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Nerve Reconstruction Double Incision: A Groundbreaking Approach to Top Surgery

Medically reviewed by Paul Gonzales on June 6, 2024.

The loss of meaningful sensation to the nipple-areola complex is often a cost of undergoing a double incision (DI) top surgery with free nipple grafting (FNG). At the GCC, we are proud to announce a collaboration with Dr. Ziv Peled (he/him) that will allow us to offer patients the option to restore nipple sensation after top surgery. Dr. Peled is helping us provide a sensation preservation technique, also known as nerve reconstruction, neurotization or re-innervation top surgery. Dr. Peled is a board-certified plastic and peripheral nerve surgeon who has performed over 700 neurotization procedures for mastectomy patients. He is excited to be bringing his expertise to serve GCC patients.

Generally speaking, the double incision technique allows surgeons to remove medium to large amounts of chest tissue to maximize the flatness and tightness of the chest. Many of our patients experience a dilemma in that they want a flat chest, but do not want to sacrifice nipple sensation in the process. Thanks to Dr. Peled, we’re able to offer a nerve reconstruction DI so that patients can have a flat chest while maintaining sensation in their nipples/areolas.

If you are interested in undergoing this procedure, you can book a free, virtual or in-person consultation with our board-certified top surgeons today. We invite you to learn more about this procedure below.

Why do patients choose a sensation preservation double incision?

The reasons for wanting a sensation preservation top surgery are as diverse as our patients who walk through our doors. For some patients:

• Having a meaningful ammount of nipple sensitivity might be important to experience sexual pleasure and satisfaction.
• Losing sensation in their nipples might cause them to feel disconnected from their chest post-op.
• Having a meaningful ammount of nipple sensitivity may be a source of gender dysphoria for some patients. However, top surgery may reduce feelings of dysphoria once the appearance of the chest has changed, meaning that a patient might feel more gender congruence with nipple sensitivity post-op.

If you think that nerve reconstruction DI top surgery would be right for you, you can book a virtual or in-person surgical consultation with our board-certified providers today.

Why opt for a nerve reconstruction double incision instead of another sensation preservation top surgery?

The double incision (DI) with free nipple grafting (FNG) technique is by far the most popular type of top surgery because:

• It allows surgeons to create as flat and tight of a chest as a patient desires. Chest tightness refers to how close the skin hugs the pectoral muscles and other surrounding tissues. Flatness refers to the volume left behind on the chest after top surgery.
• The FNG technique gives patients complete control over resizing the dimensions of the nipple and areola. It also gives control over where the nipples are placed on the chest. For more information, click here.

Other popular nerve preservation techniques, like the keyhole, periareolar (donut), buttonhole incisions can only be performed on patients with minimal amounts of chest tissue. The inverted T or anchor incision has a possibility of sensation preservation and is suitable for patients with medium to large-sized chests. However, the inverted T is a breast reduction technique that leaves behind a mound of tissue. Patients with medium to large-sized chests who are interested in maximizing chest tightness and flatness usually opt for the double incision procedure. That said, the DI leaves patients with one or two scars along the underside of their chest.

How is the sensation preservation DI top surgery performed?

There are two ways sensation preservation can be achieved. First, before the breast tissue is removed, the relevant nerves are meticulously dissected from it and from the chest wall. These nerves are then rejoined and connected to the underside of the tissue, close to where the nipple graft will be placed. These steps are illustrated above in panels A, B and C. The second approach is required when the disected nerve ends do not reach the underside of the new nipple location. In that case, a nerve graft is harvestedand connected to both the intact nerve and the underside of the nipple/areola complex. The effectiveness of this approach has been proven in several clinical studies.

How effective is the sensation preservation technique?

Dr. Peled has several published, peer-reviewed papers demonstrating good success with these neurotization techniques.[1-3]  Initially, he started performing nipple neurotization alongside his wife in cis women undergoing mastectomies for breast cancer prevention or treatment. For these patients, breast tissue is usually removed and then an implant or flap is placed to maintain the breast’s volume or contour. Then, the nerves are reconnected to the nipple/areolar complex in the same way as described above to allow for preservation of sensation post-op. In a study of cis women who underwent this procedure, over 80% patients had good-to-excellent sensibility scores at all areas of the breast and nipple/areola tested as early as 6 months post-op, with further improvements 12 months after surgery.[1] These chances of success may also be promising in top surgery patients.  Dr. Peled has performed hundreds of neurotization procedures. In his opinion, neurotization in the top surgery population should be as good or better because no implant or flap is placed between the chest wall and the nipple, potentially allowing for better nerve connections. It is also theoretically possible that some top surgery patients may experience better nipple sensation post-op than they had pre-op because a larger nerve bundle coming from the chest is applied directly in some cases to a smaller, resized nipple graft.

A small study of patients who underwent neurotization following top surgery maintained similar levels of sensation in their nipples post-op. Another study also found the procedure significantly improved sensory outcomes in nearly all parts of the chest extending beyond the nipples, without major operative complications.[4-5]

If you are interested in a neurotization procedure, you can schedule a virtual or in-person surgical consultation with the GCC here.

Who is a candidate for neurotization procedures?

Research suggests that BMI and the amount of tissue removed may impact nipple and chest sensation in top surgery patients undergoing neurotization procedures.4 Patients with a BMI over 30 were observed to have poor nipple sensation before surgery. Poor sensation was also observed in patients with greater amounts of breast tissue removed (800g or more). In other words, patients with a BMI over 30 or those with larger chest sizes may experience less heightened sensation in the nipples and chest after neurotization surgery.

