RESUMO
BACKGROUND: After breast surgery, patients experience significant alterations to breast sensation, which can diminish quality of life. Nerve coaptation technique, introduced in the 1990s, has gained traction in recent years. We performed a scoping review of the literature to determine the available outcomes in sensate breast reconstruction. METHODS: The review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement guidelines. EMBASE and PubMed databases were queried using standardized terminology. Studies were included if they reported original sensory outcomes following innervation techniques during breast reconstruction and were published from January 1, 1990, to April 18, 2022. Data extraction and analyses were performed on Microsoft Excel. RESULTS: From 602 screened articles, 27 studies met the inclusion criteria. Innervated autologous reconstructive procedures were described in 24, whereas the remaining 3 (all published after 2019) described direct reinnervation of the nipple-areola complex. Most (88.9%) of the studies comparing innervated versus noninnervated reconstruction reported improved sensory outcomes in at least 1 modality. Two studies investigated patient-reported outcomes using validated questionnaires, both of which reported improvement with innervated reconstruction. CONCLUSIONS: Sensate breast reconstruction has the potential to improve outcomes for patients. There is a recent progressive increase in studies involving direct nipple-areolar reinnervation. Larger, prospective studies are needed to better characterize the quality-of-life outcome using validated scales, as well as evaluate sensory and patient-reported outcomes with implant and autologous reconstruction.
Assuntos
Mamoplastia , Humanos , Mamoplastia/métodos , Feminino , Qualidade de Vida , Neoplasias da Mama/cirurgia , Mamilos/inervação , Mamilos/cirurgia , Mastectomia/métodos , Mama/inervação , Mama/cirurgiaRESUMO
BACKGROUND: To restore breast sensibility, some centers are offering nerve reconstruction as a component of implant and flap-based breast reconstruction. To interpret and contextualize the results of these procedures, it is necessary to understand the normal range of breast sensibility, the factors that affect it, and the best methods for its objective measurement. METHODS: We conducted systematic and comprehensive searches across PubMed, Web of Science, and Cochrane Library databases using keywords and controlled vocabulary for the concepts of the breast, nipple, areola, and measurement. The search results were imported into Rayyan QCRI for a blinded screening of titles and abstracts. Studies were evaluated for bias using RevMan 5 software. The results of sensory measurements were pooled, and a quantitative summary of breast sensibility was generated. RESULTS: A total of 36 articles were identified, including retrospective, cross-sectional, and prospective studies. Although there were some consistent findings across studies, such that breast sensibility is inversely related to breast volume, there was wide variability in the following parameters: population, breast condition, measurement modality, anatomic areas of measurement, and sensibility findings. This heterogeneity precluded the generation of normative breast sensibility measurements. Furthermore, we detected a high degree of bias in most studies, due to self-selection of participants and failure to record patient characteristics that may alter sensibility. CONCLUSIONS: The literature lacks consistent data delineating normative values for breast sensibility. Standardized measurements of healthy volunteers with various breast characteristics are necessary to elucidate normative values and interpret efforts to restore sensibility in breast reconstruction.
