Dual-plane versus Endoscopic Latissimus Dorsi Muscle Flap Breast Reconstruction Following Endoscopic Nipple-sparing Mastectomy

Background: We have developed an innovative integrated approach, combining reverse-sequence endoscopic nipple-sparing mastectomy (R-E-NSM) with reverse-sequence endoscopic latissimus dorsi muscle flap (R-E-LDMF) harvest for breast reconstruction (BR), through a discreet axillary incision. While both techniques demonstrate clinical feasibility, a systematic comparison of patient-reported outcomes, complications, and cost-efficacy between endoscopic implant-based BR and R-E-LDMF BR remains unexplored. Methods: A prospective, two-center cohort study was conducted from July 2021 to March 2024, enrolling breast cancer patients who underwent R-E-NSM followed by either Dual-plane BR or R-E-LDMF BR. The Primary endpoint was patient-reported outcomes assessed using the BREAST-Q reconstruction module (focusing on breast satisfaction and quality of life). Others included clinical outcomes, complications, and oncological outcomes. Results: Among 191 enrolled patients (41 R-E-LDMF vs. 150 Dual-plane), R-E-LDMF BR required longer operative times but incurred substantially lower hospitalization costs. After controlling for baseline patient characteristics, patients who underwent R-E-LDMF BR had greater satisfaction with their breasts (difference, -9.39; -16.97 to -1.80; P =0.016) at 1 year compared with patients who underwent Dual-plane BR. BREAST-Q scores showed no intergroup differences in quality of life. The R-E-LDMF group had higher rates of any and minor complications, while the major complication rates and oncological outcomes were similar between the two groups. Conclusions: The R-E-LDMF BR technique achieved comparable aesthetic results and major complication rates to the Dual-plane approach, while significantly reducing overall medical costs, despite higher minor complication rates. This approach represents a cost-effective alternative for patients seeking optimal aesthetic results with reduced financial burden.