Nerve Coaptation Improves the Sensory Recovery of the Breast in DIEP Flap Breast Reconstruction

Beugels, Jop; Bijkerk, Ennie; Lataster, Arno; Heuts, E. M.; Hulst, René R. W. J. van der; Tuinder, Stefania

doi:10.1097/prs.0000000000008160

Cited by 28 publications

(37 citation statements)

References 22 publications

(54 reference statements)

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“…Twenty-three studies were found that met parameters for inclusion into this review. Of the studies included, seven looked primarily at DIEP flaps, 3,5–10 nine looked primarily at TRAM flaps, 11–19 two studies were novel implant-based studies, 20,21 and the remaining five studies dealt with other reconstructive modalities, including some where a technique was not specified. 22–26…”

Section: Resultsmentioning

confidence: 99%

“…Supplemental Digital Content 1 includes methods from DIEP reconstruction articles. 3,5–10 ( See table 1, Supplemental Digital Content 1 , which displays DIEP article methods. http://links.lww.com/PRSGO/C172.)…”

Section: Methodsmentioning

confidence: 99%

“…Supplemental Digital Content 1 includes methods from DIEP reconstruction articles. 3,[5][6][7][8][9][10]…”

Section: Included Articlesmentioning

confidence: 99%

“…http://links.lww.com/PRSGO/C176.) Six out of seven studies had favorable conclusions regarding the utility of nerve coaptation, 3,[5][6][7][8]10 while one found inconclusive results. 9 Three out of seven studies 3,5,9 assessed subjective, patient-reported outcomes.…”

Section: Diep Studiesmentioning

confidence: 99%

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Functional and Psychosocial Outcomes following Innervated Breast Reconstruction: A Systematic Review

Abbas

Klomparens

Simman

2022

Plastic and Reconstructive Surgery - Global Open

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Background: With the incidence of breast cancer, breast cancer survival rates, and prophylactic mastectomies all increasing, efforts to optimize breast reconstruction and improve quality of life are becoming increasingly important. Nerve coaptation has been investigated for its potential to remedy the clinical and psychosocial deficits in newly reconstructed breasts. The purpose of this review is to gauge the efficacy of nerve coaptation during breast reconstruction in creating worthwhile benefits in both objective and subjective dimensions of sensation. Methods: A Prospero registered systematic review was conducted. Databases including PubMed, SCOPUS, and ScienceDirect were screened using search terms “innervation," “breast reconstruction," and “neurotization” and relevant inclusion criteria. Results: Twenty-three studies were found that met parameters for inclusion. We identified studies that assessed DIEP-based reconstruction (7), TRAM-based reconstruction (9), implant-based reconstruction (2), and five studies that looked at a variety of reconstructive modalities. Monofilament testing was the most common modality used to assess sensation, while pain, temperature, and pressure thresholds were assessed more infrequently. Various tools were used to measure psychosocial impacts, including the BREAST-Q. While the methods for evaluation of both aspects of sensation were heterogenous, there was a trend towards improved outcomes with neurotization. Conclusions: The results of this review show promising improvements in clinical and psychosocial outcomes in innervated breasts compared to non-innervated breasts. However, the heterogeneity of studies in the literature indicates that more multi-center studies with standardized methodology including the BREAST-Q, sensory testing and complication analysis are needed to adequately demonstrate the value of neurotization in breast reconstruction.

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Section: Resultsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

“…Supplemental Digital Content 1 includes methods from DIEP reconstruction articles. 3,[5][6][7][8][9][10]…”

Section: Included Articlesmentioning

confidence: 99%

Section: Diep Studiesmentioning

confidence: 99%

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Functional and Psychosocial Outcomes following Innervated Breast Reconstruction: A Systematic Review

Abbas

Klomparens

Simman

2022

Plastic and Reconstructive Surgery - Global Open

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“…The secondary outcome was postoperative mechanical detection threshold, for which data from prior studies were reused. [27][28] In these prior studies, nine anatomical points per breast were measured using a 20-piece Touch-test™ Sensory Evaluator (North Coast Medical, Inc., Gilroy, CA, USA). 23 Scores represent the logarithm of 10 times the force in milligrams required to bow the monofilament; lower values indicate better sensation.…”

Section: Variablesmentioning

confidence: 99%

Learning Sensory Nerve Coaptation in Free Flap Breast Reconstruction

Smeele

Beugels

Kuijk

et al. 2023

J Reconstr Microsurg

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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 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 < .05), but sensitivity analysis refuted this apparent learning effect (adjusted odds ratio 1.00, 95% confidence interval 1.00 – 1.01, p = .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 < .05). Conclusions 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.

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

Smeele,

Martin,

van Kuijk

et al. 2023

Microsurgery

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IntroductionCutaneous 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.MethodsWe 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.ResultsOf 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).ConclusionOur 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.

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Nerve Coaptation Improves the Sensory Recovery of the Breast in DIEP Flap Breast Reconstruction

Abstract: This trial is registered under the name "Sensory Nerve Coaptation in DIEP Flap Breast Reconstruction," ClinicalTrials.gov registration number NCT04093999 (https://clinicaltrials.gov/ct2/show/NCT04093999).

Cited by 28 publications

References 22 publications

Functional and Psychosocial Outcomes following Innervated Breast Reconstruction: A Systematic Review

Functional and Psychosocial Outcomes following Innervated Breast Reconstruction: A Systematic Review

Learning Sensory Nerve Coaptation in Free Flap Breast Reconstruction

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

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