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\begin{document}

\title{Application of downward wrapping method for implant placement in
single-port access laparoscopic breast reconstruction through the
axillary approach}



\author[1]{Dahai Chai}%
\author[2]{Xin Li}%
\author[1]{Chunli Yang}%
\author[1]{Hong Li}%
\author[1]{Bing  Lian}%
\author[1]{Yaobang Liu}%
\author[1]{Jinping Li}%
\affil[1]{General Hospital of Ningxia Medical University}%
\affil[2]{Ningxia Medical University}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
\textbf{Objective}: To explore the application of the downward flap
patch technique in single-port axillary endoscopic breast reconstruction
with implants. \textbf{Methods}: A retrospective analysis was conducted
on the clinical data of patients who underwent single-port axillary
endoscopic breast cancer radical resection with implant-based
reconstruction at the Department of Oncology Surgery, Ningxia Medical
University General Hospital from August 2020 to March 2023. The
patients' postoperative drainage volume, early complications, and breast
reconstruction satisfaction were analyzed using the BREAST-Q
questionnaire. \textbf{Results}: The average total drainage volume was
235 ml on the second day after surgery. A total of 8 patients (15.38\%)
experienced complications, including 7 cases of incision infection, 5
cases of incision dehiscence, and 2 cases of flap necrosis. There were
also 2 cases of local flap ischemic necrosis. Seven patients had wound
infections, including 3 cases of simple infection, 2 cases of flap
necrosis, and 2 cases of combined incision dehiscence. All 52 patients
completed the 3-month follow-up without any loss to follow-up. During
the follow-up period, no adverse events such as recurrence, metastasis,
or death occurred in any of the patients. The BREAST-Q scores of
patients who experienced complications were significantly lower than
those who did not. Patients with higher postoperative drainage volumes
were more likely to develop wound infections. The incidence of flap
necrosis and incision dehiscence was not related to postoperative
compression dressing or TNM staging, while the incidence of wound
infection was related to compression dressing and regional lymph node
metastasis. The breast reconstruction satisfaction score was not related
to TNM staging. \textbf{Conclusion:} Single-port axillary endoscopic
breast cancer radical resection with implant-based reconstruction
achieved good results in breast cancer treatment and shaping. The
downward flap patch technique is simple to operate, has good implant
coverage, and can achieve good breast reconstruction satisfaction.%
\end{abstract}%



\sloppy


\textbf{Introduction}

In 2020, breast cancer replaced lung cancer as the most common cancer in
the world, severely affecting women's health \textsuperscript{{[}1{]}}.
With the advancement of comprehensive treatment, breast cancer patients
have longer survival periods, and the demand for beauty is increasing.
More and more patients wish to preserve their breast appearance. In
addition, breast resection not only causes physical defects and loss of
female image, but also leads to postoperative anxiety and
depression\textsuperscript{{[}2{]}}. This crisis of confidence may lead
to sexual dysfunction, as well as damage to marriage and interpersonal
relationships \textsuperscript{{[}3{]}}. Therefore, the surgical
approach has undergone significant changes. Currently, the surgical
approach has changed from the original radical cure by enlargement or
improvement to breast cancer radical resection with breast
reconstruction while preserving the nipple-areolar complex.
Breast-conserving surgery is also a good choice for such patients, but
it is not suitable for patients with tumors/breast volumes that are
relatively high, with multiple or multiple suspicious cancer lesions or
microcalcifications \textsuperscript{{[}4{]}}. In addition, most Chinese
women have small breast sizes, and most patients have poor symmetry
after breast-conserving surgery. Furthermore, postoperative radiotherapy
is usually required after breast-conserving surgery. Therefore, most
patients currently prefer breast reconstruction surgery. Breast
reconstruction surgery for stage I or II breast cancer has emerged as a
result. Traditional reconstruction surgery often involves incisions on
the surface of the breast, resulting in obvious scarring after surgery.
Hoehler \textsuperscript{{[}5{]}} first described breast augmentation
through the axillary approach in 1973. In recent years, with the
development of endoscopic technology, breast cancer radical resection
with implant-based reconstruction while preserving the nipple-areolar
complex under endoscopic guidance has gradually been mastered by
domestic and foreign scholars and has become one of the best choices for
early breast cancer patients. The author has improved the current
single-port axillary endoscopic breast cancer radical resection and
implant patch coverage technique based on previous domestic and foreign
surgical methods, achieving good results.

