A Conversation with Dr. Constance Chen: Sensory Restoration in Breast Reconstruction

Keri Stephens:
Hello. My name is Keri Stephens and I’m joined today by my co-host, Alison Werner. We are the co-chief editors of Plastic Surgery Practice. Thank you for joining us for today’s podcast. Today, we are joined by Dr. Constance Chen, a New York-based board-certified plastic surgeon and leader in microsurgical breast reconstruction. She is here to talk to us about innovative techniques and restorative breast surgery. Dr. Chen, thank you for joining us today.

Dr. Chen:
It’s such a pleasure to be here. Thank you for inviting me.

Keri Stephens:
Thank you. Well, I have to say, this podcast interview is extremely personal for me since I underwent a double mastectomy in 2020. I personally am very familiar with the numbness that can come after a mastectomy. For me, what I’ve noticed is the safety risks and just not being able to feel when I’m burning or if say hot water is spilled on me not being able to feel that. I think people generally think in the terms of sexual function for breast sensation, but really, I’ve noticed more for the safety aspects. Is that something that you’re hearing from your patients and what are your mastectomy patients saying to you in regards to numbness?

Dr. Chen:
Well, I think that you are absolutely right that safety… And the skin is the largest organ in your body. And so, when your breasts are numb, that’s a huge area, it’s your entire chest area, which you can’t feel anything. So it’s not just a sexual thing, which is also important. I think part of it is feeling like a human being where you can feel the world around you. But I do have a story where I had a patient a few years ago who I did a breast reconstruction on and she came in after her surgery and she had a red splotch on her breast. I asked her, “What is that?” And she said, “Oh, well, I was cooking recently and I got a grease splatter from the pan and it hurt so much.” And I was like, “Well, that is terrible, but it’s also wonderful that it hurt a lot because you could feel it, address it.”

Dr. Chen:
She immediately put cool water on it, a cool compress, and it didn’t turn into a third-degree burn or a blister or anything like that. She took care of it. It was just a little pink. Alternatively, I had another patient who, a few years ago, had breast reconstruction, I think it was about six years ago. And maybe about a month or two ago, her shoulder hurt, she was lying on a heating pad and fell asleep. The next thing I know, she called me and said, “My breast is blistered and I don’t know what happened.” She had burned herself on the heating pad, but didn’t know it because she couldn’t feel it. If she had a re-sensation, she would have been able to feel that and potentially prevented that from getting to the point where… This was maybe one or two months ago and she’s still dealing with the swelling.

Keri Stephens:
Wow. Yeah, I don’t think it’s something that people generally think about when they think breast reconstruction. I mean, I knew in theory about the numbness, but until you experience it, it’s something that’s so different than, honestly, what I would’ve even expected. Yeah, I just think what you’re doing is amazing. Can you please talk about the re-sensation process and how this became a field of interest for you and just how long you’ve been doing it?

Dr. Chen:
So I’ve been doing it for, actually, I like to say 10 years but I think it’s more like 15 years now because time just marches on. I think the pandemic is this kind of lost time and it doesn’t even exist. But I’ve been doing it for a long time. When I first started doing it, I only did it in certain patients who had the right anatomy because in order to restore sensation to the breasts, I dissect a nerve from… I only do it in people who have flat reconstruction, natural tissue breast reconstruction because the nerve needs to innervate something that is alive. So I will take tissue from another part of the body, usually the lower abdomen or the upper inner thighs or some place like that. I’ll dissect out a nerve and then I’ll reconnect the nerve to a nerve in the chest wall.

Dr. Chen:
So that is how I used to do it, originally. A few years ago, there was a company called Axogen that developed a nerve graft that they started making available to plastic surgeons for breast reconstruction. Now, I do it a tiny bit differently where I still dissect out the nerve, but I don’t have to dissect out a long length of nerve, so the donor site does not lose sensation in the same way that it used to. I just need a little stub and then I connect that stub of a nerve to a nerve connector, which is then connected to this nerve graft. It’s processed from basically a cadaver and they are very picky about their nerves, so it’s only the best nerve, so to speak. And then the other side of the nerve is connected to another nerve connector and that’s connected to another nerve on the chest wall, usually, the one that used to innervate the nipple areola complex.

Dr. Chen:
Over time, the axons in the nerve regrow at a millimeter a day and the sensation is restored. There are different types of sensation and they come back at different rates. The first type of sensation to come back is deep pressure followed by light pressure, followed by pain, and then temperature is the slowest. Sometimes it may take months or even years for all of the sensation to come back, but it is a process where it eventually comes back. People who have been numb for a long time, I think they notice it coming back a little bit more quickly because they have been numb for a long time. I think people who have, for example, someone who has had normal breasts the day before, I think they still notice it coming back.

