January 12, 2026 • 36 mins
In this episode in the MedStar Health DocTalk series, host Debra Schindler talks with Dr. Meghan Milburn, FACS, director of the Breast Center at MedStar Franklin Square Medical Center, about an important and emerging advancement in breast cancer surgery: breast nerve preservation and resensation after mastectomy.
Dr. Milburn explains why loss of sensation is so common after mastectomy, affecting up to 60–80% of women, and how it can impact far more than physical feeling. Numbness and nerve pain can affect safety, intimacy, emotional wellbeing, and a woman’s sense of connection to her body, even when reconstruction looks cosmetically successful.
The conversation explores how newer surgical techniques allow surgeons to identify, preserve, and reconnect nerves at the time of mastectomy and reconstruction, helping restore sensation to the breast and nipple over time. Dr. Milburn explains how nerve regeneration works, what patients can realistically expect, and why recovery can take months to years, but with meaningful improvements for many women.
Listeners will learn:
· Why numbness and neuropathic pain occur after mastectomy
· How breast neurotization and nerve grafting are performed
· What recovery and rehabilitation look like, including sensory “retraining”
· Who may or may not be a good candidate for these procedures
· How restoring sensation can reduce pain, improve quality of life, and help women feel whole again
Dr. Milburn also shares patient experiences, discusses the emotional and psychological impact of sensation loss, and emphasizes the importance of shared decision-making, asking questions, and considering second opinions. This episode offers hope, education, and empowerment for anyone facing breast cancer surgery, and highlights how advances in surgical care are focusing not just on survival, but on long-term quality of life.
If you're in the Baltimore area and would like to schedule an appointment to discuss breast neurotization surgery, call 443-777-6500. Or to make an appointment in the DC region at MedStar Washington Hospital Center, call 202-877-7937. You can also see a specialist for nerve resensation at MedStar Georgetown University Hospital in DC. Call 202-295-0560.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:02):
Comprehensive, relevant,and insightful conversations about health
and medicine happen here when MedStarHealth, DocTalk.
These are real conversations withphysician experts from around the largest
healthcare system in the Maryland,DC region. For many women,
the decision to undergo a mastectomyor breast reconstruction brings
(00:23):
understandable fear, worriesabout symmetry, shape, size,
scars, where unnatural appearanceare normal and commonly expressed.
Will I recognize myown body in the mirror?
It often happens that themost life-altering change
can't see at all. The permanentloss of breast and nipple sensation.
(00:43):
Numbness after surgery has longbeen dismissed as unavoidable,
but losing the ability tofeel touch, temperature,
or even pain can have profound emotional,physical, and intimate consequences.
The good news, there is new hope.
Surgeons are now using advancednerve preservation and uritization or
(01:04):
resensation to reconnect sensorynerves and restore feeling to
reconstructed breasts.
I'm happy to welcome Dr. Meghan Milburn,director of the Breast Center at MedStar
Franklin Square Medical Center inBaltimore and a leader in this emerging
field about how these innovations aretransforming recovery and empowering
women to feel whole again.
(01:25):
I'm your host, Deborah Schindler. Dr.
Milburn, thank you so much for being here.
Hi, thanks for havingme. Pleasure to be here.
Explain what breastreconstruction typically involves
that would impact nerve sensation.
So typically during a mastectomy,most of the sensory nerves to the breast
and the nipple are cut and they'retransacted for oncologic
(01:46):
purposes. With reconstruction,even though we can preserve the nipple
and the breast skin and often have theplastic surgeon place an implant or an
autologous flap using a patient's owntissue and get a very normal,
appearing or aesthetically pleasingappearance to the reconstructed breast,
(02:08):
it is not normal as far as sensation.
This can be difficult from a psychologicaland emotional and mental aspect
for the patients because they're oftenfacing a hidden loss that they're not
aware of, this loss of sensation.
And this can really leadto functional impairment.
It's a loss of protectivesensation, so sunburn, heat,
(02:30):
just proprioception, knowingwhere your body is in space,
that can all be lost or diminished,as well as erogenous sensations,
but also being able to feel the hugfrom your child or from your partner as
well.
So these are all very important.
So are we talking about sensation justin the nipple area or the whole breast?
(02:50):
So the nipple as wellas the remaining breast.
And the studies have shown that mostpatients are left with little to no
sensation after mastectomy.
And not only do they have diminishedsensation or no sensation at times,
so numbness, but they can also havepain. And this can be neuropathic pain,
this can be burning,tingling, painful zaps.
(03:13):
The new procedures that we're doing,or I should say new to breast surgery,
it's actually been a well establishedsurgery for nerves that have been
transected in other parts of the body,but this decreases the chances of
post-mastectomy pain syndrome and alsohelps restore sensation.
So I was very surprised to learn in myresearch that up to 60 to 80% of women
(03:37):
experience long-term numbnessafter surgery. Does it come back?
Some it will. Most patientswill regain some sensation.
Usually it's more towardsthe perimeters of the breast.
That's because the breast has multiplesites of innervation and also the
skin has innervation as well.
(03:58):
But what we tell our nipplesparing mastectomy patients,
typically the nipple and the areola andthe central aspect of the breast will be
numb following the surgery.
Okay. Explain that nipple sparing surgery.
So with a nipple sparing mastectomy,oftentimes I will make a hidden
incision underneath the breast,along the bra line, and then I
(04:19):
surgically dissect under the skin.
There's a plane between the breasttissue and the subcutaneous tissue of the
skin all the way around the breast,including under the nipple and the areola,
and then remove the breast off thepectoralis muscle, remove all of that.
And then I work very closelywith plastic surgeons.
(04:40):
So the plastic surgeon will come in onceI'm finished and do the reconstruction,
whether that's an implant or usingthe patient's own tissue with a free
flap to reconstruct.
Are the nerves impacted differentlybased on how the reconstruction is
performed?
Is a deep flap or the implants going tohave a different impact on that nerve
(05:01):
sensation?
So the nerves are mostlyimpacted by the mastectomy.
So when the breast surgeonperforms the mastectomy,
oftentimes the lateralintercostal nerves are transected
as we dissect through the tissue. And-.
What is that? A lateral ...
So what that means is these are the nervescoming from between the ribs and the
(05:25):
rib muscles off to the sides,and then they go from the edges
of the chest wall and the ribsinto the breast and then up into the
nipple and that provides sensation.
So previously during thecourse of the mastectomy,
these nerves are cut.
Honestly,I thought that when we were going to
talk about breast neuritization orregeneration of the nerves,
(05:48):
it was around the nipple.
I thought that's where the loss was forsensation where women would feel it or
be impacted by most in their life.
So it is. It is. And again, when youcut under the nipple and the areola,
you're also transecting the other endof the nerves that go to the nipple.
(06:09):
So the nerves run from the intercostalmuscles at the edge of the chest
wall where the ribs are through andaround the breast up towards the nipple.
But with newer techniques, we'reon the lookout for these nerves,
especially off to the side.
So when I do the procedure,when I do the mastectomy, I am aware
of this. And when I get to that area,the anatomic region where the nerves are,
(06:34):
I'm very careful and I dissectthrough looking for the nerves.
