Nearly one in eight women will be diagnosed with breast cancer during their lives. Breast reconstructionThe creation of an artificial breast performed by a plastic surgeon. has evolved through both implant and autologous means to restore both volume, contour and tissue that has been lost during mastectomies. One drawback of these reconstructions has been the persistence of numbness in the reconstructed breast due to the cutting of nerves in the chest. This loss of feeling can greatly impact a patient’s quality of life from the loss of comfort from hugs, impact on intimacy, and the danger from high heat sources. 

Neurotization is a way of improving this.  Autologous reconstruction makes use of the patient’s own tissue usually available in the lower abdomen while sparing the core musculature using a flap based on the deep inferior epigastric perforators from the inferior epigastric system (DIEP). By using donor intercostal nerves in the abdominal flap and connecting them to recipient intercostal nerves in the chest, this has provided a way of overcoming the lack of sensation characteristic of the breast reconstructions. This process of neurotization has been shown to improve protective sensation, sensitivity to pressure, and even increased erogenous sensation.

The neurotization process adds approximately 30 minutes of additional operative time during the DIEP flap reconstruction.  The donor and recipient nerves can be sewn together directly under magnification, providing adequate donor and recipient nerve lengths or with the use of a conduit or nerve allograft, which serves as a nerve guide to avoid tension along the anastomosisSurgical connection..

Typically, the process of neurotization is performed by connecting the thoracicRefers to anything related to the chest area of the body. intercostal nerves of the DIEP flap (T10-12) to the third or fourth intercostal nerves in the chest.  The third or fourth intercostal nerves are selected as they are the most important in providing normal sensation to the nipple areolar complex in unaffected breasts. Nerve regeneration may take as long as 2 years for full sensation to be realized.  Studies have shown that after one year, neurotized flaps showed improvement in recovered sensation compared to non-neurotized flaps.

Who is eligible for this procedure?

Technically anyone who is a candidate for a DIEP could also have neurotization of the flap. Patients who had a prior mastectomyAn operation removing all or part of the breast. but did not undergo reconstruction or had a tissue expander/implant that was sub-optimal, could be converted to an autologous tissue transfer with neurotization. However, there are some limitations as to who can undergo this process. Neurotization cannot be performed with implant-based reconstruction. A patient would also be ineligible if they had a prior flap reconstruction because the donor nerves would not have been harvested during the initial surgery.

Flap neurotization continues to evolve.  It is a major advance in its attempt to restore sensation to the affected breast.  This has the effect of improving both the aesthetic and functional outcome of breast reconstruction, improving overall patient satisfaction.