Assuntos
Mama , Mamoplastia , Humanos , Feminino , Mamoplastia/métodos , Mama/cirurgia , Mama/inervação , Regeneração Nervosa/fisiologia , Mamilos/inervação , Mamilos/cirurgiaRESUMO
BACKGROUND: Sensory nerve coaptation in autologous breast reconstruction positively affects sensory recovery in the reconstructed breast. However, patient-reported outcomes are lacking and no conclusions on the clinical relevance of nerve coaptation could be drawn. The aim of this study was to evaluate the clinical relevance of nerve coaptation in deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: A prospective cohort study was conducted of patients undergoing innervated or noninnervated DIEP flap breast reconstruction between August of 2016 and August of 2018. Patients completed a BREAST-Q questionnaire at a minimum of 12 months' follow-up in combination with either a preoperative questionnaire or a questionnaire at 6 months' follow-up. The physical well-being of the chest domain was the primary outcome and patients answered additional sensation-specific questions. Sensation was measured using Semmes-Weinstein monofilaments. RESULTS: In total, 120 patients were included (65 innervated and 55 noninnervated reconstructions). A clinically relevant difference was found in BREAST-Q scores in favor of patients with innervated reconstructions in general and for delayed reconstructions specifically. Patients with sensate breast reconstruction more often reported better and pleasant sensation. CONCLUSIONS: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction, specifically in delayed reconstruction, resulted in clinically relevant improved patient-reported outcomes on the physical well-being of the chest domain of the BREAST-Q and that better sensation was perceived. However, the BREAST-Q does not address sensation adequately, and the introduction and validation of new scales is required to confirm the clinical relevance of nerve coaptation reliably. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Assuntos
Neoplasias da Mama , Mamoplastia , Retalho Perfurante , Humanos , Feminino , Estudos Prospectivos , Mamoplastia/métodos , Mama/inervação , Sensação/fisiologia , Neoplasias da Mama/cirurgia , Artérias EpigástricasRESUMO
BACKGROUND: Significant improvements in sensory recovery after innervated breast reconstruction have been reported. However, surgical approaches and sensory testing methods have been widely variable. This systematic review aimed to synthesize neurotization techniques and outcomes in breast reconstruction surgery. METHODS: A comprehensive literature search of the MEDLINE, Embase, Web of Science, and Cochrane databases was conducted to identify all studies reporting outcomes of neurotization in innervated breast reconstruction. Data extracted from each study included neurotization techniques, operative times, sensory methods and outcomes, and patient-reported outcomes. RESULTS: A total of 1,350 articles were identified, and 23 articles were included for analysis. Nerve coaptation was performed in 536 breasts and 419 patients, with techniques consisting of direct coaptation (65.1% of flaps), coaptation with nerve conduit (26.3%), and coaptation with nerve allograft (8.6%). The neural component of operating time ranged from 8 to 38 min, and the pooled neurotization success rate among nine studies that reported this outcome was 90.6% (95% CI: 83.6%-96.0%). Overall, innervated breasts achieved earlier and superior sensory recovery that was more uniformly distributed throughout the flap compared to non-innervated breasts. Despite high heterogeneity between studies, all included studies supported neurotized breast reconstruction to improve the rate, quality, and magnitude of sensory recovery. CONCLUSIONS: Neurotization during breast reconstruction may be worth the investment of additional operating time to increase the prospect of high-quality sensory recovery. Further investigation with standardized sensory testing methods and patient-reported outcome tools is needed to definitively support neurotization as a standard of care in breast reconstruction surgery.
Assuntos
Mamoplastia , Transferência de Nervo , Mama/inervação , Humanos , Mamoplastia/métodos , Regeneração Nervosa/fisiologia , Transferência de Nervo/métodos , Retalhos Cirúrgicos/inervaçãoRESUMO
BACKGROUND: Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex. METHODS: The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis. The authors searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/nipple-areola complex or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence estimates of nerve branches supplying the nipple/nipple-areola complex were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance checklist. RESULTS: Of 3653 studies identified, 19 were eligible for qualitative synthesis and seven for meta-analysis. The breast skin is innervated by anterior cutaneous branches and lateral cutaneous branches of the second through sixth and the nipple/nipple-areola complex primarily by anterior cutaneous branches and lateral cutaneous branches of the third through fifth intercostal nerves. The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve supply the largest surface area of the breast skin and nipple/nipple-areola complex. The lateral cutaneous branch of the fourth intercostal nerve is the most consistent contributory nerve to the nipple/nipple-areola complex (pooled prevalence, 89.0 percent; 95 percent CI, 0.80 to 0.94). CONCLUSIONS: The anterior cutaneous branch and lateral cutaneous branch of the fourth intercostal nerve are the most important nerves to spare or repair during reconstructive and cosmetic breast surgery. Future studies are required to elicit the course of dominant nerves through the breast tissue.
