By: Denise Stewart, founder of Breast and Shoulder Rehabilitation and Breast Cancer Occupational Therapist.
The soft tissues of the chest, breast, shoulder, neck and arm are directly impacted by breast cancer surgery, chemotherapy and radiotherapy. Each of these treatments will have a different impact on each person; however there are some common experiences that can be better understood and managed.
Let’s focus on mastectomy surgery, the resulting mastectomy scar and some common experiences.
I have women report that they dutifully put oil or their best cream on their mastectomy scar line every day, after the wound has healed, so they can have a soft “good” scar.
What is wrong with this treatment option you may ask? The issue is twofold:
- The scar tissue extends much further than the mastectomy (surgical) scar line where the skin was stitched together. Scar tissue forms as a normal healing response wherever tissue is cut or damaged. So effectively with a mastectomy, scar tissue needs to form over the entire area where the breast tissue was removed from against the rib cage and where the breast tissue was removed from the skin let’s call this area the mastectomy chest scar . At the side of body, the scar may form and connect to the soft tissues that travel across into the arm, the pectoral muscle, the lymphatic structures, the serratus muscle and other muscles that connect to the shoulder-blade. So potentially, the scar tissue that forms following mastectomy can be a very large area and potentially can affect the stretch of other soft tissues in the nearby areas of the arm and shoulder-blade and the ribs (mastectomy chest scar).
- Oil or cream applied to a mastectomy scar line does not cause directional stretch at the deep scar tissue of the surgical scar line or the mastectomy chest scar.
Scar tissue that forms in the healing phase often gets laid down in directions that are not in the same direction as the previous tissues. In other parts of the body when scar tissue matures (changes over time) our movement creates internal directional forces, which in turn helps to correct the direction, length and softness of the scar tissue.
Characteristics of new scar tissue at the mastectomy (surgical) scar line and the mastectomy chest scar?
Some women may have very poor feeling in this whole mastectomy chest area, it may feel dull.
The skin over the entire area may feel too connected to the rib cage and may lack stretch in the many directions that skin normally stretches.
Some women develop a significant sensitivity / pain to both light and deep touch.
In the weeks and months after surgery, the scar tissue has very limited stretch. If connections form with nearby tissue, this will cause restriction in movements in the arm. Full reach up and back behind the body may be difficult to achieve.
The mastectomy (surgical) scar line will look red or darker than your skin colour. This scar line can pucker and adhere to nearby structures (eg the pectoral muscle, the tissue covering the ribs).
Fluid may collect below the horizontal scar line because the lymphatics are not able to get passed the scar tissue.
Does scar tissue change over time?
Over time scar tissue can change, it can become stretchy, links to nearby tissue may even break away or remodel.
Pain may not be experienced when the tissue is touched and the scar line will become a lighter colour. For scar tissue to change and be remodelled it primarily requires stretch or directional force to be applied to the scar tissue, hydration (water) and a good blood supply.
It is the first requirement – stretch or directional force that poses a problem for the mastectomy scar tissue. Because of the position on the chest /rib cage, scar tissue may not actually get adequate stretch in many cases.
The usual time frame for new scar tissue to become mature, stretchy scar tissue is approximately two years. This time frame will be extended if radiotherapy is undertaken.
Can we help tight mastectomy scar tissue change and remodelling?
Because mastectomy scar tissue covers a large area and changes to scar tissue takes a long time – a supported self-management approach may need to be adopted to achieve better outcomes for women. Self-management requires:
- Learning and using self-assessment skills to evaluate stretch in tissues over the entire chest area;
- Learning and using a good arm and shoulder-blade movement assessment and recovery strategy;
- Frequently use treatments that create a positive change to the tight scar tissue over the first 6-12 months after breast surgery;
- Regularly use treatments to create a positive change to scar tissue over the 12-24 months after breast surgery;
- Regularly use treatments to create positive change to scar tissue for 2-4 years if radiotherapy was undertaken; and
- For some women a management program may need to be undertaken for decades.
Training, specialist treatments, monitoring and coaching are recognized support services for self-management programs for other chronic medical conditions. Support from breast cancer rehabilitation and exercise specialists must also be made available for women experiencing problematic tight mastectomy scar tissue.
The next blog will continue to discuss common experiences of mastectomy scar tissue and management options.
- soft tissues are muscles, skin, fat, fascia, blood vessels, nerves.
- women with severe radiotherapy damage may be an exception to this type of self-management program.
Denise Stewart, founder of Breast and Shoulder Rehabilitation and an Occupational Therapist trained in Australia at University of Queensland. Her career started at a major public hospital, providing rehabilitation to people with very serious and chronic illness and injuries.