Sensory recovery following free TRAM flap breast reconstruction

Modern Approaches to Alternative Flap-Based Breast Reconstruction: Profunda Artery Perforator Flap

Autologous free flap breast reconstruction allows for natural-appearing breasts, while avoiding the risks associated with implants, including exposure, rupture, and capsular contracture. However, this is offset by a much higher technical challenge. The abdomen remains the most common tissue source for autologous breast reconstruction. However, in patients with scant abdominal tissue, prior abdominal surgery, or a desire to avoid scarring in this region, thigh-based flaps remain a viable alternative. The profunda artery perforator (PAP) flap has emerged as a preferred alternative tissue source, due to excellent esthetic outcomes and low donor-site morbidity.

Is nerve coaptation associated with improved sensation after microvascular breast reconstruction? A systematic review

BACKGROUND

Sensation after autologous breast reconstruction is an increasingly important outcome. Several studies demonstrated improved sensation with flap neurotization but utilized heterogenous measures and follow-up intervals. This review evaluates sensory outcomes after neurotization using uniform, objective outcome measurements.

METHODS

PubMed/Medline and Embase databases were queried for articles published between January 1990 and January 2022. Inclusion criteria included studies with free flap tissue transfer breast reconstruction patients and use of Semmes-Weinstein Monofilaments (SWM) to quantify return of sensation after either neurotization or no neurotization. Reviews, case reports, and studies utilizing implants or pedicled flaps were excluded.

RESULTS

Overall, 513 articles were screened. Eleven articles met inclusion criteria for a total of 474 patients. There were 254 non-neurotized patients included as controls (Group A) and 220 neurotized patients (Group B). Mean follow-up time was similar in both groups (22.06 months vs. 22.78 months, p > 0.05). There was no significant difference in age (Group A = 49.97 years vs. Group B = 42.47 years) or BMI (Group A = 25.48 vs. Group B = 25.97) between groups. More patients in group B received radiation therapy (Group B = 32.72% vs. Group A = 20.86%, p > 0.05). Patients that received neurotization had lower mean pressure thresholds (Group A = 38.85 gm/mm² vs. Group B = 6.69 gm/mm² , p = 0.053) than comorbidity-matched controls.

CONCLUSION

Neurotization has been shown to be a safe and feasible option for enhancing return of sensation after breast reconstruction. Future studies with standardized, long-term follow-up will further elucidate the pattern of breast sensation return and the impact of neurotization.

Comparing Autologous to Device-Based Breast Reconstruction: A Pilot Study of Return in Breast Sensation

BACKGROUND

Poor breast sensation is common after mastectomy and reconstruction. In this study, we aim to define the temporal pattern of sensory changes after reconstruction and to compare the return in sensation between autologous and device-based reconstruction.

METHODS

Women undergoing mastectomy with immediate reconstruction, with either tissue expander (TE) or neurotized deep inferior epigastric perforator (DIEP) flap, were prospectively identified at their preoperative or postoperative visit at defined time points. Neurosensory testing was performed in 9 breast regions using the AcroVal pressure-specified sensory device to determine 1 point-static cutaneous thresholds. Sensitivity data were averaged between patients at each time point and plotted over time.

RESULTS

Eighty-seven patients (153 breasts) were included in this study, including 41 women (75 breasts) with DIEP flap and 46 women (78 breasts) with TE. The groups were comparable in age, body mass index, breast size, chemotherapy, radiotherapy, and number of revisional breast surgeries (P > 0.05). Compared with preoperative baseline, mean cutaneous thresholds in DIEP flap patients were comparable in most outer breast regions at 18 months postoperatively and in the entire breast, except the inner inferior region, at 3 years (P > 0.05). In contrast, mean cutaneous thresholds in TE patients continued to be significantly worse in the entire breast at 5 years postoperatively compared with baseline (P < 0.05).

CONCLUSIONS

Autologous breast reconstruction is superior in sensory recovery. Patients undergoing DIEP flap can expect sensory return to preoperative levels by 3 years, with sensation returning by 18 months in some areas of the breast. Patients undergoing device reconstruction should expect a slower and more unpredictable return in breast sensation.

