Sensate immediate breast reconstruction

Abstract

As breast cancer therapies and associated oncologic outcomes continue to improve, greater attention has been placed on quality-of-life issues after breast cancer and breast cancer risk-reducing treatments. The loss of sensation that typically occurs after mastectomy can have significant negative psychological, sexual, and functional impact on patients after surgery. Further, injury of nerves not only leads to numbness, but can also cause chronic neuropathic pain, which can be very debilitating to affected patients. In order to minimize these impacts, there is expanding uptake of surgical approaches that preserve nerves at the time of mastectomy and reconstruct injured nerves either during mastectomy or during delayed reconstruction. These advances have been facilitated by anatomic studies investigating different variants of intercostal anatomy and better understanding the course of the nerves innervating the mastectomy skin and nipple-areolar complex (NAC). With improved knowledge of the intercostal nerve anatomy, surgeons are able to carefully preserve nerves at the time of mastectomy, thus improving sensory outcomes. Additionally, nerve reconstruction techniques have advanced, particularly with newer nerve allograft technologies, which allows for nerve reconstruction to be done both at the time of mastectomy, as well as in a delayed fashion. The focus of this article is to describe the current state of sensory preservation and immediate reinnervation at the time of mastectomy and the advances that have allowed for these new approaches.

Keywords: Mastectomy; breast reconstruction; breast sensation; sensory reinnervation.

Figure 1

Schematic depiction of a preserved T4 intercostal nerve that has been preserved and is seen coursing directly from its emergence at the intercostal space into the lateral subcutaneous tissues.

Figure 2

An intraoperative photograph demonstrating the anatomy seen in Figure 1 on the contralateral side. The T3 intercostal nerve is seen within the vessel loop entering the subcutaneous tissues lateral to the lateral border of the pectoralis major muscle.

Figure 3

An intraoperative photograph showing the trajectory of T4 intercostal nerve as it was passing through the parenchyma which has now been removed. In this case, the deep and superficial branches course into one nerve trunk distally. Approximately 6 cm of the nerve was able to be preserved prior to the need for transection.

Figure 4

A near-complete extirpation of the breast tissue demonstrating a co-dominant nerve supply including both the T4 and T5 intercostals heading intra-parenchymal. Both nerves were ultimately transected distally and the more caudal and smaller nerve was harvested as an autograft to complete the nerve reconstruction in a manner similar to that depicted in the prior figure.

Figure 5

A subareolar nerve that has been identified and dissected so that an end-to-end nerve reconstruction can be performed.

Figure 6

The final nerve reconstruction is completed and demonstrated here located superficial to the acellular dermal matrix. (A) A nerve connector can be seen over the central portion of the allograft which will subsequently be slid over the coaptation site to complete a connector-assisted repair. (B) Completed connector-assisted repair.