Quality of Life, Breast Sensation, and Symptoms in Unilateral Breast Reconstruction with Direct Neurotization (Tommy Transfer) DIEP Free Flap: A Case Series Direct Neurotization Outcome
Abstract
Background: Loss of breast sensation after mastectomy can adversely affect a patient’s quality of life (QoL). Neurotization has been proposed to enhance sensory recovery following autologous breast reconstruction. However, studies reporting objective sensory outcomes and patient-reported outcome measures (PROMs) remain limited. This case series aimed to assess sensory recovery and PROMs following unilateral deep inferior epigastric perforator (DIEP) free flap breast reconstruction with direct neurotization.
Case Presentation: Four patients underwent unilateral DIEP free flap breast reconstruction with direct neurotization between February 2024 and April 2025. We performed direct end-to-end coaptation between a harvested intercostal nerve graft and the lateral cutaneous branch of the fourth intercostal nerve (LCB4). The distal end of the graft was then secured to the flap dermis. Objective sensory recovery was assessed using Semmes-Weinstein monofilament (SWM) testing across 9 breast regions. Patient-reported outcome measures (PROMs) were assessed using the Indonesian BREAST-Q Sensation Module at 0 to 6 and 6 to 12 months postoperatively. All patients demonstrated gradual objective sensory improvement. However, symptoms, sensation, and QoL trajectories varied among these individuals.
Conclusion: Sensory recovery following direct neurotization in unilateral DIEP breast reconstruction improved over time. However, objective sensory improvement did not consistently translate into improved symptoms or QoL scores. Postoperative well-being is multifactorial, underscoring the importance of integrating objective sensory testing with PROMs to comprehensively assess functional recovery.
References
Huang A, Mackenzie EL, Cho MJ. Striving for higher levels of evidence in sensory restoration in DIEP flap breast reconstruction. Gland Surg. 2025 Mar;14(3):268–71. doi:10.21037/gs-2024-524.
Djohan R, Scomacao I, Duraes EFR, Knackstedt R, Mangan R, Schwarz G. Sensory Restoration in Abdominally Based Free Flaps for Breast Reconstruction Using Nerve Allograft. Plast Reconstr Surg. 2023 Jan 4;151(1):25–33. doi:10.1097/PRS.0000000000009773.
Escandón JM, Mroueh J, Reid CM, Singh D, Sweitzer K, Ciudad P, et al. Innervated breast reconstruction: a narrative review of neurotization techniques and outcomes. Ann Transl Med. 2024 Aug;12(4):76–76. doi:10.21037/atm-23-504.
Murphy RNA, Reid AJ, Columb MO, O’Ceallaigh S, Duncan J, Holt R. Breast-Q sensory outcomes of non-neurotized, autologous, unilateral breast reconstruction with a minimum of 3-year follow-up. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2023 Oct;85:86–91. doi:10.1016/j.bjps.2023.06.054.
Shiah E, Laikhter E, Comer CD, Manstein SM, Bustos VP, Bain PA, et al. Neurotization in Innervated Breast Reconstruction: A Systematic Review of Techniques and Outcomes. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2022 Sep;75(9):2890–913. doi:10.1016/j.bjps.2022.06.006.
Beugels J, Cornelissen AJM, van Kuijk SMJ, Lataster A, Heuts EM, Piatkowski A, et al. Sensory Recovery of the Breast following Innervated and Noninnervated DIEP Flap Breast Reconstruction. Plast Reconstr Surg. 2019 Aug;144(2):178e–88e. doi:10.1097/PRS.0000000000005802.
Chang TNJ, Lu JCY, Sung CWH, Illias AM, Cheong DCF, Kao SW, et al. Elongation of intercostal nerve cutaneous branches for breast and nipple neurotization during breast reconstruction after mastectomy for breast cancer: case–control study. British Journal of Surgery. 2024 Jan 31;111(2). doi:10.1093/bjs/znae005.
Ramadan MR, Rifai DA, Atmodiwirjo P, Panigoro SS, Mukarramah DA, Sobri FB, et al. Indonesian Translation and Cultural Adaptation of the BREAST-Q Reconstruction Module. Plast Reconstr Surg Glob Open. 2025 Apr;13(4):e6705. doi:10.1097/GOX.0000000000006705.
Shyu S, Chang TNJ, Lu JCY, Chen CF, Cheong DCF, Kao SW, et al. Breast neurotization along with breast reconstruction after nipple sparing mastectomy enhances quality of life and reduces denervation symptoms in patient-reported outcome: a prospective cohort study. International Journal of Surgery. 2025 May;111(5):3235–47. doi:10.1097/JS9.0000000000002331.
Huang H, Wang ML, Ellison A, Otterburn DM. Comparing Autologous to Device-Based Breast Reconstruction. Ann Plast Surg. 2022 May;88(3):S184–9. doi:10.1097/SAP.0000000000003073.
Zhang A, Huang H, Lu Wang M, Arbuiso S, Black GG, Ellison A, et al. Breast Sensation and Quality of Life. Ann Plast Surg. 2025 Apr;94(4S):S276–82. doi:10.1097/SAP.0000000000004258.
Tsangaris E, Klassen AF, Kaur MN, Voineskos S, Bordeleau L, Zhong T, et al. Development and Psychometric Validation of the BREAST-Q Sensation Module for Women Undergoing Post-Mastectomy Breast Reconstruction. Ann Surg Oncol. 2021 Nov 14;28(12):7842–53. doi:10.1245/s10434-021-10094-y.
Soares Domingues Polita B, Lapinš J, Ģīlis A, Grucki M, Irmejs A, Gardovskis J, et al. Evaluation of Breast Skin/Nipple-Areolar Complex Sensation and Quality of Life after Nipple-Sparing Mastectomy Followed by Reconstruction. Medicina (B Aires). 2024 Oct 9;60(10):1655. doi:10.3390/medicina60101655.
Djohan R, Scomacao I, Knackstedt R, Cakmakoglu C, Grobmyer SR. Neurotization of the Nipple-Areola Complex during Implant-Based Reconstruction: Evaluation of Early Sensation Recovery. Plast Reconstr Surg. 2020 Aug;146(2):250–4. doi:10.1097/PRS.0000000000006976.
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