Sensory nerve repair in perforator flaps for autologous breast reconstruction: sensational or senseless?

The spontaneous return of sensation in autologously reconstructed breasts, especially in the Transverse Rectus Abdominis Myocutaneous (TRAM) flap, generated the belief that sensory reinnervation by nerve repair of the flap would be superfluous. This study compares the sensation of the following non-reconstructed and reconstructed breasts: (1) non-operated breasts; (2) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap with sensory nerve repair; (3) flaps of patients reconstructed with the Deep Inferior Epigastric Perforator (DIEP) flap without nerve repair; and (4) flaps of patients reconstructed with the free TRAM flap without nerve repair. Statistically significant lower pressure thresholds were found for DIEP flaps with nerve repair through Semmes-Weinstein testing. More segments of the DIEP flaps with nerve repair reacted to cold, warm and vibratory stimuli compared to flaps without nerve repair. Delayed but satisfactory sensory evoked potential responses were obtained for all reconstructed breasts, but in 46% of TRAM flaps no response could be registered compared with 23% and 0% for DIEP flaps without and with nerve repair, respectively. Questionnaires confirmed the objective data and showed return of erogenous sensation in 30% of the patients with DIEP flaps with nerve repair. Our data reconfirm the possibility of spontaneous return of sensation in pedicled and/or free lower abdominal flaps without nerve repair. Nerve repair in free DIEP flaps nevertheless does restore sensation earlier postoperatively, increases the quality and quantity of sensation in the flap and has a higher chance of providing erogenous sensation. The benefits obtained outweigh the disadvantages of the increased operating time.