Robotic breast surgery with and without tunneling using the tumescent technique

The tumescent technique has traditionally been used in nipple-sparing mastectomy to help dissection and reduce bleeding. However, its necessity in robotic nipple-sparing mastectomy (RNSM) remains unclear due to enhanced visualization offered by robotic systems. This study analyzed the feasibility of omitting tumescent in RNSM by comparing postoperative outcomes and operative times. We retrospectively reviewed 253 patients who underwent unilateral RNSM at Asan Medical Center from October 2020 to November 2023. Outcomes included adverse events classified by Clavien-Dindo system and operative times. Indocyanine green (ICG) fluorescence imaging was used to assess ischemia patterns. The tumescent group (n = 43) exhibited a higher incidence of adverse events (16.3% vs. 5.2%, P = 0.025) and hematomas (11.6% vs. 2.4%, P = 0.016) compared to the non-tumescent group (n = 210). The mean operative times for mastectomy was shorter in the tumescent group (129.4 min vs. 165.9 min, p < 0.001); however, the overall surgical time was not significantly different P = 0.827). ICG fluorescence imaging showed higher rates of diffuse pattern ischemia (P = 0.059) and NAC ischemia patterns (P = 0.015) within the tumescent group; however, these patterns were not associated with grade II or higher adverse events. Omitting tumescent in RNSM is feasible and may reduce postoperative complications, particularly hematoma, while maintaining comparable operative time and minimizing unnecessary flap trimming due to false-positive ischemia on ICG fluorescence imaging.