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. 2024 Nov 4;7(11):e2446782.
doi: 10.1001/jamanetworkopen.2024.46782.

Targeted Reinnervation During Gender-Affirming Mastectomy and Restoration of Sensation

Katya Remy  1 , Chase Alston  2 , Elyse Gonzales  2 , Merel H J Hazewinkel  2 , Katherine H Carruthers  1 , Leslie E Cohen  2 , Eleanor Tomczyk  1 , Jonathan M Winograd  1 , William G Austen Jr  1 , Ian L Valerio  1 , Lisa Gfrerer  1   2
Affiliations

Targeted Reinnervation During Gender-Affirming Mastectomy and Restoration of Sensation

Katya Remy et al. JAMA Netw Open. .

Abstract

Importance: During gender-affirming mastectomy, nerves are transected, resulting in sensory loss. Nerve preservation using targeted nipple-areola complex (NAC) reinnervation (TNR) may restore sensation.

Objective: To determine the quantitative and patient-reported sensory outcomes of TNR.

Design, setting, and participants: Prospective matched cohort study of patients undergoing gender-affirming mastectomy from August 2021 to December 2022 at Weill Cornell Medicine and Massachusetts General Hospital. Data were analyzed from January to March 2023.

Exposure: Patients who underwent TNR and matched patients who did not.

Main outcomes and measures: Mechanical detection measured with monofilaments and patient-reported outcome questionnaires were completed preoperatively and at 1, 3, 6, 9, and 12 months postoperatively. Additional quantitative sensory testing was performed preoperatively and at 12 months postoperatively. The primary outcome was mechanical detection while secondary outcomes were the additional quantitative sensory testing variables and patient-reported outcomes. Exclusion criteria included peripheral nerve disorders, unmatched patients, and incomplete follow-up.

Results: A total of 25 patients who underwent TNR and 25 matched patients who did not were included. The mean (SD) age was 24.9 (5.5) years, BMI was 26.6 (5.2), and mastectomy weight was 608.9 (326.5) g; 6 patients (12.0%) were Asian, 5 patients (10.0%) were Black or African American, and 33 patients (66.0%) were White. Repeated measures analysis of variance (ANOVA) showed that the outcomes of TNR on improving mechanical detection over time was significant at the NAC (F = 35.2; P < .001) and chest (F = 4.2; P = .045). At 12 months, mean quantitative sensory values in patients who underwent TNR reached baseline and were improved compared with patients who did not undergo TNR for monofilaments (mean [SD] NAC, 3.7 [0.5] vs 4.9 [0.9]; [data]; P < .001; chest, 3.3 [0.4] vs 3.6 [0.6]; [data]; P = .002), vibration (mean [SD] NAC, 7.7 [ 0.4] vs 7.3 [0.4]; t96 = 6.3; P < .001; chest, 7.8 [0.3] vs 7.5 [0.3]; t96 = 5.1; P < .001), 2-point discrimination (NAC, 40% vs 0%; r = 20; P = .02); chest, 4.1 [1.2] cm vs 5.7 [1.8] cm; P < .001), pinprick (mean [SD] NAC, 24.9 [21.2] mN vs 82.6 [96.7] mN; t98 = 4.1; P < .001; chest, 22.5 [25.6] mN vs 54.1 [45.4] mN; t98 = 4.6; P < .001), cold (mean [SD] NAC, 23.1 [4.7] °C vs 12.0 [7.6] °C; t98 = 8.8; P < .001; chest, 23.6 [3.1] °C vs 19.7 [5.6] °C; t98 = 4.4; P < .001), warm (mean [SD] NAC, 39.9 [5.0] °C vs 45.8 [4.2] °C; t98 = 6.3; P < .001; chest, 39.4 [3.1] °C vs 42.9 [4.0] °C; t98 = 4.9; P < .001), and pressure pain detection (mean [SD] NAC, 89.9 [45.6] kPa vs 130.5 [68.9] kPa; t86 = 3.9; P < .001; chest, 128.5 [38.0] kPa vs 175.5 [49.3] kPa; t96 = 4.0; P = .001). ANOVA demonstrated that TNR significantly improved patient-reported nipple sensation (F = 60.5; P < .001), chest light touch (F = 8.1; P = .01) and erogenous sensation (F = 8.3; P = .01). Significantly more patients who underwent TNR than those who did not reported nipple hypersensitivity until 3 months postoperatively (8% vs 4% at 12 months).

Conclusion and relevance: In this prospective matched cohort study, TNR was associated with improved quantitative and patient-reported sensation. Patients should be counseled about the risk of transient NAC hypersensitivity.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Gfrerer reported being a consultant for BioCircuit Technologies Inc outside the submitted work. Dr Valerio reported receiving personal fees from Axogen, Checkpoint Surgical, and Integra Lifesciences outside the submitted work. Dr Austen reported receiving consultant fees and royalties from Sientra and Cytrellis outside the submitted work.No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Repeated Measures Analysis of Variance of Mechanical Detection Threshold Over Time
A, Association of targeted nipple-areola complex reinnervation (TNR) with the mean mechanical detection threshold over time at the nipple-areola complex, and B, the chest. Blue line represents patients who underwent TNR, while orange line represents patients who did not.
Figure 2.
Figure 2.. Quantitative Sensory Testing
Testing of A, mechanical; B, vibration; C, 2-point discrimination; and D, pinprick at the nipple-areola complex and chest in patients who underwent targeted nipple-areola complex reinnervation as compared with patients who did not. Error bars represent SEs. aRepresents a statistically significant difference of P < .05.
Figure 3.
Figure 3.. Quantitative Sensory Testing
Testing of A, cold; B, warm; C, heat pain; and D, pressure pain detection thresholds at the nipple-areola complex and chest in patients who underwent targeted nipple-areola complex reinnervation as compared with patients who did not. Error bars represent SEs. aRepresents a statistically significant difference of P < .05.
Figure 4.
Figure 4.. Repeated Measures Analysis of Variance of Patient-Reported Outcomes Over Time
Associations of targeted nipple-areola complex reinnervation (TNR) over time with postoperative patient-reported A, nipple sensation; B, chest light touch; C, cold sensation; D, warm sensation; E, the ability the feel water from the shower; and F, erogenous sensation. Patient-reported sensation was rated as either 1 = no sensation, 2 = a little sensation, 3 = some sensation, 4 = a lot of sensation, 5 = complete sensation. Blue line represents patients who underwent TNR, while orange line represents patients who did not.
See this image and copyright information in PMC

Comment in

  • doi: 10.1001/jamanetworkopen.2024.46799

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