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Neurotized DIEP Flaps: A Timeline for Sensory Recovery
Hao Huang, BS1, Marcos Lu Wang, BA1, Angela Ellison, PA-C1, Paul A. Asadourian, MEng, BS2 and David M. Otterburn, MD1, (1)Weill Cornell Medicine, New York, NY, (2)Columbia University Vagelos College of Physicians and Surgeons, New York, NY

BACKGROUND:
Poor breast sensation is commonly reported after mastectomy and reconstruction due to the necessary disruption of sensory nerves. Further, the process of nerve regeneration is slow and unpredictable, causing some patients to experience suboptimal sensation years after initial reconstruction. At our institution, the deep inferior epigastric perforator (DIEP) flap is one solution during which the anterior cutaneous branch of the third intercostal nerve in chest undergoes coaptation to the 10th, 11th, or 12th intercostal nerve within the autologous flap. In this study, we aim to delineate the temporal and regional pattern of nerve healing with the goal of establishing a timeframe to help guide preoperative counseling.
METHODS:
In this single institution study, 41 patients (75 breasts) who underwent mastectomy with immediate reconstruction using the deep inferior epigastric perforator (DIEP) flap were prospectively identified at defined time points. Sensitivity evaluation was performed in nine breast regions, utilizing the AcroVal pressure-specified sensory device (AxoGen, Alachua, FL) to determine 1-point static cutaneous thresholds at which stimulus was perceived. Higher thresholds indicated worse sensitivity and nerve functionality. Sensitivity data was averaged between patients at each time point, plotted over time, and compared with preoperative baseline measurements.
RESULTS:
In our cohort, patients undergoing DIEP flap reconstruction had an average age of 52.19 and average BMI of 26.97. Compared to preoperative baseline, mean cutaneous thresholds for the DIEP group at 18 months postoperatively were comparable only in the outer superior, outer medial, and outer lateral breast regions (p>0.05) (Figure 1). There was still a significant difference in the mean cutaneous thresholds in the outer inferior, inner superior, inner medial, inner inferior, inner lateral, and nipple-areola complex regions (p<0.05). In addition, cutaneous thresholds at 24 months or more postoperatively were comparable to baseline in all regions of the breast except the inner inferior region.
CONCLUSIONS:
Patients who undergo DIEP flap reconstruction can expect sensory recovery to preoperative levels by 24 months or more postoperatively, with sensation returning even sooner in the outer superior, outer medial, and outer lateral breast regions. Our results can help inform preoperative counseling and guide patient expectations on the nerve healing timeline following surgery. Further work is needed to elucidate the impact of various oncologic regimens and medical comorbidities on the nerve regeneration timeline.


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