\textbf{Materials and methods}

Clinical data

A retrospective analysis was conducted on the clinical data of patients
who underwent single-port axillary endoscopic breast cancer radical
resection with implant-based reconstruction involving pectoralis muscle
at Ningxia Medical University General Hospital from August 2020 to March
2023. A total of 57 patient data were collected, and 5 patients with
incomplete clinical data were excluded. Analysis was performed on 52
female patients with a mean age of (42.23 \selectlanguage{ngerman}± 8.28) years (range: 25-59
years) and a mean body mass index of (23.16 ± 2.93) kg/m2 (range:
17.31-29.32 kg/m2). The tumor diameter was (2.08 ± 1.13) cm (range:
0.5-5.3 cm), and the TNM stages were as follows: stage 0 in 6 cases,
stage I in 20 cases, stage II in 19 cases, and stage III in 7 cases.
Axillary lymph node dissection was performed in 26 cases, with an
average of (18.77 ± 5.32) lymph nodes removed (range: 11-28 nodes);
sentinel lymph node biopsy was performed in 25 cases, with an average of
(4.48 ± 1.59) lymph nodes collected (range: 2-8 nodes) (Table 1); 1
patient (with in situ carcinoma) did not undergo lymph node biopsy.

2.Surgical methods

2.1.Inclusion criteria: (1) Age between 20 and 65 years old; (2) Tumor
maximum diameter \selectlanguage{english}[?]5.0 cm, or tumor maximum diameter \selectlanguage{english}[?]5.0 cm after
neoadjuvant chemotherapy; (3) Preoperative magnetic resonance imaging
shows no invasion of the nipple-areola complex, skin, or pectoralis
major muscle; (4) No distant metastasis found before surgery; (5)
Preoperative core needle biopsy confirms breast malignant tumor; (6)
Eastern Cooperative Oncology Group performance status score 0-2; (7)
Patients have the willingness for breast reconstruction.

2.2.Exclusion criteria: (1) Large breast volume or significant sagging,
which cannot provide sufficient breast volume or relatively symmetrical
appearance through simple implantation; (2) Preoperative examination or
intraoperative rapid pathological examination shows tumor invasion of
the nipple-areola complex, skin, or pectoralis major muscle; (3)
Clinical stage IIIB or later tumor before surgery; (4) Positive surgical
margin during surgery.

2.3.Selection of implants: The type and size of the implant are selected
based on the patient's breast and tumor size and personal preferences.
The size of the implant is determined using the radial measurement
method. (1) Use a caliper to measure the distance from 1.5-2.0 cm beside
the midline to the anterior axillary line, which is the maximum basal
diameter (X) of the breast. Use the same method to measure the thickness
of the outer soft tissue (Y) and inner soft tissue (Z) of the breast.
Calculate the basal diameter of the implant as X - (Y/2 + Z/2). (2) In
addition to determining the basal diameter of the implant, anatomical
implants also require the selection of implant height (low, medium,
full, or extra-full). Use the distance from the sternal notch midpoint
to the nipple as SN and the distance between the nipples as NN. If
(SN-NN) is 0-2 cm, select a medium-height implant. If (SN-NN) is
\textless{}0, indicating outward nipple deviation, select a low-height
implant. If (SN-NN) is \textgreater{}2 cm, indicating inward nipple
deviation, select a full or extra-full implant. (3) Determine the
convexity of the implant according to the reconstruction needs. Full
convex implants are used in breasts with significant sagging or skin
laxity or when a larger implant volume is desired; otherwise, medium or
low convex implants are used. Unlike traditional open implantation
breast reconstruction surgery, the tension zone caused by the incision
being far away from the implant in the endoscopic implantation breast
reconstruction surgery does not require reducing the convexity or volume
of the implant.

2.4.Surgical Procedure

The eight-step surgical operation:

1)Sentinel lymph node biopsy: General anesthesia with endotracheal
intubation, supine position, shoulder and back elevated by 25deg, the
affected limb is abducted by 60deg (Figure 1). Ten minutes before surgery,
subcutaneously inject 2 ml of methylene blue into the nipple-areola
complex of the affected side. Make a hidden incision in the axillary
fold, cut open to the subcutaneous tissue, and perform a sentinel lymph
node biopsy at the outer edge of the pectoralis major muscle. If it is
positive, perform axillary lymph node dissection. Preliminary separation
of the breast posterior space and the pectoralis major muscle posterior
space is performed to create a space for endoscopic operation. (Video 1)

2)Separation of the posterior intercostal muscles: A 7.5cm or 10cm
incision protector is inserted through the axillary incision, and a
rolled-up size 6.5 glove is placed inside the protector. The thumb,
middle finger, and little finger of the glove are each placed into 5mm,
5mm, and 12mm puncture devices and inserted into the operating equipment
(Figure 2). The index finger is inserted into a suction catheter as a
means of preventing smoke interference during the operation. CO2
pressure is used to maintain the cavity, with a pressure of 10-12mmHg.
An ultrasonic knife is used to gradually separate the posterior
intercostal muscles, cutting the chest muscles at the 3-5 rib points.
Muscle cutting points must be cut in place to prevent muscle tension
from causing tearing and bleeding. (Video 2)

