Sengkang General Hospital spearheads minimally invasive combination approach for breast cancer patients undergoing mastectomy and breast reconstruction


SINGAPORE, 25 JULY 2023 – Sengkang General Hospital's (SKH) breast and plastic surgery service has spearheaded an approach for minimally invasive (endoscopic) skin and nipple-sparing full breast removal (mastectomy) with immediate reconstruction for suitable breast cancer patients. To be offered as a standard procedure and first line of treatment over conventional approaches, this endoscopic approach allows for smaller, less conspicuous incisions, and close-to-ideal breast restoration.

With endoscopic breast surgery, surgeons are able to make incisions as small as four centimetres in discreet locations such as the under-arm or bra line. Conventional nipple-sparing mastectomy usually involves scars on the breast, nipple and areola region, or lengthy scars along the bra line or lateral breast. In Singapore, breast surgery has advanced towards "keyhole" cancer resection which uses a digital endoscope that has a long fibre optic cable system with a video camera and light attached. It displays the operative area with optimal clarity, enabling surgeons to precisely visualise and remove breast and cancerous tissue during surgery with a single-incision. In addition to the aesthetic benefit of concealing surgical scars, smaller 'off-the-breast' incisions also result in less pain, minimal operative scarring and decreased nipple, skin, and wound complications.

Endoscopic breast surgery also allows for the removal and restoration of tissues in a discrete manner. Minimally invasive breast surgery was initially developed in partnership with implant-based reconstruction, since the method of reconstruction is limited by the mini-incision size and distant location that hinders other complex methods of reconstruction. SKH has further developed technical variations allowing concurrent breast reconstruction that uses a woman's own body skin, fat, and blood vessels to recreate the breasts as a free-flap procedure. It looks and feels more natural as well as contoured, akin to natural breast tissues and is a lifelong restorative solution as opposed to implants. In Singapore, minimally invasive breast cancer surgery is currently available at select SingHealth Duke-NUS Breast Centres.

Since 2019, SKH has performed over 30 endoscopic nipple-sparing mastectomies, more than half of which were alongside immediate breast reconstruction using tissue from the abdomen. This new technique is accessible to a wide range of patients from young to elderly women, and is not limited by breast size or body mass index. It can also be offered to select patients with advanced breast cancer who have responded well to pre-surgical treatment like chemotherapy, immunotherapy, and targeted therapy. In addition, this treatment is also feasible for patients who are diagnosed with other medical conditions such as diabetes and microvascular diseases – factors previously recognised as relative contraindications.

Associate Professor Benita Tan, Senior Consultant, Breast Service, and Chairman, Division of Surgery, SKH, commented, "The team can also plan implant-based reconstruction, fat grafting, and other variations of flap reconstruction using skin and fat from areas such as the back, buttock, thighs, internal organ fat and more, for patients with challenging clinical conditions like unavailable or inadequate tissue from a selected area to recreate the breast, or offer the choice to the patient." 
With an increasing number of people diagnosed with breast cancer and surgery remaining the primary treatment option, patients are often concerned about the surgical scars and altered sizes of their breasts, in addition to worries over the disease and its prognosis. This surgical approach improves aesthetic outcomes and enhances the appearance of breasts with minimal postoperative complications to enhance quality of life and restore feminine confidence in patients.

Assistant Professor Sabrina Ngaserin, Head and Consultant, Breast Service, SKH, shared, "With over 70 per cent of cancers being diagnosed at early-stage and significant improvement in survival, breast specialists today prioritise not just treating the cancer, but the overall outcomes such as aesthetics, quality of life and long-term function, to help preserve patients' body image and sexual identity. The greatest value of the minimally invasive breast approach is the principle of 'aesthetically scarless' breast surgery, where incisions and scars are minimised, hidden yet the procedure remains within the range of oncologic safety. We would like to make this the new standard of care for our breast cancer patients."

The youngest patient who received this minimally invasive breast procedure at SKH is 36 years old and the oldest is 65. While most surgeons would traditionally avoid extensive reconstructive procedures in patients of advanced age, the SKH team believes that this endoscopic procedure is suitable for patients from a wide range of age groups. Mdm Leong, 62 years old, underwent endoscopic nipple and sparing mastectomy via a mini-inframammary (bra-line) incision followed by immediate abdominal-based free flap reconstruction in May 2021. She is one of the older patients who chose to undergo a full breast reconstruction. Mdm Leong shared, "These days, I don't feel like any breast surgery has happened to me at all. Sometimes I even forget that I was a breast cancer patient." The incision has healed well along the bra line and has become part of the normal body contour. As she preferred to undergo an abdominal muscle-sparing reconstruction, she still has an abdominal scar in the typical pattern of a 'tummy-tuck' procedure, but there is minimal functional compromise to her abdominal wall. She has since resumed work and all regular social and lifestyle activities.

Endoscopic breast-conserving surgery (partial breast resection) using a mini under arm or bra-line incision, is also offered for suitable patients at SKH. Ms Tan, 39 years old, benefitted from this technique over a year ago.  She was diagnosed with young-onset early-stage cancer in the inner upper quadrant of her left breast, an area that is traditionally challenging when it comes to obscuring incisions, with greater potential for a more obvious breast defect in the front and centre of the chest. "I underwent a one-hour day surgery procedure and returned home after a few hours of observation. The single incision is small and faint, and is not visible unless one knows it is in my underarm. My breast looks and feels almost exactly as it was before and I feel confident once again", says Ms Tan of her surgical experience. She has since completed chemotherapy and radiotherapy, is currently on hormonal therapy, and is in cancer remission.



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Farah Rahman
Senior Executive
Sengkang General Hospital
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