Targeted Nipple Areola Complex Reinnervation (TNR) in Gender-Affirming Mastectomy: A Multi- Institutional, Prospective Case Control Study of Quantitative and Qualitative Sensory Outcomes
Katya Remy, MD1, Chase Alston, MHS2, Merel Helene Josephine Hazewinkel, MD3, Katherine Carruthers, MD4, Eleanor Tomczyk, MD4, Jonathan M. Winograd, M.D.5, William G., Jr. Austen, MD6, Ian L Valerio, MD, MS, MBA7 and Lisa Gfrerer, MD, PhD3, 1Massachusetts General Hospital, Harvard University, Boston, MA, 2Weill Cornell Medicine, Weill Cornell Medical College, New York, NY, 3Weill Cornell Medicine, New York City, NY, 4Massachusetts General Hospital, Harvard Medical School, Boston, MA, 5Plastic and Reconstructive Surgery, Plastic & Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 6Harvard Medical School, Boston, MA, 7Massachusetts General Hospital, Boston, MA
Introduction: This study analyses the quantitative and qualitative sensory and pain outcomes in gender-affirming mastectomy with free nipple grafts (FNG) between subjects undergoing targeted nipple areola complex reinnervation (TNR) and controls.
Methods: 61 patients were prospectively enrolled. 33 subjects were compared to 28 controls. Monofilament testing and patient-reported outcome questionnaires were used preoperatively, and at 1, 3, 6, 9 and 12 months postoperatively. Quantitative sensory testing including temperature detection threshold, pressure pain threshold, 2-point discrimination, pinprick, and vibration were performed preoperatively and at 12 months postoperatively.
Results: Monofilament values at the NAC were significantly better in subjects compared to controls throughout follow-up (p<0.05), while values at the chest were comparable (p>0.05) (Figure 1). At 12 months postoperatively, cold and warm detection thresholds at both the NAC and chest were similar to preoperative values in subjects (p>0.05), and significantly worse in controls (p<0.05). Heat pain detection thresholds at the NAC and chest were significantly worse in both subjects and controls (p<0.05). Pressure pain thresholds at the NAC and chest were significantly improved in subjects and significantly worse in controls (p<0.05). Pinprick at the NAC was comparable to preoperative values in subjects (p>0.05), and significantly worse in controls (p<0.05). Pinprick at the chest was similar to preoperative values in both subjects and controls (p>0.05). NAC and chest vibration and 2-point discrimination remained similar to preoperative values in both subjects and controls (p>0.05) (Figure 2). Subjects reported significantly better nipple, hot, cold and erogenous sensation compared to controls (p<0.05) while chest light touch and chest pressure sensation were comparable (p>0.05). Controls reported significantly higher phantom sensation and phantom pain at 1 month postoperatively, and chest pain until 6 months compared to subjects (p<0.05). Nipple hypersensitivity was significantly higher in subjects compared to controls until 6 months (p<0.05).
Conclusion: Restoration of sensation including mechanical (light touch and pressure), temperature and pain detection thresholds, as well as erogenous sensation are significantly improved in patients undergoing TNR versus control patients. In addition, TNR is associated with significantly less postoperative phantom sensation, phantom pain and chest pain.Patients should be counselled about the risk of transient NAC hypersensitivity.
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