Sural Nerve Graft Donor-Site Morbidity in Nipple-Areola Complex Sensory Reinnervation: A Prospective Cohort Study

Background and Objectives: Sural nerve grafts are increasingly used to restore sensation after reconstructive surgery, including nipple-areola complex (NAC) reinnervation following nipple-sparing mastectomy, but donor-site morbidity has not been characterized using combined objective and patient-reported measures. We quantified this morbidity prospectively. Materials and Methods: Ten women who had undergone mastectomy with direct-to-implant reconstruction and NAC reinnervation using a sural nerve graft were assessed by photographic mapping of the donor-site deficit, the FootQ symptom and scar-satisfaction questionnaire (preoperatively, 6 months, 1 year), sural nerve conduction studies (NCS) at 12 months (at 10 months in one patient), and bedside Semmes-Weinstein monofilament and two-point discrimination (2PD) testing. Spearman correlation, Wilcoxon signed-rank, and Friedman tests were used. Results: Harvest length and deficit area were not significantly associated (ρ = -0.588, p = 0.074; bootstrap 95% CI -0.90 to +0.08); with ten patients, the analysis was underpowered and neither establishes nor excludes an association. Deficit area was strikingly variable (coefficient of variation 56%) and did not differ by neurotoxic chemotherapy exposure (five per subgroup). At 1 year, seven of nine patients (78%) had an unrecordable sural sensory action potential, yet monofilament thresholds were normal in every evaluable patient, and 2PD did not differ between limbs. FootQ symptoms increased from the preoperative assessment to 6 months (composite 1.34 to 2.19; p = 0.047), then remained mild and unchanged to 1 year (all p ≥ 0.50); scar satisfaction remained high. Conclusions: Sural graft harvest produces a highly variable and often electrophysiologically persistent donor-site sensory deficit that bedside testing and patient-reported outcomes did not detect at 1 year; because those tests used fixed anatomical sites, the discordance may reflect the territory assessed as much as test sensitivity or peripheral compensation. This small cohort neither establishes nor excludes an association between harvest length and the residual deficit, and the donor site remained clinically well tolerated.