Intraoperative Anatomy and Postoperative Sensation of Targeted Nipple Areola Complex Reinnervation in Gender-affirming Double Incision Mastectomy with Free Nipple Grafting
Katya Remy*1, Kathryn Packowski1, Chase Alston2, Liana N. Kozanno1, Katherine Carruthers1, Eleanor G. Tomczyk1, Jonathan Winograd1, William G. Austen1, Ian Valerio1, Lisa Gfrerer2
1Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; 2Plastic and Reconstructive Surgery, Weill Cornell Medicine, Weill Cornell Medical College, New York, NY
Targeted NAC reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafts (FNG) aims to improve postoperative sensation. A comprehensive understanding of relevant anatomy is important to optimize reinnervation techniques.
26 patients were prospectively enrolled. Data included demographics, intraoperative anatomy of intercostal nerves (ICN), and axon/fascicle counts. Sensation was evaluated with monofilaments preoperatively, and postoperatively at 1, 3, and 12 months.
52 mastectomies were performed. Per mastectomy, a median of 2 ICN (1-5) were used for TNR. A learning curve was associated with direct coaptation. In the first 3rd of mastectomies, an allograft was required in 100% of patients, in the second 88.2% and in the last 52.9%.
Median fascicle count was 1(1-1) in the 3rd, 2(1-7) in the 4th, 2(1-6) in the 5th, and 2(1-8) in the 6th ICN. Mean axon density was 6163.1(±1478.5) axons/mm2 in the 4th, 4221.1(±1493.7) in the 5th, and 5804.8(±2365.2) in the 6th (p=0.08).
BMI ?30kg/m2 or mastectomy weight ?800g had significantly worse preoperative sensation (p<0.05). There were no associations between number of ICN found or axon/fascicle count and preoperative sensation.
NAC sensation was significantly worse than preoperatively at 1 month (p<0.01), comparable at 3, (p>0.05) and significantly better at 12 (p<0.01).
Chest sensation was comparable to preoperatively at 1 and 3 months postoperatively (p>0.05), and significantly better at 12 (p<0.05).
There was a non-significant trend towards better postoperative NAC sensation with increased number of ICN used. There were no associations between fascicle/axon counts and postoperative sensation.
TNR for gender-affirming double incision mastectomy with FNG allows for restoration of sensation within 3 months postoperatively. There is a learning curve associated with direct coaptation of nerves to the NAC. The 4th and 5th were most often used and most often reached the NAC directly. Axon counts were not statistically significantly different. There was a trend towards better sensation with multiple ICN used.
Figure 1. Results. A. Anatomical distribution of lateral ICN branches, B. Monofilament values over time at the NAC and chest skin, C. NAC sensation over time, D. Chest skin sensation over time.
Figure 2. Intraoperative photograph showing preservation of lateral intercostal nerves for targeted nipple areola complex reinnervation.
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