If you have questions about whether or not you would be a good candidate for this procedure, you can speak with one of our board-certified top surgeons by booking a consultation.

What is recovery like? When will I feel a heightened sensation in my nipples again?

The healing timeline from this procedure is different for each patient. Patients who undergo neurotization surgery may begin to recover sensation as early as 3 months after surgery. Still, this number can vary and most patients are expected to have some sensation back by 6 months post-op. Patients can expect sensation to gradually improve within the first year after top surgery. As the nerves heal, it may be normal to experience temporary hypersensitivity or discomfort (i.e., sharp or itching sensation underneath the skin) but this often gradually disappears.

How much does nerve preservation DI top surgery cost? Is it covered by insurance?

While neurotization can be a medically necessary procedure, we cannot guarantee that it will be covered by insurance. This is because it is a relatively new procedure within the world of gender-affirming surgery.

For cash pay patients not using insurance, neurotization can cost between $5,000-$9,000. This pricing is also based on the technique used to accomplish sensation preservation. The overall cost can be determined once you have had your surgical consultation.

Can neurotization be performed as a revision surgery for former DI patients?

Neurotization is not recommended as a revision procedure for former top surgery patients due to the low probability of its success. In Dr. Peled’s experience, patients who come in for a nerve grafting procedure after they have already had their breast tissue removed have about a 50% chance of success. That is, only about half of revision patients successfully recover sensation in their nipples/areolas. With more time that passes after the initial surgery, the more likely that the nerves on the chest wall may have atrophied and thus will require more dissection or different types of grafts. Beyond the difficulty in finding a usable nerve stump from which to graft and using a long nerve graft, it may also be more difficult for the brain to re-learn the perception of stimuli from the nipples after having had little or no sensation for long periods of time. These factors may all contribute to having a lower chance of success for neurotization as part of a top surgery revision.

Conclusion:

• The double incision (DI) technique is the most common type of top surgery performed because it can remove medium to large amounts of breast tissue and help patients maximize the flatness and tightness of their chest post-op.
• The DI is often performed with a free nipple graft (FNG), which allows the surgeon to freely reposition the nipple graft on the chest and alter its dimensions. While the FNG can help patients achieve their aesthetic results, it may result in the loss of heightened, erotic nipple sensation.
• Dr. Ziv Peled (he/him) is an experienced plastic and peripheral nerve surgeon collaborating with the Gender Confirmation Center to offer sensation preservation DI top surgery and has performed over 700 neurotization procedures on top surgery and mastectomy patients.
• The novelty of this procedure in gender-affirming surgery makes it less likely to be covered by insurance, with out-of-pocket costs ranging from $5,000-$9,000.
• Patients who are seeking to remove less than 800g of breast tissue or those with BMIs below 30 may be better candidates for this procedure.
• By 3 months post-op, most patients will begin to recover sensation in their nipples. Sensation will continue to improve as the nerves heal during the first year after surgery.

Sources:

1. Peled, Anne Warren MD; von Eyben, Rie PhD; Peled, Ziv M. MD. Sensory Outcomes after Neurotization in Nipple-sparing Mastectomy and Implant-based Breast Reconstruction. Plastic & Reconstructive Surgery-Global Open 2023;11(12:) e5437
2. Peled, Anne Warren MD, Peled, Ziv M. MD, Sensate Immediate Breast Reconstruction, Peled, Gland Surgery 2024;3(4) 552-560.
3. Peled, Anne Warren MD, Peled, Ziv M. MD. Nerve Preservation and Allografting for Sensory Innervation Following Immediate Implant Breast Reconstruction. Plastic & Reconstructive Surgery-Global Open 2019; 7(7):p e2332,
4. Rochlin, Danielle H. MD*; Brazio, Phil MD*; Wapnir, Irene MD†; Nguyen, Dung MD, PharmD*. Immediate Targeted Nipple–Areolar Complex Reinnervation: Improving Outcomes in Gender-affirming Mastectomy. Plastic and Reconstructive Surgery – Global Open 8(3):p e2719, March 2020.
5. Hu, Allison C. MD1; Makarewicz, Nathan S. BA2; Sharma, Ayushi MD3; Nguyen, Dung H. MD, PharmD4. Impact of Nipple Areolar Complex Reinnervation on Sensory Outcomes Following Gender-Affirming Mastectomy. Plastic & Reconstructive Surgery-Global Open 12(1S1):p 63, January 2024.
6. Remy, Katya MD; Packowski, Kathryn; Kozanno, Liana; Winograd, Jonathan MD; Carruthers, Katherine MD; Tomczyk, Eleanor MD; Austen, William Gerald Jr. MD; Valerio, Ian MD, MS, MBA, FACS; Gfrerer, Lisa MD, PhD. Intraoperative Anatomy and Postoperative Sensation of Targeted Nipple Areola Complex Reinnervation in Gender-affirming Double Incision Mastectomy with Free Nipple Grafting. Plastic & Reconstructive Surgery-Global Open 11(10S):p 75, October 2023.
7. Naides, Alexandra BFA1; Cece, John MD1; Doshi, Kathryn PA-C2; Keith, Jonathan D. MD, FACS, MD, FACS3,2. QS14. Neurotized Chest Masculinization for Improving Nipple Sensation: Survey Results. Plastic and Reconstructive Surgery – Global Open 10(6S):p 97, June 2022.