Learning Sensory Nerve Coaptation in Free Flap Breast Reconstruction.

BACKGROUND: The aims of this study were to assess whether sensory nerve coaptation in free flap breast reconstruction is subject to learning, and to elucidate challenges of this technique. METHODS: In this single-center retrospective cohort study, we reviewed consecutive free flap breast reconstructions performed between March 2015 and August 2018. Data were extracted from medical records, and missing values were imputed. We assessed learning by exploring associations between case number and probability of successful nerve coaptation using a multivariable mixed-effects model. Sensitivity analysis was performed in a subgroup of cases with evidence of attempted coaptation. Recorded reasons for failed coaptation attempts were grouped into thematic categories. Multivariable mixed-effects models were used to examine associations between case number and postoperative mechanical detection threshold. RESULTS: Nerve coaptation was completed in 250 of 564 (44%) included breast reconstructions. Success rates varied considerably between surgeons (range 21-78%). In the total sample, the adjusted odds of successful nerve coaptation increased 1.03-fold for every unit increase in case number (95% confidence interval 1.01-1.05, p < 0.05), but sensitivity analysis refuted this apparent learning effect (adjusted odds ratio 1.00, 95% confidence interval 1.00-1.01, p = 0.34). The most frequently recorded reasons for failed nerve coaptation attempts were inability to locate a donor or recipient nerve. Postoperative mechanical detection thresholds showed a negligible, positive association with case number (estimate 0.00, 95% confidence interval 0.00-0.01, p < 0.05). CONCLUSION: This study does not provide evidence in support of a learning process for nerve coaptation in free flap breast reconstruction. Nevertheless, the identified technical challenges suggest that surgeons may benefit from training visual search skills, familiarizing with relevant anatomy, and practicing techniques for achieving tensionless coaptation. This study complements prior studies exploring therapeutic benefit of nerve coaptation by addressing technical feasibility.

Local heating-induced cutaneous vasodilation in reinnervated and noninnervated deep inferior epigastric perforator flaps.

INTRODUCTION: Cutaneous vascular reactivity to local heating in free flaps has not been characterized. We aimed to assess local heating-induced cutaneous vasodilation in reinnervated and noninnervated deep inferior epigastric perforator (DIEP) flaps. METHODS: We conducted a cross-sectional study of 21 female patients with an uncomplicated unilateral delayed DIEP breast reconstruction at least 2 years after surgery. DIEP flaps and contralateral breasts were subjected to direct local heating, and skin blood flow was assessed using laser-Doppler flowmetry. To evaluate sensory-nerve-fiber function, touch perception thresholds were assessed using a 20-piece Touch-test™ Sensory Evaluator, and cutaneous warm detection and heat pain thresholds were measured using a TSA-II device. RESULTS: Of the participants, 10 had a reinnervated DIEP flap with a single coapted nerve (mean flap weight, 610 ± 296 g) and 11 had a noninnervated DIEP flap (mean flap weight, 613 ± 169 g). Mean age was 58 ± 11 years, mean follow-up time was 5 ± 1 years, and mean BMI was 24 ± 3 kg/m2 . DIEP flaps exhibited significantly weaker cutaneous vasodilation in response to local heating than contralateral breasts (median peak skin blood flow, 59 [25th-75th percentile, 36-71] a.u. for DIEP flaps versus 94 [74-141] a.u. for contralateral breasts; p < .001). The magnitude of the response was similar between reinnervated and noninnervated flaps (median peak skin blood flow, 55 [25th-75th percentile, 39-68] a.u. for reinnervated DIEP flaps versus 66 [36-77] a.u. for noninnervated DIEP flaps; p = .75). Of participants with reinnervated DIEP flaps, 90% perceived heat pain below the 50°C safety threshold, as compared to 36% of participants with noninnervated DIEP flaps (two-tailed p = .02). CONCLUSION: Our results suggest that free flap transfer causes longstanding impairment, yet not complete abolition, of both the sensory nerve-mediated and nitric oxide-dependent local heating-induced cutaneous vasodilatory systems. We found no statistical evidence that flap reinnervation improves the ability to raise skin blood flow in response to local heating.

