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Breast: Ideas and Innovations

Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery

Djohan, Risal M.D.; Scomacao, Isis M.D.; Knackstedt, Rebecca M.D., Ph.D.; Cakmakoglu, Cagri M.D.; Grobmyer, Stephen R. M.D.

Author Information
Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 250-254
doi: 10.1097/PRS.0000000000006976
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Abstract

The concept of sensate autologous breast reconstruction is not novel, but the introduction of cadaveric nerve grafts has allowed for the development of new techniques. Recent articles have focused mainly on sensate abdominally based breast reconstruction.1,2 However, not all patients are candidates for, or desire, autologous reconstruction. To this end, we have begun performing sensate implant-based reconstruction. Although our novel technique for providing sensate implant-based reconstruction was recently reported (in press), in this communication we present our early results.

PATIENTS AND METHODS

A database was prospectively maintained for patients who underwent implant-based sensate breast reconstruction. Women with a C cup or smaller breast are ideal candidates for this procedure. This procedure is more challenging in patients with larger breasts because of the nerve length necessary to reach the nipple-areola complex area. The procedure is aborted only if the nerve cannot be identified at the time of mastectomy. The complete approach to providing sensate reconstruction has been previously published (in press). In brief, our approach starts with identification and preservation of the anterior branch of the lateral fourth intercostal nerve during the mastectomy by the breast surgeon. A processed nerve graft is used as an interpositional graft connecting the donor fourth intercostal nerve to the targeted nipple-areola complex (Fig. 1). A 7-cm nerve allograft is used, and this length has been adequate in all cases. The coaptation of the donor nerve to the nerve graft is performed under microscope or loupe magnification using 9-0 nylon suture (Fig. 2). The neurotization adds approximately 10 minutes to the breast reconstruction.

Fig. 1.
Fig. 1.:
Coaptation of the nerve allograft (blue arrow) and nipple-areola complex (red arrow).
Fig. 2.
Fig. 2.:
Coaptation of the fourth intercostal nerve (red arrow) and nerve allograft and connector (blue arrow).

The sensory recovery process was monitored using a pressure-specified sensory device. If pressure application to generate a response is above 100 g/mm2, it is considered loss of protective sensation.3 Static and dynamic tests were performed. The breast skin (mastectomy skin) and nipple-areola complex skin were divided into four quadrants. A total of eight areas were tested in each breast, including four dynamic tests (quadrants) and four static tests (12 hours, medial, 6 hours, and lateral). The data were reviewed retrospectively.

RESULTS

Thirteen patients underwent sensate implant-based breast reconstruction. Eight patients (15 breasts) were monitored for sensory recovery and were further analyzed. The average age was 38.12 ± 7.5 years, the average body mass index was 23.66 ± 4.19 kg/m2, and the mean breast specimen weight was 381.04 ± 149.5 g.

Of the eight patients, seven underwent bilateral reconstruction and one underwent unilateral reconstruction. Eleven breasts had direct-to-implant reconstruction and four had tissue expanders placed. All patients had the implant or tissue expander placed in the submuscular plane. There were no operative complications in the cohort. Five breasts had minor complications: wound dehiscence (n = 1), superficial necrosis to the nipple (n = 2), and infection (n = 2). The majority of mastectomies (n = 11) were prophylactic. One patient had neoadjuvant chemotherapy, one had neoadjuvant and adjuvant chemotherapy, and one had only adjuvant chemotherapy.

Fifteen breasts underwent one postoperative sensation test, and five of them underwent two postoperative sensation tests. The first sensory test was performed an average of 4.18 ± 2.3 months after surgery. Sensation threshold during the static test was better in the superior portion of the breast (12 hours) for the mastectomy (52.53 ± 31.18) and nipple-areola complex area (63.25 ± 34.03). The upper inner quadrant had a better threshold for mastectomy and nipple-areola complex skin during the dynamic tests than the other areas (Table 1). The second sensation test was performed an average of 10.59 ± 3.57 months after surgery. Comparing the two tests performed, the majority of the areas for mastectomy and nipple-areola complex skin were improved (Table 2). Two patients underwent bilateral reconstruction and unilateral neurotization, providing an inherent control breast. They underwent two sensory tests, where the first sensory test was performed an average 2.76 months after surgery and the second test an average of 7.91 months after surgery. Neurotized breasts had better thresholds in six of eight areas tested in comparison with nonneurotized breasts (Table 3). Historical sensory data on patients who underwent unilateral reconstruction and had sensory testing on the contralateral nonoperated breast were analyzed (Table 4).