Assuntos
Fenômenos Biológicos , Mamoplastia , Mama/inervação , Mama/cirurgia , Dissecação , Feminino , Humanos , Nervos Intercostais , Mastectomia , Mamilos/inervação , Mamilos/cirurgiaRESUMO
BACKGROUND: Restoring the sensation of the reconstructed breast has increasingly become a goal of autologous breast reconstruction. The aim of this study was to analyze the sensory recovery of the breast and donor site of innervated compared to noninnervated deep inferior epigastric perforator (DIEP) flap breast reconstructions, to assess associated factors, and to compare the differences between preoperative and postoperative sensation. METHODS: A prospective cohort study was conducted, including patients who underwent innervated or noninnervated DIEP flap breast reconstruction between August of 2016 and August of 2018. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Preoperative and postoperative sensory testing of the breast and donor site was performed with Semmes-Weinstein monofilaments. RESULTS: A total of 67 patients with 94 innervated DIEP flaps and 58 patients with 80 noninnervated DIEP flaps were included. Nerve coaptation was significantly associated with lower mean monofilament values for the breast (-0.48; p < 0.001), whereas no significant differences were found for the donor site (-0.16; p = 0.161) of innervated compared to noninnervated DIEP flaps. Factors positively or negatively associated with sensory recovery of the breast and donor site were identified. Preoperative versus postoperative comparison demonstrated significantly superior sensory recovery of the breast in innervated flaps (adjusted difference, -0.48; p = 0.017). CONCLUSIONS: This study demonstrated that nerve coaptation in DIEP flap breast reconstruction significantly improved the sensory recovery of the breast compared to noninnervated flaps. The sensory recovery of the donor site was not compromised in innervated reconstructions. The results support the role of nerve coaptation in autologous breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
Assuntos
Mama/inervação , Nervos Intercostais/transplante , Mamoplastia/métodos , Retalho Perfurante/transplante , Tato , Adulto , Mama/cirurgia , Neoplasias da Mama/cirurgia , Feminino , Seguimentos , Humanos , Mastectomia/efeitos adversos , Microcirurgia/métodos , Pessoa de Meia-Idade , Retalho Perfurante/inervação , Período Pós-Operatório , Período Pré-Operatório , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: No effective methods currently exist for breast neurotization in implant-based breast reconstruction. Here, we focused on direct neurotization (DN), in which axons regenerating from nerve stumps are directed to the mastectomy flap and aimed to assess whether DN can generate a new mechano-nociceptive field using a rat model of back skin sensory denervation. METHODS: Dorsal cutaneous nerves (DCNs) of rats were exposed and transected, leaving only the left medial branch of the DCN of thoracic segment 13 (mDCN-T13) intact. This procedure resulted in an isolated innervated field surrounded by a denervated field. The mDCN-T13 was transected, and the proximal nerve stump was sutured to the subdermis (DN subdermal group, nâ¯=â¯6) or dermis (DN dermal group, nâ¯=â¯5) of a different region of the denervated field. In the Crush group (nâ¯=â¯5), the intact mDCN-T13 was only crushed. We evaluated the generation of a new mechano-nociceptive field over time using the cutaneous trunci muscle (CTM) reflex test and histomorphometrically evaluated regenerating nerves in the reinnervated region. RESULTS: In the DN groups, the CTM reflex appeared in the DN area after postoperative week 4. The new mechano-nociceptive field gradually expanded afterwards, and by postoperative week 12, the area was substantially larger than the original region innervated by the mDCN-T13 in the DN dermal group, although not as large as that in the Crush group. In histomorphometric evaluations, many S100-positive myelinated fibers were observed in the dermis of the reinnervated area for all groups. CONCLUSION: In targeted sensory reinnervation, DN of the skin is revolutionary in that it allows a new innervated area to be generated at a desired location regardless of whether a distal nerve stump is available. DN may present an effective approach for breast neurotization in breast reconstruction after mastectomy, particularly for procedures that cannot use sensate flaps such as implant-based breast reconstruction.
Assuntos
Mama/inervação , Mamoplastia/métodos , Transferência de Nervo/métodos , Retalhos Cirúrgicos/inervação , Animais , Masculino , Mastectomia , Modelos Animais , Ratos , Ratos Sprague-DawleyRESUMO
As the sophistication of microsurgical breast reconstruction continues to evolve, plastic surgeons are focusing on techniques to improve functional and psychosocial outcomes for patients, including breast sensation. Interest in neurotization of breast flaps, among both patients and surgeons, has grown significantly in recent years. This study aimed to review the outcomes of neurotization across autologous flap reconstructions, to provide a comprehensive analysis of the efficacy of this technique in improving postoperative sensory recovery.
