Sensory reinnervation of autologous tissue TRAM flaps after breast reconstruction

Restoring Sensation through Abdominal Flap Neurotization in Breast Reconstruction

Breast sensation plays a significant role in the safety and quality of life of women who undergo mastectomy and reconstruction. In 1992, Slezak et al. introduced the concept of abdominal flap neurotization to improve sensation of the reconstructed breast. Over the next 30 years, numerous studies iterated on Slezak's technique, suggesting technical modifications and new methodologies for assessing sensory recovery. Despite evidence that reinnervation increases patient satisfaction following autologous breast reconstruction, abdominal flap neurotization remains a rarely performed procedure. In this article, we review the evolution of flap neurotization in breast reconstruction and describe our approach to facilitating sensory recovery of the breast while limiting donor site morbidity.

Is nerve coaptation associated with improved sensation after microvascular breast reconstruction? A systematic review

BACKGROUND

Sensation after autologous breast reconstruction is an increasingly important outcome. Several studies demonstrated improved sensation with flap neurotization but utilized heterogenous measures and follow-up intervals. This review evaluates sensory outcomes after neurotization using uniform, objective outcome measurements.

METHODS

PubMed/Medline and Embase databases were queried for articles published between January 1990 and January 2022. Inclusion criteria included studies with free flap tissue transfer breast reconstruction patients and use of Semmes-Weinstein Monofilaments (SWM) to quantify return of sensation after either neurotization or no neurotization. Reviews, case reports, and studies utilizing implants or pedicled flaps were excluded.

RESULTS

Overall, 513 articles were screened. Eleven articles met inclusion criteria for a total of 474 patients. There were 254 non-neurotized patients included as controls (Group A) and 220 neurotized patients (Group B). Mean follow-up time was similar in both groups (22.06 months vs. 22.78 months, p > 0.05). There was no significant difference in age (Group A = 49.97 years vs. Group B = 42.47 years) or BMI (Group A = 25.48 vs. Group B = 25.97) between groups. More patients in group B received radiation therapy (Group B = 32.72% vs. Group A = 20.86%, p > 0.05). Patients that received neurotization had lower mean pressure thresholds (Group A = 38.85 gm/mm² vs. Group B = 6.69 gm/mm² , p = 0.053) than comorbidity-matched controls.

CONCLUSION

Neurotization has been shown to be a safe and feasible option for enhancing return of sensation after breast reconstruction. Future studies with standardized, long-term follow-up will further elucidate the pattern of breast sensation return and the impact of neurotization.

Sensory nerve regeneration and reinnervation in muscle following peripheral nerve injury

Sensory afferent fibers are an important component of motor nerves and compose the majority of axons in many nerves traditionally thought of as "pure" motor nerves. These sensory afferent fibers innervate special sensory end organs in muscle, including muscle spindles that respond to changes in muscle length and Golgi tendons that detect muscle tension. Both play a major role in proprioception, sensorimotor extremity control feedback, and force regulation. After peripheral nerve injury, there is histological and electrophysiological evidence that sensory afferents can reinnervate muscle, including muscle that was not the nerve's original target. Reinnervation can occur after different nerve injury and muscle models, including muscle graft, crush, and transection injuries, and occurs in a nonspecific manner, allowing for cross-innervation to occur. Evidence of cross-innervation includes the following: muscle spindle and Golgi tendon afferent-receptor mismatch, vagal sensory fiber reinnervation of muscle, and cutaneous afferent reinnervation of muscle spindle or Golgi tendons. There are several notable clinical applications of sensory reinnervation and cross-reinnervation of muscle, including restoration of optimal motor control after peripheral nerve repair, flap sensation, sensory protection of denervated muscle, neuroma treatment and prevention, and facilitation of prosthetic sensorimotor control. This review focuses on sensory nerve regeneration and reinnervation in muscle, and the clinical applications of this phenomena. Understanding the physiology and limitations of sensory nerve regeneration and reinnervation in muscle may ultimately facilitate improvement of its clinical applications.

