Prospective Sensory Outcomes for Targeted Nipple-areola Complex Reinnervation in Gender-affirming Double Incision Mastectomy With Free Nipple Grafting
Katya Remy, Kathryn Packowski, Chase Alston, Liana Kozanno, Katherine H. Carruthers, Eleanor G. Tomczyk, Jonathan M. Winograd, William G. Austen, Ian L. Valerio, Lisa Gfrerer
Abstract
OBJECTIVE: To analyze the anatomy and sensory outcomes of targeted nipple-areola complex reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafting. BACKGROUND: TNR is a novel technique to preserve and reconstruct intercostal nerves (ICNs) to improve postoperative sensation. There is little evidence of relevant anatomy and outcomes. METHODS: Twenty-five patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient-reported questionnaires was completed preoperatively, and at 1, 3, 6, 9, and 12 months postoperatively. RESULTS: Fifty mastectomies were performed. Per mastectomy, the median number of ICN found and used was 2 (1-5). Axon and fascicle counts were not significantly different between ICN branches ( P > 0.05). Body Mass Index ≥30 kg/m 2 and mastectomy weight ≥800 g were associated with significantly worse preoperative sensation ( P < 0.05). Compared with preoperative values, nipple-areola complex (NAC) sensation was worse at 1 month ( P < 0.01), comparable at 3 months ( P > 0.05), and significantly better at 12 months ( P < 0.05) postoperatively. Chest sensation was comparable to the preoperative measurements at 1 and 3 months ( P > 0.05), and significantly better at 12 months ( P < 0.05) postoperatively. NAC sensation was significantly better when direct coaptation was performed compared with the use of allograft only ( P < 0.05), and with direct coaptation of ≥2 branches compared with direct coaptation of a single branch ( P < 0.05). All patients reported a return of nipple and chest sensation at 1 year postoperatively and 88% reported a return of some degree of erogenous sensation. CONCLUSIONS: TNR allows for restoration of NAC and chest sensation within 3 months postoperatively. The use of multiple ICN branches and direct coaptation led to the best sensory outcomes.