Dr. Chen:
I have a patient who was a brothet patient. She had prophylactic mastectomies and reconstruction. She got re-sensation. She actually says, she feels pretty normal now. She says her breasts feel pretty much the way they did before her mastectomies. But, for them, the day after surgery, yesterday, you had normal breasts today, it’s different. For someone who had implants for a long time or no reconstruction, they noticed it and I’ve noticed, personally, much more quickly. Some of them within days, they’re like, “Oh my God, I can feel things.” I was like, “Whoa, it’s a little fast.” I think sometimes the implant itself because it’s synthetic, almost blocks nerve growth and so it also makes it a little bit more difficult.

Keri Stephens:
Okay. That makes sense.

Alison Werner:
So, who is a good candidate for the resensation technique and does it work for everyone? It sounds like it’s not for everyone.

Dr. Chen:
Resensation is basically something you can do on someone who is healthy enough to have surgery. For me, I only do it in people that I do natural tissue breast reconstruction on. I do implant reconstruction too, but in those people, I have not been able to figure out how you could make an implant have sensation. And so, I don’t do it in those people. There is a woman who does do some type of resensation with implants. My understanding is that her mastectomy flaps are a little bit thicker, so I think it has more to do with leaving the nerves in the mastectomy intact more than… I mean, I just don’t see how you can otherwise do it because there’s not a nerve to connect it to on the other side that way. But so then from that standpoint, there have been studies on who it works better on.

Dr. Chen:
It tends to work best on people who don’t have as large a breast or who are slimmer. I think that makes sense because there’s not as much distance to travel. That said, I have plenty of patients who have C and D cup breasts that I did resensation on and they had really good return on resensation. So it’s not like it’s only for an A or B cup breast. In fact, both of the people who are… I have some videos on my website of patients talking about their resensation. I don’t know if I should say this, but their breasts are pretty big. So it certainly works for a larger breast. I think smokers, it’s always going to be a little bit more difficult. Uncontrolled diabetes, again, if your BMI is over 30, I think it makes it a little bit more difficult.

Dr. Chen:
But other than that, someone who is healthy. Now, I’m trying to narrow it down, but it’s anyone who had breast reconstruction. One thing is if you’ve already had a flap reconstruction and you did not have resensation, the nerve does need to be dissected out at the time of the flap elevation. If you’ve had no reconstruction or you’ve had implants or you haven’t had your mastectomy yet, then you could have resensation. If you have already had either a tram or a deep or latissimus flap or some other natural tissue reconstruction, but did not have resensation then you can’t unfortunately, go back and dissect out the nerves because they will have already atrophied. And you can’t do that.

Keri Stephens:
Can you talk about more patients that have undergone, such as myself, I have implants, implant-based reconstruction that then come to you later. Can you talk some specific examples about that and how they’re saying that having sensation has improved their lives?

Dr. Chen:
Well, I think for people who have had implants for a while, it is… Those are probably the patients where it’s most rewarding to do resensation on them because they know what it’s like to be numb. Most of them didn’t really like it. I mean, I can’t think of anybody who really liked it. For example, there is one person who might say, who talks of Jane, who talks about she’s a surrogate mom. When she first got her baby, she couldn’t feel her baby when she was on her chest. And it was just kind of sad. But then after she had breast reconstruction with resensation, I used her upper inner thighs to create her new breast, which she’s a pretty slim woman. She said it was unbelievable to feel her baby on her chest. I mean, it actually made me cry to hear her story.

Dr. Chen:
I didn’t know that about her until I saw her video. I knew she had other problems. For example, her hands were tingling and numb because her implants hurt her and all sorts of things. But I didn’t know about that story and of her daughter feeling her on her chest. And she also talks about how, when she goes swimming or takes a shower, she can feel the water running down her chest. It’s just an unbelievable feeling where she feels alive again. Tara, who’s also on there. She is someone who is a bra-up patient, her mother, her grandmother, her aunt, lots of female family members either had breast cancer or unfortunately, she saw a lot of family members die of breast cancer. When she was in her twenties, she was brothet tested and discovered she was brothet positive. And as she tells it, she feels like she got the golden ticket because now she knew why this was happening and she could do something about it.

Dr. Chen:
And so she had prophylactic, nipple, sparing, mastectomies, and implant reconstruction in her twenties. When I met her 11 years later, one of her silicone implants had ruptured, which was why she was sent to me. And so I removed them and replaced them with tissue from her lower abdomen. I did a DIEP flap on her with resensation. For her, that was life-changing too. She could not believe she could feel everything again. And she was still young when this happened. She was in her thirties.

Dr. Chen:
Other patients have asked her, do you feel sexual sensation? What do you feel? She said, “I feel everything.” Yes, including sexual sensation and she has since gotten married and whatnot. And it’s just a really nice thing because she’s going to have these new breasts for her for the rest of her life, probably longer than she ever had her implants or even her old breast, hopefully, because she’s a young woman. So it’s a great thing that she can live fully in her body as it was basically meant to be.