Development and Psychometric Validation of the BREAST-Q Sensation Module for Women Undergoing Post-Mastectomy Breast Reconstruction

BACKGROUND

Reconstructive techniques for restoring sensation to the breast after mastectomy continue to evolve. The BREAST-Q is a patient-reported outcome measure that can be used to evaluate outcomes of breast cancer treatments; however, it previously lacked scales to measure breast sensation. This paper outlines the development and validation of the BREAST-Q Sensation Module.

METHODS

Phase 1 (January 2017 through December 2018) involved qualitative and cognitive interviews with women who had undergone breast reconstruction, as well as expert input, to develop and refine the scales. In phase 2 (March through June 2019), Love Research Army (LRA) members completed the scales, and Rasch Measurement Theory (RMT) analysis was performed to examine the reliability and validity of the scales.

RESULTS

In this study, 36 qualitative and 7 cognitive interviews were conducted, and input from 18 experts was obtained. Three scales were developed to measure breast Symptoms (e.g., throbbing, burning, tingling), Sensation (e.g., feeling with light touch, through clothing, sexually), and Quality of Life impact of sensation loss. In phase 2, 1204 LRA members completed the scales. Data for each scale fit the RMT model. Reliability was high, with Person Separation Index, Cronbach alpha, and intraclass correlation coefficient values of 0.81 or higher (with and without extremes) for all three scales. Mean scores were higher (better) on the Symptoms and Quality of Life impact scales for the participants with unilateral (vs. bilateral) and autologous (vs. alloplastic) reconstruction, and for the participants who were farther out from their reconstruction.

CONCLUSION

The BREAST-Q Sensation Module can be used alone or in conjunction with other BREAST-Q scales to inform clinical care and to evaluate outcomes of new surgical approaches to restoration of breast sensation.

The role of neurotization in autologous breast reconstruction: Can reconstruction restore breast sensation?

As the sophistication of microsurgical breast reconstruction continues to evolve, plastic surgeons are focusing on techniques to improve functional and psychosocial outcomes for patients, including breast sensation. Interest in neurotization of breast flaps, among both patients and surgeons, has grown significantly in recent years. This study aimed to review the outcomes of neurotization across autologous flap reconstructions, to provide a comprehensive analysis of the efficacy of this technique in improving postoperative sensory recovery.

A Cadaveric Anatomical and Histological Study of Recipient Intercostal Nerve Selection for Sensory Reinnervation in Autologous Breast Reconstruction

BACKGROUND

 Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR.

METHODS

 Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared.

RESULTS

 A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm²) compared with that in the fourth (mean 26,474 ± 38,626 µm²), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p < 0.05).

CONCLUSION

 This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

Abdominoplasty with Scarpa Fascia Preservation: Randomized Controlled Trial with Assessment of Scar Quality and Cutaneous Sensibility

BACKGROUND

Scarpa fascia preservation during abdominoplasty has been shown to reduce complications associated with the traditional technique. As an extension of a previously published randomized controlled trial, this study aims to clarify whether preservation of Scarpa fascia during abdominoplasty has an influence on scar quality or sensibility recovery.

METHODS

This was a single-center clinical trial, involving 160 patients randomly assigned to one of two surgical procedures: classic full abdominoplasty (group A) and abdominoplasty with preservation of Scarpa fascia (group B). Patients were later convoked to assess scar quality and abdominal cutaneous sensibility. Scar quality was evaluated through the Patient and Observer Scar Assessment Scale. Cutaneous sensibility was measured on the upper and lower abdomen, using light touch, Semmes-Weinstein testing (5.07/10-g monofilament), and a 25-gauge needle.

