Transient Peripheral Neuropathy Following Autologous Breast Reconstruction: A Case Series and Evidence-Based Protocol for Risk Reduction

Free flap reconstruction is the gold standard following mastectomy, yet peri-operative peripheral neuropathies remain underrecognized complications. This study aimed to identify peri-operative risk factors for upper limb peripheral nerve injury in patients undergoing autologous breast reconstruction and propose modifications to minimize risk. Out of 155 patients undergoing autologous abdominal breast reconstruction performed by a single surgeon between 2014-2022, eight developed transient postoperative upper limb neuropraxia. All affected patients were overweight/obese and classified as American Society of Anesthesiologists class II. Neuropraxia was most frequently ulnar or ulnar-median; 75% of symptoms resolved within two days. Half of the cases occurred ipsilateral to arterial line placement, with increased risk following multiple cannulation attempts. Prolonged operative duration and complex reconstructions contributed to neuropraxia risk. A five-step protocol was developed to mitigate nerve injury: ultrasound-guided arterial line placement; arm abduction <90°; forearm supination; meticulous padding of pressure points; early postoperative limb elevation and mobilisation.