Assuntos
Neoplasias da Mama/cirurgia , Mama/inervação , Mamoplastia/métodos , Regeneração Nervosa , Transferência de Nervo/métodos , Sensação/fisiologia , Feminino , Humanos , Transplante AutólogoRESUMO
BACKGROUND: The lateral thigh perforator flap, based on the tissue of the upper lateral thigh, is an excellent option for autologous breast reconstruction. The aim of this study was to introduce the technique to perform a nerve coaptation in lateral thigh perforator flap breast reconstruction and to analyze the results by comparing the sensory recovery of the reconstructed breast and donor site between innervated and noninnervated lateral thigh perforator flaps. METHODS: A prospective cohort study was conducted of patients who underwent an innervated or noninnervated lateral thigh perforator flap breast reconstruction between December of 2014 and August of 2018. Direct nerve coaptation was performed between a branch of the lateral femoral cutaneous nerve and the anterior cutaneous branch of the intercostal nerve. Sensory testing was performed with Semmes-Weinstein monofilaments to assess the sensation of the native skin, flap skin, and donor site during follow-up. RESULTS: In total, 24 patients with 37 innervated lateral thigh perforator flaps and 18 patients with 26 noninnervated lateral thigh perforator flaps were analyzed (median follow-up, 17 and 15 months, respectively). Significantly lower mean monofilament values were found for the native skin (adjusted difference, -0.83; p = 0.011) and flap skin (adjusted difference, -1.11; p < 0.001) of the reconstructed breast in innervated compared to noninnervated flaps. For the donor site, no statistically significant differences were found between both groups. CONCLUSIONS: Nerve coaptation in lateral thigh perforator flap breast reconstruction resulted in a significantly better sensory recovery of the reconstructed breast compared to noninnervated flaps. The data also suggest that harvesting a sensory nerve branch does not compromise the sensory recovery of the upper lateral thigh.
Assuntos
Neoplasias da Mama/cirurgia , Mama/inervação , Mamoplastia/métodos , Retalho Perfurante/inervação , Tato , Adulto , Mama/patologia , Mama/cirurgia , Feminino , Seguimentos , Humanos , Mastectomia/efeitos adversos , Pessoa de Meia-Idade , Retalho Perfurante/transplante , Estudos Prospectivos , Pele/inervação , Coxa da Perna/inervação , Resultado do TratamentoAssuntos
Neurônios Adrenérgicos/patologia , Encéfalo/fisiologia , Neurônios Colinérgicos/patologia , Neoplasias/patologia , Neurogênese/fisiologia , Neurônios Adrenérgicos/fisiologia , Neoplasias Encefálicas/patologia , Neoplasias Encefálicas/secundário , Mama/inervação , Mama/patologia , Carcinogênese/patologia , Comunicação Celular/fisiologia , Neurônios Colinérgicos/fisiologia , Feminino , Humanos , Masculino , Próstata/inervação , Próstata/patologia , Microambiente Tumoral/fisiologiaRESUMO
BACKGROUND: Patient satisfaction after breast reconstruction is dependent on both esthetics and functional outcomes. In an attempt to improve breast sensibility, a sensory nerve coaptation can be performed. The aim of this study was to objectify the sensory recovery in patients who, by chance, underwent bilateral autologous breast reconstruction with one innervated and one non-innervated flap. It must be emphasized that the intention was to coaptate the sensory nerves on both sides. METHODS: The cohort study was carried out in the Maastricht University Medical Center between August 2016 and August 2018. Patients were eligible if they underwent bilateral non-complex, autologous breast reconstruction with unilateral sensory nerve coaptation and underwent sensory measurements using Semmes-Weinstein monofilaments at 12 months of follow-up. Sensory outcomes were compared using t tests. RESULTS: A total of 15 patients were included, all contributing one innervated and one non-innervated flap. All patients had a follow-up of at least 12 months, but were measured at different follow-up points with a mean follow-up of 19 months. Sensory nerve coaptation was significantly associated with better sensation in the innervated breasts and showed better sensory recovery over time, compared to non-innervated breasts. Moreover, the protective sensation of the skin can be restored by sensory nerve coaptation. CONCLUSIONS: The study demonstrated that sensory nerve coaptation leads to better sensation in the autologous reconstructed breast in patients who underwent bilateral breast reconstruction and, by chance, received unilateral sensory nerve coaptation.