A study of the pattern of sensory return in various flaps in different body areas

Insensate flaps are used in several reconstructions. A search of the literature showed that most studies are limited to particular flaps in specific body areas. There is a lack of uniform scientific data on the pattern of sensory recovery in various body parts for different kinds of flaps. We conducted a prospective observational study for over one year to study the pattern of sensory return in 74 flaps and studied the disparity in the return of sensation of touch, pain, warmth and cold. After that, we analyzed the relationship between sensory return in flaps and the region of the body (head and neck/upper limb/lower limb), type of flap (cutaneous/fasciocutaneous/musculocutaneous), age of patient and type of wound bed (surgically created defect/raw area such as post trauma, post debridement). Touch sensations were assessed by Semmes-Weinstein (SW) monofilament of 5.01 number, pain was assessed using a sterile 26 G needle, cold sensation was assessed using water at 4 °C and warm sensation was assessed using water at 44 °C. The sensations were evaluated at one-fourth and one-half of distance from the periphery to the center, at eight equidistant points along the circumference and at the center of the flap. Sensations were observed to return in the periphery of the flap earlier and in the center later. Touch sensation was recovered the earliest (three months onwards), followed by sensations of pain, warmth and cold (around the sixth month). Flaps performed in the head and neck showed the best recovery of sensation. Best recovery of sensation was observed in cutaneous flaps. Flaps performed on surgically created defects showed better recovery of sensation compared with flaps performed to cover raw areas; however, the differences were statistically nonsignificant. Children showed better recovery of sensations; however, this was not statistically significant. Sensory nerve coaptation is recommended in flaps folded on themselves and in fasciocutaneous flaps of the lower limb.

The role of neurotization in autologous breast reconstruction: Can reconstruction restore breast sensation?

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.

A Cadaveric Anatomical and Histological Study of Recipient Intercostal Nerve Selection for Sensory Reinnervation in Autologous Breast Reconstruction

BACKGROUND

 Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR.

METHODS

 Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared.

RESULTS

 A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm²) compared with that in the fourth (mean 26,474 ± 38,626 µm²), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p < 0.05).

CONCLUSION

 This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

Anatomical Considerations to Optimize Sensory Recovery in Breast Neurotization with Allograft

Background:

Breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization, but it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. This study’s purpose was to provide an anatomical basis for observed inconsistencies and therein provide a principle that can be used to develop a technical approach that will optimize sensory recovery.

Methods:

Anatomical dissections on 6 fresh cadavers, that is, 12 hemi-abdominal flaps and 12 hemi-chest dissections, were performed. The technical aspects of harvesting the abdominal flap with a nerve target, that is, inclusion of a sensory nerve branch only, recipient nerves in the chest, and the applications of allograft for acquired nerve gap reconstruction were investigated.

Results:

Abdominal flaps that include sensory-only intercostal nerve 10–12 segments and identification of recipient chest wall intercostal nerves 2–4 could be consistently performed. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization.

Conclusions:

We provide a likely anatomical explanation for suboptimal sensory recovery after deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft is prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridges sensory donor intercostal nerves to sensory recipient intercostal nerves should anatomically optimize restoration of breast sensibility.

Does intramuscular gluteal augmentation using implants affect sensitivity in the buttocks?

The evolution of techniques and materials has made gluteoplasty a safe and reproducible operation with high acceptance among surgeons and patients. Functional aspects should be considered in gluteoplasty but are poorly studied. The sensitivity of the buttocks is fundamental as it represents an erogenous zone and provides protection through sensory stimuli for the prevention of pressure sores and burns. This study aimed to evaluate the sensitivity of the gluteal region in patients undergoing gluteal augmentation with implants. We included 20 consecutive patients undergoing gluteoplasty and 20 controls not undergoing gluteal surgery. All patients are females and were being treated at the Division of Plastic Surgery of the Rio de Janeiro State University. The right and left gluteal regions were delimited, and each one was divided into four quadrants numbered 1-8. Sensitivity tests were performed in all quadrants for six different stimuli: touch, heat, cold, pain, vibration, and pressure. The mean age and BMI were 36.3 years and 26.3, respectively. No difference in sensitivity was observed in the gluteal region after augmentation gluteoplasty when compared with those patients who had no operation in this series. Prospective and controlled studies are needed to better assess these issues.