RESULTS

A total of 99 patients (group A, 54 patients; group B, 45 patients) responded to contact, with a mean follow-up time of 44 months. Concerning scar quality, Patient and Observer Scar Assessment Scale scores were similar between groups. On the upper abdomen, there was a statistically significant difference between groups on cutaneous sensibility, on the examination with the Semmes-Weinstein 5.07/10-g monofilament (group A, 79.6 percent; group B, 93.3 percent; p = 0.046) and pain (group A, 90.7 percent; group B, 100 percent; p = 0.044). No statistically significant differences were found between groups on the lower abdomen. A considerable proportion of patients (two-thirds) still presented sensibility alterations in the subumbilical area 3½ years after abdominoplasty.

CONCLUSION

Scarpa fascia preservation during abdominoplasty does not influence scar quality, but it improves sensibility recovery in the supraumbilical area.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Anatomical Considerations to Optimize Sensory Recovery in Breast Neurotization with Allograft

Background:

Breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization, but it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. This study’s purpose was to provide an anatomical basis for observed inconsistencies and therein provide a principle that can be used to develop a technical approach that will optimize sensory recovery.

Methods:

Anatomical dissections on 6 fresh cadavers, that is, 12 hemi-abdominal flaps and 12 hemi-chest dissections, were performed. The technical aspects of harvesting the abdominal flap with a nerve target, that is, inclusion of a sensory nerve branch only, recipient nerves in the chest, and the applications of allograft for acquired nerve gap reconstruction were investigated.

Results:

Abdominal flaps that include sensory-only intercostal nerve 10–12 segments and identification of recipient chest wall intercostal nerves 2–4 could be consistently performed. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization.

Conclusions:

We provide a likely anatomical explanation for suboptimal sensory recovery after deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft is prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridges sensory donor intercostal nerves to sensory recipient intercostal nerves should anatomically optimize restoration of breast sensibility.

Evaluation of the Neo-umbilicus Cutaneous Sensitivity Following Abdominoplasty

BACKGROUND

Abdominal cutaneous sensitivity loss after abdominoplasty is an undesirable outcome. However, little is known in the literature about sensitivity changes of the neo-umbilicus after abdominoplasty. The aim of this study was to evaluate post-abdominoplasty cutaneous sensitivity of the neo-umbilicus using clinical, quantitative, and reproducible methods.

METHODS

Patients who underwent abdominoplasty were included, whereas the control group consisted of healthy volunteers with similar demographic characteristics but who did not undergo abdominoplasty. The umbilicus was divided into five zones, and superficial tactile sensitivity and spatial orientation were assessed subjectively (score 1-4) and objectively (Semmes-Weinstein monofilament examination).

RESULTS

Twenty patients (45 ± 12 years) operated on consecutively between April 2012 and May 2016 and 14 healthy volunteers in the control group (39 ± 9 years) could be included. Although there were statistically significant differences (p = 0.0005) in the average cutaneous pressure thresholds between the control group (0.4 g/mm², range 0.07-2 g/mm²) and the study group (0.4 g/mm², range 0.07-4 g/mm²), patient satisfaction after a mean follow-up of 33 ± 16 months (range 10-62 months) was acceptable (mean satisfaction score 1.8 ± 0.7). Furthermore, spatial perceptions were precise in all patients and similar to the control group.

CONCLUSION

Our long-term results indicate that spontaneous reinnervation of the neo-umbilicus after abdominoplasty together with accurate spatial orientation can occur.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Herpes zoster in a free transverse rectus abdominis myocutaneous flap after delayed breast reconstruction: evidence of spontaneous reinnervation

In concert with advances in surgical reconstruction techniques and improved survival after breast cancer, both the aesthetic and functional outcomes, especially sensory recovery, of breast reconstruction have been addressed. Most studies on sensory recovery in reconstructed breasts have utilized patients’ subjective responses to touch, pain, temperature, and pressure. In contrast, this report describes a case of herpes zoster that developed in a free transverse rectus abdominis myocutaneous flap, which provides objective evidence of spontaneous reinnervation after breast reconstruction.