3)Separation of the posterior breast gap: The posterior breast gap is
generally a loose gap and can be separated using an electric knife or
ultrasonic knife. It extends from the sternum to the breast margin, and
from the edge of the breast to 1-2cm below the crease of the breast.
During the separation of the posterior breast gap, the separation speed
should be slowed down when approaching the inner edge of the rib to
prevent unexpected bleeding. (Video 3)

4)Separation of subcutaneous tissue using the tissue scissors tunnel
method: First, inject 100-150ml of swelling fluid subcutaneously
(containing 1:500,000 adrenaline and 20ml of lidocaine hydrochloride).
Since the blood vessels from the intercostal space have already been
dealt with in the previous two steps, there is very little chance of
subcutaneous bleeding, so we choose to use tissue scissors to separate
the subcutaneous tissue. Use tissue scissors to create four subcutaneous
tunnels and expand the tunnels using the outer expansion force of the
scissor head. Along the established tunnel, use the tissue scissors to
sharply separate the subcutaneous tissue to 0.5-1cm inside the glandular
edge, including the tissue below the nipple and areola. (Video 4)

5)Complete removal of breast glands under laparoscopy: Since the front
and back of the gland have been processed in advance, after the
laparoscope is inserted, only a small amount of the gland around the
gland can be seen. Use an ultrasonic knife to cut and separate along the
natural arc caused by CO2 pressure and completely remove the gland.
Thoroughly stop bleeding and rinse the wound with 1000ml of distilled
water at 42degC. Tissue samples are collected from four points of the
nipple-areola complex and sent for rapid pathology during the surgery,
confirming that there is no tumor invasion in the nipple-areola complex.
(Video 5)

6)Cutting the lower and inner edges of the pectoralis major: The
anterior and posterior gaps of the pectoralis major have been completely
separated, and the outer edge is already in a free state. Use an
ultrasonic knife to cut along the lower edge of the pectoralis major
towards the inner edge, and cut the inner edge to the fourth rib. (Video
6)

7)Suturing and patching: Fold the patch in half and flip the lower edge
up. Pre-stitch the upper edge of the patch with 3-0 Vicryl suture.
Insert the patch along the free edge of the pectoralis major and flatten
it. Continuously suture the patch to the lower edge and inner free edge
of the pectoralis major. (Video 7)

8)Wrapping the prosthesis with a downward flap patch: Insert the
prosthesis under the patch and wrap it with a downward flap patch. The
specific method is as follows: First, use an oval clamp to push the
outer patch towards the back and upper part of the prosthesis to
complete the outer prosthesis wrapping. Along the edge of the outer
prosthesis wrapping, push the lower patch towards the inner upper part
repeatedly until the patch completely wraps the prosthesis. Compare both
sides and perform shaping. Place a 15\# high negative pressure drainage
tube in the axilla and below the crease of the breast on each side.
(Video 8)

2.5.Perioperative Antibiotic Management: One dose of intravenous
antibiotics is administered 30 minutes before surgery, with an
additional dose given if the surgery lasts more than 3 hours, and
another dose given 6 hours after surgery.

3.Observational Indicators:

Record the surgical time, length of hospital stay and costs, drain
output 2 days post-surgery, body mass index, tumor size, etc. Record and
evaluate postoperative outcomes, including incision infection, skin
necrosis, incision dehiscence, implant removal, and patient satisfaction
score after reconstruction.

4.Postoperative Follow-up

Postoperative regular outpatient follow-up is conducted every 3 months,
including guidance on comprehensive treatment, assessing patient
compliance with treatment, checking for recurrence or distant
metastasis, and evaluating breast appearance. Physical examination and
ultrasound are performed based on the patient's condition, and PET-CT
and other examinations are performed for suspected metastases. A
satisfaction evaluation form is developed based on the partial content
of the Breast-Q scale, and patient satisfaction with breast appearance
and cosmetic effects is surveyed.

5.Statistical Methods

SPSS 19.0 statistical software is used for data analysis. Normally
distributed quantitative data are expressed as +-s, and t-tests are used
for intergroup comparisons. Non-normally distributed quantitative data
are expressed as M (QR), and the Mann-Whitney U test is used for
intergroup comparisons. Categorical data are expressed as frequency and
percentage, and the chi-square test is used for unordered categorical
data, while the Wilcoxon rank-sum test is used for ordered categorical
data. Differences with P\textless{}0.05 are considered statistically
significant.