Assuntos
Neoplasias da Mama/cirurgia , Mama/inervação , Mamoplastia/métodos , Recuperação de Função Fisiológica , Sensação/fisiologia , Retalhos Cirúrgicos/inervação , Neoplasias da Mama/patologia , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Estudos RetrospectivosRESUMO
Performing successful breast reconstruction after mastectomy requires communication and collaboration between the breast and reconstruction surgery teams. This allows for oncologic safety while providing esthetic and functional reconstruction. In this article, we discuss the numerous techniques we have adopted successfully into our breast reconstructive practice that were possible due to this collaboration including prophylactic lymphaticovenous bypass (LVB), tumor ultrasound-guided incision (TUGI), esthetic closure in patients not eligible or desiring reconstruction, nerve identification at time of mastectomy to allow for sensate reconstruction, and the prevention of chronic pain and strategic oncoplasty.
Assuntos
Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Mastectomia/métodos , Mama/inervação , Mama/cirurgia , Comportamento Cooperativo , Feminino , Humanos , Oncologia/organização & administração , Tratamentos com Preservação do Órgão/métodosRESUMO
INTRODUCTION: Better sensation in the reconstructed breast improves the quality of life. Sensory nerve coaptation is a valuable addition to autologous breast reconstruction. There are few publications concerning the sensory nerves of the breast and the nipple-areola complex and reports are contradictory, so it is unknown which nerve is best suited as a recipient for coaptation. The current study serves as a proof of concept. MATERIALS AND METHODS: The areas innervated by the anterior cutaneous branches (ACBs) of the intercostal nerves (ICNs) were studied on two separate occasions in two healthy women. First, the ACBs of ICNs 2-5 were individually blocked using ultrasound. Next, the ACBs of all levels were blocked simultaneously. Sensation was measured using Semmes-Weinstein monofilaments. The numbed areas corresponding to the ICNs were drawn in a raster of 2 × 2 cm. RESULTS: The largest area was supplied by the ACB of the 4th ICN, located in the upper (UIQ) and the lower (LIQ) inner quadrants of the breast. The 2nd-largest area was supplied by the ACB of the 3rd ICN. Blockage of ACBs 2-5 affected sensation in the nipple and the areola. CONCLUSIONS: Blockage of all levels 2-5 partially affected sensation in the nipple-areola complex, suggesting innervation by a nerve plexus consisting of both ACBs and lateral cutaneous branches (LCBs). ACB4 supplied the largest area of the breast in the UIQ and LIQ and could be best suited for sensory nerve coaptation to optimize sensation in the autologously reconstructed breast.
