Successful sensory preservation for the breast and nipple post-mastectomy

Justine, a 54-year-old woman with no familial breast cancer history, presents with biopsy-confirmed left breast cancer.

She undergoes initial left unilateral therapeutic mammoplasty for tumour excision.

Histopathology reveals a hormone receptor-positive, human epidermal growth factor 2-negative primary tumour with sentinel lymph node involvement. 

Multidisciplinary team review is conducted, and the team recommends that Justine undergo mastectomy, followed by adjuvant chemoradiotherapy.

Justine is interested in breast reconstruction. So when the skin-sparing, nipple-sacrificing mastectomy is performed, a temporary tissue expander is placed, to preserve the pocket during radiotherapy and prepare for later definitive reconstruction with autologous tissue taken from the abdominal area.

At mastectomy, additional malignancy and lymphovascular invasion are identified, albeit with no further nodal involvement. Postoperatively, Justine undergoes adjuvant chemotherapy followed by radiation therapy. 

Reconstruction planning

Six weeks following the completion of radiation, it will be possible for Justine to undergo definitive reconstruction of her left breast using her own tissues. She is also contemplating simultaneous risk reducing mastectomy with immediate deep inferior epigastric perforator (DIEP) flap reconstruction of both breasts.

Justine is happy with the natural size and shape of her breasts, and her stated preference is to retain, or slightly enhance if possible, the size of her breasts during a reconstruction. 

Following her initial mastectomy, Justine has complete loss of breast sensation, which is a common side-effect of this surgery, particularly when combined with a tissue expander and radiotherapy.

She arrives at her reconstruction-planning consultation with the following goals: to consider using her own tissue to reconstruct her left breast; to consider a risk-reducing mastectomy of her right breast and reconstruction using a right DIEP flap; and to preserve/reconstruct as much breast sensation as possible. 

With these goals in mind, Justine consents to procedures that involve a sensation reconstruction approach, aiming to restore as much breast and nipple-areolar complex sensation as possible.

She proceeds to a bilateral DIEP flap reconstruction, with removal of the temporary tissue expander from the left breast and risk-reducing mastectomy of the right breast.

Sensation reconstruction is performed in both breasts by rejoining the tiny cut ends of nerves arising from the chest wall to the tiny cut ends of nerves supplying the DIEP flap abdominal tissue that is taken to reconstruct the breasts. This process adds an additional 30 minutes to the surgery, which typically takes eight hours. 

Progress

The reconstruction procedure is successful, with complete survival of the abdominal tissue used to create both breasts. At six and 12 months postoperatively, objective tactile sensation testing is performed in the native breast skin and the neo-nipple areola complex.

Justine has improvement of sensation to levels considered better than protective, which is significantly more than would be expected by chance from the body’s natural healing process following this procedure. 

The left side that required tissue expander placement and radiotherapy, which had been completely numb prior to the DIEP flap procedure, shows considerable improvement in sensation. The right side has near normal feeling in the periphery and some sensation in the new nipple area.

The sensation is not “normal” and there is no pleasurable or erogenous quality. However, the breast does feel more natural, and in Justine’s words, “they just feel part of me now”. 

Discussion

A DIEP flap reconstruction is often considered a preferred approach to breast reconstruction after mastectomy, particularly when it is deemed necessary for the patient to undergo radiotherapy. This surgical procedure utilises a lower abdominal island of skin and fat at the donor site, sparing the underlying rectus abdominis muscle.

The advantages of the DIEP flap approach over older muscle harvest techniques (transverse rectus abdominis myocutaneous [TRAM] procedures) include reduced abdominal wall injury, reduced weakness and enhanced recovery. 

Read more AusDoc: A GP guide to breast implants

The sensory preservation technique was introduced to Australia in 2021.¹ This procedure involves concurrent operation by a breast surgeon and a reconstructive surgeon.

The breast surgeon performs the mastectomy and helps identify and conserve viable nerves responsible for cutaneous sensation, and the reconstructive surgeon performs the reconstruction. The sensory preservation technique may be used in either immediate or delayed breast reconstructions.

If the primary sensory nerves are not available following tumour excision, the reconstructive surgeon may use alternative sensory nerves from the chest wall, integrating them into the breast during autologous tissue reconstruction. 

Preliminary outcome findings with this innovative approach indicate variable restoration of sensation, with some patients reporting recovery of tactile and temperature sensitivity in reconstructed breasts.^1,2 This underscores the potential for nerve-sparing techniques to enhance post-mastectomy quality of life by restoring breast sensation.

Future

More plastic surgeons will be motivated to add this technique to their DIEP flap procedure, as the evidence disseminates for the improved sensory outcomes following incorporation of sensory reconstruction with mastectomy and DIEP reconstruction. Furthermore, patient advocates continue to raise awareness of the significant issue of numbness after mastectomy for women considering having a unilateral or bilateral DIEP.

The technique’s future adoption relies on widespread dissemination of outcomes and patient advocacy, moving towards a paradigm shift that incorporates sensory preservation in standard mastectomy procedures. 

Outcome

In Justine’s case, initial postoperative assessment following mastectomy indicated an absence of sensation in the prophylactic mastectomy site. However, objective monofilament testing after her surgery revealed progressive sensory improvement, with significant sensation recovery by 18 months postoperatively, particularly in the new nipple-areolar complexes, bilaterally.

This included both tactile and temperature sensations, suggesting successful nerve coaptation and integration.

On review of Justine’s longitudinal clinical findings, it became clear that her immediate postoperative sensory testing was not an accurate indicator of longer term success with sensory preservation. 

Results such as Justine’s indicate that advocacy to continue research and application of nerve-sparing techniques in breast reconstruction to enhance postsurgical sensory outcomes is warranted. Patients who desire sensory preservation during mastectomy should be encouraged to discuss this with their surgeon.

Dr Joe Dusseldorp is a reconstructive plastic surgeon at Chris O’Brien Lifehouse, Camperdown, and the Mater Clinic, North Sydney, NSW; Clinical senior lecturer in the faculty of medicine, University of Sydney.

References on request from Dr Kate Kelso.