Evaluation of abdominal cutaneous sensibility following abdominoplasty

BACKGROUND

Cutaneous hypesthesia is an undesirable postoperative outcome following abdominoplasty. The purpose of this study was to evaluate postabdominoplasty cutaneous sensibility using clinical, quantitative, and reproducible methods.

METHODS

Thirty patients who underwent abdominoplasty were divided into three groups: 0 to 12 months (short-term follow-up), 12 to 24 months (intermediate-term follow-up), and greater than 24 months (long-term follow-up) following abdominoplasty. Abdominal skin was divided into 12 areas, and superficial tactile sensibility was assessed subjectively using a patient questionnaire and objectively using Semmes-Weinstein monofilaments. Statistical analysis was performed using the t test, with significance defined as p ≤ 0.05.

RESULTS

Seventeen patients (56.7 percent) subjectively reported the presence of any abdominal cutaneous sensibility change postoperatively. Of those, 82.4 percent reported indifference toward this outcome. The greatest degree of objective sensibility loss was noted in area 8 (infraumbilical), followed by areas 5 (supraumbilical) and 11 (midline infraincisional). In these areas, there were statistically significant decreases in the average cutaneous pressure thresholds between the short-term and intermediate-term follow-up groups, the intermediate-term and long-term follow-up groups, and the short-term and long-term follow-up groups.

CONCLUSIONS

Postabdominoplasty cutaneous sensibility losses improve over time. These findings may enable plastic surgeons to better inform their patients regarding the risk of sensibility loss and the longitudinal outcome of such changes postoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Prospective study of sensation in anterior chest areas before and after a bilateral axillo-breast approach for endoscopic/robotic thyroid surgery

BACKGROUND

The bilateral axillo-breast approach for endoscopic/robotic thyroid surgery (BABA) shows good oncologic and surgical outcomes and does not result in neck scars. However, there is concern about potential sensory changes of the skin flaps after BABA, especially of the breast areas. This prospective study was undertaken to evaluate sensory changes in the skin flaps after BABA.

PATIENTS AND METHODS

A total of 19 women (mean age 36.9 ± 8.7; age range 21-51 years) who underwent BABA were enrolled. Skin flap sensory assessments were performed for each patient preoperatively and again at 1 and 3 months postoperatively. The Semmes-Weinstein monofilament test was used to evaluate the cutaneous light-pressure thresholds, a biothesiometer was used to evaluate the vibration thresholds, and an infrared thermometer was used to measure skin temperatures of the skin flaps.

RESULTS

There were changes in the sensations of the anterior chest areas over time, as determined by the Semmes-Weinstein monofilament test (1.5 vs 4.3 versus 1.4; P < 0.05) and the biothesiometer (26.8 vs 31.2 vs 22.3; P < 0.05). The sensations in the anterior chest areas normalized to preoperative levels at 3 months postoperatively. No significant differences were seen in the infrared thermometer test at any of the time points (36.2 vs 36.2 vs 36.3 °C; P = 0.9927).

CONCLUSIONS

While anterior chest area sensations were changed at 1 month postoperatively, the sensations normalized at 3 months after BABA. These results suggest that BABA has minimal adverse effects on anterior chest area sensation.

Pilot study of breast sensation after breast reconstruction: evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery

BACKGROUND

Some sensation to the breast returns after breast reconstruction, but recovery is variable and unpredictable. We primarily sought to assess the impact of different types of breast reconstruction [deep inferior epigastric artery perforator (DIEP) flaps versus implants] and radiation therapy on the return of sensation.

METHODS

Thirty-seven patients who had unilateral or bilateral breast reconstruction via a DIEP flap or implant-based reconstruction, with or without radiation therapy (minimum follow-up, 18 months; range, 18-61 months) were studied. Of the 74 breasts, 27 had DIEP flaps, 29 had implants, and 18 were nonreconstructed. Eleven breasts with implants and 10 with DIEP flaps had had prereconstruction radiation therapy. The primary outcome was mean patient-perceived static and moving cutaneous pressure threshold in nine areas. We used univariate and multivariate analyses to assess what independent factors affected the return of sensation (significance, P < 0.05).