Herpes zoster in a free transverse rectus abdominis myocutaneous flap after delayed breast reconstruction: evidence of spontaneous reinnervation

In concert with advances in surgical reconstruction techniques and improved survival after breast cancer, both the aesthetic and functional outcomes, especially sensory recovery, of breast reconstruction have been addressed. Most studies on sensory recovery in reconstructed breasts have utilized patients’ subjective responses to touch, pain, temperature, and pressure. In contrast, this report describes a case of herpes zoster that developed in a free transverse rectus abdominis myocutaneous flap, which provides objective evidence of spontaneous reinnervation after breast reconstruction.

Pilot study of breast sensation after breast reconstruction: evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery

BACKGROUND

Some sensation to the breast returns after breast reconstruction, but recovery is variable and unpredictable. We primarily sought to assess the impact of different types of breast reconstruction [deep inferior epigastric artery perforator (DIEP) flaps versus implants] and radiation therapy on the return of sensation.

METHODS

Thirty-seven patients who had unilateral or bilateral breast reconstruction via a DIEP flap or implant-based reconstruction, with or without radiation therapy (minimum follow-up, 18 months; range, 18-61 months) were studied. Of the 74 breasts, 27 had DIEP flaps, 29 had implants, and 18 were nonreconstructed. Eleven breasts with implants and 10 with DIEP flaps had had prereconstruction radiation therapy. The primary outcome was mean patient-perceived static and moving cutaneous pressure threshold in nine areas. We used univariate and multivariate analyses to assess what independent factors affected the return of sensation (significance, P < 0.05).

RESULTS

Implants provided better static (P = 0.071) and moving sensation (P = 0.041) than did DIEP flaps. However, among irradiated breasts, skin over DIEP flaps had significantly better sensation than did that over implants (static, P = 0.019; moving, P = 0.028). Implant reconstructions with irradiated skin had significantly worse static (P = 0.002) and moving sensation (P = 0.014) than did nonirradiated implant reconstructions.

CONCLUSIONS

Without irradiation, skin overlying implants is associated with better sensation recovery than DIEP flap skin. However, with irradiation, DIEP flap skin had better sensation recovery than did skin over implants. Neurotization trended toward improvement in sensation in DIEP flaps.

Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities

There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves “untreated”. Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.

Update on Breast Reconstruction Using Free TRAM, DIEP, and SIEA Flaps

Breast reconstruction using autologous tissue is commonly accomplished using the transverse rectus abdominis myocutaneous (TRAM) flap. The establishment of microvascular surgery led to the development of the free TRAM flap because of its increased vascularity and decreased rectus abdominis sacrifice. The muscle-sparing free TRAM, DIEP, and SIEA flap techniques followed in an effort to decrease abdominal donor site morbidity by decreasing injury to the rectus abdominis muscle and fascia. Data have accumulated over the past decade that show that muscle- and fascia-sparing techniques, such as the use of DIEP flaps, result in measurably better postoperative abdominal strength. However, muscle-sparing techniques do not appear to decrease the risk of abdominal bulging or hernia, and there are no significant differences in patient-reported abdominal weakness or functional impairments. The SIEA flap is presented as a reemerging method that can virtually eliminate abdominal donor site morbidity. Sensory nerve coaptation to improve reconstructed breast sensation is also reviewed.

