There have been so many amazing advances in breast cancer and breast reconstruction surgery over the past several decades. One of the newer techniques is sensation-preserving mastectomy. It’s really exciting stuff, so I’ve asked two of the pioneers in this field, Drs. Anne Peled and Ziv Peled, to share some information on the topic!
Ziv and Anne are a power couple of plastic surgeons in San Francisco while Anne also has extensive training in oncologic breast surgery.
I’ll let them take it from here!
Sensation-Preserving Mastectomy – The Next Frontier in Breast Reconstruction
Advances in the treatment of breast cancer help minimize the negative side effects of surgery. They also help people look much more like their pre-surgery selves. However, one of the major challenges for people having mastectomy and reconstructive surgery is the loss of sensation that typically occurs after their operation.
Numbness can potentially be extensive, extending from the collar bone to the upper abdomen. It can also make recovering and moving past surgery difficult in many different aspects of peoples’ lives. Fortunately, though, there’s recently been a huge shift towards preserving sensation at the time of mastectomy. There is a also a shift restoring sensation for people who’ve already had surgery and are numb afterwards.
What is a sensation-preserving mastectomy?
In traditional mastectomies, nerves running along the edge of the breast and through the breast itself are injured and/or cut. This can lead not only to numbness, but also to chronic pain from nerve scar tissue (neuroma) formation at the injury site. With sensation-preserving mastectomies, a two-fold approach helps people regain most, if not all, of their sensation.
First, care is taken to carefully preserve any nerves that can safely be kept from an oncologic standpoint. Nerves must be running in the subcutaneous layer right under the breast skin in order to be safely preserved. These nerves also must be away from any tumors. Preserved nerves are usually the 4th or 5th superficial, lateral intercostal nerves, though sometimes the 3rd can be seen and maintained as well.
The major nerve to the nipple-areolar complex usually runs right through the breast tissue. Unfortunately in this case, it can’t be preserved. Thus nerve reconstruction is often done as the second step in helping sensation return. This involves keeping as much of the lateral intercostal nerve as can be safely kept before it starts branching into the breast tissue. Then, the nerve gets cut and the rest of the mastectomy is completed. Then, nerve reconstruction is done from the lateral intercostal nerve to a subareolar nerve near the nipple. This is done using either a cadaver nerve graft or another intercostal nerve that would have to be cut anyway as part of the mastectomy.
Both nerve preservation and reconstruction can be done at the time of mastectomy. Maximal return of sensation typically takes between 12 and 18 months.
What are the results from sensation-preserving mastectomy?
As this is a relatively new technique, the data on outcomes are still somewhat limited. However, there are several centers across the United States offering this approach who have multiple years’ worth of data. Previously published studies and conference presentations have demonstrated over 80% of patients report return of most, if not all, breast and nipple sensation. Studies also describe that the vast majority of patients have nipple responsiveness to touch and temperature. Further, they also report that sensation preservation allows for improved intimacy and sexual function compared to traditional mastectomy.
Are there options for restoring sensation if the mastectomy has already been performed?
While the best chance for maintaining sensation is at the time of mastectomy, sensation restoration can be attempted in a delayed fashion. Nerve reconstruction has been done for decades with autologous reconstruction. In this surgery, a sensory nerve is harvested with the flap and coapted to a sensory nerve in the chest during reconstruction. This can be a very effective way of restoring sensation after mastectomy. It is particularly effective in a delayed reconstruction where a large skin paddle is used as part of the reconstruction.
More recently nerve reconstruction has also been offered in a delayed fashion for people who have had implant-based reconstruction. This can be more technically challenging and unpredictable. It requires identifying an intercostal nerve with sufficient length for a nerve reconstruction, which may not be possible if nerves have been significantly injured during the mastectomy. If nerves can be found, however, nerve reconstruction can be done using cadaveric allografts with subsequent potential restoration of sensation.
The future of breast reconstruction
It’s an exciting time for the world of breast reconstruction. These new advances allow for people to not only look, but actually feel, like themselves after mastectomy!
It is so important to me to provide my patients with the most innovative and effective surgeries to restore form and function in breast reconstruction. Sensation-preserving mastectomy and reconstruction are the next steps in this evolution.
So, a huge thank you to Drs. Anne and Ziv Peled for sharing their work and inspiring me and other plastic surgeons to keep pushing forward!
If you are interested in learning more about plastic & reconstructive surgery, here are some other posts!
- Sorta Random Sunday: Basics of Breast Reconstruction
- Sorta Random Sunday: What Does A Plastic Surgeon Actually Do?
- Sorta Random Sunday: March is Lymphedema Month
- Sorta Random Sunday: All About Reconstructive Microsurgery
What do you think? Have you heard of sensation-preserving mastectomy? What are new innovations in your area of medicine? Let me know in the comments below!