\textbf{Results}

1.Basic Surgical Data:

All 52 eligible patients in this group underwent single-port axillary
endoscopic sub-glandular gland resection, immediate implant-based breast
reconstruction, and sentinel lymph node biopsy. Axillary lymph node
dissection was performed as needed based on the patient's condition, and
stage I implant-based reconstruction was performed under endoscopy. The
surgical duration ranged from 55 to 259 minutes, with an average of
168.10 minutes. Intraoperative bleeding volume ranged from 20 to 200 mL,
with an average of 80 mL. The postoperative hospital stay was 2 to 4
days, with an average drain output of 120 mL on the first day and 90 mL
on the second day. The total drain output over 2 days had an average of
235 mL.

2.Postoperative Complications and Follow-up

There were 8 cases of postoperative complications (15.38\%), including 7
cases of incision infection, 5 cases of incision dehiscence, and 2 cases
of skin flap necrosis. Two patients experienced local flap ischemic
necrosis, with one patient recovering well after debridement and
suturing, while the other patient had the implant removed due to
radiation dermatitis 5 months after radiotherapy. Of the 7 patients with
incision infection, 3 had a simple infection and recovered after local
drainage and antibiotic treatment, while the other 4 cases were
complicated with skin flap necrosis or incision dehiscence and required
further debridement and suturing. One of these patients had good
incision healing, while the other patient had poor infection control and
had the implant removed. All 52 patients were followed up for 3 months
postoperatively without any events such as recurrence, metastasis, or
death. The average BREAST-Q score (out of 100) for the 52 patients at 3
months postoperatively were as follows: breast satisfaction, 71.40
points; sexual satisfaction, 75.61 points; social and psychological
well-being, 71.99 points; physical well-being, 77.55 points, and
satisfaction with medical services, 75.67 points. The score for patients
with complications was significantly lower than that of patients without
complications. Patients with higher drain output were more likely to
develop incision infection (Tables 2-1, 2-2, and 2-3). The incidence of
skin flap necrosis and incision dehiscence was not related to whether or
not pressure dressing was applied postoperatively or the TNM stage
(Tables 3 and 4). The incidence of incision infection was related to the
application of pressure dressing and regional lymph node metastasis
(Table 5). The score for breast satisfaction was not related to the TNM
stage (Table 6).

\textbf{Discussion}

1.The use of laparoscopic technology in the treatment of breast cancer
has a long history, and single-port endoscopic subcutaneous gland
excision via the axillary approach has ultimately become the most
suitable approach.

Originally, laparoscopic technology was mainly used to obtain skin flaps
for reconstruction. Since Fine\textsuperscript{{[}6{]}}et al. used
laparoscopy to obtain latissimus dorsi flaps in 1994, more and more
people have been involved in the innovation of this technology. This
technology can achieve better hemostasis, improve visualization, promote
wound healing, and reduce postoperative pain. Initially, people used
suspension systems or traction wires to obtain a larger operating
space\textsuperscript{{[}7{]}}. With the development and improvement of
endoscopic technology, Pomel\textsuperscript{{[}8{]}}et al. introduced
CO2 gas injection technology in 2003. During the separation process, CO2
gas pressure can not only obtain a good operating space, but also
provide a clear plane for separation, thus simplifying the operation. In
addition, in the development of laparoscopic breast reconstruction
technology, some scholars have adopted the three-stab
technique{[}9{]}(one 12mm camera stab and two 8mm operation stabs).
Since breast reconstruction surgery requires the removal of gland tissue
and placement of implants, the three-stab technique requires an
additional incision in the armpit for such operations, which increases
the number of incisions and operation steps, and has gradually been
replaced by the axillary single-incision technique. In 2018,
Serra-Mestre{[}10{]}et al. introduced the use of a single incision in
the armpit for breast resection and reconstruction. The use of the
axillary single-incision technique can not only perform some suturing
and separation operations directly under visualization, but also is very
suitable for the removal of breast tissue and placement of implants, and
has been increasingly recognized by scholars. This incision can be
hidden when the arm is lowered or covered with a bra.