Recovery of sensation in immediate breast reconstruction with latissimus dorsi myocutaneous flaps after breast-conservative surgery and skin-sparing mastectomy

In breast reconstruction, sensation in the reconstructed breasts affects the patients' quality of life along with its aesthetic outcome. Fortunately, less invasive procedures such as breast-conservative surgery (BCS) and skin-sparing mastectomy (SSM) have greatly contributed to the improved aesthetic outcome in immediate breast reconstruction. However, there are few reports on the recovery of breast sensation after BCS and SSM. We retrospectively reviewed 104 consecutive patients who underwent immediate breast reconstruction with the latissimus dorsi myocutaneous flap between 2001 and 2006 at our institution. The sensations of pain, temperature, touch, and vibration were examined at the nipple and skin envelope during the follow-up period (range: 12-61 months, mean: 31 months), and a stratified analysis was performed to determine the critical factors affecting the sensation recovery after BCS and SSM. We found that large breast size significantly impaired the recovery of sensation in the nipple and skin envelope after BCS as well as SSM. Older age and high body mass index value were the factors which negatively affected the sensation in the skin envelope after SSM. While all our BCS patients underwent postoperative radiation therapy, it did not negatively affect the recovery of sensation in SSM patients. On the basis of these findings, we could further improve the sensation of the reconstructed breasts after BCS and SSM. Especially after SSM, the use of innervated flaps is recommended in the patients with large breast, increased age, or obesity when the nipple-areola complex is resected.

Donor site sensitivity after breast reconstruction with deep inferior epigastric artery perforator flap

The aim of this study was to examine pressure sensitivity at the donor site after breast reconstruction with deep inferior epigastric artery perforator (DIEAP). In a cross-sectional survey, 2 groups of patients were analyzed. The DIEAP group consisted of 30 women who had previously had secondary breast reconstruction with DIEAP flap after mastectomy for breast cancer. The control group consisted of 7 women with no previous abdominal incisions planned for secondary breast reconstruction with DIEAP. Pressure thresholds were tested within the margins of the abdominal wall using Semmes-Weinstein monofilaments. In the DIEAP group a pattern of higher pressure thresholds was observed in the proximity of the scar. Comparing the 2 groups, significant higher pressure thresholds were found in the DIEAP group in the scar on both sides and in the midline from the scar to the umbilical level. Our data show that the abdominoplasty performed during breast reconstruction with DIEAP reduces cutaneous sensitivity in the donor site area.

Thermal injuries to autologous breast reconstructions and their donor sites--literature review and report of six cases

Breast reconstruction using autologous techniques has now become the gold standard. In recent years the focus has been on maintaining excellent cosmesis whilst minimising the incidence of partial or complete flap loss and donor site morbidity. However, an area which is frequently overlooked is the sequelae resulting from denervation of these flaps and their donor sites which can potentially lead to thermal injury. We report on six patients who sustained burns following free autologous breast reconstruction using either a DIEP or a muscle sparing TRAM. Four of the burns were confined to the flap skin paddle and two to the abdominal donor site. To prevent such thermal injuries all patients undergoing flap reconstruction should be educated regarding the vulnerability of the flap and its donor site as well as means of protecting these susceptible areas during daily activities.

Sensibility following Innervated Free TRAM Flap for Breast Reconstruction

BACKGROUND

The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast.

METHODS

Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern.

RESULTS

Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout.

CONCLUSIONS

Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to breast reconstruction.

Patterns of sensory and autonomic reinnervation of long-standing myocutaneous microvascular flaps and split-skin grafts applied to fascial beds

BACKGROUND

There is a paucity of reports in the literature examining the pattern of sensory and autonomic neural recovery of myocutaneous microvascular flaps and skin grafts to the lower limbs after a prolonged period of time.

OBJECTIVES

To investigate the recovery of sensation and autonomic nerve activity in long-standing split-skin grafts applied to fascial beds and in myocutaneous microvascular flaps.

METHODS

THE PATIENTS WERE DIVIDED INTO TWO GROUPS: group A consisted of patients with a split-skin graft applied to a fascial bed (n=11) and group B consisted of patients with free microvascular flaps (n=4). Patients in both groups underwent various clinical subjective and objective tests, including the measurement of electrical resistance and thermal sensory analysis. Laser Doppler flowmetry was used to investigate the blood flow patterns.

RESULTS

Patients in both groups showed significantly reduced sensory modalities. However, the findings of both the electrical resistance and laser Doppler flowmetry were significantly different among the patients in group A compared with controls. In contrast, electrical resistance and laser Doppler flowmetry test results were similar in group B and controls.