Assuntos
Mama/inervação , Mama/fisiologia , Nervos Intercostais/anatomia & histologia , Nervos Intercostais/fisiologia , Sensação/fisiologia , Adulto , Feminino , Voluntários Saudáveis , Humanos , Mamoplastia , Bloqueio NervosoRESUMO
BACKGROUND: Pectoral nerves (PECS II) block is a popular regional analgesia technique for breast surgery. PECS II block or local infiltration by surgeon may improve outcomes including quality of recovery (QoR). METHODS: In this multicenter randomized clinical trial, 104 female patients undergoing breast surgery received: (1) PECS II block with local anesthetic and surgical infiltration with 0.9% saline (PECS group) or (2) PECS II block with 0.9% saline and surgical infiltration with local anesthetic (infiltration group). Patients, anesthetists, surgeons, nursing staff, and research assistants were blinded to group allocation. Patients received standardized general anesthesia and multimodal analgesia. The primary outcome was the global score (maximum score, 150; good recovery, 118) of the multidimensional (pain, comfort, independence, psychological, emotional) QoR-15 questionnaire measured 24 hours postoperatively. Secondary outcomes were pain, and its functional interference measured 24 hours and 3 months postoperatively using the Brief Pain Inventory (BPI) short form (0, optimal; 120, worst possible). Randomly assigned groups were compared on outcomes using the Wilcoxon rank-sum test, and the results were reported as median difference with 95% confidence interval. RESULTS: One hundred eight patients were recruited from August 17, 2016 to June 8, 2018, and 4 patients were withdrawn. Twelve patients from 104 had mastectomy, with the remainder having less invasive surgery. Baseline QoR-15 global scores reported as median [quartiles] were 135 [129, 143] in the PECS group and 139 [127, 143] in the infiltration group. The 24-hour QoR-15 global score reported as median [quartiles] was 131 [116, 140] in the PECS group and 123 [117, 143] in the infiltration group (P = .60), with median difference (95% confidence interval) of -2 (-9 to 5). The median difference reported as infiltration minus PECS for QoR-15 domains was pain 0 (-2 to 1), physical comfort -1 (-3 to 2), physical independence 0 (-2 to 1), psychological support 0 (0-0), and emotions 0 (-1 to 2) (P > .28). The BPI pain subscale at 24 hours (0-40, lower score indicates less pain), reported as median [quartiles], was 7 [2, 13] in the PECS group and 10 [5, 17] in the infiltration group (P = .15). The BPI global score at 24 hours, reported as median [quartiles], was 20 [7, 36] in the PECS group and 23 [10, 43] in the infiltration group (P = .34) and at 3 months was 0 [0, 14] and 0 [0, 11] (P = .85). CONCLUSIONS: After mostly minor surgery for breast cancer, PECS II block was not superior to local infiltration by the surgeon.
Assuntos
Neoplasias da Mama/cirurgia , Mama/inervação , Mama/cirurgia , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Nervos Torácicos/efeitos dos fármacos , Idoso , Analgesia/métodos , Anestesia Geral/métodos , Estudos de Equivalência como Asunto , Feminino , Humanos , Pessoa de Meia-Idade , Manejo da Dor/métodos , Medição da Dor , Período Pós-Operatório , Inquéritos e Questionários , Resultado do TratamentoAssuntos
Encéfalo/citologia , Neoplasias da Mama/patologia , Movimento Celular/fisiologia , Células-Tronco Neurais/fisiologia , Neurogênese/fisiologia , Neoplasias da Próstata/patologia , Animais , Mama/inervação , Diferenciação Celular , Feminino , Humanos , Masculino , Camundongos , Camundongos Transgênicos , Metástase Neoplásica , Próstata/inervaçãoRESUMO
Breast cancer is the most commonly diagnosed invasive cancer in women worldwide. While hypoesthesia is a known sequela after mastectomy, patients are now inquiring with renewed interest about the degree and timing of sensation after mastectomy. This is a topic that has generated much research interest. However, while there have been advances in the field, there are few, well-done studies that allow for an accurate answer to this question. In this article, relevant breast and donor site anatomy is reviewed for sensate autologous breast reconstruction. Additional donor sites apart from the typically utilized abdomen are analyzed with relevant anatomical discussions. Outcomes are presented; however, due to the heterogeneity of the patient population, surgical approach and postoperative sensory testing, it is difficult to compare results between studies. Future directions and unanswered questions regarding sensate autologous breast reconstruction are highlighted. While great strides have been made in providing sensate autologous breast reconstruction, there are still many unanswered questions. Thus, the collaboration between surgical teams and sharing of outcomes is crucial to allow for optimization of this powerful surgical approach.
