Annals of Surgical Oncology

, Volume 26, Issue 10, pp 3216–3223 | Cite as

The “Nipple Whipple”?! A Pilot Study to Assess the Ergonomic Effects of Nipple-Sparing Mastectomy

  • Katherine KopkashEmail author
  • Kevin Novak
  • Kristine Kuchta
  • Irene Yashina
  • Elizabeth Poli
  • Sarah Rabbitt
  • Catherine Pesce
  • David Winchester
  • Katharine Yao
Breast Oncology



Nipple-sparing mastectomies (NSMs) with reconstruction are believed to be more difficult to perform than skin-sparing mastectomies (SSMs), but there is little quantitative data to support this claim.


This prospective study analyzed four surgeons performing mastectomies. Electromyography (EMG) electrodes placed on selected muscle groups on each surgeon were used to capture muscle exertion intraoperatively and a percentage of maximum voluntary exertion was calculated (%MVE). Data regarding surgeon demographics, exercise habits, musculoskeletal problems, and surgery-specific workload was collected using a questionnaire.


A total of 61 mastectomies were analyzed; 40 were NSM and 21 were SSM/total mastectomies. NSM were considered to be more mentally demanding and physically demanding than SSM (p < 0.001). When the surgeons’ EMG data was analyzed as a group, there was a statistically significant difference in %MVE for NSM versus SSM at high muscle activity in bilateral anterior deltoid muscle groups and at average muscle activity for the left anterior deltoid muscle only. At low muscle activity, there was a statistically significant increase in activation for SSM versus NSM in bilateral cervical erector spinae. Repeated measures ANOVA was performed, which showed statistically significant differences at high muscle activity between NSM and SSM in the left cervical erector spinae and bilateral anterior deltoid muscles.


Our pilot study shows that intraoperative EMGs can assess muscle activity for mastectomy operations and show a difference between NSM and SSM. This is the first study to provide quantitative data on muscle strain with NSM.



The authors thank Jennifer Jaffe for her help with preparing the manuscript and figures for publication.


The authors do not have anything to disclose.


