Advancements in Mastectomy: Preserving and Restoring Breast Sensation Through Innovative Surgical Techniques

For surgeons performing mastectomies to treat breast cancer, there have traditionally been two primary focuses in terms of outcomes: completely treat the patient’s cancer and preserve the breast’s aesthetic as much as possible. While advances in the procedure over the past few decades have drastically improved the likelihood of achieving both objectives, patients have increasingly been reporting an unexpected phenomenon – breast numbness.

“The goal with breast reconstruction is not just to restore the breast’s form or aesthetics,” says Risal Djohan, MD, a plastic surgeon at Cleveland Clinic. “Now, there is more of a focus on restoring and maintaining function and sensation to protect patients from injuring themselves. I’ve had patients who burnt themselves while cooking because they didn’t feel the heat from the stove. It’s important for surgeons and patients to recognize the breast numbness following mastectomy can be treated, and we’ve made great strides in terms of our understanding of the anatomy and developing surgical techniques that can preserve or restore sensation.”

A shift in focus

After helping to pioneer a nipple-sparing technique for mastectomies in 2001, and then publishing a review of those results in 2010, Dr. Djohan wanted to advance the procedure even further by focusing on breast sensation.

“In order to preserve or restore sensation, we needed to reconsider the anatomy of the breast,” says Dr. Djohan. “We recognized that the intercostal nerve plays a major role in providing sensation to the breast, but we wanted to understand its role at a deeper level. Perhaps most importantly, we also wanted to be able to reliably predict its location so surgeons can do a better job of preserving it during mastectomy.”

He published his results in a 2019 article for Plastics and Reconstructive Surgery, which demonstrated that in 10 female cadavers, the research group was able to consistently identify the nerve’s predictable location. They found that the nerve has a diameter of 2 mm, and it typically exited from under the fourth rib. The average distance from the nerve to the sternum was 13.1 ± 1.3 cm (range, 10 to 15 cm), and the average distance from the midclavicular line was 11.8 ± 2.2 cm (range, 8 to 16 cm). In all 10 cadavers, the nerve exited at the lateral border of the pectoralis minor or within 2 cm from the lateral border. The nerve also travels under the thoracodorsal vessels, which can help with its identification.

“Our goal with that paper was two-fold,” explains Dr. Djohan. “First, we wanted to help surgeons understand the importance of the intercostal nerve. Then, once they recognize how important this nerve is for sensation, it becomes equally important for them to understand where it’s located so it can be preserved.”

With a better understanding of the intercostal nerve’s impact and location, Dr. Djohan believes improving communication and collaboration between breast surgeons and plastic surgeons is the next step. “It’s important for oncology surgeons to understand that when it’s possible to preserve the intercostal nerve, then it should be preserved,” he says. “However, in cases where it’s necessary to cut the nerve because of the tumor’s location, those nerves can still be repaired or reconnected to provide sensory function.”

Restoring sensation

Historically, implants were typically the primary option for patients undergoing breast reconstruction. But Dr. Djohan says that he’s seeing more post-mastectomy patients who would prefer to use their own tissue rather than implants for breast reconstruction.

“We typically tell patients that they have two options: either implant or tissue from the belly,” says Dr. Djohan. “There are patients who might be hesitant about having additional surgery or abdominal scars, so those patients may be more comfortable with implants. But we’re seeing more patients with hesitancy about implants or who want to get rid of some of their fatty abdominal tissue, so they may have more interest in using their own tissue instead.”

Aware of the presence of nerves within the abdominal tissue, Dr. Djohan and his team wondered if these nerves could be protected and employed to restore sensation to the breasts. They worked with cadavers to map out the predictable locations of these nerves in the abdominal wall. “The sensory nerves are on either side of the navel,” says Dr. Djohan. “We found that going 3.5 cm out laterally from the navel and then about 6.5 cm down from there is typically where these nerves are located.”

For surgeries, Dr. Djohan creates a 3D map to help him identify where his patient’s sensory abdominal vessels and nerves are likely located. Then with sensory nerves from the abdominal wall intact, he’ll use sutures to reconnect those nerves into the chest. Although this approach increases the likelihood of restoring breast sensation, Dr. Djohan stresses that the rehabilitation process after surgery is incredibly important.

“I tell my patients, ‘If you do not follow the rehab protocol, the likelihood of the sensation coming back is less successful,’” explains Dr. Djohan. “The abdominal nerve approach gives them a head start, but if they’re not diligent with their rehab, the sensation level will be muted. It’s similar to rehab for an orthopedic injury. The initial surgery will help restore ability and some motion, but without the rehab, the patient won’t get their full range of motion back or the joint will be stiff.”

The rehab and healing process takes about nine months to a year-and-a-half to get the full level of sensation back. Patients are instructed to touch all quadrants of the breast at least twice a day in front of a mirror. “This helps them register in their mind where they're supposed to have sensations,” says Dr. Djohan. “If they don't do that, that sensation return will not happen, and the patient will have a suboptimal outcome.”

Patients also come back at least twice a year for testing to see how they’re progressing. Dr. Djohan and his staff use a computerized model to monitor how a patient’s sensation is returning based on a battery of sensory tests.

One of the last hurdles

Although Dr. Djohan and his team have published several papers detailing the success of their reconstructive microsurgeries, access to the treatment remains limited due to insurance coverage.

“When we look at the patients having the reconstructions and the patients who are getting insurance approval for it, there’s quite a bit of variance in terms of socioeconomics when comparing them to the patients who are not getting approved,” says Dr. Djohan. “We feel that this is unfair, so we decided to do a retrospective review study looking at the accessibility for this procedure and the associated inequities and implications.”

He continues, “We found that access differed significantly by socioeconomic status. We know that these surgeries improve outcomes and improve patient safety, so we hope that the insurance companies will reevaluate and expand their coverage. Just as with all medical procedures and healthcare access, it’s important that all patients are given an equal opportunity for better outcomes.”