Breast reconstruction leaves visible scars, which could be a target of stigma, and a source of medical complications. Robotic surgery makes it possible to reduce the size of a scar and to place it away from the breast, under the armpit. Dr Sarfati was the first to use a Da Vinci Xi robot for this technique. which is set to grow given the rise of genetic screening, which is increasing the demand for prophylactic surgery. Benjamin Sarfati is a surgeon specialising in aesthetic, plastic and reconstructive surgery. He works at the Gustave Roussy Institute and in private practice. In this esanum interview, he explains the state-of-the-art in medical technology for breast reconstruction.
In 2015, I was the first to use a Da Vinci Xi robot for breast reconstruction surgery. The Gustave Roussy Institute had recently been equipped with this model, which has four articulated arms. It was already used for visceral, gynaecological, urological and other surgery, but no one had thought of using it for breast surgery and the Da Vinci Xi was not approved for this organ.
I immediately saw the potential of the robot, because it could solve a recurrent problem linked to traditional breast reconstruction surgery: the scar. Firstly, because a scar near the breast is a permanent reminder to the patient that she has had a removal. Secondly, because this type of surgery can lead to complications such as necrosis or infection.
Thanks to the robot, I was able to reduce the size of the scar. It is now only about 3-4 cm, compared to 10 cm for a conventional surgery. Above all, I was able to place the scar at a distance, under the patient's armpit.1 This changes everything because the scar becomes invisible, hidden under the arm, when the person looks in the mirror. I have received patients from all over France and even from abroad because they carry genetic mutations that predispose them to breast cancer. These people refused the operation because of the scar. Now some of them accept it, and with this technique they have much less of a feeling of being mutilated.
Another advantage is that the incision is far away from the skin tissue of the breast, which is particularly fragile after a mastectomy. Gas is blown in during the operation, so there is no need to place spacers under the skin. In the end, the vascularisation of the tissue is preserved, which reduces the risk of necrosis. The risk of infection is also reduced because the prosthesis is no longer in direct contact with the scar. The only drawback is that this technique is not suitable for all breast shapes, especially if they are too large or have too much ptosis.
In 2015, I was allowed to operate on 80 patients in the MARCI clinical study. These were only people with a genetic mutation that predisposes them to cancer. The first operation took seven hours. Now it takes about an hour and a half per breast, just like conventional surgery. In the end, I operated on 130 breasts.
"I decided to have both breasts removed as a preventative measure after discovering that I carry the BRCA mutation. My personal story and my faith in medicine motivated this choice. Once I had made my decision, I opted for the unprecedented solution offered by Dr. Sarfati. I preferred to wait eight months, due to the delay in obtaining authorisations, before being able to have the operation with the robot which avoids a scar on the breast. This technique would eliminate a huge risk of developing breast cancer without mutilating the breast."2
Anna, the first patient operated on by Dr. Sarfati in the MARCI study
Because the robot was not approved for this type of surgery. The study was completed a year and a half ago. Thanks to its conclusive results, the company Intuitive, which manufactures the robot, was able to request CE marking for breast surgery. It has only just been granted this and only for prophylactic operations.
During all this time I was able to operate on patients from Brazil, the USA, etc. but not from Europe. It was infuriating. In Asia, there has been a strong craze for this technique, and since they don't have this obstacle of authorisation, surgeons are already using it on a daily basis. On the other hand, the Americans are still at the study stage.
We are finally going to be able to create a reference training centre for this technique at Gustave Roussy. The expectation is enormous. The demand for prophylactic surgery has exploded with the widespread use of genetic screening and progress in the field of breast reconstruction. We will first have to put together a team of trainers. I won't be able to do everything on my own, especially as I also have a private plastic surgery practice.3
250 French establishments are already equipped with a Da Vinci. For gynaecological surgeons already used to the robot, training will be quick. For neophytes, it will be necessary to master the robot and then learn our specific technique in four stages: theoretical training, observation in the operating theatre, training on a cadaver and then mentoring thanks to the dual controls.
They are enthusiastic, both in France and abroad. They want to come to Paris for training. The robot is becoming more and more established in the operating theatre, in orthopaedics, in neurology, etc. It is the future of surgery. Of course, there are always those who are reluctant, who say "We did it very well before". Some believe that patients don't care about scars. I think they will come to the conclusion that when given the choice, patients will opt for robotic surgery. The cost at the moment is about €3000 per operation. The robot itself costs about two million euros, but dozens of institutions in France are already equipped.
The priority now is to carry out studies to validate this technique in the context of cancer surgery. But we must not try to use the robot at all costs. For example, the robot is of little interest for cosmetic surgery because the incisions are already small.
Dr. Benjamin Sarfati is a surgeon specialising in aesthetic, plastic and reconstructive surgery. He works at the Gustave Roussy Institute and in private practice.
Interview by Benoît Blanquart
1. The classic surgical techniques result in a scar located either in the fold under the breast or more rarely on the edge of the areola.
2. Institut Gustave Roussy – «Elles témoignent»