CONCLUSIONS

Both split-skin grafts applied to fascial beds and microvascular flaps on the lower limb had poor sensory recovery. However, after 15 years, the microvascular flaps regained the ability to sweat and some degree of thermoregulatory function. This may imply that the long-standing myocutaneous free flaps regained some aspects of their autonomic innervation, whereas the split-skin grafts had not.

Sensory Recovery in the Sensate Free Transverse Rectus Abdominis Myocutaneous Flap

BACKGROUND

Preservation and restoration of sensation to improve the quality of the reconstruction have not always been considered a priority in efforts to reconstruct the breast. Studies have documented spontaneous recovery of sensation in reconstructed breasts, but this recovery was variable and unpredictable. The authors conducted a pilot study to compare sensory recovery in innervated versus noninnervated microsurgical breast reconstruction patients.

METHODS

The authors investigated a group of 14 patients who had undergone microsurgical breast reconstruction with a muscle-sparing free transverse rectus abdominis myocutaneous flap. Seven patients had reinnervation of their flaps, and seven did not. The two patient groups were similar in age (mean age, 46 years for the innervated group and 51 years for the noninnervated group) and length of follow-up (mean duration of follow-up, 39 months for the innervated group and 40 months for the noninnervated group). Sensitivity to fine touch was assessed using Semmes-Weinstein monofilaments. By testing over a defined grid and over the entire reconstructed breast, it was possible to develop color maps, or sensory topograms, of the areas sensing different levels of pressure for each patient. The patient's ability to differentiate between hot (60 degrees C) and cold (5 degrees C) was recorded.

RESULTS

In a comparison of sensation in flap skin (skin paddle of rectus abdominis myocutaneous flap) with nonflap skin (native breast skin), sensitivity to fine touch was statistically better in (1) innervated flap skin compared with noninnervated flap skin (p = 0.003), (2) innervated nonflap skin compared with noninnervated flap skin (p = 0.006), (3) innervated nonflap skin compared with noninnervated nonflap skin (p = 0.037), and (4) innervated flap skin compared with noninnervated nonflap skin (p = 0.006). Temperature differentiation was significantly better in patients with innervated flaps than in patients with noninnervated flaps in all zones (p = 0.02). These differences persisted beyond a follow-up period of 3 years.

CONCLUSIONS

The authors' findings confirm that reinnervation of microsurgically reconstructed breasts achieves sensory recovery that is superior to that in breasts reconstructed without reinnervation. If sensation is important and the anatomical factors are favorable, reinnervation may represent a worthwhile refinement in attempts to achieve normality for patients undergoing breast reconstruction.

Nipple-areola reconstruction in autologous breast reconstruction: Chinese patients' perspective

Twenty-five consecutive patients who had nipple-areola reconstruction (NAR) using a modified S dermal-fat flap technique in the Division of Plastic Surgery, Department of Surgery, Kwong Wah Hospital, between 1995 and 2000 were studied. The nipple projection and sensation (to light touch and pinprick) were assessed by a designated surgeon who was not involved in the reconstructive process. This was followed by a questionnaire on the patients' perception of the various physical characteristics of the reconstructed nipple-areola complex (NAC) when in the nude. They were then asked to rate their satisfaction according to a 4-grade grading scale and whether they would recommend this procedure to other women with a similar condition. There was no major complication associated with this procedure. The mean projection of the reconstructed nipple at 18 months was 3.27 mm. The mean projection of the opposite normal nipple was 8 mm. The sensation to light touch and pinprick were 28% and 50% of the normal side, respectively. The majority of the patients were pleased with the reconstruction despite gradual loss of nipple projection and inadequate return of sensation. All patients would recommend this procedure to other women with similar disease. The creation of a NAC on the reconstructed breast mound seemed to enhance patients' satisfaction in this study.