And once I identify a nerve,sometimes it could be more than one,
I preserve that as much aspossible and then I transect it.
We try to get as much length of thatnerve as possible to save for the
microvascular plastic surgeon tocome in and do the nerve grafting. So
(06:57):
this is very important forme to preserve the nerves,
finish the mastectomy, removeall of the breast tissue.
And then when the plastic surgeoncomes in, he is able to take,
or she is able to take the nervestump that's there and take a
graft and sew the nerve graft tothe nerve and then attach the other side
(07:19):
of the graft to the back of the nipple.
And then over time,as the patient's nerve
actually regenerates andthe nipple, and this is what's going
to provide re-sensation to the breast.
Will it feel normal for the woman?
Because I know that I have hadnerves cut either on my hand,
(07:43):
for example, and I can touch anarea of my thumb and it is not-.
Normal.
... where the cut was. It'sdifferent. It's a different sensation.
So I've wondered about that after thebreast is cut and then you reestablish
these nerves, is it goingto be like it was before?
Probably not.
(08:03):
And we are certainly not promising thatthis is Back to the way you were before,
but we know that nerves grow about amillimeter a day or an inch a month.
And over time,with the nerve preservation
and the resensation,it should significantly improve
sensation to the breast.
(08:23):
Whereas before, or without this procedure,most of the chest and the breast is numb.
Some of the studies are showing that about75% of women had excellent sensation
at 12 months after the procedureto very light touch. And
(08:44):
this is extremely important.
None of the patients in these studieshave experienced neuropathic pain or
neuromas within the study period,and that's not the case in patients
who don't have the procedure.
I also want to emphasize that becausenerves grow a millimeter a day,
(09:05):
this is a longer process. Sofrom the studies, at a minimum,
patients should begin to notice someimprovement in sensation at about the six
month mark.
And we know from studies with breastresensation,
as well as other studies looking atnerves in other part of the body,
it's that six month to 12 monthwindow where you see the most gains in
(09:27):
improvement in sensation.
But breast cancer patients arealso seeing continued gains,
although smaller amount upto 24 months, so two years.
It is a slow process,but it's very exciting where
previously patients hadnumbness and they may have some
return of more peripheral sensation,but still pretty significant
numbness throughout the breast,as well as pain.
(09:54):
Can you explain the difference betweennumbness and nerve pain after surgery?
So numbness is really lack of sensation,diminished light touch versus the
tingling is more of paresthesias.
That's that tingling feelingwhen your foot or your arm falls
asleep. That's all nerve pain.
(10:15):
And for some people, there canalso be a burning quality as well,
or even a sharp,very significant neuropathic pain.
I guess they come back, howmany weeks after a mastectomy?
So usually I see patients postoperativelyone to two weeks after surgery,
and then oftentimes we seethem at three or six months,
(10:38):
and then about every six months,continuing on just to monitor them for
their cancer journey and survivorship.
Oftentimes, the plastic surgeonswill see them more frequently.
They are doing testing and follow up inthe office and monitoring that as well.
There's some little filaments or lighttouch that you can do just to monitor the
(10:59):
different quadrants of the breast,as well as the nipple and the areola.
One of the other important things toknow is that patients really need to take
an active role in this process.
So just like so many otherinjuries and challenges,
whether it's stroke rehabor just rehabbing your knee
(11:19):
patients really benefit bydoing rehabilitation and
maintaining those cortical pathwaysfrom the breast to the brain. We
recommend they do this one to twotimes a day as much as possible,
and that really helps train the brain andmap everything out and really maintain
those current cortical connections.
(11:41):
What is that a cortical connection ora cortical pathway and how do women
help with that?
So what that is,is that's just your brain's knowledge
of what the breasts feel like,whether it's to light touch
or vibration or heat or cold.
And so even if the breasts are numb,by continuing to stimulate
(12:01):
that area with ice,a Q-tip, even a small brush for vibration,
you're still using thenerves that are there,
trying to get some signals through andmaking sure you don't lose the pathways
and the memory that is in the brain.
So similar to stroke rehab as well.
(12:24):
So you're literally trying to feel thesensation in your breast to exercise
those nerves?
Exactly. Yeah. It's all about exercise.
That's a huge component of mypractice is really encouraging
patients in their prehabilitation,the rehabilitation, exercise.
We know it's crucial tobreast cancer survival,
(12:46):
decreasing recurrence, also helpingdecrease the risk of breast cancer.
And then it also makes such animprovement in their functional outcomes,
no matter what type of breastcancer surgery they've had,
whether it's lumpectomy withradiation or mastectomy,
a lot of times you get scar tissue.
So I strongly encourage mypatients to do their exercises,
(13:08):
their stretches, as well asstrength training and cardio.
All of that is extremely helpful forthem to heal on their cancer journey.
Let me understand, you go in, the patientgoes in for her scheduled mastectomy,
the reconstruction is done right after,and then the nerve regeneration surgery
is performed all in the same day.
(13:28):
Right. So we like to thinkof it as one stop shopping.
So we work very closely asa team, the breast surgeons,
as well as the plastic surgeons,and we all work in conjunction.
So as I'm doing the mastectomy, I'mlooking for and preserving the nerves.
Once the cancer operation is finished,I am essentially tag teaming
with the plastic surgeon.
(13:50):
So then the plastic surgeon cancome in, do the reconstruction.
And during the courseof the reconstruction,
he is also doing the nervereconstruction as well.
Nerve resensitizing in thebreast is relatively new.
So what I'm understanding thenis before a few years ago maybe
(14:11):
a woman would get a mastectomy and wasthere any effort at that time to preserve
that nerve or- So typically-I mentioned before,
it was just thought of as an unavoidable.
Right. So typically, no. Okay.
Typically with the mastectomies,it was just a part of the surgery and
it was explained to patients that theywould have some numbness.
(14:32):
I think many patientsare unprepared for this
aspect. And again, like so many things,I think until you truly experienced it,
you don't understand it.
We know that women often feel depressedor have anxiety about their body's
response to touch.
There's a lot of grief that goes intowith a breast cancer diagnosis as well as
(14:54):
subsequent treatments.
And oftentimes women report that theyfeel like their body is no longer their
own and have a disconnectwith their breast,
even though when they look in the mirror,they have an excellent cosmetic outcome,
but it's that sensationand the loss of touch and
feeling, as well as the potentialfor pain that really impacts them.
(15:18):
It has to be a huge psychologicaland emotional adjustment for sure to
lose that sensation.
Can women who have had the mastectomybefore nerve preservation was being
considered come back andhave that surgery still years
later?
So that's a great question,and this is something that
is under investigation.
(15:42):
The chances of findingthe nerve oftentimes
and having a functional outcome are low.
I know some plastic surgeonsare willing to try it,
especially if the patient has togo back for additional surgery for
reconstruction.
Oftentimes there's some additionalsurgeries where there is some adjustment
(16:05):
to the reconstructed breast.
Some plastic surgeons feelthat if they're in the OR,
they will attempt to take a look and seeif there's any nerve that is still able
to be preserved and thenreconstructed. But generally, no.
