Nipple-sparing mastectomy results in injury to sensory nerves that supply the breast and nipple-areolar complex (NAC). This leads to diminished or complete sensory loss, which can negatively impact patients’ quality of life postoperatively.1 In our experience, attempting to restore sensation to the NAC presents relatively minimal risk to patients. We believe that attempts at preservation and restoration of NAC sensation should be offered to women undergoing nipple-sparing mastectomy, where resources permit.
ANATOMY AND ADVANTAGES
Sensory innervation to the breast is mainly derived from the anterolateral and anteromedial branches of the third, fourth, and fifth intercostal nerves. During removal of breast parenchyma, sensory nerves are transected, resulting in the development of painful neuromas and/or permanent sensory loss.
Location of these nerves is predictable, allowing for uncomplicated identification at the time of extirpation. Preservation of sensory nerves should be considered as long as oncologic success is not compromised. In cases where sensory nerves cannot be preserved, coaptation of allograft or autograft from transected nerve endings to the undersurface of the NAC can be performed. In delayed reconstruction, cut nerve ends can be dissected and tagged for localization at a later date.
Prior studies have demonstrated that neurotization does not prolong operative time in autologous reconstruction.2 In our experience, this is also true for implant-based reconstruction. Furthermore, attempted reinnervation poses minimal risk, while potentially improving patients’ postoperative quality of life. Reinnervation may incur additional cost; however, patients are unlikely to bear this financial burden as an adjunct to breast reconstruction, and we argue that the potential benefits of reinnervation outweigh the possible risks.
SUPPORTING LITERATURE
Coaptation of intercostal nerves to the NAC with allograft in implant-based reconstruction has demonstrated satisfactory postoperative sensory outcomes.3 Neurotization of the NAC using autografts has been described using branches of intercostal nerves.4 If the nerve deficit from transected nerve to NAC is minimal, creation of dermatosensory peripheral nerve interfaces may also be considered.
ANECDOTAL SUPPORT
A New York Times article recently highlighted the decreased quality of life many women experience after mastectomy.5 The physical and psychological impact of injuries, decreased sexual arousal, inability to feel a hug from loved ones, and breast exposure after an unrecognized shift in clothing demonstrate the significant impact that sensory loss has after breast surgery. Therefore, this issue warrants increased attention.
CONCLUSIONS
If resources are available to perform neurotization, plastic surgeons can advocate for patients by educating their surgical oncology colleagues that it is being offered and include a discussion regarding neurotization in their reconstructive consultation. Additionally, plastic surgeons can undertake further research to better characterize the benefits and potential drawbacks of neurotization. Given that neurotization is a fairly straightforward procedure in patients undergoing nipple-sparing mastectomy and reconstruction, by not studying it further, we risk losing the chance to restore a vital sense of self in this patient population.
DISCLOSURE
The authors have no financial interest in relation to the content of this article.
REFERENCES
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