  1. 1.
    Catanzarite T, Tan-Kim J, Whitcomb EL, Menefee S. Ergonomics in surgery: a review. Female Pelvic Med Reconstr Surg. 2018;24(1):1–12.Google Scholar
  2. 2.
    Azvolinsky A. Nipple-sparing mastectomies as safe as more radical surgeries. 2015. Accessed 9 Apr 2019.
  3. 3.
    Krajewski AC, Boughey JC, Degnim AC, et al. Expanded indications and improved outcomes for nipple-sparing mastectomy over time. Ann Surg Oncol. 2015;22(10):3317–23.CrossRefGoogle Scholar
  4. 4.
    Filho PA, Capko D, Barry JM, et al. Nipple-sparing mastectomy for breast cancer and risk-reducing surgery: the memorial sloan-kettering cancer center experience. Ann Surg Oncol. 2011(18):3117.CrossRefGoogle Scholar
  5. 5.
    Cruz LD, Moody AM, Tappy EE, et al. Overall survival, disease-free survival, local recurrence, and nipple–areolar recurrence in the setting of nipple-sparing mastectomy: a meta-analysis and systematic review. Ann Surg Oncol. 2015;22(10):3241–9.CrossRefGoogle Scholar
  6. 6.
    Jackson RS, Sanders T, Park A, et al. Prospective study comparing surgeons’ pain and fatigue associated with nipple-sparing versus skin-sparing mastectomy. Ann Surg Oncol. 2017;24(10):3024–31.CrossRefGoogle Scholar
  7. 7.
    Szeto GP, Poon JT, Law WL. A comparison of surgeon’s postural muscle activity during robotic-assisted and laparoscopic rectal surgery. J Robot Surg. 2013;7(3):305–8.CrossRefGoogle Scholar
  8. 8.
    Kuorinka I, Jonsson B, Kilbom A, et al. Standardised Nordic questionnaires for the analysis of musculoskeletal symptoms. Appl Ergon. 1987;18(3):233–7.CrossRefGoogle Scholar
  9. 9.
    Wilson MR, Poolton JM, Malhotra N, Ngo K, Bright E, Masters RS. Development and validation of a surgical workload measure: the surgery task load index (SURG-TLX). World J Surg. 2011;35(9):1961–9.CrossRefGoogle Scholar
  10. 10.
    Albright EL, Schroeder MC, Foster K, et al. Nipple-sparing mastectomy is not associated with a delay of adjuvant treatment. Ann Surg Oncol. 2018;25(7):1928–1935.CrossRefGoogle Scholar
  11. 11.
    Sisco M, Kyrillos AM, Lapin BR, Wang CE, Yao KA. Trends and variation in the use of nipple-sparing mastectomy for breast cancer in the United States. Breast Cancer Res Treat. 2016;160(1):111–20.CrossRefGoogle Scholar
  12. 12.
    Yavuz M, Kesiktas E, Kesiktas NN, Acarturk S. Lighted retractor-assisted transaxillary approach in gynecomastia correction. Ann Plast Surg. 2006;57(4):370–3.CrossRefGoogle Scholar
  13. 13.
    Moser T, Lecours J, Michaud J, Bureau NJ, Guillin R, Cardinal E. The deltoid, a forgotten muscle of the shoulder. Skelet Radiol. 2013;42(10):1361–75.CrossRefGoogle Scholar
  14. 14.
    Coopey SB, Mitchell SD. Nipple-sparing mastectomy: pitfalls and challenges. Ann Surg Oncol. 2017;24(10):2863–8.CrossRefGoogle Scholar
  15. 15.
    Kuo YL, Wang PS, Ko PY, Huang KY, Tsai YJ. Immediate effects of real-time postural biofeedback on spinal posture, muscle activity, and perceived pain severity in adults with neck pain. Gait Posture. 2019;67:187–93.CrossRefGoogle Scholar
  16. 16.
    Ashikari AY, Kelemen PR, Tastan B, Salzberg CA, Ashikari RH. Nipple sparing mastectomy techniques: a literature review and an inframammary technique. Gland Surg. 2018;7(3):273–87.CrossRefGoogle Scholar
  17. 17.
    Stucky CH, Cromwell KD, Voss RK, et al. Surgeon symptoms, strain, and selections: Systematic review and meta-analysis of surgical ergonomics. Ann Med Surg (Lond). 2018;27:1–8.CrossRefGoogle Scholar
  18. 18.
    Fisher SM, Teven CM, Song DH. Ergonomics in the operating room: the cervicospinal health of today’s surgeons. Plast Reconstr Surg. 2018;142(5):1380–7.CrossRefGoogle Scholar
  19. 19.
    Seagull FJ. Disparities between industrial and surgical ergonomics. Work. 2012;41 Suppl 1:4669–72.Google Scholar
  20. 20.
    Szeto GP, Ho P, Ting AC, Poon JT, Tsang RC, Cheng SW. A study of surgeons’ postural muscle activity during open, laparoscopic, and endovascular surgery. Surg Endosc. 2010;24(7):1712–21.CrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Katherine Kopkash
    • 1
    • 2
    Email author
  • Kevin Novak
    • 3
  • Kristine Kuchta
    • 1
  • Irene Yashina
    • 3
  • Elizabeth Poli
    • 4
  • Sarah Rabbitt
    • 1
  • Catherine Pesce
    • 1
    • 2
  • David Winchester
    • 1
    • 2
  • Katharine Yao
    • 1
    • 2
  1. 1.Department of SurgeryNorthShore University HealthSystemEvanstonUSA
  2. 2.Pritzker School of MedicineUniversity of ChicagoChicagoUSA
  3. 3.Department of NeurophysiologyNorthShore University HealthSystemEvanstonUSA
  4. 4.Department of SurgeryUniversity of ChicagoChicagoUSA

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