Alison Werner:
Wow.

Keri Stephens:
Yeah.

Alison Werner:
That’s amazing. Well, so let’s talk about where this all fits into the profession. Are many of your colleagues incorporating the resensation process into reconstructive surgeries. And is it a part of specialty training for plastic surgeons who focus on breast reconstruction?

Dr. Chen:
No, most of my colleagues are not incorporating resensation in their practices. In large part because most plastic surgeons who do breast reconstruction are not micro-surgeons. In order to repair a nerve, which this is a one-millimeter structure, you have to be comfortable if not using a microscope, then using loops, and most breast… 70% of breast reconstructions in this country are implant-based. And you do not need to be a micro-surgeon to do that. But even amongst micro-surgeons, it’s not that common because of market-driven forces having to do with product availability. The nerve racks are expensive, so most hospitals do not want to pay for it. In addition, there’s a lot of pressure to do cases quickly and operate on as many patients as possible. That is not really consistent with doing special things like restoring sensation to somebody’s breasts.

Keri Stephens:
Okay, so I know in my mastectomy group, a lot of people they’ve been talking about this a little bit, my mastectomy groups on Facebook. There are some doctors that do write this resensation, I don’t know if they exactly know the word to describe it, but can nerve regeneration and when you feel again, how do people like me or people that are undergoing mastectomy for the first time find doctors that do this technique?

Dr. Chen:
That is a great question. I’m going to say, Andrea is not going to love this answer, because she probably wants me to say go on the Axogen website, but I don’t think that’s the right answer because frankly, not everyone who does sensory restoration use the Axogen nerve graft. So I don’t mean to… I’m just saying this because I’m sorry about that, but over a period of 10 years, sorry. I know, but it’s true. And so I do happen to use it. I think it’s a great product, but if someone is interested in sensory restoration, probably… I don’t know an easy answer to that, but I think it’s going to be quote-unquote, doing your research, which may be looking up sensory restoration online, the patient boards, and things like that. The woman I talked about who is very passionate about sensory restoration.

Dr. Chen:
I don’t… You said she’s not an Axogen person like that. I don’t even know if she uses enough pounds, does she? [inaudible 00:15:54].

Speaker 4:
She does.

Dr. Chen:
Oh, she does.

Speaker 4:
Yeah. She’s on it now.

Dr. Chen:
Oh, she is. Okay.

Speaker 4:
W-H-C-R-A. So when they find somebody it’s their right to reconstructions.

Dr. Chen:
Right, right. But that’s not the question. It’s how do you find someone who does sensory? So how do you find someone who does sensory restoration? I mean, honestly, that’s one of those things in any profession. Years ago, I had my ACL repaired and I had to choose between two orthopedic surgeons. One was the orthopedic surgeon for the 49ers. The other one was a really nice guy that I met who was the pediatric orthopedic surgeon at Stanford, where I was a medical student at the time. And I cornered an orthopedic resident to try and get me to tell me which one I should pick.

Dr. Chen:
And she wouldn’t say, and finally, she said, “Well, don’t tell anyone I said this, otherwise I’m going to get fired, but I would go with the orthopedic guy. He has a bad bedside manner, but he gets it every time.” And so that is really hard information to come by unless you’re actually in the field. Even amongst classic surgeons, frankly, I’ll bet you not every plastic surgeon knows about resensation even. And so…

Keri Stephens:
I was not… Nobody mentioned that to me. There was never…

Dr. Chen:
It’s not a thing. It’s not a thing unless you are a micro-surgeon who is at the forefront of your field, who is innovative, and like I said, I’m part of a group of micro-surgeons around the world. We meet every couple of years to talk about the latest and greatest, but that’s a very small group of people.

Dr. Chen:
It’s not like a special club or anything like that. I mean, it’s not a formal organization. So how do you… It’s a hard thing. I think that for a patient is probably going to be patient boards, word of mouth, which is not a great way to go about it. Looking online, you could go on the Axogen site, they have some doctors, but there are going to be more people who do sensory restoration than just those people. And so I don’t know, I’m not giving a great answer, but…

Keri Stephens:
No. I mean, I think that just the fact-

Dr. Chen:
Knowing that it exists and that’s [inaudible 00:18:06].

Keri Stephens:
That’s the biggest part. I don’t think a lot of people know this exists and I’m really glad that we have you on our podcast telling everyone that it does. And I think this is going to change lives. I think if someone hears this and I think a lot of women will be really interested in this.

