I sat down with Dr. Chet Nastala of PRMA Plastic Reconstructive Microsurgical Associates while visiting their practice in San Antonio for BRA Day 2025. We discuss TruSense® and sensate breasts, the PRMA service mark and surgical method they use to reconstruct nerves to improve sensation to the breast.
The following is a summary of our discussion that you can listen to on the DiepCJourney® podcast. We have included the entirety of the interview below from episode 88: PRMA’s TruSense® in Breast Reconstruction for Sensate Breasts.
Dr. Nastala’s Training and Background
Dr. Nastala began his training in the northeast and attended Harvard for his undergraduate degree. He attended Duke for medical school and did his surgical training at the University of Pittsburg. There he completed training combining plastic surgery, general surgery, some surgical oncology, and research.
He has been at PRMA plastic surgery for twenty-five years. He is particularly interested in the sensation of the breast, nerve repairs, and optimizing outcomes for breast reconstruction for their patients. They continue to bring forward and improve the field of autologous breast reconstruction using the body’s own tissue to form a more natural breast with ultimately better sensation using the TruSense® technique . Dr. Nastala states that research in the area of sensate breasts has been ongoing for many years. Although there have been many advances he tells us, “Still we’re not there yet to the perfect breast reconstruction with excellent sensation because there are limitations of the body’s own ability to regenerate the nerves even after they’re repaired.”
The Nerve Anatomy of the Breast to Understand Breast Reconstruction for Sensate Breasts
The nerves arise from the spinal cord which is in our back, and we also have nerves coming out from our brain. Ultimately, all the nerves come around our body and through and between our thoracic segments. The breast itself is on top of the rib cage with nerves that come between the ribs, the intercostal spaces, and then penetrate the intercostal muscles supplying the gland itself and the skin and nipple in a very complex way.
There are nerves that penetrate on the lateral side of the breasts (the side portion under the armpit area). Additionally, there are nerves that go deep within the chest wall and penetrate on medial side of the breast (the area closest to the center of the chest). These nerves envelope the breast.
The Nerve Anatomy of the Breast in Sensate Breasts
The nerves arise from the spinal cord which is in our back, and we also have nerves coming out from our brain. Ultimately, all the nerves come around our body and through and between our thoracic segments. The breast itself is on top of the rib cage with nerves that come between the ribs, the intercostal spaces, and then penetrate the intercostal muscles supplying the gland itself and the skin and nipple in a very complex way.
There are nerves that penetrate on the lateral side of the breasts (the side portion under the armpit area). Additionally, there are nerves that go deep within the chest wall and penetrate on medial side of the breast (the area closest to the center of the chest). These nerves envelope the breast.
Breast Cancer Treatment
Breast cancer treatment is multimodal, meaning:
- There is surgery to remove the breast.
- There is chemotherapy to eliminate cancer cells in the body.
- There is immunotherapy to change the immune system response to cancer.
- There is radiation therapy.
Dr. Nastala describes it this way. “It used to be a three-legged stool and now it’s a four- or five-legged table and there are many, many things that will come in the future.”
Preserving the Nerves at the Time of a Mastectomy
Mastectomy surgery has improved over the years and refined with each successive decade making surgery more comfortable for the patient. The nerves that are severed in a mastectomy can now “mostly” be preserved to a certain extent. Dr. Nastala tells us that nerves go from a cable similar to a cable that you plug into your phone about two to three millimeters in size. These small nerves arborize or branch to the breast itself. The nerve sensation to the nipple is different that the nerve sensation to the overlying skin. This is because those nerves branch out, similar to a river tributary going in different directions. At the chest wall to where the breast comes that nerve is severed during a mastectomy.
These nerves come from the third, fourth, firth, and sixth intercostal spaces. If those nerves can be preserved as they come into the breast then there is a small stump or segment of nerve which can then be repaired to a flap. If you have an implant, some surgeons can take a graft of a nerve and bring that nerve all the way up to underneath the nipple. This nerve is essentially like a cable that provides signals.
When a nerve is innervated with the TruSense® technique, a service mark developed at PRMA, this signifies that they are taking a nerve from your body and taking a nerve from the flap (a donor nerve and recipient nerve). These two nerves are then connected and wrapped by a little segment of vein or artery to keep them in a good position using tiny sutures to repair that nerve.
Is Sensation to the Breast Immediate After Using TruSense® in Breast Reconstruction?
The process of connecting the nerves is the first step in nerve repair. It does not ensure that you will regain sensation because as we all know, sometimes after a cut we are still numb similar to how your are in your breast or other parts of the body that have been cut by surgery. The body has to regenerate by growing those nerve fibers within the tube of the nerve that is farthest where the sensory input comes back to our body.
Some of the things that affect the ability of our nerves to regenerate are:
- Age makes the nerve growth much slower as part of the natural aging process.
- Radiation
- Diabetes
- Smoking
A Coordinated Effort to Restore Breast Sensation
Part of what they are trying to do with every patient is work with the breast surgeon to preserve those nerves as much as possible. This means not to cauterize them at the chest level but trace them out into the breast and allow them to have those nerves preserved. As far as the sensation to the skin and nipple, the nerves branch and if the breast surgeon is able to see those nerves coming into the skin they can preserve the entire nerve because that’s not part of the breast.
But a nerve that’s running within the breast itself has to be cut during the mastectomy. This coordinated effort between the breast surgeon and plastic surgeon helps patients retain as much sensation as possible.
Looking at Progress and Possibilities in Sensate Breast and Breast Surgery
We go on to discuss the many and ongoing studies on restoring sensation to the breast and how this technique will continue to develop over time. As part of our conversation, Dr. Nastala and I also address post mastectomy pain syndrome that patients can experience due to nerves that are cut during a mastectomy. This topic is complex and of interest to many patients. As with any recovery, time and patience are involved. Nerves grow back at a rate of approximately one inch per month. Dr. Nastala also mentions the value of post-oncology rehab programs that help improve the sensation to the breast.
A Personal Note Regarding Restoring Sensation to the Breast
You will find a number of interviews on the DiepCFoundation YouTube channel on this topic. Use the search engine at the top and type in the word “Nerve” or “Sensation.” The pioneers, like Dr. Nastala and his team at PRMA, along with other notable surgeons across the world are continuing to improve this procedure. Not all surgeons, breast, or reconstructive microsurgeons practice nerve preservation for a few reasons.
When patients contact me with a desire to have feeling and sensation to their breasts, I will continue to educate them about this topic and lead them to surgeons who are interested in and perform this technique.
We can acknowledge uncertainty while still charting a way forward. It is through clarity and understanding the possibility and potential in a shared decision-making process with your surgeon that patient outcomes improve. Thank you Dr. Nastala for your time and expertise on the TruSense® technique and sensate breasts.
Thank you for covering this Terri. I really appreciate how you centred quality of life and the practical reasons sensation matters, not just the technical side. This episode will be genuinely helpful for anyone trying to make informed choices about reconstruction. Marie Ennis-O’Connor
I appreciate you reading and sharing the blog Marie. It is likely very apparent I do enjoy interviewing these skilled surgeons to assist patients with their decision process.
~ Terri Coutee