The nerves have already been transectedand they're either difficult to
identify or they're just too short. Again,because the nerves grow slowly,
(16:31):
but there's only a certain lengththat they can grow. Generally,
it's about five to seven centimetersthat we use as the graft,
something much longer than that.
And when you say graft,that means you're getting that piece
of nerve from somewhere else? Correct.
Correct. Where do you take that from?
So you can use the body's ownnerves that you can harvest. Again,
(16:53):
you're then treating a new area ofnumbness when you're taking the nerve.
Oftentimes,if the patient is having autologous
reconstruction with their own tissue,such as a deep flap where they're taking
skin and subcutaneous fat from thetummy and using that to
reconstruct the breast,sometimes the plastic surgeon can find
a nerve in there and use that as thereconstruction, or there are
(17:15):
commercially available nerve grafts.
Artificial nerve graftsor maybe cadaver parts?
Cadaveric nerve grafts.
And that has been one of theissues in the last couple of years
where just trying to get insurancereimbursement for these cadaveric
(17:36):
grafts and for the procedure itself,that's certainly been a
stumbling block for moresurgeons and more
institutions to offer this.
Let's say money isn't an option. It couldwork. It could actually be effective.
That is the standard.
That's what we typically.
Use for these.
Yeah. We use the.
Ketavert block.That's pretty amazing.
(17:56):
Oh.
It is. It really speaks to the importanceof us having sensation in our breasts,
doesn't it? It.
Does. Just like any other part ofthe body, it's not just erogenous,
it's just not the need forsensation, but it's protective.
It decreases the risk ofpain and it's functional.
How long does it take toregenerate the nerves?
How long is that portion of the surgery?
(18:17):
So that portion of thesurgery really depends.
It adds about 15 to 30 minutesto my portion of the case,
so not too, too much longer.
And then if we have a great nerve,the plastic surgeon is very happy with.
You can do that pretty quickly, again,15 to 30 minutes at most. If
we're using a cataveric graft,it's two small sutures to
(18:39):
connect the nerve with thenerve graft, and then it's attached
to the backside of the nipple.
So not too, too long.
Some people have beautifulnerves and absolutely perfect.
Other people have very tiny, small, kindof wimpy nerves that if we see that,
(19:00):
then we want to look forsome additional nerves,
see if there's a little bit bettercandidate in order to do this.
And there's some womenthat for whatever reason,
whether it's anatomy or just the locationof the cancer or we just can't find
it. Even if we plan to do it, there'ssome women where it's unsuccessful.
(19:20):
It sounds like you're talking aboutit's just one nerve that you're working
on per breast. Is there-.
Generally, it's just one. Again,depending on the anatomy and whether
the patient is having an implant or anautologous flap,
sometimes the plastic surgeonwill reconnect more than one,
but the goal is to do one perside. And that would be enough?
(19:45):
It seems like there's a lotof nerves in your breasts.
Yeah. Yeah. So again, it's not perfect,but it's very exciting. Yeah.
It's improved.
It is significantly.
What kind of feedback doyou get from your patients?
If someone's listening to this nowand they're considering or facing a
mastectomy or reconstructivesurgery, or even implants,
(20:06):
maybe they didn't have breast cancerand they have implants put in.
Does that affect your nerves?
So that's a great question. I think ifsomeone is having a breast augmentation,
depending on where the implant is placed,there is a possible risk of
nerve injury and decreasednipple sensation or nipple numbness.
(20:27):
It really depends on the surgeonand the anatomy of the patient.
Everyone's different.
So someone having areduction, for example,
wouldn't necessarily need a nervepreservation procedure and then a nerve
regeneration procedure.
So usually not for that. Usuallywith the breast reductions,
(20:48):
oftentimes patients will have numbnessalong the bottom of the breast,
sometimes to the nipple, but muchof that is generally preserved.
If they've had that and then down theline they go on to have a masttectomy,
usually we can still preserve thenerves because they're lateral.
They're off to the side, atthe side of the chest wall.
Maybe you can share a patient experiencewho's had this procedure and share with
(21:11):
us what the feedback's been.
Sure.
So one of the most surprising feedbackthat I heard from a patient was
that at about six months she feltlike her breasts were a part of
her. And she said prior to this withthe mastectomy and the reconstruction,
with the numbness and the changes,she just didn't feel or mentally
(21:38):
feel like these were her breasts. Butshe said at about six months or so,
she started noticing some sensation andfeeling and really felt like then they
became a part of her body.
And that was amazingto hear because again,
you know all of thenerves are regenerating,
not just the ones that were reconnecting,but a lot of the smaller branches of
(21:58):
the nerves under the skin and from themuscle,
everything is regenerating andgrowing and waking up and it was so
amazing to hear that.
And.
Just see how we'd helped her.
Right.
Until you told me that story when Iread that women felt very detached from
their breasts after areconstruction or mastectomy,
(22:19):
I thought it was more of anemotional detachment that they were
experiencing,but it sounds like it's more like when
your foot is asleep and you're walking onit and you don't feel your foot.
I think it's a combination andI think the two go hand in hand.
It's that emotional and psychologicalaspect as well as the feeling.
(22:40):
The.
Numbness, the absence of sensation.
I'm trying to imagine what that islike and appreciate the ability to
restore that. Do you find it tobe more successful than not? So.
I think it's early. Again,we have been limited with being able to
do these procedures with the insurancereimbursement,
(23:02):
which is one of the reasons why I thinkat many places it hasn't taken off.
But again,it's two years before you're really
going to see the full impact.
And some patients are even reporting,I've heard from other surgeons that their
patients are saying even four or fiveyears later, they're still
continuing to have some improvement,which I think gives a
lot of hope for this.
(23:24):
Do you forewarn women who are facinga surgery or scheduled for a surgery
that the numbness and the lossof sensation is going to follow?
Always.
And that's something Ihad always counseled women
list of risks and possible complicationswhen we're talking about the surgery.
But I don't think I was aware about howimpactful this was,
(23:49):
especially with the emotional aspectand really the functional aspect as well
with this. And just being in practiceand seeing patients come back doing well,
I also think that oftentimespatients are not telling us this
and whether that's sideeffects from chemotherapy or
(24:10):
menopausal or sexual symptomsrelated to their treatment,
I think oftentimes patients are notgoing to volunteer that information.
It's really up to us as cliniciansto ask them very specific questions.
And that's one thing that I've learnedover the years. And I'm happy to say
that as part of survivorship,being focused on the quality
(24:30):
of life is just as important astreating the cancer itself.
And the NCCN guidelines have a lot ofguidance on how to manage
a slew of side effectsof treatment, and this is just one more
tool in our toolbox to help with that.
And when you have thoseconversations with your patients,
(24:53):
are you suggesting that this nervepreservation might be necessary or
is necessary and thatthere are steps to take to
restore that sensation andI guess get them to opt in
or do they ask for it?
So I've only had one patientrecently who's asked for it,
(25:15):
but I think-.
Everybody else,you're telling them that this could happen
and we would like to do this surgery?
It could. We're starting to. I mean, Ithink too, women are so educated now.
There's a lot of information insupport groups and social media groups.