Table 1. - First Sensory Test
Areas* Mastectomy Skin† NAC Skin†
12 hr 52.53 ± 31.18 63.25 ± 34.03
Medial 56.63 ± 37.45 67.54 ± 30.91
6 hr 66.82 ± 32.08 77.56 ± 24.83
Lateral 84.58 ± 24.15 74.42 ± 27.28
UOQ 31.26 ± 31.81 46.82 ± 32.72
UIQ 13.70 ± 11.56 29 ± 26.75
LIQ 25.21 ± 17.16 47.52 ± 37.58
LOQ 51.60 ± 29.20 51.74 ± 32.89
NAC, nipple-areola complex; UOQ, upper outer quadrant; UIQ, upper inner quadrant; LIQ, lower inner quadrant; LOQ, lower outer quadrant.
*Twelve hour, medial, 6 hour, and lateral are static tests; UOQ, UIQ, LIQ, and LOQ are moving tests.
†Mean ± SD.

Table 2. - Sensory Test Results in Five Breasts That Underwent Two Tests
Areas* Mastectomy Skin 1† Mastectomy Skin 2† Delta NAC Skin 1† NAC Skin 2† Delta
12 hr 89.12 ± 11.83 66.66 ± 27.74 9.18 88.26 ± 20.73 53.16 ± 25.21 35.1
Medial 89.12 ± 11.83 55.52 ± 31.47 33.6 88.3 ± 22.91 56.54 ± 30.57 31.76
6 hr 98.2 ± 3.91 79.38 ± 32.75 18.82 87.3 ± 28.39 73.82 ± 33.28 13.48
Lateral 99.28 ± 1.6 86.38 ± 25.21 12.9 91.3 ± 19.28 76.34 ± 33.28 14.96
UOQ 40.5 ± 34.28 10.65 ± 11.27 29.87 60.14 ± 29.31 31.78 ± 21.44 28.36
UIQ 16.32 ± 12.56 10.45 ± 5.39 5.87 33.54 ± 25.34 12.48 ± 5.53 20.06
LIQ 33.94 ± 20.79 23.02 ± 16.10 10.92 61.98 ± 41.58 32.38 ± 28.6 29.6
LOQ 65.18 ± 27.71 51.55 ± 43.91 13.63 73.34 ± 34.9 42.42 ± 35.77 30.92
NAC, nipple-areola complex; UOQ, upper outer quadrant; UIQ, upper inner quadrant; LIQ, lower inner quadrant; LOQ, lower outer quadrant.
*Twelve hour, medial, 6 hour, and lateral are static tests; UOQ, UIQ, LIQ, and LOQ are moving tests.
†Mean ± SD.

Table 3. - Results for the Two Patients That Underwent Unilateral Neurotization and Bilateral Reconstruction
Areas* No Nerve Graft Test 1 No Nerve Graft Test 2 Delta Nerve Graft Test 1 Nerve Graft Test 2 Delta Delta between no Graft 2 and Graft 2
12 hr 100 78.8 21.2 75.75 32.3 43.45 46.5
Medial 77.7 18.35 59.35 73.1 40.5 32.6 −22.15
6 hr 100 57.85 42.15 68.25 52.85 15.4 5
Lateral 100 100 0 78.4 61.3 17.1 38.7
UOQ 99.7 27.95 71.75 40.75 17.6 23.15 10.35
UIQ 42.1 13.4 28.7 15.1 7.8 7.3 5.6
LIQ 75.3 14.15 61.15 53.25 35.75 17.5 −21.6
LOQ 89.25 21.25 68 56.7 50.95 5.75 −29.7
UOQ, upper outer quadrant; UIQ, upper inner quadrant; LIQ, lower inner quadrant; LOQ, lower outer quadrant.
*Twelve hour, medial, 6 hour, and lateral are static tests; UOQ, UIQ, LIQ, and LOQ are moving tests.

