Objective
Minimal invasive nipple-sparing mastectomy have gradually become a useful technique for breast cancer surgery. The approach allows a single small incision in less visible location with better preservation with the breast envelope. In the past, most of the reconstructions were performed as implant-based reconstruction due to the small incision. Autologous reconstruction provides a more consistent natural results with better tolerance to radiation. The aim of this retrospective review was to investigate the safety and early outcome of minimal invasive nipple-sparing mastectomy with immediate microsurgical breast reconstruction, summarize our experience, and provide useful information in clinical practice.

Material and Methods
Data analysis was conducted based on reviewing a single plastic surgeon’s experience on breast reconstruction from January 2018 to July 2020 at a single institution using immediate free flap transfer after minimal-invasive or conventional nipple-sparing mastectomy. Complications including hematoma, infection, poor wound healing, flap failure, skin necrosis, NAC necrosis, fat necrosis and local recurrence were reviewed.

Results
A total of 56 patients that underwent nipple-sparing mastectomy (NSM) followed by free flap transfer were enrolled, 41 of which received conventional NSM and 15 of which received minimal invasive NSM. We compared the demographic and treatment characteristics between the two groups. Scar position (p<.001) and the selection of recipient artery (p<.001) and vein (p<.001) presented significant difference between the two groups. Minimal invasive NSM with free flap transfer had a higher ratio of incision placed in the anterior axillary line (86.7%) with the use of thoracodorsal artery (86.7%) and vein (80.0%) as recipient vessels.
In the conventional NSM group, 36 (87.8%) patients had reconstruction with DIEP flap and 5 (12.2%) with PAP flap. In the minimal invasive NSM group, 12 (80.0%) patients had reconstruction with DIEP flap and 3 (20.0%) with PAP flap. Outcomes regarding acute and chronic complications, total complications, local recurrence rate and positive margin rate revealed no significant difference.

Conclusion
Minimal-invasive nipple-sparing mastectomy provides a better aesthetic restoration of the mastectomy pocket by placing the incision at anterior axillary line which in the meantime increases the difficulty of tumor resection, microvascular anastomosis and flap inset in immediate microsurgical breast reconstruction. Our results, however, suggest that microsurgical breast reconstruction can still be performed safely in minimal-invasive nipple-sparing mastectomy with compatible results to immediate microsurgical breast reconstruction following conventional nipple-sparing mastectomy.

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