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American Association for Hand Surgery

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Neurotization Techniques and Outcomes in Innervated Breast Reconstruction: A Systematic Review and Pooled Analysis
E. Shiah, E. Laikhter, C. D. Comer, S. M. Manstein, V. P. Bustos, P. A. Bain, B. T. Lee, and S. J. Lin
Beth Israel Deaconess Medical Center, Harvard Medical School

Background: Significant improvements in sensory recovery after innervated breast reconstruction have been reported and found to correspond with increased patient satisfaction and quality of life. However, surgical approaches and sensory testing methodologies in the current literature have been widely variable. This systematic review aimed to synthesize neurotization techniques and outcomes in innervated breast reconstruction surgery.

Methods: A literature search of the Medline, Embase, Web of Science, and Cochrane databases was conducted to identify all studies reporting outcomes of neurotization in innervated breast reconstruction. Review articles, textbook chapters, non-English language studies, studies with fewer than four patients (case reports or small case series), and studies that evaluated sensory outcomes after breast reconstruction without nerve coaptation were excluded. Data extracted from each study included neurotization techniques, operative times, sensory methods and outcomes, and patient-reported outcomes.

Results: A total of 1,350 abstracts were screened and 23 articles were included for analysis. Nerve coaptation was performed in at least 536 breasts and 419 patients, with techniques consisting of direct coaptation (65.1% of flaps), coaptation with nerve conduit (26.3%), and coaptation with nerve allograft (8.6%). The neural component of operating time ranged from 8 to 38 minutes, and the pooled neurotization success rate from meta-analysis of nine studies that reported this outcome was 90.6% (95% CI: 83.6%-96.0%). Nerve coaptation challenges included unfavorable flap orientation, anatomical variations, excessive scar tissue, and irretrievable nerve damage. Overall, innervated breasts achieved earlier and superior sensory recovery that was more uniformly distributed throughout the flap compared to non-innervated breasts. Furthermore, dual neurorrhaphy (16.6% of flaps) demonstrated superior sensory outcomes compared to single neurorrhaphy. Despite high heterogeneity between studies, all studies supported innervated breast reconstruction to improve the rate, quality, and magnitude of sensory recovery.

Conclusion: While the acceptance of neurotization as standard of care in breast reconstruction remains debatable, likely in part due to the variability across study designs, surgical approaches, and sensory testing methodologies, it is important for reconstructive surgeons to continue to reassess the benefits of breast flap sensory nerve coaptation and to remain aware of emerging microsurgical nerve repair techniques. Future studies are also warranted to evaluate the effects of radiation therapy and flap thickness on sensory recovery outcomes. Familiarity with existing neurotization options and flexibility with incorporating new techniques may allow plastic surgeons to continue pushing the frontiers of breast reconstruction in order to provide maximal quality of life to an increasing number of mastectomy patients.

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