Breast Skin Reinnervation Following MastectomyAmelia Van Handel, MD, Ema Zubovic, MD, Thomas Tung, MD

Division of Plastic & Reconstructive Surgery, Washington University in St. Louis

Results: Patient-Reported OutcomesResults: Sensation

Fig 1: Average 2PD for control and study patients in each of four breast quadrants. Red-filled quadrants are those in which study patients had better sensation than control.

Fig 2: Percentage of breast quadrants with a specific 2PD. 80% of study patients have normal 2PD, compared to 30% of control patients.

Fig 3: Average SWM test. Smaller average indicates better sensation. Red-filled quadrants are those in which the study population had better sensation than control. However, all patients had diminished or loss of protective sensation in all quadrants.

Objectives & Hypothesis

Objective: Report sensation and pain outcomes on a small series of patients who have undergone sensory reinnervation of native breast skin at the time of mastectomy and reconstruction

Hypothesis: nerve repair or breast skin neurotization will result in improved sensation and decreased pain

• Changes in breast sensation are common following mastectomy and reconstruction

• Chronic pain, known as Post-Mastectomy Pain Syndrome, affects 22-72% of patients, and is hypothesized to be neuropathic pain

• Previous studies have reported success in performing innervated autologous flaps for reconstruction

• Skin flap represents only a small portion of the reconstructed breast surface

• Most reconstructions are implant-based, rather than autologous

Background

Two groups (Table 1)

• STUDY: mastectomy and tissue expander reconstruction WITH nerve repair or breast skin neurotization

• CONTROL: mastectomy and tissue expander reconstruction WITHOUT nerve procedure

Outcomes

• Sensation

• 2-point discrimination (2PD)

• Semmes-Weinstein Monofilament (SWM) Test

• Pain questionnaire

• Breast-Q: physical well-being of the chest

Data collection points

• Preoperative

• After tissue expansion is complete, but before expander is replaced with permanent implant (4-6 months post-op)

• 2-4 months after implant placement

• 8-14 months after implant placement

Methods

Contact Information

Amelia Van Handel, MD; avanhandel@wustl.edu

Table 1: Patient demographicsControl Study

Patients 9 4

Breasts 17 7

Radiation 2 (11.8%) 1 (12.5%)

Mean age 49.6 49.6

Mean follow up 17.1 months 10.6 months

Methods, continued

• Lateral cutaneous branchof the intercostal nerve innervates the lateral breast• Can be repaired directly

to provide reinnervation• Anterior cutaneous branch

of the intercostal nerve innervates the medial breast• Can be used for breast

skin neurotization

Control

Study

Control

Study

9.6

2.5

10.9

2.8

10.7

5

10.2

8.6

Control

Study

Control

Study

5.10

3.82

5.16

4.98

5.42

4.87

5.12

6.13

Normal light touch 2.36-2.83

Diminished light touch 3.22-3.61

Diminished protection 3.84-4.31

Loss of protection 4.56-6.65

Conclusions

Breast skin reinnervation following mastectomy has shown promising results in a small group of patients by improving sensation and patients’ satisfaction with their breast reconstruction.

Limitations:

• Small study size

• Did not assess all sensory modalities (temperature, vibration)

Future studies:

• Basic science study for proof of concept and to determine radius of nerve sprouting into dermis

• Cost analysis for increased anesthesia time & procedures

Fig 4: Breast Q module scores. Higher Scores in study patients indicate lower frequency of pain, tenderness, aching, throbbing, and nagging.

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30

40

50

60

70

80

90

STUDY CONTROL

• Nerve procedure chosen based on available anatomy• Nerve repair (n=1)• Breast skin neurotization (n=4)

Intercostal Nerve RepairProximal and distal ends of the lateral cutaneous intercostal nerve are identified and repaired with 9-0 nylon suture & glue.

Breast Skin Neurotization

The full length of the anterior cutaneous branch of the intercostal nerve is dissected from beneath the rib.

The lateral cutaneous branches, shown in this photo, are much shorter. All are brought outside the submuscular pocket.

The submuscular pocket is closed while the intercostal nerve branches remain outside the pocket.

The nerves are brought up to the native breast skin. Subcutaneous fat is removed from the underside of the skin flap to expose 1cm areas of dermis. Nerve ends are coapted to the dermis with fibrin glue, avoiding tension and taking care not to cross the incision line.

0%10%20%30%40%50%60%70%80%90%

100%

STUDY CONTROL

2-3mm 4-5mm 6-7mm 8-9mm10-11mm 12-13mm 14mm or greater

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