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Anatomical Considerations to Optimize Sensory Recovery in Breast Neurotization with Allograft

Ducic, Ivica, MD, PhD*,†; Yoon, Joshua, MD; Momeni, Arash, MD; Ahcan, Uros, MD, PhD§

Plastic and Reconstructive Surgery – Global Open: November 7, 2018 - Volume Latest Articles - Issue - p
doi: 10.1097/GOX.0000000000001985
Latest Articles: PDF Only

Background: Breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization, but it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. This study’s purpose was to provide an anatomical basis for observed inconsistencies and therein provide a principle that can be used to develop a technical approach that will optimize sensory recovery.

Methods: Anatomical dissections on 6 fresh cadavers, that is, 12 hemi-abdominal flaps and 12 hemi-chest dissections, were performed. The technical aspects of harvesting the abdominal flap with a nerve target, that is, inclusion of a sensory nerve branch only, recipient nerves in the chest, and the applications of allograft for acquired nerve gap reconstruction were investigated.

Results: Abdominal flaps that include sensory-only intercostal nerve 10–12 segments and identification of recipient chest wall intercostal nerves 2–4 could be consistently performed. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization.

Conclusions: We provide a likely anatomical explanation for suboptimal sensory recovery after deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft is prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridges sensory donor intercostal nerves to sensory recipient intercostal nerves should anatomically optimize restoration of breast sensibility.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

From the *Washington Nerve Institute, McLean, Va.

Department of Surgery, The George Washington University, Washington, D.C.

Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, Calif.

§Plastic and Reconstructive Surgery, University of Ljubljana, Ljubljana, Slovenia, EU.

Published online 7 November 2018.

Received for publication August 22, 2018; accepted September 5, 2018.

Disclosure: Dr. Ducic is the Medical Director of AxoGen. Dr. Momeni is a consultant for AxoGen. Study specimens, allografts, and nerve connectors were donated by AxoGen, while none of the authors received any direct or additional financial compensation for this study. Dr. Yoon and Dr. Ahcan do not have a financial interest in any of the products, devices, or drugs mentioned in the article. The Article Processing Charge was paid for by the authors.

Product listing: REXBETI digital 6-inch electronic caliper (commercially available for sale); Nerve Allograft (Avance nerve graft = processed human nerve graft) (AxoGen, Inc, Alachua, Fla.); AxoGuard Nerve Connector (=Porcine Submucosa Nerve Connector), (AxoGen, Inc, Alachua, Fla.).

Ivica Ducic, MD, PhD, Washington Nerve Institute, 7601 Lewinsville Road, Suite 460, McLean VA, 22102, E-mail:

Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.