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Melanie Cole (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole, and joining me today is Dr. Lisa Gfrerer. She's an assistant professor in Plastic and Reconstructive Surgery at Weill Cornell Medicine, and she's here to highlight chest and breast reinnervation surgeries. Dr. Gfrerer, it's a pleasure to have you join us today. This is something that I feel not many people know something about. Can you tell us about chest and breast reinnervation? And when in the course of gender-affirming surgery or cancer treatment is this considered?

Dr Lisa Gfrerer: Thank you so much for the invitation. I really appreciate a chance to talk about this topic and raise awareness because I feel a lot of our patients are not aware of all the options they have during breast reconstruction and chest reconstruction after mastectomy.

In terms of breast reinnervation, this is a procedure that's available to any patient undergoing mastectomy, whether it's for cancer or for gender-affirming surgery. The reason why we do breast reinnervation is because we have noticed that numbness is a big problem after both procedures. And at the time of the initial surgery, the initial mastectomy, we can offer breast reinnervation.

Melanie Cole (Host): This is interesting. So, tell us about some of those sensory deficits that can result from mastectomy. How have you seen them affect the quality of life of patients that are undergoing these procedures?

Dr Lisa Gfrerer: Unfortunately, during any mastectomy procedure, because the breast tissue is removed, the nerves that travel to the nipple-areolar complex and the chest skin have to be removed as well as part of this procedure. Now, we have found a way to preserve these nerves, essentially find them before we cut them and reattach them to the nipple-areolar complex and the chest skin to reestablish that anatomic connection.

Now, if we don't do that, if we don't reinnervate the breast, unfortunately, the areas that these nerves travel to are numb, namely the nipple-areolar complex and the chest skin. And this can be very uncomfortable. we've learned from patients that there is a foreign body feeling and it is hard to feel certain sensations such as light touch and pressure, warm and cold, and that translates into things like feeling the shower, feeling a hug, feeling clothing. So, it's really a big problem for a lot of patients.

The other thing that can happen when nerves are cut and not reconstructed is that patients can develop pain and also phantom feelings, because the nerves are no longer attached and there's a feeling that the breast is still there, although it is not.

Melanie Cole (Host): What an odd sensation that must be. So, tell us a little bit more about the surgical technique itself to preserve these nerves and reinnervate the chest, skin, and nipple. Tell us a little bit about really what you're doing.

Dr Lisa Gfrerer: So during the initial mastectomy procedure, if you're a patient undergoing cancer surgery, your mastectomy surgeon will start with the mastectomy. And when they reach the side of your chest, the nerve surgeon will come in and look for those nerves and preserve as much length as possible, and then reconnect the nerves when the mastectomy is done to the nipple-areolar complex and chest skin. If you're a transgender patient, the plastic surgeon and nerve surgeon will do all that themselves and preserve the nerves on the side of your chest and reconnect them.

Melanie Cole (Host): So, how are you using these techniques to help patients? You just mentioned in gender-affirming surgery and mastectomy. So, tell us a little bit about the services that you offer for transgender patients.

Dr Lisa Gfrerer: What I offer for transgender patients, and we are speaking specifically about transgender patients who undergo female-to-male gender-affirming mastectomies, is I offer the mastectomy plus the reinnervation, so I will do the standard mastectomy and free nipple grafting, but then I will preserve the nerves and I will reattach them to the nipple-areolar complex. And we've found that patients regain sensation after around three months after this procedure in both the nipple-areolar complex and the chest skin.

Melanie Cole (Host): Are there some patients for whom this is not an option? Can you tell us a little bit about what patients are eligible for this type of procedure?

Dr Lisa Gfrerer: Absolutely. So for the transgender patients, really any patient that undergoes female-to-male transgender or gender-affirming mastectomy with free nipple grafting is eligible. There are no patients that are not eligible. In breast cancer care, patients that are eligible are ones that have a breast size up to a C cup and, ideally, will not undergo radiation treatment.

Melanie Cole (Host): Doctor, this is just absolutely fascinating, what you're doing to help people. Is this an outpatient procedure? You mentioned the three-month timeframe. Nerves take a long time to heal. So, this is outpatient and then what happens after that?

Dr Lisa Gfrerer: The procedure really only adds about 30 minutes or so to a regular mastectomy procedure, so it doesn't prolong the operative time. It doesn't prolong the recovery. However, because nerves take some time, as you said, to regrow, we don't see results immediately and have to be patient. In transgender patients, I would say 90% after three months have regained sensation. In breast cancer care, we have to wait even longer. And the reinnervation doesn't occur for around a year. But the nerve part itself does not change recovery. You can still go home after surgery. Usually after transgender surgery, you go home the same day. After breast cancer surgery, you go home the next day. But this is just the regular recovery that you would have after your mastectomy.

Melanie Cole (Host): Doctor, if a patient does have to have chemotherapy or radiation, does that slow down that nerve healing process? Do any of these adjuvant therapies that might come after mastectomy slow down that procedure's results?

Dr Lisa Gfrerer: The short answer is yes, the nerve regeneration will be slower, but we don't know how much slower or if there is a lot of negative impact. We know from other areas of the body that there can be a negative impact of these adjuvant therapies on nerve regeneration. Additionally, we will help guide you through that process until your nerves are regenerated.

Melanie Cole (Host): This is not something a lot of people know about. A lot of people have not heard about this condition or the need for reinnervation. Do you feel that there needs to be more research and guidelines from the medical community itself?

Dr Lisa Gfrerer: Yes, absolutely. And I'm doing a lot of work on, A, trying to raise awareness that sensation is important after mastectomy in both cancer patients and transgender patients. And my team and others around the country are doing prospective studies to generate more data to help people understand both the sensory deficits that result and also the effects of reinnervation and the benefits of reinnervation.

Melanie Cole (Host): So as we wrap up, I'd like you to speak about research and care treatments that are available should patients want to learn more, and what should breast cancer patients or gender-affirming surgical patients consider when they're discussing with their physicians as far as the benefits and risks of these procedures.

Dr Lisa Gfrerer: There are several articles online about gender-affirming and breast cancer reinnervation. There are some articles under my name, but also others. So if you just type in reinnervation after breast cancer surgery or reinnervation after transgender surgery, you will find more information on it. And this information is growing as we speak, as we're trying to generate more patient-friendly information on the topic.

When you're talking to your healthcare provider, I just think it's important to bring up sensation and the possibility of numbness and pain and phantom pain, and they will be able to guide you through the options you have, and whether or not reinnervation is right for you. For now, we don't think this adds risk to the normal procedure that you're undergoing, except for that it adds some OR time.

Melanie Cole (Host): Thank you so much, Dr. Gfrerer, for joining us today and sharing your incredible expertise. And thank you, this is really a great topic to discuss. And Weill Cornell Medicine continues to see our patients in person as well as through video visits, and you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcast, Spotify and Google Podcast. And for more health tips, please visit weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole.

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