Experimental model for evaluation of the cutaneous sensitivity of the abdomen

The purpose of this study is to report an experimental model to evaluate several modalities of sensibility and to map the areas of the abdominal wall with decreased sensibility after abdominoplasty. Patients were divided in two groups: in the control group, patients had no previous abdominal incisions and patients of the experimental group had been undergone abdominoplasty. The sensibility evaluation of patients from the experimental group was made from 12 to 60 months after the operation. The abdominal skin was divided into twelve areas; nine of them were above the abdominoplasty incision and three below it. Sensibility to superficial touch, superficial pain, hot and cold temperature, vibration was tested and recorded as positive if the patient mentioned that he felt the stimulation or negative. Sensibility to pressure was tested with the use of different weights; therefore, a value was obtained when the patient felt the pressure. A specific test was used to evaluate each modality of sensibility. The experimental model designed to test skin sensibility after abdominoplasty showed to be feasible in patients.

Further experience with innervated autologous flaps in postoncologic breast reconstruction

Restoration of sensation remains an area of minimal concern in autologous breast reconstruction. In contrast, it is routine for the reconstructive surgeon to include sensory restoration as part of the reconstruction of the upper and lower limb and the head and neck. We have utilized sensate autologous soft tissue units for breast reconstruction and present the results of a four-year period. Among a cohort of 15 women who underwent sensate breast reconstruction improvement in all sensory modalities tested, both rapidity of sensory return and strength of sensation were noted when compared to reported sensory outcomes among women undergoing non-sensate breast reconstruction. Final sensory levels approached but did not equal the non-reconstructed contralateral breast. Operative times and wound healing complications were not statistically increased in sensate reconstructions as compared to a group on non-sensate reconstructions. The results of the study suggest that sensate reconstruction is a reasonable addition to autologous breast reconstruction.

Sensibility of the Abdomen after Abdominoplasty

Abdominal skin hypesthesia may occur after abdominoplasty. The purpose of this study was to find out (1) which sensibility modalities are decreased and (2) which areas of the abdominal wall are affected, so that patients can be warned preoperatively about this condition. Forty patients were divided in two groups of 20 patients each. In the control group, patients had no previous abdominal incisions. The sensibility evaluation of patients from the experimental group was made from 12 to 60 months after abdominoplasty, with an average of 31.5 months. These patients were divided into two groups of 10 patients each, a short-term follow-up group (12 to 30 months postoperatively) and a long-term follow-up group (31 to 60 months postoperatively). The abdominal skin was divided into 12 areas; nine were above the abdominoplasty incision and three were below it. Sensibility to superficial touch, superficial pain, and hot and cold modalities was recorded as positive in all areas by a variable number of patients of the experimental group. However, in area 8 (hypogastric area), a statistically significant number of patients had decreased sensibility in all sensibility modalities (Fisher's test and t test). Patients in the experimental group also showed decreased sensibility to hot and cold temperature in area 11 (pubic area). Sensibility to pressure decreased significantly in all areas of the abdomen when compared with the control group (t test). When patients of the short-term follow-up group were compared with those of the long-term follow-up group, there was no statistically significant difference for all modalities of sensibility in the areas studied, except for area 5. In this area it was found that long-term follow-up patients recovered sensibility to cold and hot temperatures. These findings help plastic surgeons to orient their patients about possible risk of exposure to injuries in the areas with decreased sensibility after abdominoplasty. Most importantly, as these patients have decreased sensibility to pressure and hot temperature in a more extensive area of the abdomen, they are exposed to a higher risk of burn injury.

Burn injuries after latissimus dorsi breast reconstruction in a cold climate

The transposed and 'native' skin of a reconstructed breast using autogenous tissue transfer has impaired sensation. Two cases of thermal injury following latissimus dorsi breast reconstruction are reported. Both cases were due to the overnight application of a hot-water bottle to the reconstructed breast. We suggest that all patients should be warned of this potential complication especially in cold climates.

