Nerve Reconstruction in Alloplastic Breast Reconstruction: Expanding the Indications for Breast Reinnervation
Elizabeth A Moroni, MD MHA, Janina Keuper, MD, Zhazira A Irgebay, MD, Elizabeth A Bailey, MD MS and Andrea Moreira, MD, University of Pittsburgh Medical Center, Pittsburgh, PA
Introduction
With broadening indications for nipple sparing mastectomy and advances in reconstructive techniques, plastic surgeons can offer amazing results to our patients with a very high satisfaction rate. However, the loss of sensation after mastectomy can be devastating for patients’ quality of life, and even a risk for injury. Prior studies have shown successful reinnervation in autologous breast reconstruction, but this has not been widely studied in implant-based reconstruction, which is more challenging due to the frequent absence of a distal nerve stump target for reinnervation.
Methods
Our group began performing nerve reconstruction in conjunction with breast reconstruction following mastectomy in April 2021. From April 2021-May 2022, all patients who underwent nerve reconstruction were followed postoperatively with the Semes Weinstein monofilament testing as well as the BREAST-Q Sensation Module, a validated Patient-Reported Outcomes Measure dedicated to breast sensation. Our reinnervation procedure involves dissecting the 4th and 5th intercostal nerves at lateral chest and then coapting this nerve with a distal stump under the nipple-areola complex identified and preserved during the mastectomy. If a nerve gap exists after placement of implant/tissue expander, a nerve allograft is used to bridge this gap.
Results
Sixty-five patients were included in the analysis, representing 113 breasts. Forty-eight patients underwent bilateral mastectomy/reconstruction (96 breasts) while 17 patients underwent unilateral mastectomy/reconstruction. Fifty-eight of these patients (106 breasts) were nipple-sparing mastectomies. Age ranged from 27y to 71y (mean 45y), BMI ranged from 18 to 39 (mean 25). Most patients (n=54) underwent mastectomy for cancer diagnosis, while 11 patients underwent prophylactic surgery due to high-risk genetic diagnosis. Most patients (n=34) underwent Direct-to-Implant (DTI) reconstruction, while 24 underwent staged alloplastic reconstruction with a tissue expander and 8 underwent autologous reconstruction. Autologous reconstructions were excluded from the analysis.
Breast resection volume ranged from 122 to 1358g, with mean intercostal nerve dissection 5.2cm (range 0-16cm). On average, a 440cc implant was used for DTI reconstruction (range 210-755cc); if a tissue expander was placed, on-table fill averaged 400cc (range 250-600cc).
Using the BREAST-Q sensation module and Semes Weinstein monofilament testing, we observed improved sensation over time, with no abnormal sensation or pain.
Conclusions
Breast re-sensation after mastectomy is possible for patients undergoing autologous and implant-based reconstruction. While more validated tools are necessary to assess the overall quantitative return of breast sensation after nerve reconstruction, our data suggests positive impact of breast sensation on patient quality of life which increases with time from mastectomy.
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