• Home
• Top Surgery
• Top Surgery Techniques
• Nerve Preservation Double Incision

Nerve Preservation Double Incision Top Surgery

The double incision procedure is the most commonly performed chest reconstruction top surgery due to its ability to remove excess tissue and skin, resulting in a flat and tight chest. It also allows for areolas to be resized and repositioned based on a patient’s preferences using a free nipple graft. Traditionally, the cost of grafting the nipples is that they lose heightened, erotic sensation. Due to advances in nerve reconstruction techniques, patients no longer have to choose between having a heightened, erotic nipple sensation or having a flat chest with repositioned/resized nipples. A nerve preservation technique may help patients experience higher, erotic sensation in their nipples with a double incision top surgery.

What is a standard vs. a nerve preservation double incision procedure?

The standard double incision top surgery is one of the most reliable procedures to achieve tightness, flatness and symmetry of the chest. For some patients, there are trade-offs to this technique. First, it leaves visible, horizontal scars below the pectoral muscle. Second, it is associated with a risk of reduced chest and/or nipple sensation since the nipple is cut off from its original blood and nerve supply to be re-attached as a skin graft. This means that if the nipple regains sensation post-op, it has a normal level of tactile sensitivity, like the rest of the chest. In other words, it loses its heightened, erotic sensation.

Nerve preservation double incision allows patients to undergo a double incision chest reconstruction without losing heightened sensation in the chest and nipples.  This is accomplished through neurotization or the process of joining nerve endings together to restore nerve function.

What are the chances of sensation being preserved? When will I feel heightened sensation again in my nipples?

Post-op sensation is dependent on the amount, size, and length of nerves used and whether any post-op complications occurred. Sensation may begin to return in 6-12 weeks after surgery. We usually assess the success of the nerve reconstruction at 2 timepoints: first at 6-12 months post-op, then 18-24 months post-op.

How is a nerve preservation double incision performed?

Nerve preservation can be accomplished either through nerve transfer and/or nerve grafting. A transfer involves the rerouting of a nearby healthy nerve to the desired place (i.e., the nipples) whereas grafting requires harvesting a healthy nerve elsewhere in the body or the use of a cadaver nerve product purchased from a medical supplier. These techniques may be used in combination depending on the number and length of healthy nerves present and will vary between individuals.

The branches of the intercostal nerves (Figure A) are used as donor nerves to provide sensation to nipple grafts. The nipple graft placement and length of the donor nerve are taken into consideration to determine the technique that will be used. Most often, one donor nerve (Figure B) is long enough to reach the nipple graft, in which case that nerve is connected to a bundle of sensory nerves that is bundled to the graft. The hope and expectation that the body’s sensory intercostal nerve will grow into the sensory nerve to then preserve heightened sensation in the region of the nipple graft (Figure C).

Are there other double incision procedures that preserve sensation?

Any nipple-sparing or nipple-preserving techniques carry a greater probability of preserving heightened sensation in the nipples post-op. This is because nipple-sparing top surgeries leave the nipple attached to its original nerve and blood supply. For some, the trade-off of a nipple-sparing procedure is that some tissue is left behind, meaning that total flatness cannot be achieved. Additionally, since the nipple will not be grafted, surgeons have much less control around resizing and repositioning them. You can read more about the nipple-sparing double incision technique here and the inverted-T or anchor technique here. You can read more about the science behind the nipple-sparing technique here.