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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
BackgroundLoss 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.
MethodsPatients 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.
Results30 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).
ConclusionDIEP 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 superior | 36.50 [24.10, 63.20] | 61.40 [31.20, 92.20] | 0.429 | |
Outer medial | 52.40 [17.20, 67.10] | 37.50 [20.35, 74.80] | 0.869 | |
Outer inferior | 68.80 [38.55, 87.85] | 50.80 [27.90, 86.00] | 0.305 | |
Outer lateral | 57.50 [21.15, 83.85] | 67.80 [40.30, 75.40] | 0.849 | |
Inner superior | 78.80 [58.65, 87.85] | 83.00 [76.30, 97.00] | 0.340 | |
Inner medial | 72.50 [44.90, 85.75] | 82.90 [60.30, 89.20] | 0.731 | |
Inner inferior | 77.10 [57.80, 96.85] | 84.50 [64.50, 100.00] | 0.700 | |
Inner lateral | 87.80 [58.20, 100.00] | 98.20 [37.60, 100.00] | 0.906 | |
Nipple-areolar complex | 55.90 [29.60, 90.20] | 83.60 [57.20, 94.70] | 0.340 | |
| | | | |
Overall breast sensitivity | 64.58 [40.06, 78.99] | 78.28 [40.60, 82.06] | 0.680 | |
| | | | |
| Direct Coaptation (n = 11) | Nerve Allograft (n = 17) | p-value | Normative Values |
Time at survey (months) | 94.42 [71.98, 112.56] | 60.45 [59.82, 70.34] | 0.013 | |
| | | | |
BREAST-Q Scale | | | | |
Psychosocial wellbeing | 93.00 [74.50, 100.00] | 77.00 [66.00, 100.00] | 0.289 | 70.7 |
Sexual wellbeing | 62.00 [54.50, 100.00] | 62.50 [29.25, 67.00] | 0.194 | 56.5 |
Satisfaction with breasts | 64.50 [61.00, 100.00] | 65.00 [51.00, 82.00] | 0.463 | 57.8 |
Physical wellbeing of the chest | 100.00 [92.00, 100.00] | 88.50 [74.00, 100.00] | 0.249 | 92.6 |
Breast sensation | 36.50 [27.50, 50.00] | 42.00 [24.00, 71.00] | 0.814 | N/A |
Breast symptoms | 92.50 [81.25, 100.00] | 91.00 [71.00, 100.00] | 0.807 | N/A |
Quality of life: Sensation impact | 85.50 [74.50, 89.00] | 68.00 [54.00, 76.00] | 0.139 | N/A |
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