Compared with traditional surgery, laparoscopic surgery has the
following advantages: (1) Axillary approach for radical breast cancer
resection results in a small incision and the removal of axillary lymph
nodes first, which is more in line with the principle of tumor-free
surgery compared to traditional surgery. (2) Compared with traditional
surgery, laparoscopic surgery can enlarge the tissue by 4 times, which
can display the intraoperative anatomical structures more clearly, avoid
the occurrence of collateral damage, and provide more accurate
protection for nerves and blood vessels, thereby minimizing
postoperative discomfort for patients{[}11{]}. (3) Traditional surgery
incisions are often located on the surface of the breast. After
reconstruction, the skin tension is large, and local tissue swelling
occurs. The skin incision destroys the subcutaneous vascular network,
leading to an increasedrisk of skin necrosis and infection{[}12{]}. In
addition, incision necrosis and infection can increase the risk of
implant exposure and infection, leading to the risk of implant failure.
Laparoscopic surgery via the axillary approach can perfectly avoid
similar complications {[}13{]}. In our study, a total of 8 patients had
postoperative complications, with a complication rate of 15.38\%. In
Sakamoto's study {[}14{]}, the total incidence of complications in 89
patients who underwent laparoscopic nipple-sparing mastectomy was 22\%
(20 cases), including 1 case of infection (1.1\%), 3 cases of skin flap
necrosis (3.4\%) and 16 cases of nipple necrosis (18\%). Among them, 7
cases were partial necrosis (7.9\%), and 9 cases were complete necrosis
(10\%). Liu et al. {[}15{]} collected clinical data from 23 patients who
underwent axillary approach laparoscopic stage I breast reconstruction
with implants, and 4 cases (17.39\%) had postoperative complications,
including 2 cases of partial ischemic necrosis of the nipple-areola
complex. Balasubramanian et al. {[}16{]} found that the incidence of
incision complications between traditional autologous immediate implant
breast reconstruction was 24.3\%. Based on the above data on incision
infection and skin necrosis, the incidence of incision complications in
axillary approach laparoscopic immediate implant reconstruction surgery
is lower than that in traditional immediate implant reconstruction.
Moreover, due to its more concealable incision, the axillary
single-incision technique will eventually become the most suitable
approach.

2.Can laparoscopic surgery achieve the goal of radical treatment?

Firstly, laparoscopic surgery is only a change in the surgical approach
and does not change the scope of gland removal and lymph node
dissection. According to literature reports, the local recurrence rate
is equivalent between subcutaneous gland resection with nipple-areola
complex preservation under laparoscopy and traditional modified radical
surgery {[}11{]}{[}13{]}{[}17{]}. Lai HW {[}18{]} and others have shown
that there is no significant difference in local recurrence (p=0.89),
distant metastasis (p=0.08), and overall survival (p=0.14) between
laparoscopic breast surgery and traditional breast surgery. Laparoscopic
surgery is feasible and safe for breast cancer patients. In our study,
all 52 patients obtained negative margins. Among the 26 patients who
underwent axillary lymph node dissection, the average number of lymph
nodes obtained was 18.77+-5.32, and among the 25 patients who underwent
sentinel lymph node biopsy, the average number of lymph nodes obtained
was 4.48+-1.59. There were 18 patients with lymph node metastasis, and no
tumor recurrence or metastasis was found in these patients during the
3-month follow-up after surgery. Our data indicate that laparoscopic
surgery can meet the requirements of open surgery in obtaining negative
margins and lymph node removal. As for disease-free survival and overall
survival, due to the short follow-up time, this study did not conduct
in-depth analysis.

3.How to reduce nipple and areola necrosis?

Preserving the nipple-areola complex (NAC) is a crucial step in ensuring
the aesthetic appearance of breast reconstruction {[}20{]}. The
traditional concept is that when preserving the nipple-areola complex,
the tumor should generally be more than 2 cm away from the nipple-areola
complex. However, more and more literature in recent years has shown
that a distance of more than 1 cm can also preserve the nipple-areola
complex {[}20{]}{[}21{]}, and the local recurrence rate does not
increase under the premise of ensuring negative margins. This finding
provides a basis for preserving the nipple-areola complex for more
breast cancer patients. Ischemic complications involving the
nipple-areola complex (NAC) are an important issue in nipple-sparing
mastectomy (NSM) {[}22{]}. According to literature reports, the
incidence of NAC necrosis after breast reconstruction surgery is between
2.5\% and 8.8\% {[}23{]}. The blood supply of the nipple-areola complex
mainly includes small blood vessels from the surrounding skin and
subcutaneous tissue, as well as intercostal perforating vessels from the
glandular tissue. Glandular resection will damage the perforating
vessels. If the subcutaneous fat around the nipple-areola complex is not
preserved enough during the operation, it may affect the blood supply of
the nipple-areola complex {[}24{]}. Some studies have shown that
incisions on the breast surface, especially those related to the
nipple-areola complex, can cause NAC ischemia {[}21{]}. To avoid NAC
necrosis, we try to preserve the full-thickness skin flap in the area
far away from the tumor during the surgery to protect the intradermal
and subdermal vascular network. Laparoscopic surgery via the axillary
approach does not involve any skin incision on the breast and preserves
the integrity of the subcutaneous vascular network, which greatly
reduces the incidence of NAC ischemia and necrosis. There has been a
report that robot-assisted laparoscopic surgery can reduce the incidence
of NAC ischemia and necrosis to 0\% {[}25{]}. Therefore, laparoscopic
surgery provides technical support for preserving the nipple-areola
complex in breast cancer patients.

