Northeastern Society of Plastic Surgeons

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Nerve Allograft Demonstrates Comparable Long-term Objective and Subjective Breast Sensation to Direct Coaptation in Neurotized Deep Inferior Epigastric Perforator Flap Reconstruction
Ashley Zhang*, Sophia Salingaros, Sophia Arbuiso, Chase Alston, Isaiah J. Rhodes, Marcos Lu Wang, Grant G. Black, David Otterburn
Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, NY

Background
Loss of breast sensation after mastectomy and breast reconstruction is associated with decreased psychosocial outcomes and quality-of-life. Recognizing the critical role of breast sensation in patient satisfaction, neurotized breast reconstruction has become a highly investigated topic. While direct nerve coaptation is the gold standard for neurotization, nerve allografts increase candidacy for neurotization and circumvent the increased operating time associated with dissecting enough length on native nerves. Herein, we investigate long-term sensory and BREAST-Q outcomes in patients receiving deep inferior epigastric perforator (DIEP) flap reconstruction neurotized by direct coaptation and nerve allograft.

Methods
Patients receiving neurotized DIEP reconstruction with direct coaptation or a nerve allograft were retrospectively identified and invited to undergo breast sensation testing with a pressure-specified sensory device. Nine breast areas were tested, and then averaged across the entire breast for an overall breast sensitivity measurement. Patients also completed the reconstruction and sensation modules of the BREAST-Q questionnaire.

Results
30 patients (53 flaps) were included in this study, with 18 flaps reconstructed with direct nerve coaptation and 35 flaps reconstructed with an allograft. The overall breast cutaneous sensitivity measurement was 64.58 g/mm2 [40.06, 78.99] in the direct coaptation group and 78.28 g/mm2 [40.60, 82.06] in the nerve allograft group, with no significant differences overall (p=0.680) or at any specific breast area. BREAST-Q surveys were returned by 11 patients receiving an autograft with average follow-up time of 94.42 months and 16 patients receiving an allograft with average follow-up time of 61.56 months. The two groups had comparable scores for all survey scales (p>0.05).

Conclusion
DIEP flaps neurotized by direct coaptation and nerve allograft have similar long-term objective and patient-reported breast sensation. When direct nerve coaptation is not possible, use of allograft offers a comparable long term result.
Table 1: Sensory and BREAST-Q Outcomes of Flaps Innervated by Direct Coaptation vs. Nerve Allograft
 Direct Coaptation (n = 11)Nerve Allograft (n = 12)p-value 
Time at measurement (months)92.67 [60.35, 112.52]84.79 [65.05, 88.21]0.537 
     
Measurement areas    
Outer superior36.50 [24.10, 63.20]61.40 [31.20, 92.20]0.429 
Outer medial52.40 [17.20, 67.10]37.50 [20.35, 74.80]0.869 
Outer inferior68.80 [38.55, 87.85]50.80 [27.90, 86.00]0.305 
Outer lateral57.50 [21.15, 83.85]67.80 [40.30, 75.40]0.849 
Inner superior78.80 [58.65, 87.85]83.00 [76.30, 97.00]0.340 
Inner medial72.50 [44.90, 85.75]82.90 [60.30, 89.20]0.731 
Inner inferior77.10 [57.80, 96.85]84.50 [64.50, 100.00]0.700 
Inner lateral87.80 [58.20, 100.00]98.20 [37.60, 100.00]0.906 
Nipple-areolar complex55.90 [29.60, 90.20]83.60 [57.20, 94.70]0.340 
     
Overall breast sensitivity64.58 [40.06, 78.99]78.28 [40.60, 82.06]0.680 
     
 Direct Coaptation (n = 11)Nerve Allograft (n = 17)p-valueNormative Values
Time at survey (months)94.42 [71.98, 112.56]60.45 [59.82, 70.34]0.013 
     
BREAST-Q Scale    
Psychosocial wellbeing93.00 [74.50, 100.00]77.00 [66.00, 100.00]0.28970.7
Sexual wellbeing62.00 [54.50, 100.00]62.50 [29.25, 67.00]0.19456.5
Satisfaction with breasts64.50 [61.00, 100.00]65.00 [51.00, 82.00]0.46357.8
Physical wellbeing of the chest100.00 [92.00, 100.00]88.50 [74.00, 100.00]0.24992.6
Breast sensation36.50 [27.50, 50.00]42.00 [24.00, 71.00]0.814N/A
Breast symptoms92.50 [81.25, 100.00]91.00 [71.00, 100.00]0.807N/A
Quality of life: Sensation impact85.50 [74.50, 89.00]68.00 [54.00, 76.00]0.139N/A


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