How to Find the Nerve: Nipple Nerve Allograft Reconstruction for Sensory Restoration in Nipple-Sparing Mastectomy

Loss of nipple-areolar complex (NAC) sensation following nipple-sparing mastectomy (NSM) remains a significant psychosocial, psychosexual, and quality-of-life concern for patients. Sensory neurotization using nerve allografts has emerged as a promising technique for NAC sensation restoration with prior studies demonstrating favorable outcomes, including more than 80% of patients achieving good-to-excellent sensory recovery (Peled et al.); however, reproducible identification and safe dissection of the main NAC sensory nerve during oncologic surgery can be challenging. This video demonstrates a standardized, oncologically safe approach to identifying and dissecting the lateral intercostal sensory breast nerve for NAC reinnervation during NSM.

The video presents a step-by-step operative technique performed during NSM in a patient undergoing immediate implant-based reconstruction with planned sensory restoration. Key steps include standard NSM dissection except the lateral dissection, herniation of the breast parenchyma laterally, identification of the lateral intercostal sensory nerve at the fourth intercostal space approximately 2-cm lateral to the lateral border of the pectoralis minor, and nerve dissection and transection with adequate length for coaptation. This is performed prior to permanent implant placement to facilitate exposure and allow inversion of the nipple-areolar complex. A nerve allograft is subsequently coapted to the NAC by the plastic reconstructive surgeon.

The lateral fourth intercostal sensory nerve was identified and safely dissected without compromising oncologic principles. The technique allowed sufficient nerve length for tension-free allograft coaptation. Immediate direct-to-implant reconstruction was successfully completed, and the patient demonstrated satisfactory early postoperative outcomes, including objective NAC sensation restoration.

This video provides a reproducible and oncologically safe method for identifying and dissecting the lateral NAC sensory intercostal nerve during NSM. Standardization of this technique may facilitate broader adoption of NAC sensory restoration as part of breast reconstruction.