Assoc Prof Sanjay Warrier: The 3cm endoscopic mastectomy changing breast cancer surgery

Leading Sydney breast cancer surgeon Associate Professor Sanjay Warrier is performing endoscopic nipple sparing mastectomies through a small incision positioned away from the front of the breast, an approach designed to reduce visible scarring and surgical trauma while supporting recovery and improved cosmetic outcomes for women.
 

For generations, a mastectomy has been associated not only with the loss of breast tissue but also with significant visible surgical scars, however a minimally invasive technique now being performed in Australia is changing the way breast cancer patients can undergo the operation.
 

Using a small camera called an endoscope, Associate Professor Warrier is able to access and remove breast tissue through the small incision while preserving the breast skin and, where oncologically appropriate, the nipple and areola.  
 

"We are not removing less breast tissue because the incision is smaller, we are changing the way we access that tissue," Associate Professor Warrier said.
 

"For an appropriately selected patient, we can perform the mastectomy through an incision of around three centimetres positioned away from the front of the breast, using an endoscopic camera to provide a magnified view during surgery.
 

"Breast cancer surgery has changed enormously and one of the areas I am particularly interested in is how we can continue to make surgery less invasive without compromising the fundamental objective of treating the cancer appropriately."
 

Why the position of the scar matters
 

Associate Professor Warrier said advances in breast cancer survival have rightly increased the focus on what life looks like after treatment.
 

"For a woman undergoing a mastectomy, treating the cancer is obviously our priority, but that doesn't mean we should ignore how she will feel about her body afterwards," he said.
 

"Women may live for many decades after breast cancer surgery, so reconstruction, body image, scarring and quality of life matter enormously.
 

"The endoscopic approach enables us to position a relatively small access incision away from the breast mound rather than having the surgical access directly across the front of the breast."

When appropriate, implant based breast reconstruction can also be undertaken during the same operation.
 

A camera changes how the surgeon sees
 

During an endoscopic nipple sparing mastectomy, an endoscope provides a magnified view of the surgical field while breast tissue is carefully separated from surrounding structures.
 

Associate Professor Warrier uses a technique known as reverse sequence endoscopic nipple sparing mastectomy, where the deeper plane between the breast and chest muscle is developed first before the remaining breast tissue is dissected under endoscopic visualisation.
 

"Instead of requiring a larger conventional access point to see and operate, the endoscope becomes our eye inside the surgical field," Associate Professor Warrier said.
 

"The technology enables us to work through a much smaller access point, but patients need to understand that a small scar does not make this a small operation.
 

"It remains major breast surgery and carries the risks and recovery considerations associated with mastectomy and reconstruction."
 

Not every woman will be suitable
 

Associate Professor Warrier stressed that the technique is not appropriate for every patient.  Suitability can depend on the location and characteristics of the cancer, whether the nipple can safely be preserved, breast size and shape, nipple position, the amount of excess skin and the type of reconstruction required.
 

Nipple preservation is not appropriate where cancer involves the nipple or tissue immediately beneath it and is generally not appropriate in inflammatory breast cancer.
 

"This is where we have to be very careful not to turn a surgical advancement into a broad sweeping solution, Associate Professor Warrier said.
 

"The first question is always what is oncologically appropriate for the individual woman.  If an endoscopic operation is appropriate, then we can consider it. If it isn't, we use another approach.
 

"Smaller scars should never come before appropriate cancer surgery."
 

What does the evidence show?
 

Minimally invasive endoscopic mastectomy techniques have been performed internationally for a number of years, particularly in Asian surgical centres.
 

A 2025 meta analysis published in BJS Open comparing endoscopic and conventional nipple sparing mastectomy reported higher cosmetic satisfaction among the endoscopic groups studied and found no significant difference in reported oncological outcomes over a mean follow up period of up to 52 months.  The analysis also found endoscopic procedures generally took longer to perform.
 

Associate Professor Warrier said the findings are encouraging but longer term evidence remains important.

"We have to be responsible when talking about new surgical approaches because enthusiasm should never get ahead of evidence," he said.
 

"The current research is encouraging, particularly around cosmetic outcomes, but much of the available evidence comes from observational studies involving selected patients and longer term outcomes continue to be established.
 

"Patients deserve both innovation and transparency."
 

From robotic surgery to endoscopic surgery
 

Associate Professor Warrier has had a longstanding interest in minimally invasive breast surgery and performed his first robotic breast surgery in September 2018, becoming one of the early Australian surgeons to perform the procedure.
 

He began offering reverse sequence endoscopic nipple sparing mastectomy in May 2026 at Chris O'Brien Lifehouse in Camperdown.
 

"The direction of surgery generally is towards doing what we need to do while reducing unnecessary impact on the patient wherever possible," Associate Professor Warrier said.
 

"We've seen that transformation across many surgical specialties and breast surgery is continuing to evolve as well.
 

"For selected women, minimally invasive endoscopic mastectomy represents another option in that evolution."
 

A smaller incision doesn't mean a smaller decision
 

Associate Professor Warrier said women considering mastectomy should discuss all appropriate surgical options rather than focusing on one technique.
 

Depending on the diagnosis and individual patient, alternatives can include breast conserving surgery, conventional nipple sparing mastectomy, skin sparing mastectomy and different forms of immediate or delayed reconstruction.  Some women may also choose not to undergo breast reconstruction.
 

"There is no single best mastectomy for every woman because every cancer, breast and patient is different," Associate Professor Warrier said.
 

"What is exciting is that we have more options and increasingly sophisticated ways of tailoring surgery to the individual woman.
 

"A three centimetre incision sounds remarkable, but the important story isn't simply the size of the scar.  It is about continuing to challenge ourselves as surgeons to treat breast cancer effectively while also considering the body and life a woman has after that treatment."
 

About Associate Professor Sanjay Warrier

Associate Professor Sanjay Warrier is a past President and current committee member of Breast Surgeons of Australia and New Zealand (BreastSurgANZ). His views are those of his own, not BreastSurgANZ. Associate Professor Warrier's surgery is located at the Chris O'Brien Lifehouse and he also has clinics at Oxford Street, Bondi Junction, Macquarie Street and newly opened rooms in Campbelltown, Sydney. He is published in numerous peer-reviewed journals and won the Royal Prince Alfred Hospital's Patron's Prize for best scientific research.  In addition, he was also recently recognised on the international stage, receiving the India Australia Business and Community Alliance (IABCA) Australia India Science, Research and Development Award at the organisation's Gala in Mumbai. The award, one of the most significant honours across the Australia-India corridor, acknowledges outstanding contributions to science and research that strengthen bilateral ties between the two nations.

www.drsanjaywarrier.com.au