Flap Neurotization in Breast Reconstruction with Nerve Allografts: 1-year Clinical Outcomes

Abstract

Autologous breast reconstruction is widely regarded as the gold standard approach following mastectomy. However, the lack of sensation continues to present a reconstructive challenge. In this study, clinical outcomes following abdominal flap neurotization with processed human nerve allograft were investigated.

Methods: In this prospective analysis, patients who underwent microsurgical breast reconstruction with (Group 1) or without (Group 2) abdominal flap neurotization at a single institution were investigated. Processed human nerve allograft (Avance, AxoGen, Alachua, Fla.) was used in all cases of flap neurotization. Only patients with a follow-up of ≥12 months were included. Cutaneous pressure threshold was tested using Semmes-Weinstein monofilaments (SWMF) at 9 pre-defined locations.

Results: A total of 59 patients (96 breasts) were enrolled into the registry. Of these, 22 patients (Group 1: N = 15, 22 breasts; Group 2: N = 7, 14 breasts) had a complete data set with ≥12 months follow-up. Measuring cutaneous pressure thresholds, we observed a greater likelihood for return of protective sensation (SWMF ≤ 4.31) in neurotized breasts in 8 of the 9 examined zones. Additionally, flap neurotization was associated with a greater likelihood for return of protective sensation in the majority of the reconstructed breast-that is, ≥5 zones (55% versus 7%; P < 0.01).

Conclusion: Flap neurotization using processed nerve allograft resulted in a greater degree of return of protective sensation to the reconstructed breast than reconstructions without neurotization at ≥12 months.

Fig. 1.

Dissection of internal mammary vessels and the recipient nerve (ie, anterior branch of ICN3). Note that the vicinity of the recipient nerve to the recipient vessels simplifies flap inset, as opposed to when the lateral ICN is used.

Fig. 2.

Intraoperative findings after completion of microvascular anastomosis and tension-free nerve coaptation.

Fig. 3.

Sensory examinations were performed by blinded examiners at pre-defined locations in a random sequence, using SWMF.

Fig. 4.

Cutaneous pressure measurement. A greater likelihood for return of protective sensation (SWMF ≤ 4.31) was noted in Group 1 in 8 of the 9 examined zones.

Fig. 5.

Sensory recovery at ≥12 months. Flap neurotization was associated with a greater likelihood for return of protective sensation in the majority (ie, ≥5 zones) of breasts (P < 0.01).

Fig. 6.

Limiting dissection to the sensory branch only when raising the abdominal flap results in a rather short nerve segment that mandates the use of a bridging material for flap neurotization upon flap transfer.