t-test for quantitative criteria. Binary logistic regression was used to determined independent significant criteria. Analysis was evaluated per patient number. P-value ‹= 0.05 was considered as significant.


During 2-years (2016-17), 310 patients were operated (331 IBR with 21 bilateral IBR): 229 (73.9%) for primary BC, 45 (14.5%) for ILBCR and 36 (11.6%) for prophylactic mastectomy, with 112 NSM (36.1%), 197 SSM (63.5%) and 1 standard mastectomy (0.3%). NSM were achieved in 27.9% for primary BC (64/229) (57/199: 28.6% without NAC and 7/30: 23.3% with NAC), 44.4% for ILBCR (20/45) and 77.8% for prophylactic mastectomy (28/36) (Table 1). For patients with bilateral mastectomy (15 NSM and 6 SSM), IBR were performed with definitive implant in 20 cases and expander implant in 1 patient. Breast cup-size was significantly correlated with mastectomy weight.