Optimising neurorrhaphy position without compromising flap inset in neurotised abdominal based breast reconstruction

Neurotization represents a promising adjunct in the technique of autologous breast reconstruction following mastectomy (1). However, there is a paucity of literature on the actual technique of neurotization and the practicality of selecting donor and recipient nerves when considering pedicle length, perforator position and flap inset plan. We describe the neurotization technique in detail which permits a number of flap inset patterns, with no additional donor site morbidity, and minimal extra surgical time. This includes an ideal technique for the selection and harvest of recipient nerves when considering ipsilateral or contralateral flap transfer with 180-degree and 90-degree flap rotation, respectively. The selection of flap sensory branches is from the 10th, 11th, and 12th intercostal nerves. The selection of the dominant perforators, laterality of the nerves, and craniocaudal positioning need to be factored into the decision-making process to obtain sufficient length to achieve a tension free coaptation. Although nerve conduits have been described to compensate for this, this adds a significant additional cost and may affect the regenerative potential due to additional coaptation sites. The potential donor nerves are the anterior branch of the 3rd intercostal nerve, including the collateral branch along the superior aspect and the lateral cutaneous branch of the 4th intercostal space. We provide a practical discussion and algorithm based on our case series of recipient and donor nerve harvests, as it pertains to breast shaping to achieve a tension-free repair that in turn ensures maximal regeneration across the coaptation site.