The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps

Recent developments in autogenous breast reconstruction using the rectus abdominis myocutaneous free flap include attempts to reinnervate the flap tissue. We have carried out anatomical studies to determine the nature of abdominal-wall cutaneous innervation, with particular emphasis on the harvesting of sensate flaps. Dissections were performed on four embalmed and 12 fresh human cadavers (32 sides). The lowest five intercostal nerve trunks were identified and traced to the lateral border of the rectus sheath. A detailed dissection of the intramuscular course of the nerves and associated vasculature was performed. The relationship of the nerves to the vascular perforators used for rectus abdominis myocutaneous flaps was determined visually, and confirmed histologically. In contrast to previous studies, we show that nerves supplying cutaneous sensation can travel with both medial and lateral vascular perforators. In order to confirm clinically useful innervation, the abdominal flap skin of five patients undergoing TRAM flap reconstruction was stimulated electrically, and sensory recordings were made directly from the related intercostal nerve just prior to flap harvest. These studies represent, to our knowledge, the first clinical application of neurophysiological techniques to outline the perforator neurosomes of flaps based on the deep inferior epigastric vascular axis. We provide the first comprehensive study of abdominal-wall innervation with regard to sensate free-flap harvest. Our dissections show complex patterns of abdominal skin innervation that have not been previously described. The implications for sensate free TRAM and DIEP flap reconstructions, as well as the potential for more accurate inclusion of innervated flap skin, are discussed.

Nipple reconstruction using the C-V flap technique: a long-term evaluation

Numerous procedures are available for nipple reconstruction with no true universal favorite. This study presents long-term follow-up data for nipple reconstruction using the C-V flap technique. Patients were identified by searching the Breast Reconstruction Database, and they were asked to return for a follow-up visit. All those who underwent nipple reconstruction using the C-V flap technique between January of 1992 and December of 1996 were reviewed in an attempt to conduct a long-term follow-up evaluation. The response was poor, and 11 patients participated in the study and returned for follow-up. They all completed a questionnaire, which focused on patient satisfaction using a visual analogue scale. Nipple measurements were taken with a caliper and compared with the opposite breast for symmetry. Fourteen nipple reconstructions were evaluated in 11 patients with an average follow-up of 5.3 years. All patients had undergone transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions. Patient satisfaction was 42 percent with nipple projection, 62 percent with pigmentation, and 26 percent with sensation. Overall patient satisfaction with the procedure was 81 percent. Average nipple projection of the reconstructed nipple was 3.77 mm and was not statistically different when compared with the opposite nipple. Long-term subjective evaluation of the C-V flap technique does report a loss in nipple projection; however, overall patient satisfaction at 5.3 years is good, as is the ability to restore symmetry with the opposite breast.

Evaluation of abdominal sensibility after TRAM flap breast reconstruction

One commonly expressed concern regarding transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction surgery is the return of sensation to the abdomen. Although many studies have focused on abdominal wall muscle incompetence or herniation, there is limited literature discussing postoperative abdominal sensation. The purpose of this study was to assess abdominal sensation a minimum of 1 year after pedicled TRAM flap surgery for breast reconstruction. Twenty-five female patients who underwent TRAM flap breast reconstruction a minimum of 1 year before the study were compared with 10 female volunteer controls. Subject and control abdomens were specifically divided into 12 zones, then assessed for superficial touch, superficial pain, temperature, and vibration using various techniques. Fischer's exact test was used for analysis with the p value set at p = 0.05. The degree to which superficial touch was affected was then tested using Semmes-Weinstein monofilaments. Student's t test was used for analysis with the p value set at p = 0.05. For all four sensory modalities, subjects were found to have decreased sensation in zones 5 and 8, the supraumbilical and infraumbilical regions. This was statistically significant. When assessed with Semmes-Weinstein monofilaments, the sensation of the subjects' abdomens was significantly decreased compared with controls. Significance was found in all zones. This study clearly demonstrates that there is a significant and persistent reduction in abdominal sensibility following TRAM flap surgery. The distribution of the deficits is consistent and involves the midline supraumbilical and infraumbilical regions. The TRAM flap has become the procedure of choice for postmastectomy autogenous breast reconstruction. It provides the plastic surgeon with a relatively safe, reliable, and aesthetically pleasing method of breast reconstruction. Since its inception, the TRAM flap and its abdominal closure have undergone numerous modifications designed to minimize donor-site morbidity and create a natural-looking breast. In addition to creating an aesthetically pleasing breast, the TRAM flap has the potential advantage of postoperative improvement in abdominal contour.

