ObjectiveTo preliminarily compare the aesthetic outcomes, complication risks, and safety between endoscopic nipple-sparing mastectomy (E-NSM) and conventional open mastectomy (COM). MethodsPatients who underwent E-NSM at Sichuan Cancer Hospital and West China Hospital of Sichuan University between January 2023 and October 2024 were consecutively enrolled as the endoscopic group. Patients who underwent COM at the two centers during the same period were enrolled as the open (control) group through 1:2 propensity score matching. The two groups were compared with respect to patient-reported aesthetic outcomes (BREAST-Q, SCAR-Q, and Harris scores), postoperative complication rates, and oncological safety events. ResultsAll enrolled patients were female. Forty-four patients were included in the endoscopic group and 84 in the open group, with mean ages of (50.3±9.2) years and (50.8±9.2) years, respectively. The median follow-up durations were 5.5 (2.0, 10.0) months in the endoscopic group and 5.0 (1.9, 11.0) months in the open group (P=0.912). Regarding postoperative BREAST-Q scores, the endoscopic group scored significantly higher than the open group in satisfaction with breasts [58.0 (53.0, 66.0) points vs. 44.0 (39.0, 53.0) points ], psychosocial well-being [(79.0±12.1) points vs. (71.0±10.0) points], sexual well-being [(41.8±4.8) points vs. (35.3±6.7) points], and chest function [50.0 (40.0, 55.0) points vs. 40.0 (36.0, 50.0) points] (all P<0.001). In terms of the Harris score, the proportions of patients rated as "fair" and "poor" were lower in the endoscopic group than those in the open group (P<0.001). Regarding SCAR-Q scores, the endoscopic group scored significantly better than the open group in the appearance, symptom, and psychosocial domains (P<0.001). There was no significant between-group difference in shoulder abduction range of motion (P=0.875), and the scar length was significantly shorter in the endoscopic group (P<0.001). No tumor recurrence or metastasis was observed in either group during follow-up. ConclusionFor female patients with breast cancer, E-NSM provides better short-term aesthetic outcomes than COM, and there is no significant difference in complication rates between the two procedures.