I think the word is going to get outthere with the potential benefits for this
procedure. Now that I'm here at MedStar,I've talked to my partner and
(25:36):
the plastic surgeon as well,and everyone is on the same page where
we really feel like this should be thedefault that offering-
Routine. Routine. Routine,that it should be just a part of all
of the nipple sparing masttectomies andpotentially even some of the skin
sparing mastectomies as well.
I think that's important to mention,and especially since women don't know
this could happen or might happen,or apparently will happen, that they
(25:59):
will lose sensation in their breasts,that it just becomes a normal part
of the reconstructive process.
What should women ask for?
So I think it's most important to talkto your surgeon and the rest of your
team, your medical oncologist,and talk to them about your cancer,
(26:21):
the recommended treatment plans,and then just ask questions
because most patients have choicesfor their treatment.
And there are many different routes orpathways that we can take to get you to
the same endpoint. For example,many women are candidates for
lumpectomies followed by radiation or amasttectomy and generally
(26:42):
survival is exactly the same,but it's really about talking
about what's recommended,individualizing the treatment plan for
each specific patient, their cancer,but also their anatomy, their lifestyle,
what's important to themas far as quality of life.
And these are the things that I reallyenjoy talking to my patients about and
(27:04):
working together as a team. I mean,it's all about shared decision making.
Who wouldn't be someone that youwould suggest we try this with?
What patients might ask for would you say,"You're not a good candidate
for this? " I'm sorry.
That's a great question.
There's certainly anatomiclimitations to the nerve grafts.
(27:26):
But you wouldn't know thatuntil you're in there, right?
Well, for women that are havingimplant-based reconstructions,
we know the nerve has to go up andaround and over the implant to get
from that nerve stump bythe ribs to the nipple.
It's just a matter of distance. So ifsomeone wanted a very large implant,
the nerve would not be ableto transverse that far,
(27:48):
so they would not be good candidates.
You would know that in advance. Now,what about the women whose
nipples could not be spared,they're reconstructed or tattooed?
I've even seen that there are surgeriesto create a perky nipple. Sure,
sure. Could they get theirsensations installed?
Yeah. Yeah. And those are incredible.
(28:10):
The 3D nipple tattoos are gamechangers. I mean, they're so realistic.
I think they bring a lot ofclosure and completeness to the
reconstruction. And again, it's all aboutthat emotional aspect and wellbeing.
We have also talked about performingthis procedure in the skinsbury
mastectomies where the nippleand the areola are removed,
(28:32):
but if we can still preservethe nerve and have the
plastic surgeon use the nerve graft,that can still provide significant
sensation to the remaining chest. Again,it's not always about the nipple itself,
it's bringing sensation back to thereconstructed breast and the chest.
And then also very important forfunction as well as helping decrease the
(28:57):
chances of neuroma formationor neuropathic pain.
Okay.
So what I'm hearing is that you canprobably restore some breast sensation,
but maybe not to the tattooed nipple.
Right, right. Okay. We're early on.
We are. We are. This is early.
And again, the tattooed nipple isnot a nipple, but it's still skin.
(29:17):
So if we can get that nervegraft as close as possible,
right behind the tattooed nipple,we would be providing sensation to that
skin and the anterior aspect of thebreast.
Can restoring sensation improve thepsychological wellbeing and sexual
health for women?
I think it does.
(29:38):
Do you get feedback aboutthat from your patients?
So a lot of it is anxietyand depression and grief,
disconnect with their body and resentment,anger that women often experience as
they go through treatment and havethe side effects and the
changes to their body.
And oftentimes there's a changein relationship Such that many
(30:01):
women are caregivers and now they'rethe ones having to be taken care of.
So that certainly changes the dynamic.
Many of my patients are young orin their 40s or 50s and they're in
the midst of everything. They'reraising kids, they're busy at work.
Oftentimes they're takingcare of aging parents.
And now they have been just punchedin the gut with this diagnosis and
(30:25):
treatment and all of the timeand financial impacts of a
cancer diagnosis and treatment plusthe side effects. They don't feel well.
And then often there arelasting side effects.
And whether that's peripheralneuropathy, numbness in the breast,
menopausal symptoms, hot flashes,night sweats, vaginal atrophy,
(30:47):
decreased or no libido,this significantly affects a
woman from where she was. And yes,I mean, I think anything that
then helps restore wholeness andimproves psychological and
emotional wellbeing is so crucial.
It helps with their relationship withtheir partner as well as their self-esteem
(31:08):
and.
Sense of self.
What is it most important for women toknow about breast neurotization or nipple
resensation? What's the takeaway?
Because we don't want people to have anymisconceptions about what is available
and what is not, right? But we want togive them hope. I want to give them hope.
Right. And I think that is the mostimportant takeaway from this is that
(31:30):
there is hope. Breastcancer is devastating,
but there is so much positive news,especially the last couple
of years. And going forward,we've come a long way just from a breast
surgical and oncologic perspectivein that for a long time,
(31:51):
reconstruction was minimal or notoffered. For the last couple of decades,
we know that nipple sparingmastectomies are safe from a cancer
standpoint and we've been offering that.
We're also decreasing thelymph node surgery as much as
possible to help decrease the risk oflymphedema and also doing some things
(32:11):
before and after surgery to helptreat that or minimize the risk.
Same thing with chemotherapy.
We're really focused on moretargeted systemic therapies.
We have improved radiation planningtechniques where we spare healthy tissue.
And again, less invasive surgerywith a focus on obviously cancer
(32:32):
treatment is number one priority,but we know that the cosmetic
outcome and the functional outcomeare such a key component of that as well.
I think it's important for patients toask their surgeons about what
types of procedures they do,what they recommend, and then
consider getting a second opinion.
(32:54):
I encourage all of my patients to geta second opinion with a breast cancer
diagnosis, just becauseit is often overwhelming.
And I want to make sure that they feelcomfortable with their treatment team.
I never, never hold it against anyoneif they want to get a second opinion.
We tout that all the time, getting asecond opinion. You mentioned neuromas.
(33:17):
And I wanted to ask about that becauseneuromas have been described to me as a
bundle of angry nervesthat want to regenerate,
but have nowhere to gobecause they've been cut.
And I know about thatbecause of our hand surgeons.
Do women experience that in the breastafter surgery? And can you treat that?
Absolutely.
And that's why it is so importantto start identifying and preserving
(33:39):
these nerves, because that canhappen. Nerves have a function.
They want to grow, theywant to do their job.
And when you cut the nerves duringthe course of a cancer operation,
you're exactly right.
You wind up with an angry ballof nerves that don't have a true
sensation function, sothey're causing pain.
Even if we're not doing nerve grafting,one of the things that I can do during
(34:01):
the course of the mastectomy is I canidentify the nerve, transect it,
and then I can tuck it into the muscle andkeep it happy there. And that decreases
the risk of neuroma formation and pain.
They'll still have numbness sincewe're not doing nerve grafting,
(34:21):
but it can significantly decreasethe risk of pain from that nerve.
We're not truly doing anything new in thebreast that hasn't been done elsewhere
in the body,whether it's on the hands or the
extremities of the face. Nerve grafting isnot new. That is well established.
What is newer is doing that in the breastand showing that there's a need for
(34:42):
it, that it improves sensation,it improves pain outcomes,
and really making this a seamlessoperation. That's what's new.