In this study, subcutaneous dissection was performed using tissue
scissors and a cold knife. Yilmaz {[}26{]} et al. found that the use of
a high-frequency electric knife can produce high local temperatures at
the incision site, and the cytokine levels are higher than those in the
scalpel and ultrasound groups, which can lead to more tissue damage and
acute inflammatory reactions. Increased exudate can significantly
increase the rate of skin flap necrosis. In this study, it was also
found that patients with higher drainage volumes after surgery were more
likely to develop wound infections (p=0.032). Similar results have been
obtained by many scholars both at home and abroad
{[}27{]}{[}28{]}{[}29{]}{[}30{]}{[}31{]}. The use of a cold knife to
dissect the subcutaneous tissue can reduce thermal damage and has a good
effect in preventing skin necrosis. In this study, it was found that
applying pressure to the incision can increase the incidence of incision
infections (p=0.035). In addition, in this study, there were two cases
of skin flap necrosis, both of which were in the pressure dressing group
(p=0.254). Due to the small number of cases, further testing is needed
to determine whether there is a correlation between these two factors.

4.How to achieve better shaping results?

Patient satisfaction with the reconstructed breast's shape and size is
an important indicator that affects patient satisfaction. In 2020, Dong
Won Lee et al. {[}32{]} compared breast reconstruction surgery using
laparoscopic and open surgery. They evaluated patient satisfaction with
scar repair, observer scar evaluation scores, breast shape and symmetry,
and found that the laparoscopic group had higher satisfaction rates than
the open surgery group. The aesthetic appearance of the incision is also
an important factor that affects patient satisfaction. The incision
through the axilla is concealed, and the incision is smaller than that
of open surgery. The local tension around the axilla is small, and the
resulting scar is not obvious. Therefore, the satisfaction of the
laparoscopic group in this regard is better than that of the traditional
surgery group. The magnifying effect of laparoscopic surgery can better
preserve the wrinkles under the breast and avoid improper dissection of
the cavity, which can cause implant displacement or bilateral
hemispherical deformities {[}33{]}. In this study, we used the downward
wrapping method to wrap the implant, which was pioneered in this study.
Through technical improvements, we found that using this method to wrap
the implant is more convenient, and the patch is smoother. No implant
displacement was found during the follow-up after surgery. In this
study, we conducted a Breast-Q questionnaire survey on patients 3 months
after surgery, and the results showed that the breast satisfaction score
was above 70 points. In the study by Qiu J et al. {[}34{]}, the
psychological and social health and sexual health scores of the
laparoscopic reconstruction group were significantly higher than those
of the open group (49.4 points and 40.8 points). Haiqian Xu et al.
{[}35{]} also found that in an average follow-up of 10 months, patient
satisfaction with the breast was higher than before surgery
(satisfaction score of 64.9+-5.6, 14.7+-11.0). The results of this study
did not investigate the patients' preoperative Breast-Q questionnaire,
and further verification is needed with longer follow-up time.

However, in clinical practice, laparoscopic surgery alone is not
omnipotent. Due to the limited space in the retropectoral space, for
patients with a breast volume of \textgreater{}500ml or significant
breast ptosis, simple implant placement cannot meet the symmetry
requirements {[}36{]}. For such patients, contralateral breast reduction
and lifting surgery are often required to meet the requirements.

\textbf{Conclusion}

The transaxillary single-port laparoscopic radical mastectomy and
modified breast reconstruction technique have achieved good results in
the radical treatment and aesthetic outcomes of breast cancer. The
downward wrapping method for the implant is simple to perform, has good
wrapping properties, and can achieve good breast satisfaction. This
study is not a prospective study, so it is not possible to make a
scientific comparison in terms of surgical time, incision infection,
skin necrosis, etc. Further conclusions need to be verified in future
studies.

