Neurotization of the Nipple-Areola Complex in Nipple Sparing Mastectomy: Systematic Review of Techniques, Sensitivity, and Sexual Well-Being.

INTRODUCTION: Nipple sparing mastectomy (NSM) can improve domains of body image and sexuality, but preservation of the nipple-areola complex (NAC) does not guarantee sensory maintenance. NAC neurotization/reinnervation techniques have been proposed to restore sensitivity and optimize quality of life. The aim was to synthesize evidence on ACN reinnervation after NSM with immediate reconstruction, including techniques, objective measures, PROs, and complications. METHODS: This is a systematic review according to PRISMA (CRD420261331412). We searched PubMed/MEDLINE, Embase, and Cochrane, without date restriction, for terms related to NSM, NAC, neurotization/cooptation/neural grafts, and sensory evaluation. Included were studies on NSM with immediate reconstruction that described reinnervation/preservation directed at the NAC and reported objective sensory outcomes and/or BREAST-Q. RESULTS: Overall, 411 records were identified and 12 studies were included. There was a predominance of series and cohorts in implant-based reconstruction, often pre-pectoral. The techniques were convergent, with intercostal branches (mainly 4th; 3rd-5th) and, in the majority, processed allografts (∼7 cm) directed to the subareolar plexus/areolar dermis; there were variations with autologous graft and delayed neurotization. Objective measures (PSSD, monofilaments, and two-point discrimination) suggested improvement throughout follow-up, with gains in the first 6-12 months. In a comparative prospective cohort, neurotization was associated with better psychosocial and sexual well-being scores and greater perception of nipple sensation. Major complications were uncommon and no persistent neuromas or dysesthesias were reported; oncological outcomes were poorly reported. CONCLUSION: NAC reinnervation after NSM is feasible and demonstrates progressive sensory recovery, with emerging evidence suggesting benefits in patient-centered outcomes, including psychosocial and sexual well-being. Current evidence also highlights the clinical relevance of sensory preservation as part of a more functional and humanized reconstructive approach. However, important gaps remain due to heterogeneous methodologies, non-randomized designs, and limited oncological reporting, reinforcing the need for standardized prospective studies.