Assuntos
Mama/inervação , Hipestesia/prevenção & controle , Mastectomia/efeitos adversos , Neoplasias da Mama/cirurgia , Feminino , Retalhos de Tecido Biológico/transplante , Humanos , Nervos Intercostais/transplante , Mastectomia/métodos , Complicações Pós-Operatórias/etiologiaRESUMO
More and more women opt for breast reconstruction with autologous tissue after breast removal. Reconstruction with a deep inferior epigastric perforator (DIEP) flap is the most common technique. In this operation, the nerves of the DIEP flap are cut. This creates a denervated reconstructed breast which is not only numb, but also lacks autonomic response. This makes the tissue more susceptible to thermal injury. We present a case of a 66-year-old woman who underwent uncomplicated breast reconstruction with a DIEP flap 8 months ago. She recently noticed a second-degree burn on her reconstructed breast after she had been sitting in the sun whilst dressed. She did not feel anything and noticed it by accident. Familiarity with this phenomenon is important for all parties involved in care and aftercare of breast cancer and breast reconstruction, so adequate information can be provided. Reinnervation of the reconstructed breast could be a solution, but more research is needed.
Assuntos
Implantes de Mama/efeitos adversos , Mama/inervação , Mamoplastia/efeitos adversos , Retalho Perfurante/inervação , Queimadura Solar/etiologia , Idoso , Neoplasias da Mama/cirurgia , Feminino , HumanosRESUMO
BACKGROUND: The breast and the factors that affect the sensitivity of the nipple-areola complex have been a significant subject of study in recent years. The main purpose of this study was to provide an objective assessment of the effect of volumetric differences on nipple-areola complex sensitivity. METHODS: Data were collected examining the right breast of 34 female volunteers. The mechanosensitive Aß-fiber and mechanoinsensitive C-fiber function of the nipple-areola complex was assessed after mechanical and chemical stimulation, respectively. Flare responses were elicited chemically by the application of histamine by means of iontophoresis and recorded by laser Doppler imaging. The correlation of the maximum flare area responses with the breast volume and nipple-areola complex and the response from the von Frey fiber test was estimated using linear regression analysis. RESULTS: Nipple-areola complex area increased with breast volume and, similarly, the area of histamine-induced axon reflex flare response follows the larger nipple-areola complex. However, a larger nipple-areola complex correlated with higher local mechanical thresholds. Higher mechanical thresholds were linked to smaller axon reflex area, suggesting combined small- and thick-fiber neuropathy. CONCLUSIONS: Objective small-fiber assessment using laser Doppler imaging and subjective mechanical threshold tests were used successfully to quantify function of Aß and C fibers in the nipple-areola complex. Increased breast volume was linked to larger nipples, but also to impairment of Aß and C fibers. Sensory testing can be incorporated into preoperative and postoperative management of patients undergoing breast operations to assess changes of neuronal function of the nipple-areola complex after surgery.
Assuntos
Mamilos/diagnóstico por imagem , Mamilos/inervação , Sensação/fisiologia , Limiar Sensorial , Adulto , Mama/inervação , Feminino , Voluntários Saudáveis , Humanos , Fluxometria por Laser-Doppler/métodos , Valores de Referência , Estudos de Amostragem , Adulto JovemRESUMO
The sensory innervation to the breast originates from the medial and lateral cutaneous branches of the third to fifth intercostal nerves, which are at risk for injury or loss during mastectomy. Providing reinnervation after mastectomy was introduced almost 20 years ago, but it is not widely performed, perhaps because of the difficulty of locating a recipient nerve. The authors have performed cadaveric dissections to allow for precise anatomical localization of the lateral intercostal branch providing breast sensation. Bilateral chest dissections were performed on 10 female cadavers. The lateral intercostal nerve providing sensation to breast tissue was identified. The distances from the sternum, the midclavicular line, and the lateral pectoralis minor-in addition to nerve diameter-were measured. The nerve was successfully identified bilaterally in all cadavers. The majority of nerves (16 of 20) exited from under the fourth rib. The average distance from the sternum was 13.1 ± 1.3 cm (range, 10 to 15 cm) and the average distance from the midclavicular line was 11.8 ± 2.2 cm (range, 8 to 16 cm). The nerve exited at the lateral border of the pectoralis minor or within 2 cm from the lateral border for all cadavers. The diameter of the nerve was consistently 2 mm. The nerve traveled under the thoracodorsal vessels, aiding in identification. The authors identified the predictable location of the lateral intercostal nerve providing sensation to the breast. The authors hope that by enabling surgeons to locate this nerve, more well-conducted studies will be performed investigating techniques and outcomes for breast reinnervation.