RESULTS

Implants provided better static (P = 0.071) and moving sensation (P = 0.041) than did DIEP flaps. However, among irradiated breasts, skin over DIEP flaps had significantly better sensation than did that over implants (static, P = 0.019; moving, P = 0.028). Implant reconstructions with irradiated skin had significantly worse static (P = 0.002) and moving sensation (P = 0.014) than did nonirradiated implant reconstructions.

CONCLUSIONS

Without irradiation, skin overlying implants is associated with better sensation recovery than DIEP flap skin. However, with irradiation, DIEP flap skin had better sensation recovery than did skin over implants. Neurotization trended toward improvement in sensation in DIEP flaps.

Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities

There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves “untreated”. Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.

Update on Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Breast reconstruction using autologous tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing free TRAM, DIEP, and SIEA flap techniques followed in an effort to decrease abdominal donor site morbidity by decreasing injury to the rectus abdominis muscle and fascia. Data have accumulated over the past decade that show that muscle- and fascia-sparing techniques, such as the use of DIEP flaps, result in measurably better postoperative abdominal strength. However, muscle-sparing techniques do not appear to decrease the risk of abdominal bulging or hernia, and there are no significant differences in patient-reported abdominal weakness or functional impairments. The SIEA flap is presented as a reemerging method that can virtually eliminate abdominal donor site morbidity. Sensory nerve coaptation to improve reconstructed breast sensation is also reviewed.

Donor site sensitivity after breast reconstruction with deep inferior epigastric artery perforator flap

The aim of this study was to examine pressure sensitivity at the donor site after breast reconstruction with deep inferior epigastric artery perforator (DIEAP). In a cross-sectional survey, 2 groups of patients were analyzed. The DIEAP group consisted of 30 women who had previously had secondary breast reconstruction with DIEAP flap after mastectomy for breast cancer. The control group consisted of 7 women with no previous abdominal incisions planned for secondary breast reconstruction with DIEAP. Pressure thresholds were tested within the margins of the abdominal wall using Semmes-Weinstein monofilaments. In the DIEAP group a pattern of higher pressure thresholds was observed in the proximity of the scar. Comparing the 2 groups, significant higher pressure thresholds were found in the DIEAP group in the scar on both sides and in the midline from the scar to the umbilical level. Our data show that the abdominoplasty performed during breast reconstruction with DIEAP reduces cutaneous sensitivity in the donor site area.

Thermal injuries to autologous breast reconstructions and their donor sites--literature review and report of six cases

Breast reconstruction using autologous techniques has now become the gold standard. In recent years the focus has been on maintaining excellent cosmesis whilst minimising the incidence of partial or complete flap loss and donor site morbidity. However, an area which is frequently overlooked is the sequelae resulting from denervation of these flaps and their donor sites which can potentially lead to thermal injury. We report on six patients who sustained burns following free autologous breast reconstruction using either a DIEP or a muscle sparing TRAM. Four of the burns were confined to the flap skin paddle and two to the abdominal donor site. To prevent such thermal injuries all patients undergoing flap reconstruction should be educated regarding the vulnerability of the flap and its donor site as well as means of protecting these susceptible areas during daily activities.

Sensibility following Innervated Free TRAM Flap for Breast Reconstruction

BACKGROUND

The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast.

METHODS

Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern.

RESULTS

Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout.

CONCLUSIONS

Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to breast reconstruction.

