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Sensory nerve coaptation may enhance recovery of breast sensation and quality of life (QoL) after autologous breast reconstruction, but high-quality clinical evidence is lacking. We evaluated whether sensory nerve coaptation in deep inferior epigastric perforator (DIEP) flap breast reconstruction improves postoperative breast sensation and patient-reported QoL.

In this double-blind randomized controlled trial, patients undergoing DIEP-flap breast reconstruction were assigned to either innervated or non-innervated reconstruction. In the intervention group, the sensory branch of the tenth, eleventh, or twelfth intercostal nerve was coapted to the anterior cutaneous branch of the second or third intercostal nerve at chest level.

Breast sensation was measured preoperatively and at 3, 6, 12, 18, and 24 months postoperatively using Semmes-Weinstein monofilaments (SWM; tactile thresholds), the pressure-specified sensory device (PSSD; static and dynamic pressure sensation), and TSA-2 (temperature thresholds). Means were calculated for the flap skin, native skin, and total breast skin. QoL was assessed using the BREAST-Q Reconstruction Module.

A total of 118 patients (182 reconstructed breasts: 80 innervated, 102 non-innervated) were analyzed. Sensation improved over time in both groups. At 24 months, innervated breasts demonstrated significantly better tactile thresholds for flap skin and total breast skin compared with controls. Recovery of tactile sensation occurred significantly faster in the innervated group.

Static and moving pressure sensation was also superior in innervated breasts at 24 months, with lower PSSD-thresholds in flap and total breast skin and faster recovery. Thermal testing showed limited between-group differences, except for improved recovery of cold pain sensation in flap skin in the innervated group.

Patients with innervated reconstruction reported clinically meaningful improvements in several BREAST-Q domains, including Psychosocial Well-Being (12 and 24 months), Sexual Well-Being (24 months), and Physical Well-Being of the Abdomen (12 months).

Sensory nerve coaptation in DIEP-flap breast reconstruction significantly enhances recovery of sensation and is associated with clinically meaningful improvements in patient-reported QoL. These findings provide high-level evidence supporting routine consideration of sensory nerve coaptation.

Sensibility of the breast after reconstruction plays an important role in safety and quality of life. Although the first description of a sensitized Transverse Rectus Abdominis Myocutaneous (TRAM) flap was published in 1992 by Slezak et al., sensate flaps are still not standard of care. Generally, in flap-based breast reconstruction, plastic surgeons are focused on the aesthetic result, which is visible, but the advantages of functional aspects remain hidden from view. And so do the nerves without a trained eye during surgery.

A literature search was conducted to adequately represent existing publications. PubMed, Embase, and Cochrane Library were searched to find articles dealing with surgical techniques and providing detailed anatomical descriptions of sensate flaps in breast reconstruction. Based on the 600 sensate flaps for breast reconstruction performed at the last author's institution, we developed tips and tricks to make a successful nerve coaptation for the donor site as well as the recipient site.

Descriptions in the body of the literature were systematically listed.
Regarding our own insights, for the donor sites, all the different flaps for breast reconstruction were analyzed and tips and tricks described to make them sensate. For the acceptor site, details to visualize the recipient nerve and to obtain enough length were described.

The evidence for the benefits of sensate flaps for breast reconstruction is growing. Therefore, it is our goal to make this technique accessible to more surgeons and ultimately to more patients. This detailed surgical concept and gaze training will make it easier to adopt the technique and hopefully lead to its wider use for successful flap reinnervation.

To map and synthesize the current evidence on nipple–areola complex (NAC) sensory outcomes and nerve-related complications following primary cosmetic breast augmentation according to incision type.

A PRISMA-ScR–compliant scoping review following the Joanna Briggs Institute framework was performed. PubMed, Embase, Scopus, and the Cochrane Library were searched (January 2000–July 31, 2025), with supplementary Google Scholar screening. Eligible studies included women undergoing primary cosmetic breast augmentation reporting nipple–areola complex (NAC) sensory outcomes or nerve-related complications by incision type; revision, reconstructive, mastopexy–augmentation, and non-English studies were excluded.

Two independent reviewers conducted screening and data extraction. Extracted variables included study design, sample size, incision type, implant plane, follow-up, sensory assessment modality, and NAC outcomes. Both objective testing and patient-reported outcomes were included. Findings were synthesized descriptively by incision type with consideration of key modifying surgical factors.

