Don't Bury the Circuit: A Pilot Study Comparing Sensation in Buried vs Non-Buried DIEP Flaps
Marcos Lu Wang, BA1, Hao Huang, MD2, Tara M. Chadab MD MS2, Angela Ellison, MS1, Paul A. Asadourian, MEng3, David M. Otterburn, MD1
1Weill Cornell Medicine, New York, NY; 2NewYork-Presbyterian Hospital, New York, NY; 3Columbia University Irving Medical Center, New York, NY
Background: Neurotized DIEP flaps have been shown to improve sensory recovery following mastectomy and reconstruction. With the recent trend toward nipple-sparing mastectomies, sensation likely originates within the buried DIEP flap and then innervates the breast skin. In contrast, for patients undergoing skin-sparing mastectomies, the DIEP flap skin is preserved, brought up to the surface, and directly innervated. In this study, we aim to evaluate inner breast region sensation between patients whose DIEP flap is buried and whose DIEP flap skin is brought to the surface.
Methods: Seventy patients who underwent mastectomy with immediate reconstruction using the DIEP flap were prospectively identified. Of these, 60 patients underwent nipple-sparing mastectomy with buried DIEP flap reconstruction while 10 patients underwent skin-sparing mastectomy with non-buried DIEP flap reconstruction. Patients in both cohorts received nerve grafting using the 70 x 1-2 mm Avance Nerve Graft in identical fashion. Sensitivity evaluation was performed in five inner breast regions (corresponding to the non-buried DIEP flap skin area) using the AcroVal pressure-specified sensory device to determine 1-point cutaneous thresholds at which stimulus was perceived. Higher thresholds indicated worse sensitivity. Sensitivity data was averaged between patients, plotted over time, and compared between the two cohorts.
Results: The buried and non-buried DIEP flap cohorts were comparable in age, body mass index, medical comorbidities, and oncologic regimen (p > 0.05). In the buried DIEP cohort, at 6 months postoperatively, there was a statistically significant difference in inner breast region sensitivity measurements compared to baseline levels (p < 0.001). In contrast, in the non-buried DIEP cohort, at 6 months postoperatively, sensation in the inner breast region was comparable to preoperative baseline levels (p = 0.236). At 24 months postoperatively, inner breast region sensitivity measurements in both cohorts were comparable to preoperative baseline measurements (p > 0.05).
Conclusions: Neurotized DIEP flap skin raised directly to the surface confers earlier sensory recovery than buried DIEP flaps. In patients who undergo skin-sparing mastectomies with non-buried DIEP flap reconstruction, they can expect significantly better sensation in the inner regions of the breast at 6 months postoperatively. In patients who undergo nipple-sparing mastectomies with buried DIEP flap reconstruction, they can expect sensation in the inner breast to return to preoperative baseline levels at a later timepoint--beginning as early as 24 months postoperatively. Our results can help inform preoperative patient counseling on mastectomy and reconstructive approach from a breast sensation perspective.
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