Innervation of the Female Breast and Nipple: A Systematic Review and Meta-Analysis of Anatomical Dissection Studies.

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.

Patient-Reported Outcome Measures Used for Assessing Breast Sensation after Mastectomy: Not Fit for Purpose.

AIMS: The aims of this review were (i) to evaluate whether patient-reported outcome measures used in clinical studies for assessing sensation after mastectomy and breast reconstruction are suitable for this purpose, and (ii) to explore whether any measures used for assessing sensation after non-oncologic breast surgery are worth modifying for use in post-mastectomy patients. METHODS: PRISMA guidelines were followed (PROSPERO number CRD42020178066). We searched six databases for studies of oncologic (i.e., therapeutic, prophylactic, and reconstructive) and non-oncologic breast surgery (e.g., breast reduction) in which sensation was assessed with a patient-reported outcome measure. From the selected studies, we extracted eligible measures, evaluated their fitness for purpose, and summarized the content of sensation-specific items. RESULTS: Of 6728 articles identified, we selected 135 studies that used 124 eligible patient-reported outcome measures. For 97% of these measures, details regarding development and measurement properties were unavailable. Four (3%) validated measures-the Sensory Disturbances subscale of the Breast Cancer Sequelae Cause Scales, the Discomfort subscale of the Breast Sensation Assessment Scale (BSAS), Didier et al.'s questionnaire for "Assessment of the patients' satisfaction with cosmetic results, physical and emotional impact of mastectomy", and the Breast Specific Pain subscale of the Breast Cancer Treatment Outcomes Scale (BCTOS)-each contain at least one item pertaining to breast sensation, but target different concepts of interest. In total, the measures feature 215 sensation-specific items, most of which concern symptom severity (97%) as opposed to impact on daily functioning (3%). CONCLUSION: Patient-reported outcome measures used in clinical studies for assessing sensation after mastectomy and breast reconstruction are unsuitable for this purpose: they are either non-validated or non-specific. We failed to identify any measures for use in non-oncologic breast surgery populations worth modifying. To collect meaningful, patient-relevant data regarding sensation after mastectomy, it is pertinent that future clinical trials adopt psychometrically robust, specific patient-reported outcome measures.

Acceptance of contralateral reduction mammoplasty after oncoplastic breast conserving surgery: A semi-structured qualitative interview study.

OBJECTIVES: Oncoplastic breast conserving surgery (BCS) frequently induces asymmetry. Contralateral reduction mammoplasty (CRM) is therefore part of the oncoplastic approach. Our patients frequently declined CRM when offered as a second-stage procedure after the completion of adjuvant treatments. This qualitative interview study was conducted to explore the factors involved in patient decision-making about CRM. MATERIALS AND METHODS: From the prospective hospital database of patients who underwent oncoplastic BCS for stage I-III breast cancer since 2010, 25 patients were sampled using stratified purposeful sampling on age, preoperative cup size, and time elapsed since the completion of adjuvant treatments. Nine had undergone CRM. Individual face-to-face semi-structured interviews were conducted at the hospital or at patients' homes. The interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Data saturation occurred after analysis of the fifth interview, although variability within the data kept expanding until the last interview was coded. RESULTS: Eighteen patients reported postoperative breast asymmetry. Breast symmetry was important to our patients and information provision about CRM had been adequate. The following factors motivated patients to choose CRM: perceivable asymmetry, satisfaction with the outcome of oncoplastic BCS, and the wish for breast reduction before cancer diagnosis. Patients weighed these considerations against their concerns about surgery risks and recovery time. Reluctance to have nonessential surgery to the unaffected breast was an important reason to decide against CRM. CONCLUSION: Breast asymmetry is often tolerated after oncoplastic BCS because of concerns about surgery risks and recovery time and reluctance to have nonessential surgery to the healthy breast.