What role does breast neurotization play in restoring sensation after breast reconstruction, and how are advances in microsurgical nerve repair helping surgeons approach this important aspect of patient care?
In Episode 105 of the DiepCJourney® podcast, I am joined by Dr. Joseph Serletti, Chief of Plastic Surgery at the University of Pennsylvania, to discuss his experience using Nerve Tape®, a suture-free solution for connecting nerves during microsurgical procedures.
Dr. Serletti’s Background in Sensate Breasts and Published Data on Nerve Tape®
Dr. Serletti is a pioneer in free flap autologous breast reconstruction, using a patient’s own tissue to reconstruct the breast, and is internationally recognized for his work in reconstructive microsurgery, including breast, head and neck, and extremity reconstruction.
The published data on the efficacy of Nerve Tape® is published on the Biocircuit website. My interest in this product began when I tried it at a medical conference. To my surprise, I successfully wrap the Nerve Tape®, tugged on it, and thought to myself, if I could do this so seamlessly on the demonstration Biocircuit had set up, I really wanted to talk to surgeons who are successfully using it to find out a little bit more.
Background on Neurotization of Breasts
Dr. Serletti tells us that for thirty-five years microsurgeons have been performing breast reconstruction using abdominal tissue. About ten years ago, a company, Axogen, produced a nerve graft. The nerve graft is a cadaveric nerve that is used instead of harvesting nerves from the patient.
One of the real challenges before we could make breasts sensate, is that microsurgeons can make a really nice aesthetic result in terms of breast reconstruction, but the breasts had very diminished sensation. Although it looked great, the patient didn’t seem all that natural despite being made of very natural tissue.
How Breast Neurotization Restores Sensation After Reconstruction
When the Axogen nerve grafts became available microsurgeons very quickly started to neurotize, which is the term that means to make them sensate. Up until about a year ago, microsurgeons took two 8-0 nylon sutures and put sutures across neurorrhaphy, how they put the nerve together.
The size of these nerves is small and that suture can be challenging to assure yourself that you have a very accurate apposition of the nerve ends. This method was performed for a number of years, studied, and published in plastic surgery journals looking at a large population of patients that were neurotized and comparing them to those who were not neurotized. The findings showed that patients who were neurotized show much better sensation over time than those who did not have neurotization. He points out based on this information he shared that neurotization definitely works.
How Nerve Tape® Improves Nerve Repair During Breast Neurotization
Dr. Serletti shares that he met Brandon Mark at a conference and was shown the Nerve Tape®. It was soon after that he began using it sharing, “It’s a quantum leap improvement in terms of trying to do the neurorrhaphy” He was referring to using the 8-0 nylon sutures and added there is no suture obstructing the connection. There are very fine hooks that go into the epineurium. He demonstrates with his hands and fingers in the video how you get great coaptation where the end of one nerve is right up against the end of another nerve. Then you wrap it making the coaptation “quite strong with the Nerve Tape®.” Dr. Serletti tells us that the Nerve Tape® is also faster compared the suture method.
Early Experience and Long-Term Sensation Outcomes with Nerve Tape®
He tells us he has been using it for only about a year and it is important to get a couple of more years using the tape behind them where they can compare Nerve Tape® neurorrhaphies to suture neurorrhaphies and final patient outcomes in terms of what their final sensation is like.
Dr. Serletti feels very strongly, “the Nerve Tape® is going to get the better sensation.” He bases this on his experience and seeing how well the nerves are coapted with no suture interrupting that connection and instead held by the fine hooks. He states, “It leaves you with a very strong feeling that this is about the best way you are going to coapt two nerves.”
Protective Benefits of Restoring Sensation After Breast Reconstruction
I add to the conversation sharing my experience hearing from patients about sensate nerves. Many associate sensations with erogenous feeling but don’t often discuss the protective benefits of sensate nerves. Dr. Serletti agrees and tells us he has had more than one patient come into his clinic with accidental burn wound to their breast reconstruction. This is caused from things like a heating pad or hot water because they didn’t feel it.
Nerve Tape® in Implant-Based Breast Reconstruction and Nipple Neurotization
Breast neurotization was first used with reconstruction using a patient’s own tissue and has now expanded to implant-based reconstruction. Dr. Serletti explains that attaching a nerve behind the nipple with tiny sutures was difficult. But Nerve Tape® makes the connection easier and more secure.
During the procedure, the surgeon connects the nerve that provides nipple sensation to a nerve graft. In nipple-sparing implant reconstruction, Nerve Tape® holds the graft securely against the back of the nipple without traditional stitches.
Nerve Tape® Stability and Ease of Use in Surgery
I ask Dr. Serletti whether Nerve Tape® has ever failed when tested in the operating room. He quickly replies, “No.” Then he explains that although a sutured nerve connection can occasionally shift when a tissue flap is moved, and must then be repaired, he has not experienced this problem with Nerve Tape®.
He adds that the residents at his teaching hospital are equally enthusiastic about how easy it is to use.
Key Takeaways About Breast Neurotization, Recovery, and Insurance Coverage
- Patients want breast reconstruction that restores sensation.
- More research is needed to fully evaluate the effectiveness of Nerve Tape®.
- Nerves regenerate at approximately 1 millimeter per day.
- Patients may need two to three years to achieve their maximum level of sensation.
- Dr. Serletti obtains insurance preauthorization before performing neurotization.
- Insurance coverage may be denied when a carrier considers neurotization experimental, rather than because of the Women’s Health and Cancer Rights Act (WHCRA).
Final Words from Dr. Serletti
Final Words from Dr. Serletti
“I’ve said this years ago that not just in breast but in head and neck, extremity, any type of reconstruction, we can get the soft tissue there and we can get overall soft tissue results and for a long time we never paid attention to sensation. But it’s incredibly important. It’s really doing a complete reconstruction if you can restore sensation. While the breast was obvious, we started doing it in both head and neck and extremity reconstruction to try and give those reconstructions some form of sensation as well. Sensation is the last of our reconstructive efforts that we really need to get better. And we’re getting there.” ~ Joseph M. Serletti, MD