American Society for Peripheral Nerve

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Breast Skin Reinnervation following Mastectomy
Amelia Van Handel, MD1, Ema Zubovic, MD1 and Thomas Tung, MD2, (1)Washington University, St. Louis, MO, (2)Plastic Surgery, Washington University School of Medicine, Saint Louis, MO

Skin-sparing mastectomy is a morbid and disfiguring procedure. Breast reconstruction contributes to the patient's recovery both physically and psychologically. However, the spared native breast skin remains insensate and can cause paresthesias and chronic pain. The use of innervated flaps for reconstruction can help to restore some sensation, but the flap skin paddle is often a small portion of the reconstructed breast surface, the majority of which is made up by denervated native breast skin. Reinnervation of the native breast skin has not been previously described. Our objective is to report sensation, pain, and satisfaction outcomes in a small series of patients who have undergone reinnervation of their native breast skin at the time of mastectomy.

All patients underwent mastectomy and tissue expander reconstruction. Patients in the study arm also underwent nerve procedure for sensory reinnervation of the native breast skin at the time of initial surgery. Our first patient underwent direct nerve repair. However, we have not been able to consistently identify the distal sensory nerves in subsequent patients and we therefore developed a technique of harvesting intercostal sensory nerves for transfer. These were coapted directly to the dermis of the underside of the mastectomy skin flaps. Usually, two to three intercostal nerves were used per side. Sensation was evaluated postoperatively by Semmes-Weinstein filaments and 2-point discrimination. Patients also completed a breast pain questionnaire and Breast-Q survey at several timepoints post-operatively.

Five patients have undergone breast skin reinnervation at the time of mastectomy and tissue expander placement for a total of eight reconstructed breasts and were compared to a cohort of patients who underwent the same procedure without breast skin reinnervation. Follow-up ranged from 6-18 months. Patients who received nerve transfer reinnervation had better return of sensation as measured by both Semmes-Weinstein filaments and 2-point discrimination. Results of the pain questionnaire indicate study patients have pain levels similar to control, providing reassurance that the procedure is not causing additional pain or neuroma formation. Study patients also score higher on the Breast-Q survey.

Reinnervation of native breast skin following mastectomy is possible and provides better return of sensation. This may help to provide superior and more complete reconstruction by restoring sensation as well as form. The incidence of chronic paresthesias, discomfort or pain may also be reduced and may contribute to a better quality of life in the long term for breast cancer survivors.

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