Thirty-seven studies including >13,000 patients were analyzed. Persistent NAC sensory deficit was uncommon (<5%). Large retrospective cohorts showed a nearly threefold higher rate of sensory alteration and areolar pain with periareolar compared with inframammary incisions, whereas prospective objective studies often found no significant difference. Lateralized inframammary incisions consistently preserved sensation, while central inframammary placement increased inferior-pole sensory loss. Implant-to-breast volume ratio and implant plane were stronger predictors of outcome than incision alone. Transareolar access produced objective sensory deficits with low subjective symptoms. Transaxillary evidence was limited but anatomically demonstrated a nerve “danger zone.” Transumbilical augmentation showed negligible NAC sensory change. Most studies relied on subjective assessment, limiting direct comparison.

Long-term NAC sensory deficit after augmentation is rare. Lateralized inframammary incisions provide the most favorable profile, whereas periareolar access carries higher relative risk but low absolute morbidity. Surgical technique and implant variables outweigh incision choice, and standardized objective testing is needed.

Sensory restoration of flaps is gaining increasing attention in reconstructive surgery. Although epineural coaptation has been described decades ago, it has not become standard practice, and clinical assessment of re-sensitization remains largely subjective and investigator-dependent. Objective and reproducible outcome measures are needed. Animal models offer controlled conditions to evaluate flap reinnervation and may provide translational tools for future clinical trials. This systematic review aimed to identify and analyze methods used to assess flap re-sensitization in animal models.

A systematic literature search of PubMed, Embase, and Cochrane Library was conducted in accordance with PRISMA guidelines (last search: July 31, 2024). Studies evaluating sensory recovery in flap surgery using animal models were included. Data extracted comprised animal model, flap type, nerve intervention, sensory testing method, and evaluation timeframe. Descriptive statistical analysis was performed.

Out of 219 identified records, 15 studies involving 421 animals (397 rats, 24 mice) met inclusion criteria. Sensory recovery was assessed using either behavioral or immunohistochemical methods. Behavioral evaluation included measurement of the cutaneous trunci muscle (CTM) reflex (3 studies, n=117), allowing functional assessment of mechanonociceptive recovery. Immunohistochemical analysis predominantly utilized protein gene product 9.5 (PGP 9.5; 10 studies, n=225) and calcitonin gene-related peptide (CGRP; 9 studies, n=218) to quantify nerve fiber density and sensory reinnervation patterns. PGP 9.5 served as a pan-neuronal marker reflecting overall nerve regeneration, while CGRP enabled targeted assessment of sensory fiber regrowth. Despite providing measurable insights into reinnervation dynamics, considerable heterogeneity in flap design, nerve handling, outcome measures, and follow-up duration limited direct comparison across studies.

Behavioral testing and immunohistochemical markers represent valuable tools for assessing flap re-sensitization in animal models. Standardization of experimental protocols and outcome reporting is essential to enhance comparability and translational relevance. Integration of advanced proteomic approaches may further improve objectivity and pave the way toward patient- and investigator-independent evaluation methods in future clinical trials.

Loss of nipple–areolar complex (NAC) sensation is a common and underrecognized consequence of mastectomy due to transection of intercostal sensory nerves, potentially contributing to diminished quality of life, impaired protective sensation, and chronic neuropathic pain. Although restoration of breast sensation through nerve preservation, transfer, and grafting has gained attention in oncologic and gender-affirming reconstruction, application of these principles to mastectomy with free NAC preservation remains limited. We report a case of bilateral mastectomy with free NAC grafting and targeted re-innervation in a BRCA1-positive patient, demonstrating the feasibility of integrating peripheral nerve reconstruction to optimize sensory outcomes while maintaining oncologic safety.

A 50-year-old BRCA1-positive patient with left-sided breast cancer underwent bilateral mastectomie with free NAC grafting and immediate targeted re-innervation. Three intercostal sensory branches were identified bilaterally at the inferior border of the pectoralis major, dissected, and transected distally. Donor nerves were passed through a central dermal perforation and distributed in a fan-shaped pattern beneath the neo-areola. On the right, autologous intercostal nerve grafts were required for tension-free coaptation. Microsurgical coaptation were performed with 9-0 nylon and fibrin sealant. The NAC grafts were secured and covered with negative-pressure dressings. Sensory recovery was assessed using Semmes–Weinstein monofilaments, sharp–dull discrimination, and temperature testing at 3,6 and 12 months post op.

Progressive improvement was observed over 12 months. At 6 months, NAC monofilament thresholds were 3.84 (right) and 3.61 (left), indicating return of protective sensation (≤4.56). Surrounding chest skin demonstrated near-normal sensitivity (2.36–3.22 bilaterally), with corresponding recovery of sharp–dull and temperature perception.

Targeted NAC re-innervation through direct neurotization during mastectomy with free NAC preservation is feasible and was associated with early return of protective sensation. Incorporating peripheral nerve reconstruction principles into NAC-preserving mastectomy may improve functional outcomes. Further studies are needed to assess long-term sensory outcomes, patient-reported benefits, and the potential for hypersensitivity.