Sensory restoration in abdominally-based free flap for breast reconstruction using nerve allograft

Abstract

Background: Neurotization in breast reconstruction can be performed with the aid of nerve grafts and conduits to decrease the tedious dissection and overcome size mismatch. However, there has yet to be a formal analysis of this approach. The goal of this study was to evaluate sensory recovery after neurotized abdominally based free flaps for breast reconstruction using the authors’ novel technique and analyze factors that could affect sensory recovery. Methods: A novel technique using processed nerve allograft in combination with a nerve conduit was used. Dynamic and static sensation recovery tests were performed in patients who underwent neurotized or nonneurotized abdominally based free flap reconstructions. Demographics, surgical details, and complications were analyzed. Statistical analyses were performed using chi-square and Mann-Whitney tests. Results: Fifty patients (78 breasts) were analyzed: 60 breasts with neurotized reconstruction and 18 breasts without. For patients with more than 12 months of follow-up, the neurotized cohort demonstrated improved dynamic tests compared to the nonneurotized cohort (38 ± 21.69 versus 56.17 ± 20.8, respectively; P = 0.014). Factors associated with decreased sensory return in patients who underwent neurotized reconstruction were diabetes, higher body mass index, skin-sparing mastectomy, higher American Society of Anesthesiologists class, history of radiation therapy, or history of hormonal therapy. Conclusions: This is the first study to report on outcomes of neurotized autologous breast reconstruction using a nerve graft and conduit technique. The authors’ approach resulted in improved sensory outcomes compared to those in patients who did not undergo sensory reconstruction. Importantly, factors that can interfere with sensory recovery were identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Careful Where You Cut: Strategies for Successful Nerve-preserving Mastectomy

“…Although numerous publications have reported improved outcomes with breast neurotization, results can vary due to differences in techniques. [1][2][3][4][5][6][7][8][9][10][11][12]18,19 The combination of nerve-sparing mastectomy and breast neurotization with autografts or allografts may enhance sensory recovery in the breast. For reliable evaluation of outcomes, standardization of nervesparing mastectomy and NAC neurotization techniques is essential.…”

“…The restoration of sensation after mastectomy has been reported, albeit with varying rates of success. 4–13 The absence of sensory perception in the chest wall or reconstructed breast not only impacts a patient’s psychological well-being but also presents the risk of potential thermal injuries due to the lack of protective sensation. 14–16…”

“…3 The restoration of sensation after mastectomy has been reported, albeit with varying rates of success. [4][5][6][7][8][9][10][11][12][13] The absence of sensory perception in the chest wall or reconstructed breast not only impacts a patient's psychological well-being but also presents the risk of potential thermal injuries due to the lack of protective sensation. [14][15][16] Reconstructive surgery has recognized the need for techniques to restore sensation, and recent developments have extended neurotization procedures beyond autologous reconstruction to implant-based procedures.…”

An Evolving Landscape

“…7,9,20 A likely component of the improved sensation in the autologous cohort was the neurotization of the abdominal flap to the third intercostal nerve using a nerve allograft. Djohan et al 22 demonstrated that breasts reconstructed with abdominal flaps which have been neurotized in a similar fashion develop increased sensation compared with nonneurotized controls.…”

Sensate immediate breast reconstruction

“…Emphasis on standardization of technique and outcomes measurements has been seen in recent years to help optimize outcomes, including the creation of a multi-site prospectively collected registry that has been shown to have promising early results ( 33 ). Most recently, Djohan et al reported outcomes from a large case-control study looking at neurotization with nerve allografts in combination with nerve conduits during abdominally based free flap reconstruction, with significantly improved sensation seen at 1-year follow-up in the neurotized cohort ( 34 ). Another large study assessing delayed-immediate reconstruction with neurotized DIEP flaps showed return to baseline sensation in nearly all quadrants of the breast at 2-year follow-up ( 35 ).…”