Sensory reinnervation of a musculocutaneous flap: an experimental rabbit study

Sensory neurotisation of a muscle (sensory nerve transfer to the motor nerve of a muscle) produces muscle sensibility, but not skin sensibility. How to achieve sensation of a musculocutaneous flap remains a challenge to reconstructive microsurgeons. The purpose of our study was to determine if multiple nerve grafts which were placed vertically between the neuromuscular entrance zone of a muscle and a target area of dermis on the overlying skin could improve sensation. Thirty-six gracilis musculocutaneous flaps (18 rabbits) were raised and divided into three groups: group 1 consisted of 12 sensory neurotised gracilis musculocutaneous flaps with five nerve grafts each; group 2 consisted of another 12 sensory neurotised gracilis flaps with 10 nerve grafts each; and the control group consisted of 12 sensory neurotised gracilis musculocutaneous flaps without any nerve grafts. All nerve grafts spanned the distance between the neuromuscular entrance zone of the gracilis muscle and a specified 3 cm diameter area of the skin island. The saphenous nerve (sensory) was coapted to the obturator nerve (motor nerve of the gracilis) in an effort to achieve improved sensation of the skin island in the musculocutaneous flaps. After 6 months, the flaps were individually evaluated using cortical somatosensory evoked potentials (CSSEP) using normal, painful, cold and hot stimuli. One unoperated rabbit was studied as the baseline CSEEP for comparison. Retrograde horseradish peroxidase (HRP) labelling was then performed to evaluate the possibility of newly established neural pathways. Results of the CSSEP testing revealed that flaps possessing 10 nerve grafts (group 2) demonstrated better sensation when compared to flaps possessing five nerve grafts (group 1) or no nerve grafts (control group). Furthermore, retrograde HRP labelling proved that a new neural pathway had been established from the skin island to the dorsal root ganglia of S1 and S2 via the interposed nerve grafts and the sensory neurotised gracilis muscle in groups 1 and 2 rabbits. The control group did not display any sensory regeneration.

Alternatives aux prothèses mammaires

The use of implants is a basic technique in breast reconstruction after mastectomy, for the correction of breast abnormalities or even more in aesthetic breast augmentation. However, especially in difficult cases, implants can have inconveniences and insufficiencies (poor natural aspect, necessity of replacement, capsular contracture). To mitigate these, numerous alternatives were developed. These autologous techniques use mainly the pedicled or free musculocutaneous flaps, which were at first used in breast reconstruction. Their indications were then widened in surgery of breast abnormalities and in aesthetic surgery of the breast. Main alternatives, described, in the breast implants are envisaged by clarifying their advantages, inconveniences, indications and contraindications. The current place of the fat grafting in breast plastic surgery is defined by taking into account the most recent data.

Sensory Recovery in the Sensate Free Transverse Rectus Abdominis Myocutaneous Flap

BACKGROUND

Preservation and restoration of sensation to improve the quality of the reconstruction have not always been considered a priority in efforts to reconstruct the breast. Studies have documented spontaneous recovery of sensation in reconstructed breasts, but this recovery was variable and unpredictable. The authors conducted a pilot study to compare sensory recovery in innervated versus noninnervated microsurgical breast reconstruction patients.

METHODS

The authors investigated a group of 14 patients who had undergone microsurgical breast reconstruction with a muscle-sparing free transverse rectus abdominis myocutaneous flap. Seven patients had reinnervation of their flaps, and seven did not. The two patient groups were similar in age (mean age, 46 years for the innervated group and 51 years for the noninnervated group) and length of follow-up (mean duration of follow-up, 39 months for the innervated group and 40 months for the noninnervated group). Sensitivity to fine touch was assessed using Semmes-Weinstein monofilaments. By testing over a defined grid and over the entire reconstructed breast, it was possible to develop color maps, or sensory topograms, of the areas sensing different levels of pressure for each patient. The patient's ability to differentiate between hot (60 degrees C) and cold (5 degrees C) was recorded.

