Journal Logo


A Novel Method for Neurotization of Deep Inferior Epigastric Perforator and Superficial Inferior Epigastric Artery Flaps

Spiegel, Aldona J. M.D.; Salazar-Reyes, Hector M.D.; Izaddoost, Shayan M.D.; Khan, Farah N. M.D.

Author Information
Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 29e-30e
doi: 10.1097/PRS.0b013e3181905564
  • Free


Currently, surgical goals for breast reconstruction tend to relegate breast sensation to a position of secondary importance. Many surgeons admit to not pursuing neurotization for several reasons: “reasonable” spontaneous reinnervation, difficulty in finding the recipient nerve, increased donor-site morbidity, increased complexity, prolonged surgical time, and no difference in flap survival rate.1 Several studies have demonstrated that patients with sensate breast reconstruction not only have higher satisfaction rates and benefit from injury prevention, but also show improved pressure and temperature discrimination versus their noninnervated peers.2–5

The presence of a readily available, undamaged recipient nerve limits routine innervation. Currently, the nerve of choice is the lateral cutaneous branch of the fourth intercostal nerve. However, this nerve is frequently injured during mastectomy and lies in a different microsurgical field, thereby increasing flap inset complexity.

We present a novel technique for routine neurotization of deep inferior epigastric perforator and superficial inferior epigastric artery flaps with the medial branch of the third intercostal nerve, which is readily found during the dissection of the internal mammary vessels.

The abdominal skin is supplied segmentally by the lower thoracic intercostal nerves (T6 through T12), which terminate anteriorly to provide a lateral branch and a medial branch. After the intercostal nerves enter the rectus abdominis, cutaneous branches join the deep inferior epigastric vascular axis, forming neurovascular bundles. The nerve most proximal to the pedicle is selected for the donor nerve. Here, the accompanying inferior perforator is not used for flap perfusion and is ligated, thereby preventing flow obstruction. The nerve is cut at the fascia to preserve the motor function of the rectus while providing sensation to a major portion of the breast mound.

The breast is supplied by the lateral cutaneous and medial anterior branches of the second to sixth intercostal nerves, of which the third to fifth lateral and the second to fifth anterior branches supply the nipple-areola complex. The lateral branch of the fourth intercostal nerve has been the traditional recipient nerve. This nerve is frequently cauterized during mastectomies and is difficult to find in delayed reconstructions.

To overcome this problem, we use the medial branch of the third intercostal nerve, located near the internal mammary recipient vessels, which are dissected out in the third interspace, preserving the rib. With this approach, the third intercostal cutaneous and sensory nerve is easily dissected. The nerve is incised at the lateral border of the sternum and coapted to the flap donor nerve (Fig. 1). If the nerves are limited in length, a neurotube may be used. Since the third intercostal nerve is readily visualized during dissection of the IMVA, routine neurotization of the flap can be accomplished in an average time of 15 minutes.

Fig. 1.
Fig. 1.:
The recipient vessels are easily dissected out in the third intercostal space with complete preservation of the rib. The nerve is incised at the lateral border of the sternum and then reflected laterally, where it is coapted to the donor nerve from the deep inferior epigastric perforator or superficial inferior epigastric artery flap.

This technique offers the possibility of routine deep inferior epigastric perforator and superficial inferior epigastric artery flap innervation with an undamaged donor nerve that is reliably found in the recipient vessel microsurgical field, without a significant increase in operative time. To objectively assess this technique, a formal sensory evaluation is being performed. We believe this neurotization technique is a beneficial tool that can help reduce the physical and emotional toll of breast cancer on our patients.


The authors hereby certify that to the best of their knowledge, no financial support or benefits have been received by them, by any member of their immediate family, or any individual or entity with whom they have a significant relationship from any commercial source which is related directly or indirectly to the scientific work which is reported on in the article.

Aldona J. Spiegel, M.D.

The Methodist Hospital

Institute for Reconstructive Surgery

Houston, Texas

Hector Salazar-Reyes, M.D.

Division of Plastic Surgery

Baylor College of Medicine

The Methodist Hospital

Institute for Reconstructive Surgery

Houston, Texas

Shayan Izaddoost, M.D.

Division of Plastic Surgery

Baylor College of Medicine

Houston, Texas

Farah N. Khan, M.D.

Division of Plastic Surgery

University of South Florida

Tampa, Fla.


1. Beahm EK, Walton RL. Sensibility following innervated free TRAM flap for breast reconstruction (Discussion). Plast Reconstr Surg. 2006;117:2128.
2. Yap LH, Whiten SC, Forster A, Stevenson HJ. Sensory recovery in the sensate free transverse rectus abdominis myocutaneous flap. Plast Reconstr Surg. 2005;115:1280.
3. Yano K, Hosokawa K, Takagi S, Nakai K, Kubo T. Breast reconstruction using the sensate latissimus dorsi musculocutaneous flap. Plast Reconstr Surg. 2002;109:1897.
4. Temple CL, Tse R, Bettger-Hahn M, MacDermid J, Gan BS, Ross D. C. Sensibility following innervated free TRAM flap for breast reconstruction. Plast Reconstr Surg. 2006;117:2119.
5. Blondeel PN, Demunyck M, Mete D, et al. Sensory nerve repair in perforator flaps for autologous breast reconstruction: Sensational or senseless? Br J Plast Surg. 1999;52:37.

Section Description


Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:

Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at We strongly encourage authors to submit figures in color.

We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2009American Society of Plastic Surgeons