Protective sensation isa big component of this,
but it's also just the intimacy inhugging someone and feeling that.
Restoring sensation isn't cosmetic.
(35:03):
It's about restoring identityand normalcy, intimacy,
safety, and long-term emotional wellbeing.
I'm certain this will become standardof care with enough time because there's
so many benefits.
Thank you for sharing your expertisewith us here on MedStar Health Doc Talk.
Thank you so much for having me.
(35:23):
My pleasure.
If you're in the Baltimore area andwould like to schedule an appointment to
discuss breast neurotization surgery, call443-777-6500. Thank you. Thank you. Sure.
Or to make an appointment in the DCregion at MedStar Washington Hospital
Center, call 202-877-7937.
(35:47):
You can also see a specialist fornerve resensation at MedStar Georgetown
University Hospital in DC. Call202-295-0560.
To comment on this podcast or recommenda topic for another episode of Doc Talk,
send an email to doctalk@medstar.net.
Comprehensive, relevant,and insightful conversations about health
and medicine happen here when MedStarHealth, DocTalk.
These are real conversations withphysician experts from around the largest
healthcare system in the Maryland,DC region. For many women,
the decision to undergo a mastectomyor breast reconstruction brings
(00:23):
understandable fear, worriesabout symmetry, shape, size,
scars, where unnatural appearanceare normal and commonly expressed.
Will I recognize myown body in the mirror?
It often happens that themost life-altering change
can't see at all. The permanentloss of breast and nipple sensation.
(00:43):
Numbness after surgery has longbeen dismissed as unavoidable,
but losing the ability tofeel touch, temperature,
or even pain can have profound emotional,physical, and intimate consequences.
The good news, there is new hope.
Surgeons are now using advancednerve preservation and uritization or
(01:04):
resensation to reconnect sensorynerves and restore feeling to
reconstructed breasts.
I'm happy to welcome Dr. Meghan Milburn,director of the Breast Center at MedStar
Franklin Square Medical Center inBaltimore and a leader in this emerging
field about how these innovations aretransforming recovery and empowering
women to feel whole again.
(01:25):
I'm your host, Deborah Schindler. Dr.
Milburn, thank you so much for being here.
Hi, thanks for havingme. Pleasure to be here.
Explain what breastreconstruction typically involves
that would impact nerve sensation.
So typically during a mastectomy,most of the sensory nerves to the breast
and the nipple are cut and they'retransacted for oncologic
(01:46):
purposes. With reconstruction,even though we can preserve the nipple
and the breast skin and often have theplastic surgeon place an implant or an
autologous flap using a patient's owntissue and get a very normal,
appearing or aesthetically pleasingappearance to the reconstructed breast,
(02:08):
it is not normal as far as sensation.
This can be difficult from a psychologicaland emotional and mental aspect
for the patients because they're oftenfacing a hidden loss that they're not
aware of, this loss of sensation.
And this can really leadto functional impairment.
It's a loss of protectivesensation, so sunburn, heat,
(02:30):
just proprioception, knowingwhere your body is in space,
that can all be lost or diminished,as well as erogenous sensations,
but also being able to feel the hugfrom your child or from your partner as
well.
So these are all very important.
So are we talking about sensation justin the nipple area or the whole breast?
(02:50):
So the nipple as wellas the remaining breast.
And the studies have shown that mostpatients are left with little to no
sensation after mastectomy.
And not only do they have diminishedsensation or no sensation at times,
so numbness, but they can also havepain. And this can be neuropathic pain,
this can be burning,tingling, painful zaps.
(03:13):
The new procedures that we're doing,or I should say new to breast surgery,
it's actually been a well establishedsurgery for nerves that have been
transected in other parts of the body,but this decreases the chances of
post-mastectomy pain syndrome and alsohelps restore sensation.
So I was very surprised to learn in myresearch that up to 60 to 80% of women
(03:37):
experience long-term numbnessafter surgery. Does it come back?
Some it will. Most patientswill regain some sensation.
Usually it's more towardsthe perimeters of the breast.
That's because the breast has multiplesites of innervation and also the
skin has innervation as well.
(03:58):
But what we tell our nipplesparing mastectomy patients,
typically the nipple and the areola andthe central aspect of the breast will be
numb following the surgery.
Okay. Explain that nipple sparing surgery.
So with a nipple sparing mastectomy,oftentimes I will make a hidden
incision underneath the breast,along the bra line, and then I
(04:19):
surgically dissect under the skin.
There's a plane between the breasttissue and the subcutaneous tissue of the
skin all the way around the breast,including under the nipple and the areola,
and then remove the breast off thepectoralis muscle, remove all of that.
And then I work very closelywith plastic surgeons.
(04:40):
So the plastic surgeon will come in onceI'm finished and do the reconstruction,
whether that's an implant or usingthe patient's own tissue with a free
flap to reconstruct.
Are the nerves impacted differentlybased on how the reconstruction is
performed?
Is a deep flap or the implants going tohave a different impact on that nerve
(05:01):
sensation?
So the nerves are mostlyimpacted by the mastectomy.
So when the breast surgeonperforms the mastectomy,
oftentimes the lateralintercostal nerves are transected
as we dissect through the tissue. And-.
What is that? A lateral ...
So what that means is these are the nervescoming from between the ribs and the
(05:25):
rib muscles off to the sides,and then they go from the edges
of the chest wall and the ribsinto the breast and then up into the
nipple and that provides sensation.
So previously during thecourse of the mastectomy,
these nerves are cut.
Honestly,I thought that when we were going to
talk about breast neuritization orregeneration of the nerves,
(05:48):
it was around the nipple.
I thought that's where the loss was forsensation where women would feel it or
be impacted by most in their life.
So it is. It is. And again, when youcut under the nipple and the areola,
you're also transecting the other endof the nerves that go to the nipple.
(06:09):
So the nerves run from the intercostalmuscles at the edge of the chest
wall where the ribs are through andaround the breast up towards the nipple.
But with newer techniques, we'reon the lookout for these nerves,
especially off to the side.
So when I do the procedure,when I do the mastectomy, I am aware
of this. And when I get to that area,the anatomic region where the nerves are,
(06:34):
I'm very careful and I dissectthrough looking for the nerves.
And once I identify a nerve,sometimes it could be more than one,
I preserve that as much aspossible and then I transect it.
We try to get as much length of thatnerve as possible to save for the
microvascular plastic surgeon tocome in and do the nerve grafting. So
(06:57):
this is very important forme to preserve the nerves,
finish the mastectomy, removeall of the breast tissue.
And then when the plastic surgeoncomes in, he is able to take,
or she is able to take the nervestump that's there and take a
graft and sew the nerve graft tothe nerve and then attach the other side
(07:19):
of the graft to the back of the nipple.
And then over time,as the patient's nerve
actually regenerates andthe nipple, and this is what's going
to provide re-sensation to the breast.
Will it feel normal for the woman?
Because I know that I have hadnerves cut either on my hand,
(07:43):
for example, and I can touch anarea of my thumb and it is not-.
Normal.
... where the cut was. It'sdifferent. It's a different sensation.
So I've wondered about that after thebreast is cut and then you reestablish
these nerves, is it goingto be like it was before?
