J Reconstr Microsurg 2021; 37(02): 136-142
DOI: 10.1055/s-0040-1715878
Original Article

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

1   Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
,
Marissa Suchyta
1   Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
,
Krishna S. Vyas
1   Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
,
Nirusha Lachman
2   Department of Anatomy, Mayo Clinic, Rochester, Minnesota
,
Samir Mardini
1   Division of Plastic Surgery, Mayo Clinic, Rochester, Minnesota
,
Michael Saint-Cyr
3   Division of Plastic Surgery, Baylor Scott and White Health, Temple, Texas
› Institutsangaben
Funding This study received part funding from AxoGen, Inc. (grant no. FP00083113).

Abstract

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.

Note

This work was presented at the American Society of Reconstructive Microsurgery 2018.




Publikationsverlauf

Eingereicht: 10. April 2020

Angenommen: 15. Juli 2020

Artikel online veröffentlicht:
30. August 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Holmström H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg 1979; 13 (03) 423-427
  • 2 Temple CL, Ross DC, Kim S. et al. Sensibility following innervated free TRAM flap for breast reconstruction: part II. Innervation improves patient-rated quality of life. Plast Reconstr Surg 2009; 124 (05) 1419-1425
  • 3 Blondeel PN, Demuynck M, Mete D. et al. Sensory nerve repair in perforator flaps for autologous breast reconstruction: sensational or senseless?. Br J Plast Surg 1999; 52 (01) 37-44
  • 4 Mori H, Akita K, Hata Y. Anatomical study of innervated transverse rectus abdominis musculocutaneous and deep inferior epigastric perforator flaps. Surg Radiol Anat 2007; 29 (02) 149-154
  • 5 Yap LH, Whiten SC, Forster A, Stevenson JH. The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps. Br J Plast Surg 2002; 55 (01) 35-45
  • 6 Puonti HK, Jääskeläinen SK, Hallikainen HK, Partanen TA. A new approach to microneurovascular TRAM-flap breast reconstruction--a pilot study. J Plast Reconstr Aesthet Surg 2011; 64 (03) 346-352
  • 7 Spiegel AJ, Menn ZK, Eldor L, Kaufman Y, Dellon AL. Breast reinnervation: DIEP neurotization using the third anterior intercostal nerve. Plast Reconstr Surg Glob Open 2013; 1 (08) e72
  • 8 Lehmann C, Gumener R, Montandon D. Sensibility and cutaneous reinnervation after breast reconstruction with musculocutaneous flaps. Ann Plast Surg 1991; 26 (04) 325-327
  • 9 Lapatto O, Asko-Seljavaara S, Tukiainen E, Suominen E. Return of sensibility and final outcome of breast reconstructions using free transverse rectus abdominis musculocutaneous flaps. Scand J Plast Reconstr Surg Hand Surg 1995; 29 (01) 33-38
  • 10 Liew S, Hunt J, Pennington D. Sensory recovery following free TRAM flap breast reconstruction. Br J Plast Surg 1996; 49 (04) 210-213
  • 11 Blondeel PN, Van Landuyt K, Monstrey S. Surgical-technical aspects of the free DIEP flap for breast reconstruction. Operative Tech Plast Reconstr Surg 1999; 6: 27-37
  • 12 Slezak S, McGibbon B, Dellon AL. The sensational transverse rectus abdominis musculocutaneous (TRAM) flap: return of sensibility after TRAM breast reconstruction. Ann Plast Surg 1992; 28 (03) 210-217
  • 13 Place MJ, Song T, Hardesty RA, Hendricks DL. Sensory reinnervation of autologous tissue TRAM flaps after breast reconstruction. Ann Plast Surg 1997; 38 (01) 19-22
  • 14 Knackstedt R, Gatherwright J, Cakmakoglu C, Djohan M, Djohan R. Predictable location of breast sensory nerves for breast reinnervation. Plast Reconstr Surg 2019; 143 (02) 393-396
  • 15 Hansson HP. Histochemical demonstration of carbonic anhydrase activity. Histochemie 1967; 11 (02) 112-128
  • 16 Schindelin J, Arganda-Carreras I, Frise E. et al. Fiji: an open-source platform for biological-image analysis. Nat Methods 2012; 9 (07) 676-682
  • 17 Stromps J-P, Bozkurt A, Grieb G, Kim B-S, Wiezik M, Pallua N. Spontaneous reinnervation of deep inferior epigastric perforator flaps after delayed breast reconstruction. J Reconstr Microsurg 2016; 32 (03) 169-177
  • 18 Tindholdt TT, Tønseth KA. Spontaneous reinnervation of deep inferior epigastric artery perforator flaps after secondary breast reconstruction. Scand J Plast Reconstr Surg Hand Surg 2008; 42 (01) 28-31
  • 19 Magarakis M, Venkat R, Dellon AL. et al. Pilot study of breast sensation after breast reconstruction: evaluating the effects of radiation therapy and perforator flap neurotization on sensory recovery. Microsurgery 2013; 33 (06) 421-431
  • 20 Temple CL, Tse R, Bettger-Hahn M, MacDermid J, Gan BS, Ross DC. Sensibility following innervated free TRAM flap for breast reconstruction. Plast Reconstr Surg 2006; 117 (07) 2119-2127 , discussion 2128–2130
  • 21 Santanelli F, Longo B, Angelini M, Laporta R, Paolini G. Prospective computerized analyses of sensibility in breast reconstruction with non-reinnervated DIEP flap. Plast Reconstr Surg 2011; 127 (05) 1790-1795
  • 22 Akdeniz Dogan Z, Farhadi J. Evaluation of Sensation on Mastectomy Skin Flaps following Immediate Breast Reconstruction. J Reconstr Microsurg 2020; 36 (06) 420-425
  • 23 Shridharani SM, Magarakis M, Stapleton SM, Basdag B, Seal SM, Rosson GD. Breast sensation after breast reconstruction: a systematic review. J Reconstr Microsurg 2010; 26 (05) 303-310
  • 24 Knackstedt R, Grobmyer S, Djohan R. Collaboration between the breast and plastic surgeon in restoring sensation after mastectomy. Breast J 2019; 25 (06) 1187-1191