Table.1.52 General clinical data of patients\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Project & Statistic\tabularnewline
Age at surgery (years) & 42.23\selectlanguage{ngerman}±8.28\tabularnewline
Hospitalization days & 8.1\selectlanguage{ngerman}±4.8\tabularnewline
Total cost & 40954.17\selectlanguage{ngerman}±13278.56\tabularnewline
Surgical duration (min) & 168.1\selectlanguage{ngerman}±65.96\tabularnewline
Height (M) & 1.61\selectlanguage{ngerman}±0.04\tabularnewline
Weight (Kg) & 59.85\selectlanguage{ngerman}±7.29\tabularnewline
BMI\selectlanguage{english}(kg/m\textsuperscript{2}\selectlanguage{english}) Tumor diameter (cm) TNM Phase 0 (example)
Phase I (example) Phase II (example) Phase III (example) & 23.16\selectlanguage{ngerman}±2.93
2.08±1.13 6\selectlanguage{english}(11.54\%\selectlanguage{english}) 20\selectlanguage{english}(38.46\%\selectlanguage{english}) 19\selectlanguage{english}(36.54\%\selectlanguage{english})
7\selectlanguage{english}(13.46\%\selectlanguage{english})\tabularnewline
Axillary lymph node dissection (example) Lymph node dissection (number)
Sentinel lymph node (example) Lymph nodes detected(number) Nation & 26
18.77\selectlanguage{ngerman}±5.32 25 4.48±1.59\tabularnewline
The Han nationality & 38(73.08\%)\tabularnewline
The Hui nationality & 13(25.00\%)\tabularnewline
The Miao nationality & 1(1.92\%)\tabularnewline
\bottomrule
\end{longtable}

Table.2-1.Skin flap necrosis and patient satisfaction\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Skin flap necrosis & Skin flap necrosis & t-value &
P-value\tabularnewline
& No(n=50) & Yes(n=2) & &\tabularnewline
Breast satisfaction score & 72.11\selectlanguage{ngerman}±7.42 & 53.75\selectlanguage{ngerman}±1.77 & 3.466 &
0.001\tabularnewline
Medical service satisfaction score & 77.10\selectlanguage{ngerman}±18.93 & 40.00\selectlanguage{ngerman}±0.00 & 2.746 &
0.008\tabularnewline
Psychosocial health score & 72.43\selectlanguage{ngerman}±7.32 & 61.00\selectlanguage{ngerman}±4.24 & 2.179 &
0.034\tabularnewline
Physical health score & 77.68\selectlanguage{ngerman}±8.73 & 74.25\selectlanguage{ngerman}±1.77 & 0.55 &
0.585\tabularnewline
Sexual health score & 76.15\selectlanguage{ngerman}±10.18 & 62.00\selectlanguage{ngerman}±2.83 & 1.946 &
0.057\tabularnewline
\bottomrule
\end{longtable}

Table.2-2.Wound dehiscence and patient satisfaction\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Wound dehiscence & Wound dehiscence & t-value & P-value\tabularnewline
& No(n=47) & Yes(n=5) & &\tabularnewline
Breast satisfaction score & 72.85\selectlanguage{ngerman}±6.8 & 57.8\selectlanguage{ngerman}±6.97 & 4.694 &
\textless{}0.001\tabularnewline
Medical service satisfaction score & 79.04\selectlanguage{ngerman}±17.65 & 44\selectlanguage{ngerman}±8.94 & 4.352 &
\textless{}0.001\tabularnewline
Psychosocial health score & 72.88\selectlanguage{ngerman}±7.27 & 63.6\selectlanguage{ngerman}±4.34 & 2.787 &
0.007\tabularnewline
Physical health score & 77.87\selectlanguage{ngerman}±8.86 & 74.5\selectlanguage{ngerman}±4.96 & 0.833 &
0.409\tabularnewline
Sexual health score & 76.84\selectlanguage{ngerman}±9.68 & 64\selectlanguage{ngerman}±10.2 & 2.808 &
0.007\tabularnewline
\bottomrule
\end{longtable}

Table.2-3.Wound infection, patient satisfaction and drainage flow\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Wound infection & Wound infection & t-value & P-value\tabularnewline
& No(n=45) & Yes(n=7) & &\tabularnewline
Second day total drainage (ml) & 116.18\selectlanguage{ngerman}±76.34 & 184.29\selectlanguage{ngerman}±73.79 & -2.205 &
0.032\tabularnewline
Breast satisfaction score & 73.62\selectlanguage{ngerman}±5.37 & 57.14\selectlanguage{ngerman}±8.47 & 6.953 &
\textless{}0.001\tabularnewline
Medical service satisfaction score & 80.78\selectlanguage{ngerman}±14.73 & 42.86\selectlanguage{ngerman}±17.99 & 6.157 &
\textless{}0.001\tabularnewline
Psychosocial health score & 73.32\selectlanguage{ngerman}±6.89 & 63.43\selectlanguage{ngerman}±5.97 & 3.588 &
0.001\tabularnewline
Physical health score & 78.06\selectlanguage{ngerman}±9 & 74.29\selectlanguage{ngerman}±4.19 & 1.083 &
0.284\tabularnewline
Sexual health score & 77.77\selectlanguage{ngerman}±9.24 & 61.71\selectlanguage{ngerman}±5.09 & 4.468 &
\textless{}0.001\tabularnewline
\bottomrule
\end{longtable}