Microvascular reconstruction of the breast

The growth of microsurgical procedures has led to significant technological, scientific, and clinical advances that have made these procedures safe, reliable, reproducible, and routine in most major medical centers. In many instances, free flap reconstruction has become the primary reconstructive method for many major defects, including breast reconstruction. The advantages of free flap breast reconstruction include better flap vascularity, broader patient selection, easier insetting of the flap, and decreased donor site morbidity. Free flap breast reconstruction can occur either at the time that the mastectomy is performed or as a delayed reconstruction following a previous mastectomy. Immediate reconstructions have the advantage of avoiding scar contracture and fibrosis within the mastectomy flaps and at the recipient vessel site. The most common recipient vessel sites are the thoracodorsal vessels and the internal mammary vessels. The thoracodorsal vessels are most frequently used in immediate reconstruction because they are partially exposed during the mastectomy procedure. The internal mammary vessels are used more frequently in delayed reconstructions, to avoid repeat surgery in the axilla. This recipient site also allows more medial placement of the reconstruction. Flap selections for free autogenous breast reconstruction include the transverse rectus abdominis myocutaneous (TRAM) flap, the superior gluteal myocutaneous flap, the inferior gluteal myocutaneous flap, the lateral thigh flap, and the deep circumflex iliac soft tissue flap (Rubens). The TRAM flap is most commonly used in free flap breast reconstruction. For patients with inadequate abdominal tissue or prior abdominal surgery, the superior gluteal flap is typically used. Both the TRAM flap and the superior gluteal flap can be designed as perforator flaps, preserving all of the involved muscle and, in the TRAM perforator, all the rectus fascia. These flaps are more technically demanding, with minimal impact on donor site function. The other flaps are less frequently used and limited to special patient circumstances. Free flap autogenous breast reconstruction provides a natural, long-lasting result with a high degree of patient satisfaction. Semin. Surg. Oncol. 19:264-271, 2000.

Somatosensory status after pedicled or free TRAM flap surgery: a retrospective study

The transverse rectus abdominis musculocutaneous (TRAM) flap is widely used in autologous breast reconstructions. In transferring tissue as a pedicled or free flap, alterations in sensibility are unavoidable. This study evaluated somatosensory function in the reconstructed breast at least 2 years after pedicled or free TRAM flap surgery. Thirteen patients who had a pedicled TRAM flap and 13 patients who had a free TRAM flap participated in the study. The patients completed a questionnaire regarding subjective sensibility and their general opinion of the reconstructed breast. Somatosensory examinations to study the sensations of touch, warmth, cold, and pain were performed using nonquantitative and quantitative techniques. An age-matched control group of eight women who had never had breast surgery was also examined because the majority of the women who had breast reconstruction also had a mammaplasty performed on the contralateral breast, which disqualified it as a control. The majority of the patients reported that the reconstructed breast felt like a real breast. However, sensibility to touch, warmth, cold, and pain was decreased in the study groups compared with the control group. No clinically significant differences existed in sensibility between the pedicled and free TRAM flap groups.

Breast reconstruction by means of innervated rectus abdominis myocutaneous flap

We performed immediate breast reconstruction in 22 patients using rectus abdominis myocutaneous flap accompanied by neurorrhaphy in the past 2 years. In the neurorrhaphy, the 11th intercostal nerve, which controls the sensation of the myocutaneous flap, was anastomosed to the lateral cutaneous branch of the 4th intercostal nerve, which controls the sensation of the breast. Our study included 15 patients, and the postoperative follow-up period was 4 to 24 months, with an average of 14.0 months. For control subjects, there were 16 cases of rectus abdominis myocutaneous flap, whose sensory nerve had not been reconstructed (postoperative follow-up period 11 to 41 months, average 24.1 months). The sensory examination included tests of touch, pain, and temperature. The innervated myocutaneous flap sensation showed gradual recovery at about 6 months after surgery and reached the value of the normal side after about 1 year. In the control subjects, recovery of sensation was not observed at all in the first 10 postoperative months. Then, after more than 1 year, the recovery was gradual and reached the value of the normal side in only some control subjects. Therefore, we consider the present technique useful for recovery of sensation in immediate breast reconstruction.