Table 4. - Historical Control Patients’ Nonoperated Breast Sensory Information
Areas* Mastectomy Skin† Nipple†
12 hr 22 ± 15.06 25.16 ± 26.53
Medial 18.24 ± 21.38 20.6 ± 20.56
6 hr 22.77 ± 24.82 28.26 ± 22.66
Lateral 20.62 ± 20.80 34.8 ± 34.83
UOQ 16.55 ± 19.54 13.85 ± 17.74
UIQ 12.17 ± 15.8 13.8 ± 13.85
LIQ 8.97 ± 11.45 12.45 ± 11.38
LOQ 20.3 ± 24.89 12.2 ± 4.8
UOQ, upper outer quadrant; UIQ, upper inner quadrant; LIQ, lower inner quadrant; LOQ, lower outer quadrant.
*Twelve hour, medial, 6 hour, and lateral are static tests; UOQ, UIQ, LIQ, and LOQ are moving tests.
†Mean ± SD.

DISCUSSION

The dominant sensory innervation to the breast originates from the medial and lateral cutaneous branches of the third to fifth intercostal nerves, all of which are at high risk for injury during a mastectomy.4,5 The degree and timing of sensation that returns following mastectomy vary widely in the literature.6–12 The ability to provide sensate breast reconstruction holds the promise of allowing for return of both protective and erogenous sensation, and potentially improving breast-related quality-of-life.13–17 The first report of autologous sensate breast reconstruction by Blondeel et al. used the anterior ramus of the lateral branch of the fourth intercostal nerve.18 Later, Spiegel et al. used the third anterior intercostal nerve as the recipient nerve because of the ease of dissection and location within the surgical field.19 Recent articles and reviews have focused mainly on sensate abdominally based breast reconstruction.1,2

Our group previously characterized the location of the lateral fourth intercostal nerve in cadaveric studies to allow for ease of identification and preservation during mastectomy.20 We work closely with our breast surgeon to preserve this nerve to allow coaptation to the nipple-areola complex.

Although there is no preoperative sensory information available for these patients, use of historical control data (Table 4) demonstrates a reduction in postoperative sensation, regardless of whether sensate reconstruction was attempted. However, these measurements were obtained an average of 5.66 months postoperatively, and this would not be adequate time for nerve regeneration to occur. Although only five breasts underwent two rounds of sensory testing, an improvement in all regions of the breast can be observed despite an average of only 10.59 months postoperatively (Table 2). The patient in a cohort in whom only unilateral sensate reconstruction was possible provides an inherent control for analysis. In this patient, although sensory recovery was observed both with and without a nerve graft, in the majority of breast regions, at the time of the second sensory testing, there was improved sensation with a nerve graft.

There are limitations to our study, such as the small sample size and lack of preoperative sensation level measurements. Although some patients in our cohort underwent direct-to-implant reconstruction, there were too few patients undergoing tissue expander expansion to perform subgroup analysis to determine the role that fill volume has on sensation. Spontaneous sensory recovery can be expected after nipple-sparing mastectomies. Thus, it would be beneficial to have a control group to compare sensation recovery in these cohorts. However, as this is a novel technique, we wished to share our approach to empower other surgeons to attempt sensate implant-based breast reconstruction. As we enroll additional patients, we will perform subgroup analysis to determine whether patient or breast characteristics impact the success of this procedure. We will continue to follow all patients to determine long-term results, and we plan on performing quality-of-life assessments to help justify the cost of this procedure.

Numerous questions remain in the field of sensate breast reconstruction that warrant exploration. We used one nerve coaptation and the lateral fourth intercostal nerve as the donor nerve, as this is the dominant nerve supply to the nipple-areola complex. However, the breast receives sensation from numerous other nerves, and the optimal number of coaptations and the optimal placement has yet to be determined. The impact of chemotherapy, radiation therapy, and graft length on the return of breast sensation has yet to be analyzed.

Conclusions

This is the first study to report on results obtained after performing sensate implant-based breast reconstruction. There is the tendency for sensation restoration of the nipple-areola complex after sensate implant-based reconstruction. We will continue to follow these patients and enroll more patients in this prospective analysis to help address these critical questions.

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