BACKGROUND: There has been a steady evolution over the past few decades in postmastectomy breast reconstruction techniques. Nipple-sparing mastectomy approaches combined with immediate reconstruction can provide excellent cosmetic outcomes for women, but absent or significantly diminished postoperative breast and nipple/areolar sensation remain major drawbacks. We present a novel technique for implant reconstruction combining several of the latest advances in breast oncologic surgery, reconstructive surgery, and peripheral nerve surgery to achieve what we feel to be an optimal outcome both in terms of esthetics and sensation.
METHODS: Eleven women (21 breasts) underwent nipple-sparing mastectomy and single-stage, direct-to-implant, prepectoral breast reconstruction. During the mastectomy, a careful dissection performed along the lateral aspect of the breast allowed identification and in some cases preservation of the T4 and T5 intercostal nerves. In cases where the nerves could be preserved without compromising the oncologic safety of the mastectomy, they were left intact heading into the subcutaneous tissue of the lateral mastectomy skin flap. When preservation was not feasible, neurotization of the nipple/areolar complex (NAC) utilizing allograft coapted from either the T4 or T5 lateral intercostal nerves proximally to subareolar nerves distally identified at the completion of the mastectomy. Two-point discrimination was measured preoperatively in all 4 areolar quadrants and the nipple and repeated postoperatively at 3 and 6 months. Sensation to gross, light touch throughout the rest of the reconstructed breast was also assessed (with an added evaluation point of 1 month postoperatively), as was patient satisfaction with their overall breast and NAC sensation.
RESULTS: At the time of submission, 7 women (13 breasts) had ≥6 months of follow-up, with another 3 patients (6 breasts) with over 3 months of follow-up. In patients with ≥3 months follow-up, NAC 2-point discrimination was found to be preserved compared with preoperative values in 16 breasts (84%), was worse in 2 breasts (11%) of patients, and had actually improved in 1 breast (5%). All of the patients in studied had grossly intact sensation to light touch throughout the majority of, if not their entire, reconstructed breasts. All patients reported good satisfaction with their sensory outcomes. None of the women developed hyperesthesia, allodynia, or other symptoms concerning for neuroma formation.
CONCLUSIONS: This initial pilot study demonstrates as a proof of concept that nerve grafting in conjunction and/or careful nerve preservation at the time of nipple-sparing mastectomy with implant-based breast reconstruction is safe and effective, with a nearly 90% rate of preserved sensation postprocedure. Longer follow-up may yield even greater return of sensation than seen here or possibly improved sensation from the preoperative baseline, particularly in patients receiving adjuvant chemotherapy or radiation therapy that could delay neurotization.