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“Prospective Sensory Outcomes for Targeted Nipple-areolaComplex Reinnervation in Gender-affirming Double IncisionMastectomy With Free Nipple Grafting’

“Prospective Sensory Outcomes for Targeted Nipple-areolaComplex Reinnervation in Gender-affirming Double IncisionMastectomy With Free Nipple Grafting’

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 Reviewed by Reza Lankarani M.DVolume 282, Number 1, July 2025DOI: 10.1097/SLA.0000000000006192Annals of SurgerySummary:This prospective cohort study by Remy et al. (2025) presents a significant contribution to gender-affirming surgery by rigorously evaluating the novel technique of Targeted Nipple-Areola Complex Reinnervation (TNR) during double-incision mastectomy with free nipple grafting (FNG). The primary strength lies in its comprehensive, prospective design, meticulously tracking sensory outcomes (quantitative monofilament testing and patient-reported questionnaires) in 25 patients (50 mastectomies) at multiple time points up to 12 months postoperatively. This longitudinal approach robustly demonstrates that TNR facilitates restoration of NAC and chest sensation to baseline within 3 months, with significant *improvement* over baseline observed at 12 months – a finding with profound implications for patient quality of life. Furthermore, the study provides crucial, previously unavailable anatomical data on intercostal nerves (ICNs), confirming comparable axon/fascicle counts across branches (3rd-6th lateral ICNs) and establishing a median of 2 nerves utilized per mastectomy. The analysis linking surgical technique to outcomes is particularly valuable; it conclusively shows that direct coaptation of ≥2 ICN branches to the NAC yields superior and faster sensory recovery compared to using allografts alone or coapting only a single branch.Methods:Twenty-five patients (50 mastectomies) were prospectively enrolled between 2021 and 2022. Data collected included demographics, surgical technique, and axon/fascicle counts from a subset of patients (n=15). Quantitative sensory evaluation was performed using Semmes-Weinstein monofilaments preoperatively and at 1, 3, 6, 9, and 12 months postoperatively. Qualitative patient-reported questionnaires on sensation, pain, and satisfaction were also administered at various postoperative time points. The study evaluated the influence of intraoperative nerve anatomy, axon and fascicle counts, and nerve repair techniques (direct coaptation vs. allograft) on sensory outcomes.Results:A median of 2 ICN branches were found and used per mastectomy.Preoperatively, a higher Body Mass Index (BMI \ge30 g) and mastectomy weight (\ge800 g) were associated with significantly worse sensation.Postoperatively, NAC sensation was initially worse at 1 month but comparable to preoperative values at 3, 6, and 9 months, and significantly better at 12 months. Chest sensation followed a similar trend, becoming significantly better at 12 months.Direct coaptation of the ICN to the NAC resulted in significantly better NAC sensation compared to using allografts only.Utilizing two or more ICN branches for direct coaptation led to superior sensory outcomes compared to a single branch.At 12 months postoperatively, 95.6% of patients had equal or improved NAC monofilament values, and 100% had equal or improved chest skin sensation.Patient-reported outcomes showed good subjective return of sensory functions, with 88% of patients reporting a return of some degree of erogenous sensation at 12 months post-surgery.Nipple hypersensitivity decreased over time, from 42% at 3 months to 8.0% at 12 months. Chronic pain was reported in 32% of patients throughout the study period, decreasing to 10% at 12 months, while phantom pain was absent at 12 months.It demonstrates TNR effectively restored NAC and chest sensation within 3 months postoperatively. The study concluded that using multiple ICN branches and direct coaptation techniques yielded the best sensory outcomes.Key findings include:• Restoration of sensation : 95.6% of patients showed equal or improved NAC sensation at 12 months compared to preoperative baseline, with 88% reporting erogenous sensation recovery.• Technical advantages : Direct coaptation of ≥2 intercostal nerve (ICN) branches yielded superior sensory outcomes compared to allograft-only techniques.• Reduced chronic pain : Only 10% of patients reported chest pain at 12 months, significantly lower than historical rates (27.3%) post-GAM.• Anatomic insights : Axon and fascicle counts across ICN branches were comparable, suggesting flexibility in donor nerve selection, though the 4th and 5th ICNs were most consistently viable.The study underscores TNR’s potential to mitigate common postoperative complications of GAM, including sensory loss, phantom pain, and chronic neuropathic discomfort.Strengths:Innovative Technique Evaluation : This is the first prospective study to quantify sensory recovery following TNR in GAM, addressing a critical gap in gender-affirming surgical outcomes. Prior work focused on oncologic breast reconstruction 17–20, leaving GAM-specific reinnervation understudied.Prospective Design: The prospective nature of the study provides a higher level of evidence compared to retrospective reviews, allowing for systematic data collection and follow-up.Comprehensive ...

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