American Society for Peripheral Nerve

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Anatomical Considerations for Breast Neurotization
Ivica Ducic, MD, PhD1; Erick DeVinney, BS2
1Washington Nerve Institute, McLean, VA; 2AxoGen Inc, Alachua, FL

Introduction: Autologous breast reconstruction following mastectomy restores the size, shape and symmetry of the breast. Over past few decades, with advancements in technical details, success and overall patient outcomes, microsurgical breast reconstruction became the standard and safe reconstructive choice to women with breast cancer. One remaining obstacle is related to breast sensitivity following autologous reconstruction, as reconstructed flap is denervated. Recent evidence based data suggest breast neurotization is justified and offers faster innervation and better quality, more-normal breast sensibility. Current literature lacks standardization of neurotization techniques, as the wide range of technical difficulties and approaches are reported.

Methods: Breast neurotization related literature and available technical approaches were reviewed. Cadaveric dissections were done to define optimal donor and recipient nerves for DIEP breast reconstruction.

Results: Current literature significantly favors the breast neurotization. Techniques reported various successes, include direct flap neurotization, conduit-assisted and autograft neurotizations. Common limitations reported inclue too large nerve gap to be bridged, and limited arc of rotation restricting proper aesthetic flap positioning. Evidence-based data suggest as low as 40% of nerve regeneration if defect is >1cm, posing as significant deficit to conduit neurotization, while human allograft data reported are comparable to autograft. Autograft neurotizations, in addition to limited available length, required extended abdominal wall fascia dissection, serving as an open invitation to post-operative hernias, thus both limiting autografting choices.

We performed cadaveric dissections to define ICN 11 and 12, where both donor nerves were easily and reproducibly identified as DIEP flap is harvested. Similarly, ICN 2 and 3 are expected to be routinely found along ribs inferior border, and crossing recipient vessels. After vascular anastomosis were completed, 1.5mmx70mm human allograft (Avance, AxoGen, FL) serving as the interposing graft between donor and recipient nerves allows tension free nerve reconstruction, eliminating gap length and arc of rotation limitations of other reported techniques.

Conclusion: Recently revisited breast neurotization is subject to a number of high quality studies, aiming to improve quality of life to post-mastectomy women with DIEP flap breast reconstruction. Although various technical suggestions are reported, we present reliable and reproducible anatomical preparation of single vs dual donor and recipient nerves. In addition, due to technological advancements, discussed applications of human nerve allograft is suggested to eliminate gap size, arch or rotation and potential hernia issues. While technical details will be shared, clinical studies are underway to objectively validate suggested technical improvements, and thereby help standardize discussed surgical advancements.

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