Single axillary incision for minimal access (endoscopic or robotic-assisted) nipple sparing mastectomy: axillary crease or lateral chest wall incision?

Minimal access nipple sparing mastectomy (MA-NSM), including endoscopic- (E-NSM) and robotic-assisted (R-NSM) techniques, enables NSM to be performed through aesthetically favourable incisions without compromising oncologic safety. While early MA-NSM used dual incisions, current practice favours a single axillary incision (SAI), most commonly placed at the axillary crease or along the lateral chest wall corresponding to the level of the nipple-areolar complex (NAC). This is a retrospective study of all patients who underwent MA-NSM via a SAI either the axillary or lateral chest wall approach between January 2012 to June 2025 at a single institute. Clinicopathologic characteristics, surgical outcomes, postoperative complications and patient reported outcome measures (PROMs) were analyzed. The study included 371 MA-NSM cases, of which 222 (59.8%) were performed via an axillary crease incision and 149 (40.2%) via a lateral chest wall incision. For E-NSM, operative time was significantly shorter with the lateral chest wall approach than with the axillary approach (132.2 ± 46.4 vs. 188.3 ± 97.2 min, p < 0.001), whereas no such difference was seen in R-NSM. Delayed wound healing is significantly higher in the lateral chest wall group compared to the axillary crease group (6.7% vs. 0.5%, p < 0.001). PROMs including post-operative sensory outcomes were comparable between the two groups. Shorter operative time with the lateral chest wall approach was noted in E-NSM but not in R-NSM. Both the axillary crease and lateral chest wall approaches remain viable options for MA-NSM with similar postoperative complications and patient satisfaction.