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surgery , which typically takes eight hours .
Progress
The reconstruction procedure is successful , with complete survival of the abdominal tissue used to create both breasts . At six and 12 months postoperatively , objective tactile sensation testing is performed in the native breast skin and the neo-nipple areola complex . Justine has improvement of sensation to levels considered better than protective , which is significantly more than would be expected by chance from the body ’ s natural healing process following this procedure .
The left side that required tissue expander placement and radiotherapy , which had been completely numb prior to the DIEP flap procedure , shows considerable improvement in sensation . The right side has near normal feeling in the periphery and some sensation in the new nipple area . The sensation is not “ normal ” and there is no pleasurable or erogenous quality . However , the breast does feel more natural , and in Justine ’ s words , “ they just feel part of me now ”.
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during autologous tissue reconstruction .
Preliminary outcome findings with this innovative approach indicate variable restoration of sensation , with some patients reporting recovery of tactile and temperature sensitivity in reconstructed breasts . 1 , 2 This underscores the potential for nerve-sparing techniques to enhance post-mastectomy quality of life by restoring breast sensation .
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Sensory preservation breast surgery was introduced to Australia in 2021 . |
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Future
More plastic surgeons will be motivated to add this technique to their DIEP flap procedure , as the evidence disseminates for the improved sensory outcomes following incorporation of sensory reconstruction with mastectomy and DIEP reconstruction . Furthermore , patient advocates continue to raise awareness of the significant issue of numbness after mastectomy for women considering having a unilateral or bilateral DIEP . The technique ’ s future adoption relies on widespread dissemination of outcomes and patient advocacy , moving towards a paradigm shift that incorporates sensory preservation in standard mastectomy procedures .
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What is the most likely diagnosis ?
a Fordyce spots
b HSV infection
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c Genital warts ( HPV infection )
d Pearly penile papules
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Discussion
A DIEP flap reconstruction is often considered a preferred approach to breast reconstruction after mastectomy , particularly when it is deemed necessary for the patient to undergo radiotherapy . This surgical procedure utilises a lower abdominal island of skin and fat at the donor site , sparing the underlying rectus abdominis muscle . The advantages of the DIEP flap approach over older muscle harvest techniques ( transverse rectus abdominis myocutaneous [ TRAM ] procedures ) include reduced abdominal wall injury , reduced weakness and enhanced recovery .
The sensory preservation technique was introduced to Australia in 2021 . 1 This procedure involves concurrent operation by a breast surgeon and a reconstructive surgeon . The breast surgeon performs the mastectomy and helps identify and conserve viable nerves responsible for cutaneous sensation , and the reconstructive surgeon performs the reconstruction . The sensory preservation technique may be used in either immediate or delayed breast reconstructions .
If the primary sensory nerves are not available following tumour excision , the reconstructive surgeon may use alternative sensory nerves from the chest wall , integrating them into the breast
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Outcome
In Justine ’ s case , initial postoperative assessment following mastectomy indicated an absence of sensation in the prophylactic mastectomy site . However , objective monofilament testing after her surgery revealed progressive sensory improvement , with significant sensation recovery by 18 months postoperatively , particularly in the new nipple-areolar complexes , bilaterally .
This included both tactile and temperature sensations , suggesting successful nerve coaptation and integration . On review of Justine ’ s longitudinal clinical findings , it became clear that her immediate postoperative sensory testing was not an accurate indicator of longer term success with sensory preservation .
Results such as Justine ’ s indicate that advocacy to continue research and application of nerve-sparing techniques in breast reconstruction to enhance postsurgical sensory outcomes is warranted . Patients who desire sensory preservation during mastectomy should be encouraged to discuss this with their surgeon .
References on request from kate . kelso @ adg . com . au
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ANSWER The correct answer is a . Fordyce spots are heterotopic sebaceous glands , which mostly occur on the oral and genital mucosa and skin . They are considered a normal anatomical variant , are not sexually transmitted , nor are they infectious .
Fordyce spots usually appear as small ( 1-5mm ) discrete papules that are yellow-white and are often confused with STIs . They usually appear in puberty , when gland enlargement is stimulated by hormonal factors . Thus their appearance can cause high levels of anxiety in young adult patients .
They are generally harmless and require no treatment , however electrosurgery and laser treatment can be used if there are significant cosmetic concerns . Patients should be advised to avoid picking or squeezing the spots as this carries a risk of scarring .
Genital HSV usually results in painful , fluid-filled vesicles and is thus generally easy to diagnose based on the typical clinical features .
Genital warts can be distinguished from Fordyce spots by their dermoscopic appearance of cauliflower-like structures . They often protrude out of the skin surface .
Pearly penile papules occur exclusively on the coronal sulcus of the glans penis — these are also considered a normal anatomical variant .
In this case , simple reassurance was the management approach , and the patient was most satisfied to know that the appearance of his genitals was certainly normal .
References on request from kate . kelso @ adg . com . au
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