Probably not.
(08:03):
And we are certainly not promising thatthis is Back to the way you were before,
but we know that nerves grow about amillimeter a day or an inch a month.
And over time,with the nerve preservation
and the resensation,it should significantly improve
sensation to the breast.
(08:23):
Whereas before, or without this procedure,most of the chest and the breast is numb.
Some of the studies are showing that about75% of women had excellent sensation
at 12 months after the procedureto very light touch. And
(08:44):
this is extremely important.
None of the patients in these studieshave experienced neuropathic pain or
neuromas within the study period,and that's not the case in patients
who don't have the procedure.
I also want to emphasize that becausenerves grow a millimeter a day,
(09:05):
this is a longer process. Sofrom the studies, at a minimum,
patients should begin to notice someimprovement in sensation at about the six
month mark.
And we know from studies with breastresensation,
as well as other studies looking atnerves in other part of the body,
it's that six month to 12 monthwindow where you see the most gains in
(09:27):
improvement in sensation.
But breast cancer patients arealso seeing continued gains,
although smaller amount upto 24 months, so two years.
It is a slow process,but it's very exciting where
previously patients hadnumbness and they may have some
return of more peripheral sensation,but still pretty significant
numbness throughout the breast,as well as pain.
(09:54):
Can you explain the difference betweennumbness and nerve pain after surgery?
So numbness is really lack of sensation,diminished light touch versus the
tingling is more of paresthesias.
That's that tingling feelingwhen your foot or your arm falls
asleep. That's all nerve pain.
(10:15):
And for some people, there canalso be a burning quality as well,
or even a sharp,very significant neuropathic pain.
I guess they come back, howmany weeks after a mastectomy?
So usually I see patients postoperativelyone to two weeks after surgery,
and then oftentimes we seethem at three or six months,
(10:38):
and then about every six months,continuing on just to monitor them for
their cancer journey and survivorship.
Oftentimes, the plastic surgeonswill see them more frequently.
They are doing testing and follow up inthe office and monitoring that as well.
There's some little filaments or lighttouch that you can do just to monitor the
(10:59):
different quadrants of the breast,as well as the nipple and the areola.
One of the other important things toknow is that patients really need to take
an active role in this process.
So just like so many otherinjuries and challenges,
whether it's stroke rehabor just rehabbing your knee
(11:19):
patients really benefit bydoing rehabilitation and
maintaining those cortical pathwaysfrom the breast to the brain. We
recommend they do this one to twotimes a day as much as possible,
and that really helps train the brain andmap everything out and really maintain
those current cortical connections.
(11:41):
What is that a cortical connection ora cortical pathway and how do women
help with that?
So what that is,is that's just your brain's knowledge
of what the breasts feel like,whether it's to light touch
or vibration or heat or cold.
And so even if the breasts are numb,by continuing to stimulate
(12:01):
that area with ice,a Q-tip, even a small brush for vibration,
you're still using thenerves that are there,
trying to get some signals through andmaking sure you don't lose the pathways
and the memory that is in the brain.
So similar to stroke rehab as well.
(12:24):
So you're literally trying to feel thesensation in your breast to exercise
those nerves?
Exactly. Yeah. It's all about exercise.
That's a huge component of mypractice is really encouraging
patients in their prehabilitation,the rehabilitation, exercise.
We know it's crucial tobreast cancer survival,
(12:46):
decreasing recurrence, also helpingdecrease the risk of breast cancer.
And then it also makes such animprovement in their functional outcomes,
no matter what type of breastcancer surgery they've had,
whether it's lumpectomy withradiation or mastectomy,
a lot of times you get scar tissue.
So I strongly encourage mypatients to do their exercises,
(13:08):
their stretches, as well asstrength training and cardio.
All of that is extremely helpful forthem to heal on their cancer journey.
Let me understand, you go in, the patientgoes in for her scheduled mastectomy,
the reconstruction is done right after,and then the nerve regeneration surgery
is performed all in the same day.
(13:28):
Right. So we like to thinkof it as one stop shopping.
So we work very closely asa team, the breast surgeons,
as well as the plastic surgeons,and we all work in conjunction.
So as I'm doing the mastectomy, I'mlooking for and preserving the nerves.
Once the cancer operation is finished,I am essentially tag teaming
with the plastic surgeon.
(13:50):
So then the plastic surgeon cancome in, do the reconstruction.
And during the courseof the reconstruction,
he is also doing the nervereconstruction as well.
Nerve resensitizing in thebreast is relatively new.
So what I'm understanding thenis before a few years ago maybe
(14:11):
a woman would get a mastectomy and wasthere any effort at that time to preserve
that nerve or- So typically-I mentioned before,
it was just thought of as an unavoidable.
Right. So typically, no. Okay.
Typically with the mastectomies,it was just a part of the surgery and
it was explained to patients that theywould have some numbness.
(14:32):
I think many patientsare unprepared for this
aspect. And again, like so many things,I think until you truly experienced it,
you don't understand it.
We know that women often feel depressedor have anxiety about their body's
response to touch.
There's a lot of grief that goes intowith a breast cancer diagnosis as well as
(14:54):
subsequent treatments.
And oftentimes women report that theyfeel like their body is no longer their
own and have a disconnectwith their breast,
even though when they look in the mirror,they have an excellent cosmetic outcome,
but it's that sensationand the loss of touch and
feeling, as well as the potentialfor pain that really impacts them.
(15:18):
It has to be a huge psychologicaland emotional adjustment for sure to
lose that sensation.
Can women who have had the mastectomybefore nerve preservation was being
considered come back andhave that surgery still years
later?
So that's a great question,and this is something that
is under investigation.
(15:42):
The chances of findingthe nerve oftentimes
and having a functional outcome are low.
I know some plastic surgeonsare willing to try it,
especially if the patient has togo back for additional surgery for
reconstruction.
Oftentimes there's some additionalsurgeries where there is some adjustment
(16:05):
to the reconstructed breast.
Some plastic surgeons feelthat if they're in the OR,
they will attempt to take a look and seeif there's any nerve that is still able
to be preserved and thenreconstructed. But generally, no.
The nerves have already been transectedand they're either difficult to
identify or they're just too short. Again,because the nerves grow slowly,
(16:31):
but there's only a certain lengththat they can grow. Generally,
it's about five to seven centimetersthat we use as the graft,
something much longer than that.
And when you say graft,that means you're getting that piece
of nerve from somewhere else? Correct.
Correct. Where do you take that from?
So you can use the body's ownnerves that you can harvest. Again,
(16:53):
you're then treating a new area ofnumbness when you're taking the nerve.
Oftentimes,if the patient is having autologous
reconstruction with their own tissue,such as a deep flap where they're taking
skin and subcutaneous fat from thetummy and using that to
reconstruct the breast,sometimes the plastic surgeon can find
a nerve in there and use that as thereconstruction, or there are
(17:15):
commercially available nerve grafts.
Artificial nerve graftsor maybe cadaver parts?
Cadaveric nerve grafts.
And that has been one of theissues in the last couple of years
where just trying to get insurancereimbursement for these cadaveric
(17:36):
grafts and for the procedure itself,that's certainly been a
stumbling block for moresurgeons and more
institutions to offer this.
