Endoscopic Nipple-sparing Mastectomy: A Step-by-step Technical Guide and Early Experience

Background: Endoscopic nipple-sparing mastectomy (ENSM) has emerged as a minimally invasive alternative to open nipple-sparing mastectomy (NSM), offering the potential advantages of remote scar placement, magnified dissection, reduced flap trauma, and improved cosmetic outcomes.Its appeal is particularly relevant in settings seeking high-value breast surgery options without the financial burden of robotic systems.However, adoption remains limited, and practical descriptions of the technique and early feasibility are still needed.Methods: This article describes our technique for ENSM, including patient selection, operative setup, instrumentation, creation of the working space, stepwise superficial and deep dissection, retroareolar margin assessment, specimen retrieval, axillary procedures through the same access, flap perfusion assessment, and immediate reconstruction planning.Particular emphasis is placed on hydro-tumescent dissection, preservation of flap thickness and nipple-areola complex (NAC) perfusion, and practical technical tips to reduce complications during the learning curve.Preliminary perioperative and short-term outcomes from an initial feasibility series of three consecutive selected patients were reviewed descriptively.Results: In the initial three cases, all patients had clinically node-negative (cN0) disease with outer-quadrant tumors measuring 3 cm or less and underwent ENSM with immediate implant-or expander-based reconstruction.Mean operative time was 155 minutes, mean estimated blood loss was 70 mL, and median hospital stay was one night.No patient developed NAC loss, skin flap necrosis, or required reoperation.All margins were negative.One patient reported transient nipple hypoesthesia at 3 months, which improved by 6 months.Cosmetic satisfaction was high, with a median Likert score of 5 at 6 months.Conclusion: Endoscopic NSM is technically feasible in carefully selected patients and may provide excellent scar concealment, favorable esthetic outcomes, and acceptable early safety.In resource-conscious breast surgery practice, it may represent an attractive bridge between conventional open surgery and robotic approaches.Careful patient selection, adherence to oncologic principles, meticulous flap handling, and structured progression along the learning curve are essential for safe adoption.Larger studies with longer follow-up are needed to confirm oncologic and patient-reported outcomes.