RESULTS

In a comparison of sensation in flap skin (skin paddle of rectus abdominis myocutaneous flap) with nonflap skin (native breast skin), sensitivity to fine touch was statistically better in (1) innervated flap skin compared with noninnervated flap skin (p = 0.003), (2) innervated nonflap skin compared with noninnervated flap skin (p = 0.006), (3) innervated nonflap skin compared with noninnervated nonflap skin (p = 0.037), and (4) innervated flap skin compared with noninnervated nonflap skin (p = 0.006). Temperature differentiation was significantly better in patients with innervated flaps than in patients with noninnervated flaps in all zones (p = 0.02). These differences persisted beyond a follow-up period of 3 years.

CONCLUSIONS

The authors' findings confirm that reinnervation of microsurgically reconstructed breasts achieves sensory recovery that is superior to that in breasts reconstructed without reinnervation. If sensation is important and the anatomical factors are favorable, reinnervation may represent a worthwhile refinement in attempts to achieve normality for patients undergoing breast reconstruction.

Nipple-areola reconstruction in autologous breast reconstruction: Chinese patients' perspective

Twenty-five consecutive patients who had nipple-areola reconstruction (NAR) using a modified S dermal-fat flap technique in the Division of Plastic Surgery, Department of Surgery, Kwong Wah Hospital, between 1995 and 2000 were studied. The nipple projection and sensation (to light touch and pinprick) were assessed by a designated surgeon who was not involved in the reconstructive process. This was followed by a questionnaire on the patients' perception of the various physical characteristics of the reconstructed nipple-areola complex (NAC) when in the nude. They were then asked to rate their satisfaction according to a 4-grade grading scale and whether they would recommend this procedure to other women with a similar condition. There was no major complication associated with this procedure. The mean projection of the reconstructed nipple at 18 months was 3.27 mm. The mean projection of the opposite normal nipple was 8 mm. The sensation to light touch and pinprick were 28% and 50% of the normal side, respectively. The majority of the patients were pleased with the reconstruction despite gradual loss of nipple projection and inadequate return of sensation. All patients would recommend this procedure to other women with similar disease. The creation of a NAC on the reconstructed breast mound seemed to enhance patients' satisfaction in this study.

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.

Nipple reconstruction using the C-V flap technique: a long-term evaluation

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long-term follow-up data for nipple reconstruction using the C-V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow-up visit. All those who underwent nipple reconstruction using the C-V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long-term follow-up evaluation. The response was poor, and 11 patients participated in the study and returned for follow-up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow-up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Long-term subjective evaluation of the C-V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast.

Microvascular reconstruction of the breast

The growth of microsurgical procedures has led to significant technological, scientific, and clinical advances that have made these procedures safe, reliable, reproducible, and routine in most major medical centers. In many instances, free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. The advantages of free flap breast reconstruction include better flap vascularity, broader patient selection, easier insetting of the flap, and decreased donor site morbidity. Free flap breast reconstruction can occur either at the time that the mastectomy is performed or as a delayed reconstruction following a previous mastectomy. Immediate reconstructions have the advantage of avoiding scar contracture and fibrosis within the mastectomy flaps and at the recipient vessel site. The most common recipient vessel sites are the thoracodorsal vessels and the internal mammary vessels. The thoracodorsal vessels are most frequently used in immediate reconstruction because they are partially exposed during the mastectomy procedure. The internal mammary vessels are used more frequently in delayed reconstructions, to avoid repeat surgery in the axilla. This recipient site also allows more medial placement of the reconstruction. Flap selections for free autogenous breast reconstruction include the transverse rectus abdominis myocutaneous (TRAM) flap, the superior gluteal myocutaneous flap, the inferior gluteal myocutaneous flap, the lateral thigh flap, and the deep circumflex iliac soft tissue flap (Rubens). The TRAM flap is most commonly used in free flap breast reconstruction. For patients with inadequate abdominal tissue or prior abdominal surgery, the superior gluteal flap is typically used. Both the TRAM flap and the superior gluteal flap can be designed as perforator flaps, preserving all of the involved muscle and, in the TRAM perforator, all the rectus fascia. These flaps are more technically demanding, with minimal impact on donor site function. The other flaps are less frequently used and limited to special patient circumstances. Free flap autogenous breast reconstruction provides a natural, long-lasting result with a high degree of patient satisfaction. Semin. Surg. Oncol. 19:264-271, 2000.