Table.3.Univariate analysis of flap necrosis after endoscopic breast
reconstruction\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Skin flap necrosis & Skin flap necrosis & \(\chi^{2}\)-value &
P-value\tabularnewline
& No & Yes & &\tabularnewline
pressure bandage after operation & & & &\tabularnewline
No & 20 & 0 & 1.300 & 0.254\tabularnewline
Yes & 30 & 2 & &\tabularnewline
T & & & &\tabularnewline
1 & 30 & 1 & 0.215 & 0.898\tabularnewline
2 & 18 & 1 & &\tabularnewline
3 & 2 & 0 & &\tabularnewline
N & & & &\tabularnewline
0 & 33 & 1 & 1.173 & 0.759\tabularnewline
1 & 10 & 1 & &\tabularnewline
2 & 2 & 0 & &\tabularnewline
3 & 5 & 0 & &\tabularnewline
M & & & &\tabularnewline
0 & 50 & 2 & - & -\tabularnewline
\bottomrule
\end{longtable}

Table.4.Univariate analysis of wound dehiscence after endoscopic breast
reconstruction\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Wound dehiscence & Wound dehiscence & \(\chi^{2}\)-value &
P-value\tabularnewline
& No & Yes & &\tabularnewline
pressure bandage after operation & & & &\tabularnewline
No & 20 & 0 & 1.893 & 0.169\tabularnewline
Yes & 27 & 5 & &\tabularnewline
T & & & &\tabularnewline
1 & 27 & 4 & 1.012 & 0.603\tabularnewline
2 & 18 & 1 & &\tabularnewline
3 & 2 & 0 & &\tabularnewline
N & & & &\tabularnewline
0 & 32 & 2 & 5.236 & 0.155\tabularnewline
1 & 8 & 3 & &\tabularnewline
2 & 2 & 0 & &\tabularnewline
3 & 5 & 0 & &\tabularnewline
M & & & &\tabularnewline
0 & 47 & 5 & - & -\tabularnewline
\bottomrule
\end{longtable}

Table.5.Univariate analysis of wound infection after endoscopic breast
reconstruction\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& Wound infection & Wound infection & \(\chi^{2}\)-value &
P-value\tabularnewline
& No & Yes & &\tabularnewline
pressure bandage after operation & & & &\tabularnewline
No & 20 & 0 & 5.056 & 0.035\tabularnewline
Yes & 25 & 7 & &\tabularnewline
T & & & &\tabularnewline
1 & 26 & 5 & 3.578 & 0.167\tabularnewline
2 & 18 & 1 & &\tabularnewline
3 & 1 & 1 & &\tabularnewline
N & & & &\tabularnewline
0 & 33 & 1 & 11.541 & 0.004\tabularnewline
1 & 6 & 5 & &\tabularnewline
2 & 2 & 0 & &\tabularnewline
3 & 4 & 1 & &\tabularnewline
M & & & &\tabularnewline
0 & 45 & 7 & - & -\tabularnewline
\bottomrule
\end{longtable}

Table.6.Analysis of breast satisfaction scores and TNM staging\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& \emph{n} & \(\overset{\overline{}}{x}\pm s\) & F-value & P-value\tabularnewline
T & & & &\tabularnewline
1 & 26 & 71.15\selectlanguage{ngerman}±7.89 & 2.220 & 0.121\tabularnewline
2 & 19 & 73.84\selectlanguage{ngerman}±6.39 & &\tabularnewline
3 & 2 & 62.50\selectlanguage{ngerman}±17.68 & &\tabularnewline
N & & & &\tabularnewline
0 & 30 & 73.50\selectlanguage{ngerman}±5.30 & 2.628 & 0.062\tabularnewline
1 & 10 & 66.00\selectlanguage{ngerman}±9.94 & &\tabularnewline
2 & 2 & 74.75\selectlanguage{ngerman}±6.72 & &\tabularnewline
3 & 5 & 72.70\selectlanguage{ngerman}±12.97 & &\tabularnewline
M & & & &\tabularnewline
0 & 47 & 71.87\selectlanguage{ngerman}±7.90 & - & -\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure.1.Surgical incision and posture of one-stage Breast
reconstruction with axillary single hole endoscopic prosthesis}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure.2.Insertion of Trocar for one-stage Breast reconstruction
with axillary single hole endoscopic prosthesis}

\textbf{Conflict of Interest Statement:} The authors have no conflicts
interest to declare in relatin to the content of this article.

\textbf{Funding Information:} Ningxia Natural Science Foundation
(2020AAC03385).

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\selectlanguage{english}
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