Prospective Sensory Outcomes for Targeted Nipple-areola Complex Reinnervation in Gender-affirming Double Incision Mastectomy With Free Nipple Grafting.

Abstract

Objective: To analyze the anatomy and sensory outcomes of targeted nipple-areola complex reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafting.

Background: TNR is a novel technique to preserve and reconstruct intercostal nerves (ICNs) to improve postoperative sensation. There is little evidence of relevant anatomy and outcomes.

Methods: Twenty-five patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient-reported questionnaires was completed preoperatively, and at 1, 3, 6, 9, and 12 months postoperatively.

Results: Fifty mastectomies were performed. Per mastectomy, the median number of ICN found and used was 2 (1-5). Axon and fascicle counts were not significantly different between ICN branches ( P > 0.05). Body Mass Index ≥30 kg/m 2 and mastectomy weight ≥800 g were associated with significantly worse preoperative sensation ( P < 0.05). Compared with preoperative values, nipple-areola complex (NAC) sensation was worse at 1 month ( P < 0.01), comparable at 3 months ( P > 0.05), and significantly better at 12 months ( P < 0.05) postoperatively. Chest sensation was comparable to the preoperative measurements at 1 and 3 months ( P > 0.05), and significantly better at 12 months ( P < 0.05) postoperatively. NAC sensation was significantly better when direct coaptation was performed compared with the use of allograft only ( P < 0.05), and with direct coaptation of ≥2 branches compared with direct coaptation of a single branch ( P < 0.05). All patients reported a return of nipple and chest sensation at 1 year postoperatively and 88% reported a return of some degree of erogenous sensation.

Conclusions: TNR allows for restoration of NAC and chest sensation within 3 months postoperatively. The use of multiple ICN branches and direct coaptation led to the best sensory outcomes.