Breast Skin Reinnervation following Mastectomy
Amelia Van Handel, Thomas Tung.
Washington University, Saint Louis, MO, USA.
Skin-sparing mastectomy is a morbid and disfiguring procedure. Breast reconstruction contributes to the patient's recovery both physically and psychologically. However, the spared native breast skin remains insensate which can be annoying and bothersome at the least, and can cause paresthesias and chronic pain at its worse. Over time, some sensitivity may slowly return but it remains crude and very abnormal. The use of innervated flaps for reconstruction can help to restore some sensation but the flap skin paddle is often a small portion of the reconstructed breast surface, the majority of which is made up by denervated native breast skin. Reinnervation of the native breast skin has not been previously described. Our objective is to report a small series of patients who have undergone reinnervation of their native breast skin at the time of mastectomy.
After the mastectomy was completed, and at the time of tissue expander placement, the native breast skin was reinnervated by intercostal sensory nerves. Our first patient underwent direct nerve repair as we were able to identify distal sensory nerves on the mastectomy skin flaps and severed proximal sensory nerves. However we have not been able to consistently identify the distal sensory nerves on the breast skin in subsequent patients and we therefore developed an alternative technique of harvesting intercostal sensory nerves for transfer. These were then coapted directly to the dermis of the underside of the mastectomy skin flaps for sprouting. Usually 2 intercostal nerves were used per side. This technique also provides extra nerve length to help accommodate tissue expansion. Tissue expander placement proceeded in a standard manner and the nerve transfer coaptations were completed with fibrin glue just prior to skin closure to prevent disruption of the nerve transfers during expander placement. The transferred intercostal sensory nerves were also positioned to avoid disruption at the time of second stage implant exchange. Sensation was evaluated postoperatively by Semmes-Weinstein filaments, 2-point discrimination, and patients completed a breast pain questionnaire.
Five patients have undergone breast skin reinnervation at the time of mastectomy and tissue expander placement, and were compared to an equivalent number of patients who underwent the same procedure without breast skin reinnervation. Follow-up ranged from 6-18 months. Patients who received nerve transfer reinnervation had better return of sensation as measured by both Semmes-Weinstein filaments and 2-point discrimination. Data from patient-completed surveys is still under analysis.
Reinnervation of native breast skin following mastectomy is possible and provides better return of sensation. This may help to provide superior and more complete reconstruction by restoring sensation as well as form. The incidence of chronic paresthesias, discomfort or pain may also be reduced and may contribute to a better quality of life in the long term for breast cancer survivors.
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