Dr. Chen:
I think it’s the same thing as DIEP flap breast reconstruction, 10 years ago. I told you the story earlier about when I was a resident at the University of Washington, I think I was a second-year general surgery resident and I was rotating through the plastic surgery service and I was in the combined program. So I already knew I was going into plastic surgery and the patient that I… As the resident you’re sent in to see the patient first. And that patient was a professor at the university, a really smart woman who already knew that she did not want implants, but she also didn’t want to tram because she didn’t want to sacrifice her muscle. So she felt really stuck because there were no good options from her standpoint for reconstruction. I told her, “Well, there is a great option.” I don’t think there at that point, there was nobody on the West Coast who did it, but I said, “There’s a guy in New Orleans, who’s doing something called deep inferior epigastric perforator flaps, where it’s like a tram, but you don’t take any muscle.”

Dr. Chen:
For people who are young and active and horseback ride, or basically want to keep their muscles. And it’s a great option. He had been doing this for a little bit. People were pretty upset that I told her about this sham surgery. She was upset because she was told it was a sham surgery that was not a real surgery and the person who was so upset at me, this is the only operation he does now. And so this is, I guess 15, almost 20 years ago, 20 years ago, I can’t even believe that, but it was a long time ago, maybe more than 20 years ago. At that time DIEP flaps, there was literally not a single surgeon on the West Coast at all, who did DIEP flaps. Now, I mean, if not everywhere, it’s not uncommon to be able to find a surgeon who does a DIEP flap.

Dr. Chen:
I would say everyone knows what a DIEP flap is. I think that was patient driven if I’m not mistaken. I think it was people, especially, in the prophylactic mastectomy world where people do a lot of research and they have the luxury of time to be able to choose their team and figure out what the best possible reconstruction is out there. Because these are people with normal bodies, normal breasts, no known disease, they’re having surgery, but they don’t want to wake up mutilated looking and feeling different, et cetera. So I don’t know. I think for sensory restoration, I have a feeling it’s going to need to be patient driven there too.

Keri Stephens:
Yeah. I know for me, my doctor never mentioned DIEP either. Well, I asked about-

Dr. Chen:
[inaudible 00:21:19] don’t do it. If she didn’t mention it a lot of times that means she doesn’t do it.

Keri Stephens:
Well, I think it was my first doctor. He did, but he said, I wasn’t a good candidate for it. I remember he’s like, “Oh, you’re not a candidate for DIEP.” I don’t know. But I think-

Dr. Chen:
That’s like 99% of my patients, is they have seen six other plastic surgeons, all of them said they weren’t good candidates. And that is whole nother topic of conversation, is people who are told they are only a good candidate for an implant. I mean, it’s definitely an easier operation. I’ll admit that, usually it’s because they’re too thin or some other reason, but I even had one patient come in and she was pretty chubby and her surgeon is a surgeon I work with. He’s a great micro-surgeon. He told her she wasn’t a good candidate. And I was like, “Oh, if you’re not a good candidate, who is?”

Dr. Chen:
I mean, and she wanted a DIEP flap. And I was like, “Do you want me to call him?” Because frankly, I’m thinking to myself, I want to know is there something wrong with her that she’s not telling me and why she’s not a good candidate, but I think the issue there was he worked at Sloan Kettering and they’re very, very high volume in their 80, 90% implants. And they cannot do a DIEP flap on every patient, so.

Keri Stephens:
Right. Either log.

Dr. Chen:
Yeah. So they just cherry pick who they can do it on and for whatever reason he didn’t want feel like doing it on her. He just didn’t. And so she had implants and by the time she came to me, one was ruptured, one was infected. And so we did DIEP flaps on her and her sister and her other sister. And so…

Keri Stephens:
It worked.

Dr. Chen:
Yeah. And it worked fine.

Keri Stephens:
Well, I think this will be a great next podcast topic, so we’ll make sure that we get you on our podcast again. So…

Dr. Chen:
Okay.

Keri Stephens:
Yeah.

Dr. Chen:
That is such… I mean, that is a frustrating thing because literally patients come and they’ve seen six different plastic surgeons. Some of them are okay, they don’t do it so that I can understand, but some of them they do. I have literally never met somebody who I couldn’t do a flap on. It’s yeah… It is… Yeah, that’s a whole nother topic of conversation.

Keri Stephens:
Well, and I think too, with the breast implant illness, as people have more concerns and really are moving away from the implants. So many people are explanting.

Dr. Chen:
I know.

Keri Stephens:
This seems to be… Well we’ll just have to get you on our podcast again and talk about that because I think that would be an excellent next topic about that. Our readers-

Dr. Chen:
That’d be fun. I love talking about that.

Keri Stephens:
Well, thank you so much for coming on Dr. Chen and to our listeners. Thank you for joining us. We’ll be back soon for the next Plastic Surgery Practice podcast. In the meantime, visit plasticsurgerypractice.com for the latest industry news. Until next time, take care.