Let's say money isn't an option. It couldwork. It could actually be effective.
That is the standard.
That's what we typically.
Use for these.
Yeah. We use the.
Ketavert block.That's pretty amazing.
(17:56):
Oh.
It is. It really speaks to the importanceof us having sensation in our breasts,
doesn't it? It.
Does. Just like any other part ofthe body, it's not just erogenous,
it's just not the need forsensation, but it's protective.
It decreases the risk ofpain and it's functional.
How long does it take toregenerate the nerves?
How long is that portion of the surgery?
(18:17):
So that portion of thesurgery really depends.
It adds about 15 to 30 minutesto my portion of the case,
so not too, too much longer.
And then if we have a great nerve,the plastic surgeon is very happy with.
You can do that pretty quickly, again,15 to 30 minutes at most. If
we're using a cataveric graft,it's two small sutures to
(18:39):
connect the nerve with thenerve graft, and then it's attached
to the backside of the nipple.
So not too, too long.
Some people have beautifulnerves and absolutely perfect.
Other people have very tiny, small, kindof wimpy nerves that if we see that,
(19:00):
then we want to look forsome additional nerves,
see if there's a little bit bettercandidate in order to do this.
And there's some womenthat for whatever reason,
whether it's anatomy or just the locationof the cancer or we just can't find
it. Even if we plan to do it, there'ssome women where it's unsuccessful.
(19:20):
It sounds like you're talking aboutit's just one nerve that you're working
on per breast. Is there-.
Generally, it's just one. Again,depending on the anatomy and whether
the patient is having an implant or anautologous flap,
sometimes the plastic surgeonwill reconnect more than one,
but the goal is to do one perside. And that would be enough?
(19:45):
It seems like there's a lotof nerves in your breasts.
Yeah. Yeah. So again, it's not perfect,but it's very exciting. Yeah.
It's improved.
It is significantly.
What kind of feedback doyou get from your patients?
If someone's listening to this nowand they're considering or facing a
mastectomy or reconstructivesurgery, or even implants,
(20:06):
maybe they didn't have breast cancerand they have implants put in.
Does that affect your nerves?
So that's a great question. I think ifsomeone is having a breast augmentation,
depending on where the implant is placed,there is a possible risk of
nerve injury and decreasednipple sensation or nipple numbness.
(20:27):
It really depends on the surgeonand the anatomy of the patient.
Everyone's different.
So someone having areduction, for example,
wouldn't necessarily need a nervepreservation procedure and then a nerve
regeneration procedure.
So usually not for that. Usuallywith the breast reductions,
(20:48):
oftentimes patients will have numbnessalong the bottom of the breast,
sometimes to the nipple, but muchof that is generally preserved.
If they've had that and then down theline they go on to have a masttectomy,
usually we can still preserve thenerves because they're lateral.
They're off to the side, atthe side of the chest wall.
Maybe you can share a patient experiencewho's had this procedure and share with
(21:11):
us what the feedback's been.
Sure.
So one of the most surprising feedbackthat I heard from a patient was
that at about six months she feltlike her breasts were a part of
her. And she said prior to this withthe mastectomy and the reconstruction,
with the numbness and the changes,she just didn't feel or mentally
(21:38):
feel like these were her breasts. Butshe said at about six months or so,
she started noticing some sensation andfeeling and really felt like then they
became a part of her body.
And that was amazingto hear because again,
you know all of thenerves are regenerating,
not just the ones that were reconnecting,but a lot of the smaller branches of
(21:58):
the nerves under the skin and from themuscle,
everything is regenerating andgrowing and waking up and it was so
amazing to hear that.
And.
Just see how we'd helped her.
Right.
Until you told me that story when Iread that women felt very detached from
their breasts after areconstruction or mastectomy,
(22:19):
I thought it was more of anemotional detachment that they were
experiencing,but it sounds like it's more like when
your foot is asleep and you're walking onit and you don't feel your foot.
I think it's a combination andI think the two go hand in hand.
It's that emotional and psychologicalaspect as well as the feeling.
(22:40):
The.
Numbness, the absence of sensation.
I'm trying to imagine what that islike and appreciate the ability to
restore that. Do you find it tobe more successful than not? So.
I think it's early. Again,we have been limited with being able to
do these procedures with the insurancereimbursement,
(23:02):
which is one of the reasons why I thinkat many places it hasn't taken off.
But again,it's two years before you're really
going to see the full impact.
And some patients are even reporting,I've heard from other surgeons that their
patients are saying even four or fiveyears later, they're still
continuing to have some improvement,which I think gives a
lot of hope for this.
(23:24):
Do you forewarn women who are facinga surgery or scheduled for a surgery
that the numbness and the lossof sensation is going to follow?
Always.
And that's something Ihad always counseled women
list of risks and possible complicationswhen we're talking about the surgery.
But I don't think I was aware about howimpactful this was,
(23:49):
especially with the emotional aspectand really the functional aspect as well
with this. And just being in practiceand seeing patients come back doing well,
I also think that oftentimespatients are not telling us this
and whether that's sideeffects from chemotherapy or
(24:10):
menopausal or sexual symptomsrelated to their treatment,
I think oftentimes patients are notgoing to volunteer that information.
It's really up to us as cliniciansto ask them very specific questions.
And that's one thing that I've learnedover the years. And I'm happy to say
that as part of survivorship,being focused on the quality
(24:30):
of life is just as important astreating the cancer itself.
And the NCCN guidelines have a lot ofguidance on how to manage
a slew of side effectsof treatment, and this is just one more
tool in our toolbox to help with that.
And when you have thoseconversations with your patients,
(24:53):
are you suggesting that this nervepreservation might be necessary or
is necessary and thatthere are steps to take to
restore that sensation andI guess get them to opt in
or do they ask for it?
So I've only had one patientrecently who's asked for it,
(25:15):
but I think-.
Everybody else,you're telling them that this could happen
and we would like to do this surgery?
It could. We're starting to. I mean, Ithink too, women are so educated now.
There's a lot of information insupport groups and social media groups.
I think the word is going to get outthere with the potential benefits for this
procedure. Now that I'm here at MedStar,I've talked to my partner and
(25:36):
the plastic surgeon as well,and everyone is on the same page where
we really feel like this should be thedefault that offering-
Routine. Routine. Routine,that it should be just a part of all
of the nipple sparing masttectomies andpotentially even some of the skin
sparing mastectomies as well.
I think that's important to mention,and especially since women don't know
this could happen or might happen,or apparently will happen, that they
(25:59):
will lose sensation in their breasts,that it just becomes a normal part
of the reconstructive process.
What should women ask for?
So I think it's most important to talkto your surgeon and the rest of your
team, your medical oncologist,and talk to them about your cancer,
(26:21):
the recommended treatment plans,and then just ask questions
because most patients have choicesfor their treatment.
And there are many different routes orpathways that we can take to get you to
the same endpoint. For example,many women are candidates for
lumpectomies followed by radiation or amasttectomy and generally
(26:42):
survival is exactly the same,but it's really about talking
about what's recommended,individualizing the treatment plan for
each specific patient, their cancer,but also their anatomy, their lifestyle,
what's important to themas far as quality of life.
