Quality of Life, Breast Sensation, and Symptoms in Unilateral Breast Reconstruction with Direct Neurotization (Tommy Transfer) DIEP Free Flap: A Case Series

Background: Loss of breast sensation after mastectomy can adversely affect a patient’s quality of life (QoL). Neurotization has been proposed to enhance sensory recovery following autologous breast reconstruction. However, studies reporting objective sensory outcomes and patient-reported outcome measures (PROMs) remain limited. This case series aimed to assess sensory recovery and PROMs following unilateral deep inferior epigastric perforator (DIEP) free flap breast reconstruction with direct neurotization. Case Presentation: Four patients underwent unilateral DIEP free flap breast reconstruction with direct neurotization between February 2024 and April 2025. We performed direct end-to-end coaptation between a harvested intercostal nerve graft and the lateral cutaneous branch of the fourth intercostal nerve (LCB4). The distal end of the graft was then secured to the flap dermis. Objective sensory recovery was assessed using Semmes-Weinstein monofilament (SWM) testing across 9 breast regions. Patient-reported outcome measures (PROMs) were assessed using the Indonesian BREAST-Q Sensation Module at 0 to 6 and 6 to 12 months postoperatively. All patients demonstrated gradual objective sensory improvement. However, symptoms, sensation, and QoL trajectories varied among these individuals. Conclusion: Sensory recovery following direct neurotization in unilateral DIEP breast reconstruction improved over time. However, objective sensory improvement did not consistently translate into improved symptoms or QoL scores. Postoperative well-being is multifactorial, underscoring the importance of integrating objective sensory testing with PROMs to comprehensively assess functional recovery.