Constance Chen, MD, a Plastic and Reconstructive Surgeon talks about resensation after mastectomy.
Interview conducted by Ivanhoe Broadcast News in August 2019.
I want to talk to you a little bit about the resensation option. This is something that’s pretty new. Can you tell me a little bit more about it?
CHEN: Resensation involves reconnecting nerves that have been divided during mastectomy and restoring sensation to a woman’s chest and breasts after a breast reconstruction. So in other words a woman who has had mastectomy either because of breast cancer or as a prophylaxis against breast cancer will otherwise have numb breasts if she has no breast reconstruction or if she has breast reconstruction with implants or breast reconstruction with natural tissue without nerve grafts. Resensation involves taking a nerve graft and reconnecting it to a nerve on the flap or the tissue that is used to restore a patient’s breast and connecting that to a nerve on the chest wall to restore her sensation.
Once that connection is made is it an immediate sense of sensation or does it take time for the sensation to start to come back? Can you walk me through the next process?
CHEN: Sure. It’s not an immediate sense of sensation. The axons regrow, and have to regenerate at a millimeter a day. I usually tell people it takes a year or two. Most patients report that they start feeling sensation in a few months and it can take several years for full sensation to return. Sensation returns at different rates. So the first sensation to return will be deep pressure followed by light pressure followed by pain then temperature.
How complicated is the surgery? Is this something that would take multiple hours to do?
CHEN: Resensation involves dissecting out a nerve on the flap or the tissue that is being transferred to the chest wall. That happens during the course of breast reconstruction anyway so that doesn’t really add any time. When you identify the nerve, I add a nerve connector to that nerve graft to tag the nerve. That takes maybe 15 minutes at most. Then I put the nerve graft into the nerve connector. That can take up to another anywhere from five to 15 minutes. And then a nerve is identified on the chest wall. And the nerve connector is placed on that. That’s another five to 15 minutes. And then the other side of the nerve graft is placed into the nerve connector that’s on the chest wall. So that’s another five to 15 minutes. So it could be anywhere from 20 minutes to an hour. I would say depending on the patient and the skill level of the surgeon.
It may sound like an odd or a simple question but do you have an analogy? Could you explain what it’s like?
CHEN: It’s very similar to an electrician putting wires back together for someone to restore the electrical conductivity of the nerves from one spot to another. Microsurgical breast reconstruction is like plumbing. It’s arteries bringing nutrients to the tissue and veins taking the waste products away from the tissue. So that’s like plumbing. The nerves are like electricity where you reconnect the wires so that the breast can light up.
And you had mentioned connectors and nerve graft. Is there other material that needs to go into this process? Are you adding anything?
CHEN: Nope. It’s just the patient’s own nerves, the nerve graft in between, and the connectors. The nice thing about the nerve graft is it serves like an extension cord. So in years gone by I had done a direct nerve to nerve connection. The problem with that is usually the nerves are not long enough. And it also desensitizes a patient’s donor site and recipient site when you do that. With a nerve graft you’re not tethered by the short length of native nerve. In addition the nerve graft is very well processed and whatnot so it tends to be a better quality than the patient’s native nerve. And it’s just it makes an otherwise complicated procedure much simpler because you have an extension cord for the nerve connectivity.
You’d mentioned that it’s all the patient’s own cells. Is the graft also from the patient’s own cells?
CHEN: The graft is a cadaver graft. So it’s an allograft. In other words it’s from somebody else. And those people are carefully screened and the nerves are carefully processed so all the antigens are removed so that there aren’t any immune issues.
That was my next question. A chance of rejection then or lower chance of rejection because of the process?
CHEN: Well certainly the processing lowers the chance of rejection. The graft itself is 7 centimeters by 1 to 2 millimeters. So it’s literally this big in terms of length. And then one to two millimeters wide. So just like you could have rejection of suture or you know a heart valve or something like that it’s a pretty small piece of material.
Talk to me a little bit about the benefits, Dr. Chen. What kind of a difference does this make in a patient’s and at this point we’re talking about quality of life?
CHEN: Well as a woman if I were to have breast cancer I think for me obviously the most important thing is to be free of disease. After that I would like to live the rest of my life without thinking about it a whole lot and to have all of my parts look and feel pretty much intact. I wouldn’t want to feel self-conscious when I’m in a locker room with people staring at me. I wouldn’t want to feel uncomfortable with something that’s in me that feels foreign. And then I would just want to feel like it was my own tissue that I could feel. The importance of sensation after breast reconstruction, it’s not just things like sexuality and feeling like something is your own, but sensation also has many protective functions such as pain. If you burn yourself you feel that you’ve burned yourself. If someone touches you, you can feel that someone has touched you. Though all of those things are very important, I think to most human beings, not just to women.
Is this covered by insurance?
CHEN: Yes it is. So flap neurotization or restoring sensation to a flap – and a flap is any tissue including skin, fat, bone, muscle, that is transferred from one part of the body to another with its own blood supply. So any flap neurotization should be covered by insurance.
Do you think the word just starting to get out? How new is this?
CHEN: I think the word has barely gotten out. As a surgeon you have to be very cutting edge. But as a patient you have to even know that it exists. And frankly most surgeons don’t even realize that this is something that is possible. Most plastic surgeons are not microsurgeons. Most plastic surgeons do breast reconstruction with implants. Implants block sensation if anything because it’s plastic between your chest wall and your skin so nerves can’t grow through that. So this really can only happen when someone has natural tissue breast reconstruction and it’s best done with microsurgical breast reconstruction. And so you need to find a plastic surgeon who’s a microsurgeon. These are procedures that are done either under magnification or under an operating microscope.
END OF INTERVIEW
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