Sensitivity of breasts reconstructed with the autologous latissimus dorsi flap

The purpose of this study was to measure, both objectively and subjectively, the sensitivity of breasts reconstructed with the autologous latissimus dorsi flap and to compare these results with those of other reconstruction techniques, especially the transverse rectus abdominis myocutaneous flap. The study population included 50 patients with autologous latissimus dorsi flap breast reconstruction; these patients had an average age of 51 years and an average follow-up of 27 months. Patients answered a seven-item questionnaire that attempted to define the sensitivity of the reconstructed and opposite breasts. This sensitivity was then measured objectively using standard techniques for heat, cold, and tactile sensations. After statistical analysis, these results were compared with those published for other reconstruction techniques. Overall results were comparable or superior to those published for other techniques for autologous breast reconstruction. A total of 56 percent of patients had fine or very fine sensitivity, but 70 percent deemed this sensitivity to be less than that of the opposite breast. A total of 94 percent of patients perceived the reconstructed breast as integral to their body image. The superior medial part of the breast had the greatest sensitivity, both objectively and subjectively. Autologous latissimus dorsi breast reconstruction, a good technique with excellent aesthetic results, affords satisfactory sensitivity. This is yet another advantage of the technique.

Neuronal anastomosis of the cutaneous ramus of the intercostal nerve to achieve sensibility in the latissimus dorsi transplant

PURPOSE

The return of sensory qualities in microvascular free myocutaneous transplants is of great importance in oral and maxillofacial surgery, because such sensations are responsible for improved speech and chewing. This study evaluated the results of neuronal anastomosis of sensory nerves in free microvascular anastomosed myocutaneous flaps.

PATIENTS AND METHODS

Anastomosis of the lateral cutaneous ramus of the intercostal nerve and the greater auricular nerve was performed to reestablish sensibility of the latissimus dorsi transplant. All patients had undergone tumor surgery because of an oral carcinoma and had been treated with a free microvascular myocutaneous latissimus dorsi transplant. Clinical follow-up was performed at monthly intervals postoperatively, and pain, temperature, and pressure sensations were tested, as well as 2-point discrimination and vibration perception.

RESULTS

Only 1 patient showed no sensibility in the transplant. In all other patients, pressure and pain sensations were elicited first. Next, slight touch, vibration, and sharp and blunt discrimination recovered. Thermal stimuli were sensed by only 1 patient.

CONCLUSION

Improved sensation of a latissimus dorsi transplant can be achieved by sensory nerve anastomosis.

Reestablishment of sensitivity in the latissimus dorsi transplant through anastomosis of the thoracodorsal nerve with sensitive nerves

The question as to whether anastomosis of sensory nerves is recommended for free transplants of the myocutaneous latissimus dorsi flap, reanastomosed by microvascular surgery, remains a controversial issue. In this study, a microsurgical nerve anastomosis was performed to sensitize a latissimus dorsi transplant. To determine sensation in the transplanted tissue, six patients were examined clinically. All patients had free transplants of latissimus dorsi flaps reanastomosed by microvascular surgery after tumor resection in the oral cavity. An anastomosis of the sensible auricular magnus nerve with the motor thoracodorsalis nerve was performed. Resulting sensation was determined clinically by testing for pain, temperature, pressure, two-point discrimination, and vibration. All patients showed sensation in the latissimus dorsi flap beginning between the third and the fifth month postoperatively. Therefore, resensitization of a large and voluminous myocutaneous latissimus dorsi flap should be attempted by a nerve anastomosis in this transplant.