And these are the things that I reallyenjoy talking to my patients about and
(27:04):
working together as a team. I mean,it's all about shared decision making.
Who wouldn't be someone that youwould suggest we try this with?
What patients might ask for would you say,"You're not a good candidate
for this? " I'm sorry.
That's a great question.
There's certainly anatomiclimitations to the nerve grafts.
(27:26):
But you wouldn't know thatuntil you're in there, right?
Well, for women that are havingimplant-based reconstructions,
we know the nerve has to go up andaround and over the implant to get
from that nerve stump bythe ribs to the nipple.
It's just a matter of distance. So ifsomeone wanted a very large implant,
the nerve would not be ableto transverse that far,
(27:48):
so they would not be good candidates.
You would know that in advance. Now,what about the women whose
nipples could not be spared,they're reconstructed or tattooed?
I've even seen that there are surgeriesto create a perky nipple. Sure,
sure. Could they get theirsensations installed?
Yeah. Yeah. And those are incredible.
(28:10):
The 3D nipple tattoos are gamechangers. I mean, they're so realistic.
I think they bring a lot ofclosure and completeness to the
reconstruction. And again, it's all aboutthat emotional aspect and wellbeing.
We have also talked about performingthis procedure in the skinsbury
mastectomies where the nippleand the areola are removed,
(28:32):
but if we can still preservethe nerve and have the
plastic surgeon use the nerve graft,that can still provide significant
sensation to the remaining chest. Again,it's not always about the nipple itself,
it's bringing sensation back to thereconstructed breast and the chest.
And then also very important forfunction as well as helping decrease the
(28:57):
chances of neuroma formationor neuropathic pain.
Okay.
So what I'm hearing is that you canprobably restore some breast sensation,
but maybe not to the tattooed nipple.
Right, right. Okay. We're early on.
We are. We are. This is early.
And again, the tattooed nipple isnot a nipple, but it's still skin.
(29:17):
So if we can get that nervegraft as close as possible,
right behind the tattooed nipple,we would be providing sensation to that
skin and the anterior aspect of thebreast.
Can restoring sensation improve thepsychological wellbeing and sexual
health for women?
I think it does.
(29:38):
Do you get feedback aboutthat from your patients?
So a lot of it is anxietyand depression and grief,
disconnect with their body and resentment,anger that women often experience as
they go through treatment and havethe side effects and the
changes to their body.
And oftentimes there's a changein relationship Such that many
(30:01):
women are caregivers and now they'rethe ones having to be taken care of.
So that certainly changes the dynamic.
Many of my patients are young orin their 40s or 50s and they're in
the midst of everything. They'reraising kids, they're busy at work.
Oftentimes they're takingcare of aging parents.
And now they have been just punchedin the gut with this diagnosis and
(30:25):
treatment and all of the timeand financial impacts of a
cancer diagnosis and treatment plusthe side effects. They don't feel well.
And then often there arelasting side effects.
And whether that's peripheralneuropathy, numbness in the breast,
menopausal symptoms, hot flashes,night sweats, vaginal atrophy,
(30:47):
decreased or no libido,this significantly affects a
woman from where she was. And yes,I mean, I think anything that
then helps restore wholeness andimproves psychological and
emotional wellbeing is so crucial.
It helps with their relationship withtheir partner as well as their self-esteem
(31:08):
and.
Sense of self.
What is it most important for women toknow about breast neurotization or nipple
resensation? What's the takeaway?
Because we don't want people to have anymisconceptions about what is available
and what is not, right? But we want togive them hope. I want to give them hope.
Right. And I think that is the mostimportant takeaway from this is that
(31:30):
there is hope. Breastcancer is devastating,
but there is so much positive news,especially the last couple
of years. And going forward,we've come a long way just from a breast
surgical and oncologic perspectivein that for a long time,
(31:51):
reconstruction was minimal or notoffered. For the last couple of decades,
we know that nipple sparingmastectomies are safe from a cancer
standpoint and we've been offering that.
We're also decreasing thelymph node surgery as much as
possible to help decrease the risk oflymphedema and also doing some things
(32:11):
before and after surgery to helptreat that or minimize the risk.
Same thing with chemotherapy.
We're really focused on moretargeted systemic therapies.
We have improved radiation planningtechniques where we spare healthy tissue.
And again, less invasive surgerywith a focus on obviously cancer
(32:32):
treatment is number one priority,but we know that the cosmetic
outcome and the functional outcomeare such a key component of that as well.
I think it's important for patients toask their surgeons about what
types of procedures they do,what they recommend, and then
consider getting a second opinion.
(32:54):
I encourage all of my patients to geta second opinion with a breast cancer
diagnosis, just becauseit is often overwhelming.
And I want to make sure that they feelcomfortable with their treatment team.
I never, never hold it against anyoneif they want to get a second opinion.
We tout that all the time, getting asecond opinion. You mentioned neuromas.
(33:17):
And I wanted to ask about that becauseneuromas have been described to me as a
bundle of angry nervesthat want to regenerate,
but have nowhere to gobecause they've been cut.
And I know about thatbecause of our hand surgeons.
Do women experience that in the breastafter surgery? And can you treat that?
Absolutely.
And that's why it is so importantto start identifying and preserving
(33:39):
these nerves, because that canhappen. Nerves have a function.
They want to grow, theywant to do their job.
And when you cut the nerves duringthe course of a cancer operation,
you're exactly right.
You wind up with an angry ballof nerves that don't have a true
sensation function, sothey're causing pain.
Even if we're not doing nerve grafting,one of the things that I can do during
(34:01):
the course of the mastectomy is I canidentify the nerve, transect it,
and then I can tuck it into the muscle andkeep it happy there. And that decreases
the risk of neuroma formation and pain.
They'll still have numbness sincewe're not doing nerve grafting,
(34:21):
but it can significantly decreasethe risk of pain from that nerve.
We're not truly doing anything new in thebreast that hasn't been done elsewhere
in the body,whether it's on the hands or the
extremities of the face. Nerve grafting isnot new. That is well established.
What is newer is doing that in the breastand showing that there's a need for
(34:42):
it, that it improves sensation,it improves pain outcomes,
and really making this a seamlessoperation. That's what's new.
Protective sensation isa big component of this,
but it's also just the intimacy inhugging someone and feeling that.
Restoring sensation isn't cosmetic.
(35:03):
It's about restoring identityand normalcy, intimacy,
safety, and long-term emotional wellbeing.
I'm certain this will become standardof care with enough time because there's
so many benefits.
Thank you for sharing your expertisewith us here on MedStar Health Doc Talk.
Thank you so much for having me.
(35:23):
My pleasure.
If you're in the Baltimore area andwould like to schedule an appointment to
discuss breast neurotization surgery, call443-777-6500. Thank you. Thank you. Sure.
Or to make an appointment in the DCregion at MedStar Washington Hospital
Center, call 202-877-7937.
(35:47):
You can also see a specialist fornerve resensation at MedStar Georgetown
University Hospital in DC. Call202-295-0560.
To comment on this podcast or recommenda topic for another episode of Doc Talk,
send an email to doctalk@medstar.net.
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